Indian Journal of Physiotherapy and Occupational Therapy

EDITOR-IN-CHIEF
Archna Sharma
Ex- Head. Dept. of Physiotherapy, G. M. Modi Hospital, Saket, New Delhi - 110 017
Email : [email protected]

Executive Editor
Prof. R K Sharma
Dean (R&D), Saraswathi Institute of Medical Sciences, Hapur, UP, India
Formerly at All India Institute of Medical Sciences, New Delhi

Sub Editor
Kavita Behal Sharma
MPT (Ortho)

INTERNATIONAL EDITORIAL ADVISORY BOARD NATIONAL EDITORIAL ADVISORY BOARD

1. Vikram Mohan (Lecturer) Universiti Teknologi MARA, 1. Charu Garg (Incharge PT) , Sikanderpur Hospital
Malaysia (MJSMRS),Sirsa Haryana, India
2. Angusamy Ramadurai (Principal) Nyangabgwe Referral 2. Vaibhav Madhukar Kapre (Associate Professor) MGM
Hospital, Botswana Institute of Physiotherapy, Aurangabad (Maharashtra)
3. Faizan Zaffar Kashoo (Lecturer) College Applied Medical 3. Amit Vinayak Nagrale (Associate Professor) Maharashtra
Sciences, Al-Majma'ah University, Kingdom of Saudi Arabia Institute of Physiotherapy, Latur,Maharashtra
4. Amr Almaz Abdel-aziem (Assistant Professor) of 4. Manu Goyal (Principal), M.M University Mullana, Ambala,
Biomechanics, Faculty of Physical Therapy, Cairo University, Haryana, India
Egypt
5. P.ShanmugaRaju (Asst.Professor & I/C Head) Chalmeda
5. Abhilash Babu Surabhi (Physiotherapist) Long Sault, AnandRao Institute of Medical Sciences, Karimnagar, Andhra
Ontario, Canada Pradesh
6. Avanianban Chakkarapani (Senior Lecturer) Quest 6. Sudhanshu Pandey (Consultant Physical Therapy and
International University Perak, IPOH, Malaysia Rehabilitation) Department \Base Hospital, Delhi
7. Manobhiram Nellutla (Safety Advisor) Fiosa-Miosa Safety 7. Khatri Subhash Maniklal (Professor & Principal) College of
Alliance of BC, Chilliwack, British Columbia Physiotherapy, Pravara Institute of Medical Sciences, Ahmed
8. Jaya Shanker Tedla (Assistant Professor) College of Applied Nagar, Maharashtra
Medical Sciences, Saudi Arabia 8. Aparna Sarkar (Associate Professor) AIPT, AMITY
9. Stanley John Winser (PhD Candidate) at University of Otago, UNIVERSITY, Noida
New Zealand 9. Jasobanta Sethi (Professor & Head) Lovely Professional
10. Salwa El-Sobkey (Associate Professor) King Saud University, University, Phagwara, Punjab
Saudi Arabia
10. Patitapaban Mohanty (Assoc. Professor & H.O.D)
11. Saleh Aloraibi (Associate Professor) College of Applied SVNIRTAR, Cuttack, Odisha
Medical Sciences, Saudi Arabia
11. Suraj Kumar (HOD and Lecturer) Physiotherapy Rural
12. Rashij M, Faculty-PT Neuro Sciences College of Allied Health Institute of Medical Sciences & Research, Paramedical Vigyan
Sciences, UAE Mahavidhyalaya Saifai, Etawah,UP
13. Mohmad Waseem, (Exercise Therapist) Alberta- CANADA 12. U.Ganapathy Sankar (Vice Principal) SRM College of
14. Muhammad Naveed Babur (Principle & Associate Professor) Occupational Therapy, Kattankulathur,Tamil Nadu
Isra University, Islamabad, Pakistan 13. Hemant Juneja (Head of Department & Associate Professor)
15. Zbigniew Sliwinski (Professor) Jan Kochanowski University Amar Jyoti Institute of Physiotherapy, Delhi
in Kielce 14. Sanjiv Kumar (I/C Principal & Professor) KLEU Institute of
16. Mohammed Taher Ahmed Omar (Assistant professor) Cairo physiotherapy, Belgaum, Karnataka
University, Giza, Egypt 15. Shaji John Kachanathu (Associate Professor) Jaipur
17. Ganesan Kathiresan (DBC Senior Physiotherapist) Kuching, Physiotherapy College, Rajasthan, India
Sarawak, Malaysia 16. Narasimman Swaminathan (Professor, Course Coordinator
18. Kartik Shah (Health Consultant) for the Yoga Expo, Canada and Head) Father Muller Medical College, Mangalore
19. Shweta Gore (Senior Physical Therapist) Narayan 17. Pooja Sharma (Assistant professor) AIPT, Amity university,
Rehabilitation, Bad Axe, Michigan, USA Noida
20. Ashokan Arumugam (PhD Candidate School of 18. Nilima Bedekar (Professor, HOD) Musculoskeletal Sciences,
Physiotherapy) University of Otago,,Dunedin, New Zealand Sancheti Institute College of Physiotherapy, Pune.

IFC PAGE FINAL.pmd 2 7/22/2013, 6:59 PM

 Indian Journal of Physiotherapy and Occupational Therapy
NATIONAL EDITORIAL ADVISORY BOARD SCIENTIFIC COMMITTEE
19. N.Venkatesh (Principal and Professor) Sri Ramachandra 1. Gaurav Shori (Assistant Professor) I.T.S College of
university, Chennai Physiotherapy
20. Meenakshi Batra (Senior Occupational Therapist), Pandit 2. Baskaran Chandrasekaran (Senior Physiotherapist) PSG
Deen Dayal Upadhyaya Institute for The Physically Hospitals, Coimbatore
Handicapped, New Delhi 3. Dharam Pandey (Sr. Consultant & Head of Department) BLK
21. Shovan Saha, T (Associate Professor & Head) Occupational Super Speciality Hospital, New Delhi
therapy School of allied health sciences,Manipal 4. Jeba Chitra (Associate Professor) KLEU Institute of
university,Manipal,, karnataka, Physiotherapy Belgaum, Karnataka
22. Akshat Pandey (Sports Physiotherapist) Indian Weightlifting 5. Deepak B.Anap (Associate Professor) PDVPPF's, College
Federation/ Senior Men and Woman / SAI NSNIS Patiala of Physiotherapy, Ahmednagar. ( Maharashtra)
23. Dr. Jagatheesan A (HOD-Paediatric Physiotherapy & 6. Shalini Grover (Assistant Professor) HOD-FAS,MRIU
Associate Professor) Saveetha College of Physiotherapy, 7. Vijay Batra (Lecturer) ISIC Institute of Rehab. Sciences
Thandalam, Chennai 8. Ravinder Narwal (Lecturer) Himalayan Hospital, HIHIT
24. Maneesh Arora (Professor and as Head of Dept) Sardar Medical University, Dehradun-UK.
Bhagwan (P.G.) Institute of Biomemical Sciences, Balawala, 9. Abraham Samuel Babu (Assistant Professor) Manipal
Dehradun, UK College of Allied Health Sciences, Manipal
25. Jayaprakash Jayavelu (Chief Physiotherapist) Medanta The 10. Anu Bansal (Assistant Professor and Clinical Coordinator)
Medicity, Gurgaon Haryana AIPT , Amity university, Noida
26. Deepak Sharan (Medical Director and Sole Proprietor) 11. Bindya Sharma (Assistant Professor) Dr. D. Y. Patil College
RECOUP Neuromusculoskeletal Rehabilitation Centre, New Of Physiotherapy, Pune
Delhi 12. Dheeraj Lamba (Lecturer) Institute of Allied Health
27. Vaibhav Agarwal (Incharge, Dept of Physiotherapy) HIHT, (Paramedical) Services, Education & Training (IAHSET) Govt. Medical
Dehradun 13. Soumya G (Assistant Professor) (MSRMC)
28. Shipra Bhatia (Assistant Professor) AIPT, Amity university, 14. Nalina Gupta Singh (Assistant Professor) Physiotherapy,
Noida Amar Jyoti Institute of Physiotherapy, University of Delhi
29. Jaskirat Kaur (Assistant Professor) Indian Spinal Injuries 15. Gayatri Jadav Upadhyay (Academic Head) Academic
Center, New Delhi Physiotherapist & Consultant PT, RECOUP Neuromusculoskeletal
Rehabilitation Centre, Bangalore
30. Prashant Mukkanavar (Assistant Professor) S.D.M College
of Physiotherapy, Dharwad, Karnataka 16. Nusrat Hamdani ( Asst.Professor and Consultant)
Neurophysiotherapy (Rehabilitation Center, Jamia Hamdard) New Delhi
31. Chandan Kumar (Associate Professor & HOD) Neuro-
physiotherapy, Mahatma Gandhi Mission's Institute of 17. Ramesh Debur Visweswara (Assistant Professor) M.S.
Physiotherapy, Aurangabad, Maharashtra Ramaiah Medical College & Hospital, Bangalore
18. Nishat Quddus (Assistant Professor) Jamia Hamdard, New Delhi

“Indian Journal of Physiotherapy and Occupational Therapy” An essential indexed peer reviewed journal for all physiotherapists &
occupational therapists provides professionals with a forum to discuss today’s challenges- identifying the philosophical and conceptual
foundations of the practice; sharing innovative evaluation and treatment techniques; learning about and assimilating new methodologies
developing in related professions; and communicating information about new practice settings. The journal serves as a valuable tool for
helping therapists deal effectively with the challenges of the field. It emphasizes articles and reports that are directly relevant to practice.
The journal is now covered by INDEX COPERNICUS, POLAND and covered by many internet databases. The Journal is registered with
Registrar of Newspapers for India vide registration number DELENG/2007/20988

Print-ISSN: 0973-5666, Electronic - ISSN: 0973-5674, Frequency: Quarterly (4 issues per volume).

Website: www.ijpot.com
© All Rights reserved The views and opinions expressed are of Editor
the authors and not of the Indian Journal of Physiotherapy and Archna Sharma
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Occupational Therapy does not guarantee directly or indirectly the
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IFC PAGE FINAL.pmd 3 7/22/2013, 6:59 PM

 I

Indian Journal of Physiotherapy and

Occupational Therapy
www.ijpot.com
Contents
Volume 07 Number 03 July-September 2013

1. Effect of Brief Intense TENS and Cryotherapy on the Symptoms Associated with Delayed ............................................ 01
Onset of Muscle Soreness in Healthy Male Subjects
S Aadil Rashid, Nishat Quddus, Belsare

2. The effect of Topical Application of Extra Virgin Olive Oil on Alleviating Knee ................................................................ 06
Pain in Patients with Knee Osteoarthritis: A Pilot Study
Abdul-Majeed Al Malty, Saja Hamed, Hashem AbuTariah, Mohammad Jebril

3. A Study to Compare the effectiveness of Treadmill and Cycle Ergometer on ..................................................................... 12

Endurance in Normal Subjects
Sharma Abhishek, Shah Arpita, Dey Sushant, Sharma Urvi

4. Effect of Aerobic Exercises on Serum IgE and Pulmonary Functions in Children with Bronchial Asthma ................... 15
Aisha A Hagag, Naglaa A Zaky

5. Efficacy of Scapular Movement with Mobilization in Patients with Shoulder Impingement .......................................... 20
Ajit Dabholkar, Tejashree Dabholkar, Sujata Yardi

6. Effect of Hip Position and Gender on Active Hip Internal Rotation and External ............................................................. 25
Rotation on the Dominant Side
Amit Agarwal, Amrit Kaur, Ganesh MSP

7. Electrophysiological Assessment of Clinically Diagnosed Patients of Carpal Tunnel ....................................................... 29

Syndrome in Western Maharashtra (India)
Joshi A G, Gargate A R, Patil S N

8. Effectiveness of Core Muscle Stabilization Training on Dynamic Balance in ...................................................................... 34

Mechanical Low Back Pain Patients
Apeksha O Yadav, Ketaki G Deshmukh

9. Effect of Knee Chest Position in Primary Dysmenorrhea- A Randomized Controlled Trial ............................................. 40
Arati Mahishale, Dinika Mascarenhas, Shobhana Patted

10. The effect of Strength Training on Normalizing the Tone and Strength of Spastic ............................................................. 45
Elbow Flexors in Subjects with Stroke
Bharath Kumar P V S R, V Sri Kumari, K Madhavi

11. Comparison of Supervised Rehabilitation vs. Home Based Unsupervised Rehabilitation ............................................... 50
Programs after Total Knee Arthroplasty: A Pilot Study
Bijender Sindhu, Manoj Sharma, Raj K Biraynia

12. Supervised V/s Unsupervised Constraint Induced Movement Therapy in Improving .................................................... 54
Upper Extremity Function in Spastic Hemiparetic Cerebral Palsy Children
Charu Chopra, Jaskirat Kaur

13. Effect of Proprioceptive Neuromuscular Facilitation in Hemiplegic Gait a Randomized ................................................. 59

Trial of 4 Weeks and a Follow up after 2 Weeks
Damaneek Kaur Mann, N A Ramasubramia Raja, Nidhi Bhardwaj, Jagmohan Singh

Content Final.pmd 1 8/1/2013, 8:32 AM

 II

14. Comparison of effects of Sitting-up using Rope Ladder versus Manual Supported .......................................................... 65
Sitting-up on Haemodynamic Variables in Patients after Coronary Artery Bypass Grafting
Deepti Garnawat, Faizan Ahmed, Muhammed Abid Geelani
15. Electrical Muscle Stimulation (EMS) Preserve Muscle Strength in Critically ill Patients- A Pilot Study ........................ 71
Dharam Pani Pandey, Ram Babu, Uday Shanker Sharma

16. Effect of Core Stability Exercises Versus Conventional Treatment in Chronic Low Back Pain ......................................... 76
Dheeraj Lamba, Suneeti Kandpal, Monika Joshi, Mamta Koranga, Neeta Chauhan

17. Efficacy of Electromyography Biofeedback Training on Trunk Stability in Chronic Low Back Pain .............................. 81
Hashim Ahmed, Amir Iqbal, Md Abu Shaphe

18. A Comparative Study between the effects of Static Somatosensory Balance Training and ............................................... 87
Static Vestibular Balance Training on Dynamic Balance and Fear of Fall in Institutionalized Elderly
Jyoti Laroia, Nusrat Hamdani, Majumi Mohammad Noohu

19. Efficacy of Eccentric Training and Muscle Energy Technique on Hamstring Flexibility in ............................................... 93
Sedentary College Students
Gurpreet Kaur, M Kashif Reza

20. Efficacy of Taping in Bell's Palsy ................................................................................................................................................... 98

Kaushal M, Saini S S, Singh N, Ghotra P K

21. Effect of Aerobic Exercises on Plasma Lipid Profile and Cardiorespiratory Fitness in Obese Women ......................... 104
Aisha A Hagag

22. Effect of Postoperative Ambulation on the Quality of Life in a Transtibial Amputee ...................................................... 109
Amit Saraf, Ankita Gupta, Jeewan S Prakash, Jedidiah S Prakash

23. Effect of High Power Pain Threshold Static Ultrasound Combined with Transverse ...................................................... 113
Friction Massage and Stretching on Upper Trapezius Myofascial Trigger Point
Hari Haran R, Singh Anand Kumar

24. Efficacy of Muscle Energy Technique in Combination with Strain-counterstrain ............................................................ 118
Technique on Deactivation of Trigger Point Pain
Amir Iqbal, Hashim Ahmed, Md Abu Shaphe

25. A Case Review of Perceptual Deficit in PRES: Detailed Perceptual Evaluation ................................................................ 124
is a Key to Definite Goal Achieving Techniques
Moushami S Kadkol

26. Perceived Stress, Sources and Severity of Stress among Physiotherapy Students in an Indian College ...................... 128
Tushar J Palekar, M G Mokashi

27. Effect of High Frequency, Low Magnitude Vibration on Bone Density and Lean ............................................................ 134
Content in Children with Down Syndrome
Naglaa A Zaky, Amira E Elbagalaty

28. A Comparative Study between Relaxation Technique and Aerobic Exercise in ................................................................ 140
Fatigue During Chemotherapy in Acute Lymphoblastic Leukemia in Children
Dhoriyani Narendra B, Bhatt Kaushal D, Smitha D

29. Predictors of Job Satisfaction among Physiotherapy Professionals ..................................................................................... 146

Nidhi Gupta, Shabnam Joshi

30. Cervico-thoracic Mobilization to Address LBA for a Patient with Lumbar Spondylolisthesis ...................................... 152
P P Mohanty, B Kuanar, B K Behera

31. Relationship of Cervicothoracic Curvature with Muscle Strength and ............................................................................... 156
Endurance in Subjects with Neck Pain
Parminder Kaur, Monalisa Pattnaik, Patit Paban Mohanty

Content Final.pmd 2 8/1/2013, 12:37 PM

 III

32. A Study on the Impact of Body Mass Index on Lower Back Extensor Endurance in ....................................................... 162
Apparently Healthy Subjects
V Pasupatham, Mohan Vikram, V Swaminathan, S Reka Rani

33. Study of the efficacy of the Mulligan's Movement with Mobilization and Taping ........................................................... 167
Technique as an Adjunct to the Conventional Therapy for Lateral Ankle Sprain
Punam Ghadi, Chhaya Verma

34. Comparative Study between the efficacy of Muscle Energy Technique and Static ........................................................... 172
Passive Stretching on Hamstring Flexibility in Healthy Indian College Athletes
Pratik A Gohil

35. Effect of Maitland Spinal Mobilization Therapy Versus Conventional ......................................................................... 177
Therapy in Lumbar Spondylosis with Radiculopathy
Priya Igatpurikar

36. Importance of Screening in 0-18 Months Infants by using INFANIB at Tertiary Hospital ............................................. 184
Parmar Sanjay, Praveen S Bagalkoti, Netravati Shettar, Rajlaxmi Kubasadgoudar

37. Effect of Stroke on Mantainence of Balance and Sense of Equilibrium .............................................................................. 187
Nidhi Kashyap, Savita Tamaria

38. Accessory Inspiratory Muscles Energy Technique effect on Pulmonary Function in COPD Subjects .......................... 192
Akanksha Anand, Ravinder Narwal, Girish Sindhwani
39. A Randomized Comparison of effectiveness of Clinical Exercises and Manual Therapy ............................................... 198
Procedures Versus Clinical Exercises alone in the Treatment of Osteoarthritis of Knee
Sapna S Sharma

40. Comparing the effects of Manipulation of Wrist and Ultrasound, Friction Massage and ............................................... 205
Exercises on Lateral Epicondylitis: A Randomized Clinical Study
Sharvari Joshi, Santosh Metgud, Ebnezer C

41. The effect of Tra Training alone and in Combination with Pelvic Floor Muscle Training in ........................................... 210
Women with Stress Urinary Incontinence
Chandan Kaur Khandpur, Shipra Bhatia

42. Comparison of Two Sit and Reach Tests for Measurement of Hamstring Flexibility in .................................................. 216
Female University Physiotherapy Students
Nidhi Kathuria, Sumit Kalra

43. Home Based Exercise Program for Frozen Shoulder- Follow-up of 36 Idiopathic Frozen Shoulder Patients ............. 221
Shishir S M, Manoj Abraham M, Kanagasabai R, Syed Najimudeen, James J Gnanadoss

44. Effect of Vibration on Skin Blood Flow in Type 2 Diabetes Mellitus ................................................................................... 227
Everett B Lohman, Kanikkai Steni Balan Sackiriyas, Gurinder S Bains, Kulbhushan H Dhamane,
Kinjal J Solani, Chandip K Raju, Howard W Sulzle

45. Immediate Effect of Jacobson's Progressive Muscular Relaxation in Hypertension ......................................................... 234
Nisha Shinde, Shinde KJ, Khatri SM, Deepali Hande

46. Chronic Abdominal Wall Pain in Children may be Improved by Physiotherapy ............................................................. 238
Siba Prosad Paul, Gina Farmer, Krishna Soondrum, David CA Candy

47. Functional Status and Disability in Stroke Survivors of North India .................................................................................. 240
AGK Sinha, Divya Dhamija, Supreet Bindra

48. Kinetic Chain Exercise for Patello Femoral Pain Syndrome - A Randomised Control Study ......................................... 245
Suresh Kumar T, Leo Rathinaraj A S, Jeganathan A, Vignesh Waran Vellaichamy

49. Effect of Mechanical Low Back Pain on Postural Balance and Fall Risk ............................................................................. 250
Ibrahim M M, Shousha T M, Alayat MS

Content Final.pmd 3 8/1/2013, 8:32 AM

 IV

50. Alteration in Pelvic Inclination & its Correlation with Lumbar Lordosis in Pregnant Women ...................................... 255
Madhura M Inamdar, Unnati Pandit, Bharati V Bellare

51. Barriers Associated with Community Access by Stroke Patients in Indian Population .................................................. 260
Mohammad Usman Akhtar, Shubha Arora, Man Mohan Mehndiratta

52. Immediate effects of Taping of Upper Back on Peak Expiratory Flow Rate (PEFR) ......................................................... 265
in Stable Chronic Obstructive Pulmonary Disease (COPD) Subjects
S Kimothi, V K Nambiar, B Yadav

53. Functional Status in Post-CABG Patients Following Physiotherapy- A Retrospective Analysis ................................... 270
Vinod K Ravaliya

54. Effect of Cross Training Techniques in Novice Runners ......................................................................................................... 275

Vishesh Garg, M Neethi, S K Joshi, Jagmohan Singh

55. A Study on efficacy of different Therapeutic Modalities to Alleviate Pain due to Knee Osteoarthritis ........................ 279
Bibek Adhya, Anu Gupta, Mandeep Singh Dhillon, Upendra Goswami, Vijay Kumar

56. A Comparative Study of effectiveness of Balance Training with and without Visual ...................................................... 285
Cues on Activities of Daily Living in Stroke Patients
Dhoriyani Narendra B, Patel Fagun B, Smitha D, Kagathra Shailesh, Bhatt Kaushal

57. Correlation among Cervical Pain, Neck Disability Index and Health Related Quality of ............................................... 291
Life for Subjects Suffering from Cervical Pain of Age Group 20 to 75 Years
Ms. Shubha Arora, Mrs. Taruna Mathur

58. Profile of Older Adults in Memory Outpatients' Clinic Setting and effectiveness of Novel ........................................... 297
Occupational Therapy Intervention in Patients with Mild to Moderate Dementia
Prakash Kumar, SC Tiwari, V Sreenivas, Nand Kumar, R K Tripathi, Dey AB

Content Final.pmd 4 8/1/2013, 8:32 AM

 DOI Number: 10.5958/j.0973-5674.7.3.054

Effect of Brief Intense TENS and Cryotherapy on the

Symptoms Associated with Delayed Onset of Muscle
Soreness in Healthy Male Subjects

S Aadil Rashid1, Nishat Quddus2, Belsare3

1
Jr. Physiotherapist, JMI New Delhi, 2Assistant Professor Jamia Hamdard New Delhi, 3Incharge Physiotherapy
Department Majeedia Hospital, New Delhi

ABSTRACT
Objective: The study investigated the effect of brief intense TENS and ice on pain relaxed elbow
extension angle.
Design and setting: Three sets of concentric and eccentric action induced delayed onset of the elbow
flexors of non dominant hand. Pre exercise measures were recorded for relaxed elbow extension
range and perceived muscle pain. Group A received ice treatment for 15 minutes, group B received
brief intense TENS (100 Hz, 100 milliseconds, maximum tolerable intensity), Group C received sham
TENS treatments after 48 hours of post-exercise.
Subjects: Forty five healthy male subjects
Measurements: Relaxed elbow extension angle and perceived muscle pain was recorded before
exercise, before treatment after 48 hours post exercise and after treatment.
Results: Readings were compared for difference using ANOVA it was found that there was statistically
significant difference p=0.045 (p<0.05) in VAS with the scores taken after Cryotherapy.
Conclusion: Cryotherapy was effective in reducing the perceived pain in elbow flexors after eccentric
bouts
Keywords: Pain, TENS, Relaxed Elbow Extension Angle, Delayed Onset Muscle Soreness

INTRODUCTION Numerous studies have been published describing

various strategies and interventions (i.e. nutritional
It has been well-established that exercise-induced
supplementation, pharmaceutical treatments, and
muscle damage occurs following intense exercise
therapeutic modalities) to prevent the signs and
involving eccentric contractions. The damage results
symptoms of DOMS from developing or to alleviate
in a dull, aching pain, known as delayed onset muscle
them once present. These studies have been met with
soreness (DOMS). DOMS, the most common type of
limited success and a sound and consistent treatment
muscle pain is characterized by pain/soreness that
for DOMS has not yet been established.
begins to occur 8-24 hours post-exercise.67 and increases
in intensity until it peaks at 24-72 hours and subsides Even though DOMS is a commonly experienced
5-7 days post exercise.2, 10 Other clinical signs associated phenomenon that can occur in any individual
with DOMS are consistent and include swelling, a independent of fitness level, the exact mechanism(s)
reduction in muscle strength and a decreased range of responsible for DOMS are not completely understood.
motion, all of which can contribute to an impaired A number of theories have been proposed in an
ability to perform routine daily activities. 2,18,20 attempt to explain the underlying mechanism(s)
Individuals who are not accustomed to regular responsible for DOMS. These theories include the
physical are more likely to develop DOMS than highly following: lactic acid, muscle spasm, connective tissue
trained athletes.2 and muscle damage, enzyme efflux, and inflammation.

1. aadil --1--5.pmd 1 8/1/2013, 8:31 AM

 2 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

To date, no research has been able to conclusively soreness rating scale 0 (none), 10 (extreme). The
attribute any one mechanism as the primary cause of subjects performed active flexion extension of the
DOMS or its related sensations; however, much elbow and rated any type of the soreness according to
research conducted involving exercise-induced muscle the scale18.
damage has documented events similar to those
Next relaxed-elbow extension angle which is
associated with acute inflammation response.
defined as ‘the angle between humerus and ulna when
Aims and Objectives of Study subject is standing with the arm hanging by her side
in a semi pronated position’ was assessed. The
The purpose of the study was to investigate the therapist using a permanent marker, to label
effects of ice and brief intense TENS on the following anatomical reference points on the arm, at the lateral
symptoms associated with DOMS; decrease range of edge of the acromion at the shoulder, at the lateral
motion and muscle pain. epicondyle of the elbow and radial styloid process of
the wrist. Goniometer was placed over the lateral
Materials and Method
epicondyle of the humerus with the measurement
The study investigated the effects of ice and brief arms of goniometer aligned along the lateral markers
intense TENS on muscle pain and relaxed elbow on the shoulder and wrist. The reliability (r=0.9) of this
extension angle. The design of this study consisted of measurement procedure using a standard goniometer
pre-test assessment, exercise protocol, post exercise has been previously established.
measurement, treatment protocol, and post treatment
Induction of Delayed Onset Muscle Soreness
measurement.
Repeated eccentric contractions were used to
Participants induce delayed onset muscle soreness in the elbow
A minimum of 45 healthy subjects of age 25+5 years flexors of non dominant hand. The elbow flexors were
were included in the study. Participants read and isolated by using a preacher curl bench. This device
signed consent form, which outlined the procedures enables the subject to sit with his arms resting on a
of the study. All participants reported pain-free range padded board and positioned in front of the body at
of motion about their elbow and no arm pain before 45 degree angle downwards from axilla. Resistance
the three months. The subjects were allowed to was applied to the elbow flexors of non dominant hand
by having the subject grasp a dumbbell and alternately
perform their normal activities of daily living during
flex and extend the elbow throughout range of motion.
the testing period but were asked not to stretch, take
Subject was positioned on the preacher curl device, a
pain medication, or receive any other therapy. The
one repetition maximum of the elbow flexors was
subjects were randomly assigned into three groups.
determined. The one repetition maximum represented
Group A received ice, group B received TENS, and
the amount weight the subject could lift concentrically
group C received sham TENS. The study was approved
one time before the elbow flexors become fatigued.
by Research Committee of Jamia Hamdard.
Using a weight equivalent to one repetition maximum,
Instrumentation the subject performed repeated eccentric contractions
of the elbow flexors. Each subject performed only
Visual analogue scale (VAS) was used to assess pain eccentric contractions by slowly lowering the dumbbell
(muscle soreness). Full circle goniometer was used to from fully flexed to a fully extended elbow position.
measure relaxed elbow extension angle. Preacher curl After each contraction the weight was returned to a
bench and dumbbell were used for the induction of starting position of fully elbow flexion by the therapist.
DOMS. Transcutaneous electrical stimulation and Each subject performed 3 sets of 10 repetitions of the
crushed ice securing plastic produce bags was applied exercise, with 2 minutes rest between each set.
on the elbow flexors after 48 hours of eccentric exercise
bouts. Post Exercise Measures

Pre Exercise Measures Post-exercise measurement was taken to assess the

muscle pain in the elbow flexors and relaxed elbow
Participants subjectively reported the perceived extension angle immediately after 48 hours of post
soreness in their elbow flexors using the following exercise.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 3

Treatment Protocols A permanent marker was used to label anatomical

reference points on the arm at the lateral edge of the
Group A received cold treatment by securing plastic acromion at the shoulder, the lateral epicondyle of the
produce bags filled with crushed ice over the elbow elbow and radial styloid process of the wrist. The
flexor muscle group for 15 minutes. The treatment was subjects were in the standing position with arm
given after 48 hours of exercise. Group B received the hanging by the side and goniometer was placed over
treatment by brief intense TENS of duration 0.2ms, the lateral epicondyle of the humerus with the
frequency 100 Hz, duration 15 minutes, and at highest measurement arms of goniometer aligned along the
tolerable intensity. A bipolar placement of two lateral markers on the shoulder and wrist. The relaxed
rectangular carbon electrodes, gel secured with elastic elbow extension angle was measured.
wraps were used. One electrode was placed over
musculo-tendinous junction of the biceps brachii and
RESULTS
second over the area of greatest soreness, which was
usually over the belly of brachialis. The treatment was The exercise protocol produced significant
given after 48 hours of exercise. For group C placebo differences over time for muscle pain and relaxed
transcutaneous electrical nerve stimulation was given. elbow extension angle. There was no significant
interaction between time and group, nor were there
The electrode placement was same as above. The significant difference among groups for the symptoms
parameters were set as: pulse rate=2 pulse/second, of DOMS.
phase duration=20 microseconds, intensity to
approximately 110 milliampere, and duty cycle set for Pain When both the readings were compared for
an ‘off’ time of 99 seconds and ‘on’ time of 1 seconds. difference using ANOVA it was found that there was
statistically significant difference p=0.045 (p<0.05) in
ASSESSMENT VAS with the scores taken after cryotherapy, TENS
and placebo TENS. When the scores were compared
Assessments for perceived muscle soreness, loss of using Post Hoc it was found that there was statistically
motion were performed before and after each significant difference (p<0.05) in VAS scores when
treatment. Visual analogue scale was used to evaluate comparing values of VAS post between cryotherapy
muscle soreness by making a cross (X) on the and placebo TENS. No such significant difference was
horizontal scale at their level of perceived pain. found when comparing cryotherapy with TENS and
Relaxed elbow extension angle was assessed after the with placebo TENS
treatment.

Table 1: Comparison of Pain recorded between the groups

Cryotherapy TENS Placebo TENS Repeated Post-Hoc

(n=15)M ± SD (n=15)M ± SD (n=15)M ± SD Measures ANOVA Analysis (P=)
F P 1 vs. 2 1 vs. 3 2 vs. 3
VAS Pre 4.7+0.9 4.2+1.1 4.53+.77 .782 .464 NA NA NA
VAS Post 3.42+1.1 3.9+1.1 4.4+.84 3.351 .045 .645 .04 .573

Table 2: Comparison of Relaxed Elbow Extension Angle between the groups

Cryotherapy TENS Placebo TENS Repeated

(n=15)M ± SD (n=15)M ± SD (n=15)M ± SD Measures ANOVA
F P
Relaxed Elbow Extension 161±2.1 160.8±2.24 160.1±1.64 .763 .473
Relaxed Elbow Extension Pre 138±8.82 139.1±8 141.6±7.5 .776 .467
Relaxed Elbow Extension Post 144±9.5 142.7±7.9 142.1±7.7 .296 .746

Relaxed elbow extension angleWhen the readings readings taken after cryotherapy, TENS and placebo
were compared for difference using ANOVA it was TENS. When the readings were compared for
found that there was statistically significant difference differences using Post Hoc it was found that there was
(p<0.05) in relaxed elbow extension angle with the also statistically significant difference (p<0.05) in

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 4 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

relaxed elbow extension angle with readings taken concluded that crushed ice and ice- water immersion
after cryotherapy and TENS. However the readings have greatest cooling efficiency and can sustain
for placebo TENS were not found significant decreased skin surface temperatures post application,
indicates that these agents are potentially the most
DISCUSSION clinically beneficial.82

The aim of this study was to assess the effectiveness Cryotherapy was found effective on muscle pain
of cryotherapy, brief intense TENS and placebo TENS in this study, concurring with earlier work by Eston
on delayed onset muscle soreness. The analysis and Peters in 1999, they reported reduced muscle
conform the induction of DOMS in the selected muscle soreness following repeated cryotherapy (cold water
group. The increased discomfort, decreased relaxed immersion)81 and also concurs with the results by Craig
elbow extension indicates that DOMS was successfully Denegar and David Perrin in 1992 they reported cold,
induced. This investigation showed significant time TENS and combination treatment resulted in
effects in the muscle pain and relaxed elbow extension significant decreases in perceived pain.24 However this
angle indicating that exercise induced muscle damage result contrasts with those of Yackzan et al in 1984,
was evident. These data concur with previous research they reported single treatment of ice massage had no
and lend further evidence that unaccustomed eccentric sustain effect on perceived pain.81 William Isabell et al
exercise results in elevation of indirect markers of in 1992 suggested that use of ice massage, ice massage
muscle damage and soreness.81 Peak soreness at 48 with exercise, or exercise alone was not effective in
hours concur with others who have shown maximum significantly reducing the symptoms of delayed onset
readings ranging between 24 to 48 hours post exercise. muscle soreness. They also suggested ice massage
Discrepancy between time of maximal occurrence (24 administered repeatedly over 96 hours post exercise
or 48 hours) may be attributed to the different types may be contraindicated in the treatment of exercise-
exercise, muscle groups involved, and other factors induced muscle damage.36 In this study, cryotherapy
such as gender, age, previous conditioning levels, and was not found to be more effective than brief intense
overall strength levels of the subjects.24 TENS and placebo TENS in improving relaxed elbow
extension range probably because of single
Eccentric bouts successfully produced the intervention. There is a study by Yackzan et al in 1984;
symptoms of delayed onset muscle soreness in the they found no positive effect as a result of a single
study. One of the possible causes of muscle damage application of cryotherapy36 However within group
may be due to disruption of the Z band. Clarkson and there was an increase in relaxed elbow extension angle
Sayers in1999 in their study stated that during the after the application of ice and brief intense TENS to
eccentric muscle contractions there are fewer motor the biceps muscle. The increase in elbow extension
units, thus fewer muscle fibers, activated. This may range following treatment with cold suggests
lead to an increase in tension taken through the cross interruption of a pain-spasm cycle as proposed by de
bridges of the muscle fiber resulting in disruption of Varies in 1966. Pain originating in the sensory motor
the Z band causing Z streaming.19 chain leads to reflex muscular spasm. The elimination
It is difficult to assess and quantify pain and the of pain has been associated with muscular relaxation.
analgesic response to therapeutic intervention. In within group analysis, TENS was found to be
However, the descriptive data and significant effective in treating the symptoms of DOMS
differences between the cryotherapy group and significantly, concurring with earlier work by Craig R
placebo TENS indicate that the treatment had real Denegar et al in1992 suggested that cold, TENS and
analgesic effects. Interestingly, sham TENS resulted in combined treatment were effective in treating the pain
decrease in perceived pain suggesting a small placebo and muscle spasm associated with DOMS, and that
response to TENS.24 decreased pain may not be an accurate indicator of
the recovery of muscle strength.24
In this study, the improvement in VAS score was
found to be statistically significant in cryotherapy CONCLUSION
group as compared to placebo TENS. However, the
cryotherapy group could not show its supremacy on Conclusion can be made that cryotherapy is more
brief intense TENS group in reducing the pain (VAS). effective than placebo TENS in improving perceived
There are many studies favoring the effect of pain after eccentric training but fails to show its
cryotherapy on DOMS. Jane Kennet et al in 2007 superiority in improving relaxed elbow extension

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 5

angle, thus partially proves the alternate hypothesis. 9. Abraham, W.M. (1977). Factors in delayed muscle
However it could not prove that cryotherapy is more soreness. Medicine and Science in Sports, 9(1),
effective than brief intense TENS in improving 11-20.
perceived pain and relaxed elbow extension angle, 10. Jeffrey C David O Draper, Earlene Durrant, (1998)
therefore, rejecting the experimental hypothesis Pulsed ultrasound fails to diminish Delayed-
onset muscle soreness symptoms; Journal of
Athletic Training 33(4): 341-346
ACKNOWLEDGEMENT 11. Ciccone D.C, Leggin B.G, Callmaro J.J (1991);
I am grateful to Dr. Fuzail Ahmed PT for helping Effect of ultrasound and trolamine salicylate
phonophoresis on delayed onset muscle soreness.
me out in the statistical analysis of my data. Also, I
Physical Therapy 71(9), 39-51.
would like to thank my parents for their unconditional
12. Denegar, C.R. & Perrin, D.H. (1992). Effect of
support. Lastly, I am highly grateful to all the subjects transcutaneous electrical nerve stimulation, cold,
for their co-operation. and a combination treatment on pain, decreased
range of motion, and strength loss associated with
REFERENCES delayed onset muscle soreness. Journal of Athletic
Training, 27(3), 200-206.
1. Smith LL, (1991). Acute inflammation: the 13. Howartson G, Gaze D, Van Someren K.A (2005).
underlying mechanism in delayed onset muscle The efficiency of ice massage in the treatment of
soreness. Medicine and Science in Sports and exercise muscle damage. Med Sci Sports and
Exercise, 23(5), 543-551. Exercise 15(6), 416-422.
2. Armstrong, R.B. (1984). Mechanisms of exercise- 13. 14.Clarkson, PM & Sayers, S. (1999). Etiology of
induced delayed onset muscular soreness: a brief exercise-induced muscle damage. Canadian J
review. Medicine and Science in Sports and Appl Physiology, 24: 512-520
Exercise, 16(6), 529-538. 15. Jane Kennet, Natalic Hardaker, Sarah Hobbs
3. Bobbert, M.F., Hollander A.P. & Huijing P.A. (2007) cooling efficiency of 4 common cry therapy
(1986). Factors in delayed onset muscular agents. Journal of Athletic Training 42(3) 343-348
soreness of man. Medicine and Science in Sports 16. Isabell, W.K., Durrant E., Myrer, W. & Anderson,
and Exercise, 18(1), 75-81. S. (1992). The effects of ice massage, ice massage
4. Clarkson, P.M., Nosaka, K. & Braun, B. (1992). with exercise, and exercise on prevention and
Muscle function after exercise-induced muscle treatment of delayed onset muscle soreness.
damage and rapid adaptation. Medicine and Journal of Athletic Training, 27(3), 208-217.
Science in Sports and Exercise, 24(5), 512-520. 17. De Vries HA.(1966) Quantitative
5. Clarkson, P.M. & Hubal M.J. (2002). Exercise- electromyographic investigation of the spasm
induced muscle damage in humans. American theory of muscle pain.American Journal of
Journal of Physical Medicine and Rehabilitation, Physical Medicine; 45(3):119–34.
81(11), S52-S69. 18. Mattacola, C.G., Perrin, D.H., Gansneder, B.M.,
6. Assmussen, E. (1956). Observations on Allen, J.D., Mickey, C.A. (1997). A comparison of
experimental muscle soreness. Acta Rheumatol visual analog and graphic rating scales for
Scandinavica, 1, 109-116. assessing pain following delayed onset muscle
7. DeVries, H.A. (1961). Prevention of muscular soreness. Journal of Sport Rehabilitation, 6:38-46.
stress after exercise. Research Quarterly, 32, 177.
8. Stauber, W.T. (1989). Eccentric action of muscles:
physiology, injury and adaptation. Exercise and
Sport Sciences Reviews, 17, 157-185.

1. aadil --1--5.pmd 5 8/1/2013, 8:31 AM

 DOI Number: 10.5958/j.0973-5674.7.3.055
6 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

The effect of Topical Application of Extra Virgin Olive Oil

on Alleviating Knee Pain in Patients with Knee
Osteoarthritis: A Pilot Study

Abdul-Majeed Al Malty1, Saja Hamed1, Hashem AbuTariah1, Mohammad Jebril1

1
Assistant Professor, Physical and Occupational Therapy Department, Faculty of Allied Health Sciences,
Hashemite University

ABSTRACT
Objective: To investigate and compare the effect of topical application of extra virgin olive oil (EVOO)
on the pain of osteoarthritic knee (s) with the effect of non-steroidal anti-inflammatory drugs.
Participants: A convenient sample of thirty patients with knee(s) osteoarthritis (16 females and 14
males) were randomly assigned to three groups; Group A (n=10) treated with topical application of
EVOO and exercise, group B (n=10) received topical non-steroidal anti-inflammatory drugs
(Ketoprofen gel) over the knee(s) and exercise, and group C received therapeutic exercise only.
Method: Treatment was carried out in physical therapy outpatient clinic for 5 days a week for two
weeks. Group A received topical EVOO (3ml) and group B received topical ketoprofen gel (3 cm2)
three times a day followed by therapeutic exercise. Group C received therapeutic exercise only three
times a day. Pain visual analog scale (VAS) and Western Ontario and McMaster (WOMC) universities
index measurement were taken at baseline and after two weeks of treatment.
Results: All groups showed significant improvement (p<0.001) in VAS and WOMC index after two
weeks of treatment compared to the baseline. Group comparison showed no significant difference in
both scales between groups A and B (p>0.05), however, both groups significantly experienced less
pain than group C (p<0.001).
Conclusion: Topical application of EVOO showed to be effective in alleviating the symptoms of
patients diagnosed with knee osteoarthritis compared to topical application of NSAID.
Keywords: Physical Therapy, Osteoarthritis, Olive Oil, Knee Pain, NSAID, ketoprofen

INTRODUCTION year of 2050 compared to 2003.3 Longevity and course

of the disease makes OA a major burden on
Osteoarthritis (OA) is the most common
individuals, society, and heath care system resources.4
degenerative joint disease that affects musculoskeletal
system among rheumatic diseases.1 In United States, The knee joint has the highest incidence (40%) of
Approximately 27 million people were affected by OA developing OA compared to the other joinds.5 The
2
and it’s prevalence will increase by 1.6 fold in the primary signs and symptoms associated with knee
osteoarthritis include pain, stiffness and swelling. As
Corresponding author: knee osteoarthritis progresses, symptoms generally
Abdul-Majeed Almalty become more severe and pain may become continuous
Assistant Professor rather than only during weight-bearing activities.5
Physical and Occupational Therapy Department
Hashemite University The treatment of knee osteoarthritis targets the
P.O. Box 330018 symptoms of the disease and slowing down the disease
Zarqa, 13133, Jordan progression. 5 The pharmacological interventions
Tel :(+962) (5) 3903333, Ext. 5411
include topical or oral analgesics, non-steroidal anti-
E-mail: [email protected]

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 7

inflammatory drugs (NSAIDs) and intra-articular being a NSAID-like drug.12 The NSAIDs are the most
injection (e.g. corticosteroids and hyaluronan).6 The use common medications used in treating osteoarthritis.1
of non-pharmacological interventions may be Long-term oral administration of NSAIDs can cause
concurrent with pharmacological intervention and adverse effects.13 Therefore, topical NSAIDs such as
include; patient education, life style modification, Ibuprofen, Ketoprofen and Diclofenac Sodium have
physical therapy, or traditional (folks) medicine.6-8 been used to minimize these adverse effects.14 The use
Physical therapy modalities relief symptoms, but of topical Ketoprofen has shown superiority in
sometime do not satisfy the patient’s needs. About 60– relieving symptoms of musculoskeletal problems
90% of people with rheumatic diseases more likely to compared to the other topical NSAIDs.14
seek complementary or alternative medicine and 50%
of them used botanical medicine.8 Since it’s believed that (-) oleocanthal compound
in the EVOO possess the same features as NSAID, and
Traditionally and historically, extra virgin olive oil then topical application of EVOO may have the same
(EVOO) in Jordan is widely used as a botanical effects as topical NSAID in relieving the symptoms of
medicine and highly consumed because of its high osteoarthritic knee(s). 14 We hypothesized that topical
nutritional values. Many studies have shown that application of EVOO combined with therapeutic
antioxidant effects of the olive oil contribute to prevent exercise would have the same effect as topical NSAID
a number of chronic diseases such as coronary heart (Ketoprofen) combined with exercise.
disease, 9 cancers 10 and joint arthritis because of its
suppressive effect to the free-radical production of METHOD
reactive oxygen species.11
Thirty patients (16 female, 14 male) diagnosed with
Recently, a new discovery of (-) oleocanthal, a knee(s) OA who met the inclusion and exclusion
compound found in EVOO that has a similar criteria were recruited from different rheumatology
composition as Ibuprofen may have the potential of clinics (Table 1).

Table 1: Baseline measurement for all groups.

Group (A)(N=11) Group (B)(N=10) Group (C)(N=9)

Mean SD Mean SD Mean SD p
Age 60.1 6.6 57.9 7.6 54.1 4.9 0.1
Weight 85.4 5.5 83.9 8.3 79.7 8.6 0.2
Height 169.4 5.6 167.7 5.0 166.3 6.2 0.5
BMI 29.8 2.1 30.0 3.8 28.9 3.2 0.7
VAS 69.1 7.0 60.0 13.3 61.0 7.4 0.1
WOMAC Pain 65.9 8.3 67.0 13.0 64.0 7.7 0.8
WOMAC Stiffness 77.3 12.3 63.8 13.8 67.5 14.7 0.1
WOMAC Function 64.8 6.9 60.9 4.1 66.4 10.2 0.2
WOMAC Sum Index 69.3 7.0 63.9 9.0 66.0 10.1 0.4

(A): Olive Oil Group; (B) Ketoprofen Group; (C) Exercise GroupNo significant difference has been found between the groups.

Inclusion criteria Exclusion Criteria

Symptomatic knee(s) for at least six months with 1. History of trauma, surgery, varicose veins,
moderate to severe knee(s) OA according to: paralysis, polyneuropathy, congenital
abnormalities of the lower extremities, chronic
1. Clinical and radiographical criteria of the
back pain and painful hip joint
American College of Rheumatology 15
2. Underwent knee arthroscopy, intra-articular
2. Third or fourth OA grade according to Kellgren-
Hyaluronan or corticosteroids injections during the
Lawrence Grading Scale. 16
past 3 months.

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 8 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

3. Start taking NSAID medication, and/or received Three milliliters of EVOO were topically applied
surgical or intra-articular injection procedures. to the participant’s knee in group A with a calibrated
syringe. Subjects in group B were supplied with two
The study procedures were explained to each
100 gm. pump dispenser of Ketoprofen 2.5% w/w gel.
subject, who then signed the approved informed
Each subject applied 3 cm2 on a knee by pressing the
consent by the Institutional Review Board of the
dispenser two times. The EVOO and the Ketoprofen
Hashemite University. All participants were asked to
gel were spread over the knee joint and followed by
come to the physical therapy clinic for ten days over a
the therapeutic exercise regimen. Subjects in groups A
period of two weeks, five days/week.
and B were taught to follow the same procedure at
Subjects were assigned randomly to one of three home three times a day. Subjects in group C performed
groups; group A received topical EVOO and exercise, the exercise regimen as above with no topical
group B received topical ketoprofen gel and exercise, application over the knee(s) three times a day for two
and the control group C received exercise only. The weeks. The second measurements were obtained at the
study was a single blind — the data collector therapist end of the 2nd week.
was not aware of subjects’ group. A one week washout
period prior to the enrollment in this study was given DATA ANALYSIS
for all subjects who were taking NSAID. Participants
The mean values of VAS and WOMAC index were
were allowed to take or continue taking Paracetamol
calculated and the changes within subjects were
medication when needed.
analyzed using paired t-test. The changes within the
Instrumentation groups were analyzed using one way ANOVA. All data
were analyzed using the Statistical Package for the
1. Pain visual analog scale (VAS). Social Sciences (SPSS, Inc., Chicago,IL) version 16
software.
2. Validated Arabic version of Western Ontario and
McMaster universities (WOMAC).17
RESULTS
PROCEDURES All subjects adherence to the exercises regimen has
been rated between 85-90% for groups A and B, and
Each subject received a booklet of all therapeutic
80-84% for group C. No significant difference was
exercises and full explanation and demonstration of
found between the groups.
each exercise was performed by the therapist. After
explaining the procedures to all participants, baseline Visual Analog Scale.
measurements were taken. No significant differences
were found among the groups in the baseline After two weeks of treatment, the pain had
measurements (Table 1). significantly decreased (p<0.01) for all groups (Table
2) on visual analog scale by 73% (50.9±0.7 mm) for
The exercise program consisted of: 1) Quadriceps group A, 68% (60.0±13.3 mm) and 57% (61.0±7.4 mm)
isometric contraction, 2) knee extension with resistance for groups B and C respectively. The comparison
using sand bag as tolerated, 3) Full flexion and between the groups using one way ANOVA showed
extension range of motion exercise and 4) Dynamic no significant difference between the groups (p=0.09).
stepping exercise by walking up and down on one However, the mean difference of pain scores between
flight stairs or using the training step. Ten repetitions the baseline and week two measurements for group A
of the therapeutic exercises were performed once every was significantly greater (p=0.01) than group C and
time the patient comes to the clinic and twice at home. no significant difference had been noticed between
Subjects were asked to document the exercises group A and B or group B and C (p>0.05).
repetition each day and compliance was graded based
on the number of exercises and repetitions.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 9

Table 2: The mean and standard deviation of all groups of VAS, WOMAC subscales and the total score
of WOMAC Index

Group (A)(N=11) Group (B)(N=10) Group (C)(N=9)

Baseline Post Wk 2 Difference Baseline Post Wk 2 Difference Baseline Post Wk 2 Difference
Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD
VAS 69.1 7.0 18.2* 7.5 50.9‡ 7.0 60.0 13.3 19.0* 12.0 41.0 18.5 61.0 7.4 26.0* 5.2 35.0 5.3
‡ ‡
WOMAC 65.9 8.3 25.0* 6.3 36.4 2.3 67.0 13.0 27.0* 18.9 40.0 14.7 64.0 7.7 41.5* 2.4 22.5 6.8
Pain
WOMAC 77.3 12.3 26.1* 6.7 51.1‡ 13.1 63.8 13.8 21.3* 6.0 42.5‡ 18.8 67.5 14.7 55.0* 14.7 12.5 0.0
Stiffness
WOMAC 64.8 6.9 19.2* 5.4 45.6‡ 9.3 60.9 4.1 21.8* 15.7 39.0‡ 16.9 66.4 10.2 43.8* 4.7 22.6 7.9
Function
WOMAC 69.3 7.0 25.0* 6.6 44.4‡ 6.2 63.9 9.0 23.4* 11.6 40.5‡ 12.9 66.0 10.1 46.8* 5.7 19.2 4.7
Global
Index

The mean and the standard deviation (SD) of the visual analog scale are expressed in millimeter (mm) for analog scale and WOMAC
Index sub- and global scale.*significantly different at (p<0.001) pre and post treatment, ‡ Significantly different at p<0.001 on groups
comparisons with C group. No difference had been foundbetween group A and B.

WOMAC index. quality of their lives.2 Due to the side effects of NSAID,
people with knee OA started looking for other
The mean values of WOMAC subscales (pain, alternatives to treat the symptoms of the disease. The
stiffness, and function) and global scale were selection of EVOO in treating the symptoms of knee
significantly decreased for all groups (p<0.001) after OA was based on the potentiality of EVOO to work as
two weeks of treatment using paired t-test (Table 2). A NSAID.12 The (-) oleocanthal compound in the EVOO
high correlation has been found between the VAS and seems to have the similar effect like NSAID as a
WOMAC pain subscale for the second week (r=0.8) nonselective cyclo-oxygenase inhibitor that suppress
and medium correlation at the baseline (r=0.5). the prostaglandin E2 production and relieve joint
After two weeks of treatment, the groups’ inflammation. 13 In addition, the oleic acid
comparison of all WOMAC subscales and WOMAC (monounsaturated fatty acid) is a compound found in
global scale had shown no significant different olive oil may contribute to alleviate joint inflammation
between A and B groups (p>0.05), however, both in rheumatic disease 11 and increase the skin
groups A and B were significantly different compared permeability 18 that may enhance the absorption of
to group C (p<0.001). Furthermore, the mean other compound such as (-) oleocanthal.
differences of the scores between baseline and after Therapeutic exercises are the most common
the second week for all groups had shown significant procedure used in treating knee OA, and they are more
improvement for groups A and B compared to group effective if combined with NSAID or natural NSAID-
C using one-way ANOVA. like substance. 19 All subjects showed very good
adherence to the exercises regimen proposed in this
DISCUSSION study. Apparently, simplicity of chosen knee exercises
The results of this study revealed that the symptoms enhanced patient compliance in performing these
of pain, stiffness and function were significantly exercises on a daily basis. Furthermore, combining
improved for all three groups. However, the those therapeutic exercises with NSAID motivated the
Ketoprofen gel group showed a non-significant participants to initiate and adhere to these exercises
improvement over the EVOO group and both and to overcome the fear barrier of causing further pain
practically showed significant improvement over the or damage to the knee joint. 20
exercise only group according to outcome measures. Alleviating the suffering of patients diagnosed with
Accordingly, our hypothesis has been met and proved knee OA may positively affect their activity
that the topical application of EVOO has similar effects performance, sense of adequacy and improve their
as topical application of NSAID. quality of life. Introducing olive oil as a natural
Symptoms of knee OA interferes with clients’ treatment to OA symptoms that is accessible, easily
performance of daily life activities and may affect the applicable and affordable, with no known side effects

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 10 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

can be considered as a breakthrough achievement. 3. Fontaine K, Haaz S, Heo M Projected prevalence

Most of the NSAIDs cannot be obtained without of US adults with self-reported doctor-diagnosed
medical prescription; however, EVOO requires no arthritis, 2005 to 2050. Clin Rheumatol. 2007;
medical practitioner to prescribe it. In addition, such 26:772–4.
findings can have a big value in decreasing the costs 4. Centers for Disease Control and Prevention.State
of treating such patients as the current cost of treatment prevalence of self-reported doctor-diagnosed
is high.3 arthritis and arthritis-attributable activity
limitation—United States, 2003. MMWR Morb
We concluded that topical applications of EVOO Mortal Wkly Rep. 2006; 55:477–81.
most likely produces similar effects as topical NSAID 5. Woolf AD, Pfleger B. Burden of major
on alleviating the symptoms of patients with knee(s) musculoskeletal conditions. Bull World Health
OA. Topical application of extra virgin oil in therapy Organ. 2003; 81(9):646-56.
requires further investigation. These encouraging 6. Barron M, Rubin B. Managing osteoarthritic knee
findings open new avenues in treating patients with pain. J Am Osteopath Assoc. 2007; 107:ES21–27.
knee OA and considered as a preliminary step in a long 7. Hsieh J, Dominick K. Use of non-pharmacological
way process of proving the effectiveness of using extra therapies among patients with osteoarthritis.
virgin oil in therapy for other rheumatic diseases. It Aging Clin. 2003; Exp Res 15:419–25.
should be followed up with more extensive studies 8. Rao JK, Mihaliak K, Kroenke K, Bradley J, Tierney
including larger sample sizes or combining different WM, Weinberger M. Use of complementary
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ACKNOWLEDGMENTS 9. Lopez J, Badimon L, Bonanome A et al.
This work was funded by the Hashemite University Monounsaturated fat and cardiovascular risk.
and we would like to thank all physicians and clinics Nutr Rev. 2006; 64:S2–S12.
for their help in referring our participant and we extend 10. Owen RW, Haubner R, Würtele G, Hull E,
our thanks to all patients who participated in the study. Spiegelhalder B, Bartsch H. Olives and olive oil
in cancer prevention. Eur J Cancer Prev.
Conflicts of Interest 2004;13(4):319-26.
11. Darlington L, Stone T. Antioxidants and fatty
We have no real or apparent conflict of interest to acids in the amelioration of rheumatoid arthritis
report. and related disorders. Br J Nutr. 2001; 85:251–69.
Ethical Clearance 12. Beauchamp G, Keast R, Morel D et al.
Photochemistry: ibuprofen-like activity in extra-
This study has been approved by the Research and virgin olive oil. Nature. 2005; 437:45–6.
Ethical Committee of Physical and Occupational 13. Bjordal J, Ljunggren A, Klovning A, Slordal L.
Therapy Department and College of Allied Medical Non-steroidal anti-inflammatory drugs,
Science then by the Institutional Review Board of the including cyclo-oxygenase-2 inhibitors, in
Hashemite University. osteoarthritic knee pain: meta-analysis of
randomized placebo controlled trials. BMJ. 2004;
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Committee of the American Rheumatism
conditions in the United States. Part II. Arthritis
Association. Arthritis Rheum 1986; 29:1039–49.
Rheum. 2008; 58(1):26-35.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 11

16. Kellgren JH, Lawrence JS. Radiological 19. Petersen SG, Beyer N, Hansen M, Holm L,
assessment of osteo-arthrosis. Ann Rheum Dis. Aagaard P, Mackey AL, Kjaer M. Nonsteroidal
1957; 16:494–502. anti-inflammatory drug or glucosamine reduced
17. Guermazi M, Poiraudeau S, Yahia M, et al. pain and improved muscle strength with
Translation, adaptation and validation of the resistance training in a randomized controlled
Western Ontario and McMaster Universities trial of knee osteoarthritis patients. Arch Phys
osteoarthritis index (WOMAC) for an Arab Med Rehabil. 2011 Aug;92(8):1185-93.
population: the Sfax modified WOMAC. 20. Esser S, Bailey A. Effects of exercise and physical
Osteoarthritis Cartilage. 2004; 12(6):459-68. activity on knee osteoarthritis. Curr Pain
18. Dayan N, Batheja P, Michniak, B. Oleic Acid- Headache Rep. 2011 15:423–30.
induced Skin Penetration Effects of a Lamellar
Delivery System. Cosm and toil magz. 2007;
122;73-82.

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 DOI Number: 10.5958/j.0973-5674.7.3.056
12 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

A Study to Compare the effectiveness of Treadmill and

Cycle Ergometer on Endurance in Normal Subjects

Sharma Abhishek1, Shah Arpita2, Dey Sushant3, Sharma Urvi4

1
Lecturer, SPB Physiotherapy College, Surat, Gujarat, India, 2Physiotherapist, haruch, Gujarat, India, 3Lecturer, SPB
Physiotherapy College, Surat, Gujarat, India, 4Physiotherapist, Masoom Hospital, Surat, Gujarat, India

ABSTRACT
Objective: Endurance is the ability to work for prolonged period of time. Individuals of all ages can
improve their general fitness & Endurance by participating in activities that include walking, biking,
cycling, running, swimming, stair climbing, and weight training etc2. In rehabilitation centers we
come across several patients for improvement of their general fitness & endurance. We used to give
them training on Treadmill & Cycle Ergometer. The aim of the study was to compare the effectiveness
of treadmill with cycle ergometer on endurance in normal subjects.
Material and Method: Total 20 subjects divided in group A & group B (10 subjects in each group)
Training using treadmill and cycle ergometer respectively was for continuous 30 days with progression
regularly. 12 minute walk test walk distance was used to measure the endurance after training.
Results: There is no significant difference in effectiveness of treadmill & cycle ergometer on endurance
in normal subjects. The value of tc obtained for walk distance for treadmill & cycle trainee
is 0.1998 0.2
Conclusion: The study concluded that Bicycle Ergo meter is appropriate alternative to Treadmill for
training in healthy volunteers. Training programme should be individualized.
Keywords: Endurance, Treadmill, Cycle Ergometer

INTRODUCTION systems are as Phosphagen or ATP – PC system;

Anaerobic or Glycolytic system and Aerobic system.
Endurance is the ability to work for prolonged
Increase in energy requirements during exercise
period of time & the ability to resist fatigue. It includes
requires circulatory adjustments to meet the increased
cardiovascular endurance and muscular endurance9.
need for O2 and nutrients, to remove end products of
Cardiovascular endurance refers to ability to perform
metabolism, such as lactic acid,CO2 and to dissipate
large muscle, dynamic exercise such as walking,
excess of heat3,9. The shift in metabolism occurs due to
swimming or biking for prolonged period of time 2.
co-coordinated activity of all systems of body.
Muscular endurance refers to ability of an isolated
muscle or muscle group to perform repeated The exercise testing is the part of assessment & a
contractions over a period of time. measure for improvement to see the effect of
cardiopulmonary study on subjects 16.The exercise test
Energy systems provide energy to work. They
may be used for diagnostic, prognostic & therapeutic
depend upon intensity and duration of activity. Energy
applications especially in regard to exercise
prescription. Concept of Maximal versus sub maximal
Corresponding author:
exercise test depends largely on reasons for the test,
Abhishek Sharma
Lecturer type of subject to be tested and availability of
SPB Physiotherapy College, Near Bhesan Jakatnaka, appropriate equipment & personal6. Field tests are 12
Ugat Bhesan road Surat, 395005. minute walk test and 6 minute walk test7. Sub maximal
M: 09879828368 exercise test are Cycle Ergo meter Test, Treadmill Test
E-mail: [email protected] and Step test.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 13

MATERIALS AND METHOD PROGRESSION

Research Design was comparative study with For both groups frequency & intensity are same but
Simple Random Sampling Method.Study was duration is increased from 10 to 15 minutes with 5
conducted on college students with age group between minute of warm up and 5 minute of cool down
20-25 years and mean BMI is 20-29. Subjects with age period.After training for further 15 days, all 20 subjects
group below 20 and above 25 years, subjects with were tested on 12 minute walk test & walk distances
history of cardiovascular or pulmonary disease, are collected15. At the end of 30 days of training, walk
anemia, recent musculoskeletal injury, low back ache, distances were recorded 3 times includes; before
intervertebral or facet joint pathology, metabolic training , 15 days after training and 30 days after
disorder and smoking habit were excluded from the training
study.A total of 20 subjects including 10 male and 10
female volunteered to participate in study who were DATA ANALYSIS
divided in group A and group B (10 subjects in each
group) with training for continuous 30 days. Unpaired t-test comparisons were used to test the
significance of difference (improvement) in pretraining
COLLECTION OF DATA walk distances & after 30 days training walk distances
between subjects trained with treadmill & cycle
Before starting study, subjects were informed about ergometer. Critical alpha value of 0.05 is used.
the purpose, aim & design of study. Age, Height and
Weight of all subjects were taken before study. Before RESULTS
commencement of training on treadmill or cycle ergo
Table 1: Mean of walk distance (km) in 12 min.
meter, all 20 subjects were tested on 12 minute walk walk test
test. 12 minute walk test was conducted on cemented,
even surface at College of Physiotherapy, Anand. Test Sr.No. Training of Walk distance Group A Group B
was performed in morning or in afternoon with 2 hours 1 Pre training 12.46 km 12 km
gap before & after lunch. Subjects were asked to cover 2 after 15 days 13.24 km 12.73 km
maximum distance as comfortably as they can. 30 3 after 30 days 13.62 km 13.08 km
meter area was measured with measure tape & marked
The value of t c obtained for walk distance for
with chalk stick at starting point & at end point. Subject
treadmill & cycle trainee is 0.1998 @ 0.2 & value of
touching end point & coming back to starting point is
tt = 2.11
considered as he/she has covered 60 meter (1 turn).
During 12 minute, every turn covered by subjects were So there is no significant difference (improvement)
counted. Then at the end, the turns wore converted in walk distances of subjects trained on treadmill &
into distance into kilometer. (1 turn = 60 meter). After cycle ergometer.
completing 12 minute walk test distance covered was
measured which is the outcome measure for endurance DISCUSSION
after training.
From the results it is clear that, there is no significant
TRAINING PROGRAM difference in effectiveness of treadmill & cycle
ergometer on endurance. From the study, it was
Total 10 subjects from Group A were randomly noticed that subjects with low endurance showed
selected with training on treadmill for 4 days /week better improvement than the subjects with high
with speed of 6-7 km/hour and total duration of 10 endurance, because the subjects with high endurance
minutes daily including 5 minutes of warm up and 5 need more vigorous & high intensity exercise program
minutes of cool down period. Total 10 subjects from for training as their aerobic threshold is high 10 .
Group B were randomly selected with training on cycle Comparing the results between boys trained on
for 4 days /week with speed of 30-35 km/hour. and treadmill & cycle ergo meter shows that there is slight
total duration of 10 minutes daily including 5 minutes better improvement in walk distance in subjects
of warm up and 5 minutes of cool down period6,10.After trained on treadmill 12. Comparison between girls
15 days of training on treadmill & cycle ergo meter, all shows the end results are same & have no significant
20 subjects were again tested on 12 minute walk test difference13, 14.
& new data of walk distances were collected.

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 14 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

CONCLUSION 6. ATS Statement. Guidelines for Cardio respiratory

endurance American Journal of Respiratory and
The study concluded that Bicycle Ergo meter is critical care medicine. January 15, 2003; 167 2:
appropriate alternative to Treadmill for training in 211-277.
healthy volunteers10, 11. As the maximum heart rate 7. ATS Statement. Guidelines for the Six-Minute
remains same on treadmill & bicycle ergo meter. But Walk Test American Journal of Respiratory and
individual maximum heart rate is different. So, for critical care medicine July 1, 2002; 166 1: 111-117.
every person/subject the aerobic exercise program 8. Niels B. J. Vollaard, Dimitru Constantin-Teodosiu,
must be individualized. Katarina Fredriksson Systematic analysis of
adaptations in aerobic capacity and submaximal
energy metabolism provides a unique insight into
ACKNOWLEDGEMENTS
determinants of human aerobic performance.
We are sincerely grateful to the god who showered Journal of Applied Physiology May 2009 ;106 5
his blessings and his helping hand for our research. :1479-1480.
From the bottom of our heart we are thankful to our 9. McArdle WD, Katch FI and Katch VL. (2000)
Essentials of Exercise Physiology: 2nd Edition
principal Dr. C. G. Padole for his guidance & support
Philadelphia, PA: Lippincott Williams & Wilkins.
& encouragement during my study. We are happy to
10. Higginbotham MB, Morris KG, Williams RS,
place on record sincere gratitude to guide Dr. McHale PA, Coleman RE, Cobb FR. Regulation
Manojkumar for his valuable guidance, supervision of stroke volume during submaximal and
& constructive suggestions. We are glad to express our maximal upright exercise in normal man.
sincere thanks to Dr. Manan Bhatt for his help during Circulation. 1986 Feb; 58 2:281-91.
study. The knowledge he shared with us and his 11. Hermansen L, Ekblom B, Saltin B. Cardiac output
encouragement helped us a lot. We would like to during submaximal and maximal treadmill and
mention special thanks to my entire faculty who were bicycle exercise. Journal for Applied Physiology.
always a standing rock for our great work. We are 1970 Jul; 29 1:82-6.
privilege to thank our patients without whom this 12. Clausen JP. Effects of physical training on
research was not been possible. cardiovascular adjustments to exercise in man.
Physiological Reviews. 1977; 57:779-816
Conflict of Interest: None 13. Kelley GA, Kelley KS, Tran ZV. Aerobic exercise
and lipids and lipoproteins in women: a meta-
REFERENCES analysis of randomized controlled trials. 2005
Mar; 14 2:198.
1. Kenneth R. Turley, Jack H. Wilmore. 14. Seamus P. Whelton; Ashley Chin,; Xue Xin et
Cardiovascular responses to treadmill and cycle al.Effect of Aerobic Exercise on Blood Pressure.
Ergometer exercise in children and adults. Journal A Meta-Analysis of Randomized, Controlled
of Applied Physiology September 1, 1997; 83 3: Trials.Annals of Internal Medicine. April 2, 2002;
948-957. 136 7: 493-50.
2. Paul D. Thompson, MD; David Buchner, MD; 15. De Greef MH, Sprenger SR, Elzenga CT.
Ileana L. Piña, MD; Exercise and Physical Activity Reliability and validity of a twelve-minute
in the Prevention and Treatment of walking test for coronary heart disease
Atherosclerotic Cardiovascular Disease. patients.Perceptual and Motor Skills.2005
Circulation. 2003; 107: 3109-3116. Apr;100(2):567-75.
3. Carolyn kisner, Lynn Allen Colby. Therapeutic 16. Gerald F. Fletcher, Gary J. Balady, Ezra A.
Exercise-Foundations &techniques. Amsterdam. AHA Scientific Statement Exercise
4. Susan B. O’ Sullivan, Thomas J. Schmits.Physical Standards for Testing and Training. Circulation.
Rehabilitation-assessment & Treatment. 2001; 104: 1694-1740.
5. BK Mahajan.Methods in Biostatistics.Jaypee; 6th
Edition.

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 DOI Number: 10.5958/j.0973-5674.7.3.057
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 15

Effect of Aerobic Exercises on Serum IgE and Pulmonary

Functions in Children with Bronchial Asthma

Aisha A Hagag1, Naglaa A Zaky2

1
Department of Physical Therapy for Cardiovascular/Respiratory Disorders and Geriatrics, Faculty of Physical
Therapy, Cairo University, Egypt, 2Department of Physical Therapy for Growth and Development Disorders in
Children and its Surgery, Faculty of Physical Therapy, Cairo University, Egypt

ABSTRACT
Purpose: The aims of present study was to evaluate the effect of aerobic exercise training on serum
IgE and pulmonary functions in asthma children before and after exercise program.
Subjects: 60 children with asthma participated in this study and divided randomly to exercise and
control groups.
Procedure: Fasting serum IgE and some markers indicative of respiratory functions (FEV1, FVC, and
FEV1/FVC) were measured before and after the study in both groups. Statistical analysis was
performed with the SPSS software version 15.0 using an independent paired t-test.
Results: Compared to pre-training, serum IgE decreased significantly and pulmonary function
markers increased significantly (≥0.05) after exercise program. All variables remained without change
in control group (≥0.05).
Conclusion: Aerobic exercise program was associated with a significant decrease in serum level of
IgE and improvement of pulmonary functions in asthmatic children.
Keywords: Immunoglobulin E(IgE), pulmonary functions, Asthma, Aerobic exercise

INTRODUCTION tendency to produce excessive amounts of IgE

antibodies when exposed to allergens.7
Asthma, a leading cause of chronic illness in
childhood, can have a considerable impact on the daily World Health Organization defines asthma as a
life of children 1, 2. Apart from the lower exercise chronic inflammatory disease of the respiratory
capacity and symptoms such as shortness of breath, pathways and some cells, especially mastocytes;
cough and wheeze, these children are also affected by eosinophil and T lymphocytes play an important role
physical, social, educational and emotional in the spread of it 8. IgE is produced by B cells in
impairments3. It has been reported that asthmatic response to allergens and has a short half-life 9. Recent
children have significantly poorer health-related evidence suggests that asthma has an allergic source
quality of life (QoL) than other children4. 10,11
and IgE has a key role in the initiation of both
allergic and non-allergic asthma 12,13, although its role
Chronic inflammation of the respiratory pathways
in the pathogenesis of asthma is not yet fully identified.
in patients with asthma is often associated with high
levels of immunoglobulin E (IgE) and bronchial Immunoglobulins are a heterogeneous group of
eosinophils.5, 6 proteins of the im-mune system. All immunoglobulins
are composed of four polypep-tide chains: two light
Asthma is defined as a chronic disease of the entire
(L) and two heavy (H), joined by disulfide bonds in
lung and asthma attacks may either be immediate
macromolecular compound. Based on structural
delayed or dual in onset. There is a strong association
differences in constants heavy chains,
between exposure of allergens and development of
im-munoglobulins have been divided into five classes
asthmatic symptoms. The single most important risk
(isotypes): IgG, IgA, IgM, IgD, and IgE14.
factor for development of asthma is atopy. Atopy is a

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 16 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Human studies over have shown a close association and on markers indicative of respiratory functions
between asthma the excessive response of respiratory including the forced expiratory volume in 1st
routes and levels of IgE serum 15. Scientific studies also second(FEV1), forced vital capacity(FVC) and the ratio
indicate increased IgE in asthmatic patients 7. Some of FEV1/FVC before or after exercise training in
studies also suggest that patients with atopic and asthmatic children.
asthma have relatively higher serum IgE levels than
healthy individuals (16,17). These studies point out METHOD
that increased IgE levels are often associated with
bronchus excessive response and reduced FEV1 Subjects
(forced expiratory volume within a second) as a
Sixty male children with moderate degree of
determinant of asthma intensity in these patients 18.
bronchial asthma were recruited from out patient’s
The chronic airway inflammation present in asthma clinic of Pediatric (Abo-Elreesh teaching) hospital, their
is a predominantly helper T-cell type 2 (Th2) response ages ranged from 10-15 years old. They were randomly
characterized by high levels of total and allergen- divided into exercise and control groups. The study
specific IgE, bronchial eosinophilia, CD41 T cell had local research and ethics committee approval and
infiltrate in the airways 5,19. There is considerable all subjects’, parents gave written consent.
evidence that immunologic stimulus leading to
Inclusion and exclusion criteria
degranulation of human mast cells is their activation
when the immunoglobulin E (IgE) molecules on their Inclusion criteria to study for asthma group were
surfaces bind a relevant antigen 20. IgE is produced by as existing asthma for at least 3 years. All subjects had
B cells in response to allergens and has a short half- not participated in regular exercise/diet programs for
life 9 . Human studies over have shown a close the preceding 6 months. Subjects with a history or
association between asthma the excessive response of clinical evidence of type 1 diabetes, orthopedic
respiratory routes and levels of IgE serum 21. Scientific abnormalities, immunosuppression, and other lung
studies also indicate increased IgE in asthmatic patients diseases like pulmonary tuberculosis, lung abscess,
7
. Some recent studies found a high positive association brochiectasis, tropical pulmonary eosinophilia, and
between increased IgE and asthma intensity 22. Also chest wall abnormalities, were excluded.
serum total IgE level is a strong predictor of allergy in
asthmatic children 23. All patients underwent anthropometrical
measurements, a resting spirometry testing and fasting
Several studies have proven that exercise, if blood sampling for measuring serum IgE.
sufficiently intense, leads to a highly stereotyped
immune response in healthy subjects, mediated by The measurements for weight, height and other
interplay of metabolic, endocrine and immunological anthropometrical indexes were taken pre and post-
factors 24. exercise training. Body weight and height were
measured with a standard physician’s scale and a
Published reports recommend regular physical stadiometer, respectively when subjects were in a
activity and participating in sports to be considered in fasting state when the participant had thin clothes on
the management of asthma 25. Evidence-based analysis and was wearing no shoes. Body mass index (BMI)
identifies exercise training as the most effective part was calculated using weight divided by squared
of pulmonary rehabilitation (PR) programs, which height.
comprise multidisciplinary therapy.
Fasting blood samples and spirometry was
In recent years, much research was aimed at performed before and after an aerobic exercise
explaining how the exercise affects the immune program (48 h after last exercise session) in two groups.
system. It is known that stress in-duced by sport Blood sampling were collected in order to measuring
training causes changes in the lymphatic system, but serum IgE and spirometry test was performed
so far it is not sufficiently clear what other changes measuring FEV1, FVC, FEV1/EVC the markers of
occur in the hu-man body. respiratory functions in both groups. Subjects were
asked to refrain from tea, coffee, chocolates and
Aim of the study
caffeinated soft-drinks on the day of recording
The purpose of this study was to evaluate the effects spirometry. Intervention group performed the
of three months aerobic training on serum IgE levels modified exercise test to exclude airway hyper-

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 17

responsiveness and exercise induced bronchospasm RESULTS

and then participated in an exercise training program.
The control group subjects only took part in 1-General Characteristics of both groups
measurements and were asked not to change their
No significant differences between groups in age,
habitual physical activity during the study
weight and height, BMI and duration of asthma.
course.Control and intervention groups did not receive
any nutritional recommendations. Table 1. Base line characteristics of the patients in
exercise and control groups
Modified exercise test
Item Exercise Control p-value
In this study, using a motorized treadmill (n=30) (n=30)
mean±SD mean±SD
(COSMED, Italy) a modified exercise test was carried
Age(years) 10.40±2.2 10.43±2.1 p> 0.05
out by the intervention group to exclude airway hyper-
Height(cm) 140.83±11.7 142.76±11.9 p> 0.05
responsiveness and exercise induced bronchospasm17.
Weight (kg) 50.6±3.4 51.4±4.6 p>0.05
Heart rate was monitored with a Polar heart rate
BMI(Kg/m2) 19.5±3.6 18.7±3.4 p> 0.05
device. The subjects ran continuously for 15 minutes
Duration of asthma 4.42±2.3 4.65±1.88 p> 0.05
on the treadmill (%0 incline) and at a minimum speed
required to achieve 75-85% of predicted maximum BMI=body mass index
heart rate (max HR=220-age [year]). Post exercise FEV1
Table(2): Mean, slandered deviation and significance
was measured 1, 7, and 15 minutes after the exercise of serum IgE and pulmonary function test
and the percentage of changes from baseline were
Parameter Exercise Control P value
calculated. Measurements were considered abnormal,
group group
if FEV1 decreased 10% or more from the baseline value
Serum IGE(IU/ml)
17
. No significant change was observed in subjects of (pre training) 358 ± 46 365 ± 51 NS
the intervention (Post-training) 201±11** 369 ± 45 P< 0.05
FVC(%)
Exercise training protocol pre-training 84.3 ± 6.13 82.6 ± 6.5 NS
Post-training 93.7 ± 7.3** 83 ± 5.6 P <0.05
The intervention group participated in the exercise FEV1(%)
training program which was composed of 12 weeks(3 Pre-training 75.3 ± 5.6 76.1 ± 5.8 NS
Post-training 84.3 ± 7.6** 75.8 ± 4.2 P <0.05
days a week) of continuous treadmill
FEV1/FVC
running(grade=0%), at a minimum speed required to Pre-training 68.3 ± 4.11 69.2 ± 3.11 NS
achieve75-85% of predicted maximum heart rate.The Post-training 75.3 ± 6.8** 68.4 ± 4.6 P <0.05
running time was 15 minutes at the first
**p 0.01 within group between pre- and post-training (paired t -
session,increasing by one minute every 2 sessions up test); #p value between exercise and control group. FEV1, forced
to a maximum of 30 minutes. Once the running time expiratory volume in 1s; FEV1/FVC: forced expiratory volume in
reached 30 minutes, it was maintained till the final 1s/forced vital capacity, FVC: forced vital capacity
session. The speed of running was adjusted according
to target heart rate zone (75-85% HR max). A warm up DISCUSSION
period of 10 minutes was allocated prior to the start of
The aim of this study was to investigate the effects
each exercise session.
of aerobic exercise program on serum IgE levels and
Statistical analysis to determine pulmonary functions response to this
program. These markers are indicative of respiratory
Experimental data are presented as means ± SD and functions before and after exercise training in asthmatic
were analyzed with the SPSS software version 15.0. children.
For the descriptive statistics after having checked the
homogeneity of participants. Baseline characteristics Findings of this study support the positive effects
were compared by using independent t-tests. Student’s of submaximal aerobic exercise on serum IgE and
paired‘t’ test was applied to compare the pre and post pulmonary functions in children with asthma. Twelve
training values. An alpha-error below 5% was weeks of regular submaximal treadmill training is an
considered as statistically significant effective alternative.26

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 18 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

IgE has been proven to be responsible for the release a significant improvement of pulmonary functions in
of various inflammatory mediators in asthma, such as asthmatic children and a decrease in the level of IgE.
histamine, prostaglandins, and leukotriens. These While insignificant changes in pulmonary functions
inflammatory mediators increase airway narrowing were observed in levels of these markers in the control
due to excessive mucus production, airway smooth group.
muscle spasm, and edema of the airway mucosa. 27-28
ACKNOWLEDGMENT
The body’s response to exercise is also associated
with regulation of the production and secretion of The authors would like to express their appreciation
cytokines. Cytokines play an im-portant role in the to all children and their parents who participated in
modulation of changes in the immune system during this study with all content and cooperation.
and after exercise.29
ETHICAL CLEARANCE
Our results may have clinical implications, since a
post exercise decrease in IgE are indicative of the All subjects were informed about the study
existence of temporal immunosuppression. This in procedure and signed consent forms approved by the
accordance with the observation s on decreased local research ethical Committee for the Protection of
immune responses in overtrained athletes.30 Human Subjects, at Faculty of physical therapy, Cairo
University.
The relationship between physical activity and the
suppression of the immune system is not fully Conflict of Interest
understood, but it is known that moderate intensity
exercise can improve immune defenses, while the There is no conflict of interest with any
extreme effort can reduce them by creating an organization, and this research is not funded.
increased risk of upper respiratory tract infection.
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systemic responses for atopy. Clinical & 24. Jeurissen A, Bossuyt X, Ceuppens JL, Hespel P.
Experimental Allergy 33(10): 1374–1379. The effects of physical exercise on the immune
13. Ying S, Humbert M, Meng Q (2001). Local system. Ned Tijdschr Geneeskd 2003;147:1347-51.
expression of epsilon germline gene transcripts 25. Ram FS, Robinson RM, Black PN. Effects of
and RNA for the epsilon heavy chain of IgE in physical training in asthma: a systematic review.
the bronchial mucosa in atopic and nonatopic Br J Sports Med 2000; 34: 162 -167.
asthma. Journal of Allergy and Clinical 26. Ulger Z, Demir E, Tanaç R, Gök_en D, Gülen F,
Immunology 107(4): 686–92. Darcan S, et al. The effect of childhood obesity
14. Czy|ewska-BuczyDska A., Lewandowicz- on respiratory function tests and airway
UszyDska A., Jankowski A. IgA, an essential part hyperresponsiveness. Turk J Pediatr 2006; 48 (1):
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Med. Dosw. 2007;61:38-47. 27. Gerrard JW. The biological importance of
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Zeldin DC (2009). Total IgE levels and asthma 28. Lebowitz MD, Barbee R, and Burrows B. Family
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Survey 2005-2006. Journal of Allergy and Clinical 29. Suzuki K., Nakaji S., Yamada M., Totsuka M., Sato
Immunology 124(3): 447-53. K., Sugawara K. Systemic inflammatory response
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J, Hamilton RG, Neas L (2010). Increased plasma Immunol. Rev. 2002;8:6-48
reactive oxidant levels and their relationship to 30. Field CJ,Gougeon R,Marliss E B. Circulating
blood cells, total IgE, and allergen-specific IgE mononuclear cell numbers and function during
levels in asthmatic children. Journal of Asthma intense exercise and recovery.J Appl Physiol
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Hewitt CJ, and Holdaway MD (1991). Relation Fernandes ALG. Short term effects of aerobic
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 DOI Number: 10.5958/j.0973-5674.7.3.058
20 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Efficacy of Scapular Movement with Mobilization in

Patients with Shoulder Impingement

Ajit Dabholkar1, Tejashree Dabholkar2, Sujata Yardi3

1
Associate Professor, 2Assistant Professor, 3Professor and Director, Pad. Dr. D. Y. Patil University,
Nerul, NaviMumbai

ABSTRACT
Background & Purpose of the study: Scapular kinematic alterations have been demonstrated in
subjects with impingement syndrome. These scapula movement alterations are believed to decrease
the subacromial space by failing to move the acromion away from the humeral head during arm
elevation resulting in increased compressive loads on the tendons of rotator cuff or long head of the
biceps muscle. Mulligan's movement with mobilization (M.W.M) hypothesize that positional
malalignment can be corrected with appropriate gliding. Thus this research investigates the efficacy
of scapular movement with mobilization in patients with shoulder impingement.
Aim: Efficacy of scapular movement with mobilization in patients with shoulder impingement
Objective: Assess immediate effect of scapular movement with mobilization in shoulder impingement
Research design: Exploratory study
Methodology: Scapula M.W.M was given to the patient, 10 repetitions thrice were repeated.
Outcome measures: Visual analogue scale was used to assess pain, Range of Motion in Scaption
plane was assessed by using Goniometer, Supraspinatus strength assessment was assessed in Scaption
plane, Shoulder pain and disability index (SPADI) was assessed
Data collection and analysis: Baseline data recorded for the outcome measures and post intervention
data was statistically analyzed for the level of significance. Paired t-test was done for the same.
Results: Significant differences were observed with respect to various outcome measures studied.
Visual analogue scale Mean difference is 2.880,Standard deviation difference is 1.447,95% confidence
interval difference is 2.283 to 3.477,(p<0.0001).Range of motion Mean difference is 21.28,Standard
deviation difference 11.150,95% confidence interval difference is 25.886 to 16.682, (p<0.0001).
Supraspinatus strength Mean difference is 4.40kgs, Standard deviation difference is 1.528, 95%
confidence interval difference is 5.031 to 3.769 (p<0.0001) and Shoulder pain and disability index
score (SPADI) Mean difference is 22.375, Standard deviation difference is 7.840,95% confidence interval
difference is 19.139 to 25.611,(p<0.0001).
Conclusion: Scapular movement with mobilization proved to be effective in patients with shoulder
impingement
Keywords: Impingement Shoulder, Scapular Alteration, Movement with Mobilization

INTRODUCTION sub-acromial bursae, or long head of the biceps tendon

beneath the anterior undersurface of the acromion,
Shoulder “impingement” was described by Neer
coracoacromial ligament, or undersurface of the
in 19721. Shoulder impingement is one of the most
acromioclavicular joint dur-ing elevation of the arm.
common conditions that affect the shoulder and
Another possible mechanism of impingement can be
accounts for 44–65% of all cases of shoulder pain2.
attributed to intrinsic breakdown of the rotator cuff
Impingement usually refers to compression and
tendons as a result of tension overload3.
mechanical abrasion of the rotator cuff tendons,

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 21

Serratus anterior and lower trapezius are the most METHODOLOGY

susceptible to the effects of inhibition and are most
Institutional ethics committee approval was taken
frequently involved in early phases of shoulder
to start the study.
pathology4
Written consent was taken from all the subjects who
The scapula serves many roles in order for proper participated in the study.
shoulder function to occur (W. Ben Kibler, Br J Sport
Med 2010).Scapular kinematic alterations have been 30 subjects were selected according to the inclusion
demonstrated in subjects with impingement criteria as mentioned above.
syndrome5. Outcome measures: Visual analogue scale was
used to assess pain, Range of Motion in Scaption plane
MRI study by Solem – Bertoft et al revealed that
was assessed by using Goniometer, Supraspinatus
anterior opening of the subacromial space narrowed
strength assessment was assessed in scaption plane,
as the shoulder moved from a retracted to a protracted
Shoulder pain and disability index (SPADI) was
position6
assessed.
Mulligan’s movement with mobilization (M.W.M) Procedure for scapular movement with
hypothesize that positional malalignment can be mobilization as shown in Fig 2 & 3(Innovative
corrected with appropriate gliding. Thus this research method):
investigates the efficacy of an innovative method i.e.
Scapular movement with mobilization in patients with The patient was made to sit on a stool. The therapist
shoulder impingement. stands behind the patient on the affected side. The
therapist’s left hand holds the scapula in a way that
the fingers are on the medial border of the scapula,
MATERIAL AND METHODOLOGY
web space on inferior border and the thumb on the
lateral border of the scapula. The right hand is on the
superior part of the clavicle. The right hand thumb is
on the spine of the scapula and the fingers anterior to
the clavicle. The patient is told to do the offending
movement in the scaption plane with the thumb
facing up. The therapist’s moves/assists the scapula
in upward rotation (left hand) and posterior tilting the
scapula (right hand) as the patients goes into the end
range of motion actively elevating the shoulder.
Scapula M.W.M was given to the patients, 10
repetitions thrice were repeated (48 hour follow up was
studied)

Fig. 1

Materials: Goniometer, Push-Pull Dynamometer

(Baseline), Visual Analogue scale Pen ,Paper

Study Design: Exploratory, one group pre-test and

post-test study

Inclusion Criteria: Patients with impingement of

shoulder, Hawkin’s Kennedy and Neer’s test was
positive. Scapula repositioning/Scapula retraction test
positive

Exclusion Criteria: Rotator cuff tear, frozen

shoulder, Shoulder instability Fig. 2

5. Ajit Dabolkar--20--24.pmd 21 8/1/2013, 8:31 AM

 22 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

upward rotation and posterior tilt (Lin JJ et al, J

.Electromyography Kinesiology2005,Sports Ex. Med
2008)

Studies have demonstrated that sub-jects with

shoulder impingement may present with decreased
scapular upward rotation and posterior tilt, and
increased scapular internal rotation during arm
elevation. 17, 18 . Nociceptive input may influence
peripheral and central motor control (Pain 2001).
Studies demonstrated difference in EMG activity in
particular upper and lower trapezius between people
with SIS and healthy controls (BMC Musculoskeletal
Disorders 2010)

Correctional mobilisation (a repositioning) is

sustained, pain free function is restored and several
repetitions will begin to bring lasting improvements
(Mulligan)

Inman, Saunders and Abbott 19 stated that

Fig. 3 coor-dinated activity in scapular muscles for smooth
movement of the scapula during arm motions. They
Data collection and Analysis: Baseline and Post studied raw EMG data from various muscles and
intervention data was recorded for the outcome described trapezius and lower serratus anterior as the
measures and statistically analyzed for the level of prime movers for scapular upward rotation.
significance. Paired t-test was done for the same
Overall, trapezius has been found to be more active
dur-ing abduction as compared to flexion, 20 .
RESULTS AND OBSERVATIONS Consistent with less scapular internal rotation present
Outcome Mean Mean Std Std P Value in scapular plane abduction as compared to
pre post Dev pre Devpost
flexion21, 22
VAS 7.84 4.96 1.18 1.40 <0.0001*
SUPRASPINATUS The middle and lower serratus anterior are aligned
STRENGTH 4.32 8.72 1.70 2.30 <0.0001*
with a substantial mechanical advantage for scapular
SCAPTION ROM 88.19 109.48 17.89 17.71 <0.0001*
upward rotation23, in combination with the ability to
SPADI 78.44 56.06 7.85 10.19 <0.0001*
posteriorly tilt and externally rotate the scapula
*Indicates Extremely significant
The middle and lower serratus anterior are the only
DISCUSSION scapulotho-racic muscles with the capability to both
upwardly rotate and posteriorly tilt the scapula on the
Alterations in scapula positions and motions occur thorax. Their line of action will also directly
in 68% to 100% of patients with shoulder injury (W. approximate the scapula to the thorax, which can serve
Ben Kibler).Visible alterations in scapular position and as a stable base. The functions of serratus anterior make
motion patterns have been termed scapular dyskinesis. its contribution to normal scapular kinematics during
Several investigators 8-14 have studied 3-D (3- arm elevation very significant in reducing risk for
dimensional) shoulder kinematics during arm scapular alterations identified with shoulder
elevation, including how abnormal motion may relate impingement symptoms, including reduced upward
to shoulder impingement. It has been described that rotation or posterior tilting, or in-creased scapular
during elevation of the arm in healthy subjects the internal rotation.
scapula should upwardly rotate and posterior tilt15, 16
Force couples are pre-programmed to interact with
In subjects with impingement less serratus anterior glenohumeral muscle to provide scapular position and
muscle activation and greater upper and lower stability for arm motion (Journal of Biomech1995)
trapezius activation were found with less scapular

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 23

Position and control of the scapula on the thorax CONCLUSION

play a critical role in normal function of the shoul-der.
Scapular movement with mobilization proved to
Stabilization is provided through the scapulothoracic
be effective in patients with shoulder impingement
musculature by approximating or compressing the
scapula to the thorax. Scapular motions on the thorax Clinical Implications: Scapular movement with
align the glenoid fossa with the humeral head mobilization can be used in patients with impingement
maximizing joint congruency and providing a stable shoulder demonstrating abnormal behaviour.
base for humeral motion7. Normal External rotation
of scapula during scaption coordinated action of all Acknowledgement: None
parts of trapezius and serratus anterior. (Muscle and
Funding: Nil
Nerve 2006
Conflict of Interest: None
Correction of asynchronous muscle activity,
improve dynamic stability and thereby decrease pain
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3. Soslowsky LJ, Thomopoulos S, Esmail A,
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5. Ludewig PM, Cook TM. Alterations in shoulder
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As shown in the above Model, Alignment deviation space. Clin Orthop Relat Res. 1993; 99-103
leads to impairment. Therefore, selecting Mulligan’s 7. Kibler WB, McMullen J. Scapular dyskinesis and
M.W.M for correcting the positional malalignment its relation to shoulder pain. J Am Acad Orthop
would give lasting benefits. According to the present Surg. 2003; 11(2):142-51.
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Normal kinematics of the shoulder is believed impingement. J Orthop Sports Phys Ther. 1999;
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Phys Ther. 2000; 80(3):276-91.
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10. Endo K, Ikata T, Katoh S, Takeda Y. Radiographic 17. Warner JJ, Micheli LJ, Arslanian LE, Kennedy J,
assessment of scapular rotational tilt in chronic Kennedy R. Scapulothoracic motion in normal
shoulder impingement syndrome. J Orthop Sci. shoulders and shoulders with glenohumeral
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11. Hebert LJ, Moffet H, McFadyen BJ, Dionne CE. using moire topographic analysis. Clin Orthop
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13. Laudner KG, Myers JB, Pasquale MR, Bradley JP, on the function of the shoulder joint. J Bone Joint
Lephart SM. Scapular dysfunction in throwers Surg. 1944; 26A:1-30.
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Sports Phys Ther. 2006; 36(7):485-94. electromyographic study of the trapezius muscle.
14. McClure PW, Michener LA, Karduna AR. Am J Phys Med. 1952; 31(5):363-72
Shoulder function and 3-dimensional scapular 21. McClure PW, Michener LA, Sennett BJ, Karduna
kinematics in people with and without shoulder AR. Direct 3-dimensional measurement of
impingement syndrome. Phys Ther. 2006; scapular kinematics during dynamic movements
86(8):1075-90. in vivo. J Shoulder Elbow Surg. 2001; 10(3):
15. Ludewig PM, Cook TM, Nawoczenski DA. 269-277.
Three-dimensional scapular orientation and 22. Ludewig PM, Phadke V, Braman JP, Hassett DR,
muscle activity at selected positions of humeral Cieminski CJ, LaPrade RF. Motion of the shoulder
elevation. J Orthop Sports Phys Ther. 1996; complex during multiplanar humeral elevation.
24(2):57-65. J Bone Joint Surg Am. 2009; 91(2):378-89.
16. McClure PW, Michener LA, Sennett BJ, Karduna 23. Dvir Z, Berme N. The shoulder complex in
AR. Direct 3-dimensional measurement of elevation of the arm: A mechanism approach. J
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 DOI Number: 10.5958/j.0973-5674.7.3.059
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 25

Effect of Hip Position and Gender on Active Hip Internal

Rotation and External Rotation on the Dominant Side

Amit Agarwal1, Amrit Kaur2, Ganesh MSP3

1
B.P.T, NDMVP College of Physiotherapy, Nashik, 2Assisstant Professor, NDMVP College of Physiotherapy, Nashik,
3
Associate Professor, NDMVP College Of Physiotherapy , Nashik

ABSTRACT
Objective: This study was designed to establish the influence of gender and hip flexion position on
active range of motion of the hip in external and internal rotation.
Method: 100 (50 Males & 50 Females) healthy college-age subjects with no previous hip problems
were studied. Mean age was 21.8 years with a range of 18-27 years. Hip rotation of the dominant leg
of each subject was measured in the prone (hip near 0" of flexion) and seated (hip near 90" of flexion)
positions using a standard goniometer.
Result: Data were analyzed using t test. Our results indicate Mean values of active hip ROM for
college aged students is 27.85 for internal rotation and 34.61 for external rotation in seated position &
Mean values of active hip ROM for college aged students is 35.35 for internal rotation & 42.57 for
external rotation in prone position.Females had statistically more active hip internal and external
rotation than males.
Conclusion: These findings are clinically significant and stress the importance of documenting
measurement position.
Keywords: Hip, Gender, Joint Motion

INTRODUCTION Normal range of motion values for hip internal

rotation (IR) and external rotation (ER) are reported
In physical therapy practice, the measurement of
as 40" and 50°, respectively.4 The American Academy
joint range of motion is an intrinsic component of the
of Orthopedic Surgeons5 reports normal hip IR and
evaluation and treatment of patients. The objective
ER to be 45" when rotation is measured, both with the
assessment of joint mobility is useful to determine
hip flexed at 90" and with the hip in the anatomical
deficits in flexibility, monitor patient progress, and
neutral position. However, no information is provided
influence alterations of treatment protocol. Properly
regarding the origin of the data in terms of number of
developed normative values for active and passive
subjects measured, the subjects’ gender, or the subjects’
joint range of motion can provide population-specific
age5. Norkin and White’s textbook on the measurement
references to which patients can be compared.
of joint motion is another commonly used source of
Reliability and validity of range of motion
normative values.3 Although Norkin and White use a
measurements using goniometers has been established
variety of sources to tabulate expected hip IR and ER
in previous literature.1,2,3
by both gender and age, no detailed information is
Hip range of motion can be measured in two ways, presented regarding the measurement position or type
in the high sitting position and prone position 3. of range of motion (active or passive) for which these
however there has been a significant difference in the data were obtained.3
ranges obtained in the two positions. Especially
The present study serves to improve the data
varying according to the gender. A general lack of
available for hip active range of motion in rotation by
descriptive details exists for measurements of Hip
establishing the influence of gender and patient
Rotations Range Of Motion.
position on these measurements.

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 26 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

PURPOSE OF STUDY standard stretch & warm up , the third time for the
measurement
The purpose of this study was to determine the
amount of hip active range of motion in IR and ER of The following anatomical landmarks were
male and female college-aged students in two identified for each measurement as described by
positions: prone and seated. These positions were Norkin and White 3. Specifically, the movable arm of
chosen since they are most commonly used to measure the goniometer was centered over the anterior midline
hip rotation in the physical therapy clinic. These of the lower leg, using the tibia1 crest and a point
positions differ in that the hip is in approximately 90" midway between the malleoli as reference points. The
of flexion when seated, while it is near its neutral axis of rotation was centered over the anterior aspect
anatomical position of 0" of flexion in prone. of the patella. The stationaly arm of the metal
goniometer hung in the vertical plane , so that it
Objective of this study determined whether: remained perpendicular to the floor. At the end of hip
rotation, the measurement was made to the nearest
1) Is measurements of active hip IR and ER are
degree.For the measurements, the subject’s pelvis was
influenced by the position (seated vs. prone) and
stabilized in both the prone and seated position as
2) To find the influence of Gender on hip internal and described below.
external rotation. Prone: A subject’s legs and hips were stabilized by
a standard belt positioned over the center of the
METHOD buttocks and around the table. In addition, a subject’s
100 healthy college students with no previous hip hips were stabilized by manual pressure over the
problems (50 males and 50 females) volunteered to dominant leg buttock to prevent the hip from lifting
off the table.
participate in this study. Subjects’ mean age was 21.8
years with a range of 18-27 years. All subjects signed Seated: A subject’s hips were stabilized by a
an informed consent form approved by the NDMVP standard belt draped over the upper thighs and
medical college ethical Committee before secured around the table. In addition, the dominant
participating. leg was then stabilized with loosely applied manual
pressure just proximal to the knee.
Exclusion criteria was- any Hip and knee
pathology, Limb length discrepancy greater than1cm, A soft fixation with the belt and manual pressure
Previous history of fracture around hip or knee, SI joint was provided to prevent compensation
dysfunction, Sciatic nerve tension, Femoral
Antiversion, Valus & Valgus deformity and pregnancy. with hip flexion and abduction while allowing the
thigh to move freely in the rotation direction.
All the subjects selected for study were in
comfortable clothing that permits unrestricted The results for each subject and each position were
movements at hip & free visual access to Anatomical recorded. Data were analyzed by using t test.
landmarks required to make the ROM measurements.
The dominant side has been determined by the leg RESULTS
chosen to kick the soccer ball & will be subsequently No statistically significant difference existed
used for all measurements. Active ROM of Hip in between males and females with regard to their age.
Internal Rotation & External Rotation is measured by The average age of men and women studied was 21.8
using standard goniometer. Each subject were . The subjects’ ages ranged from 18-27.mean age of
measured for active hip Internal Rotation & External females was 21.6 and males was 22.their
Rotation in both seated and prone position.3 The anthropometric measurements were not taken into
subjects were instructed to rotate the hip of his/her consideration. Our results indicate that the mean
dominant leg Internally & Externally using their values of active hip ROM of 27.85 for internal rotation
maximum effort. For each testing position(prone & and 34.61 for external rotation in seated position &
seated) & movement direction (IR & ER) AROM were Mean values of active hip ROM of 35.35 for internal
performed a total of 3 times, twice to provide a rotation & 42.57 for external rotation in prone position.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 27

Table 1. Comparison of Hip IR & ER ROM in high in physiotherapy clinic. This position differ in that hip
sitting and prone positions (MALE) is in approximately 90degree of flexion. When seated
INTERNAL ROTATION while it is near its neutral anatomical position of
MEAN OF DIFFERENCE 8.16 0degree flexion in prone.
SD 4.28
When the data from 100 subjects were pulled
SE 0.605
together we have seen that there is statistically
CAL T 13.48
significant difference. Mean values of active hip ROM
TAB T 2.02
of 27.85 for internal rotation and 34.61 for external
EXTERNAL ROTATION
rotation in seated position & Mean values of active
MEAN OF DIFFERENCE 10.32
hip ROM of 35.35 for internal rotation & 42.57 for
SD 3.644
external rotation in prone position.
SE 0.515
CAL T 20.03 The gender main effect indicates that, on average,
TAB T 2.02 women have greater hip rotation than men (p < 0.05).
Table 2. Comparison of Hip IR & ER ROM in high
This difference is greater for hip IR, with women
sitting and prone positions. (FEMALE) having 1.5" and 0.17" more rotation than men in the
seated and prone positions, respectively. For hip ER,
Internal Rotation
women have only 2.5" & 0.3 more rotation than men
MEAN OF DIFFERENCE 6.84
in both the seated and prone positions. The findings
SD 3.58
of greater hip active range of motion for IR in females
SE 1.76
are consistent with the results of Walker et al6 and
CAL T 3.88
James and Parker7 .Due to the numerous anatomical
TAB T 2.02
structures that may affect the amount of hip rotation,
EXTERNAL ROTATION
providing a detailed explanation of why the amount
MEAN OF DIFFERENCE 7.6
of hip ER is reduced in sitting and the amount of hip
SD 4.03
IR is only minimally affected by the change in position
SE 0.507 may be difficult. With the hip near a neutral anatomical
CAL T 13.33 position (in prone), ER of the hip is accompa- nied by
TAB T 2.02 an anterior glide of the fem- oral head, and rotation
Table 3. COMPARISON BETWEEN GENDERS would be lim- ited by tension in the anterior capsule
and the iliofemoral ligament8. In this same position,
INTERNAL ROTATION
IR of the hip results in a posterior glide of the femoral
SD 3.92
head, and rotation would be limited by tension in the
SE 0.392
posterior capsule and the ischiofemoral liga- ment.
CAL T 3.367
With flexion of the hip, most ligamentous structures
TAB T Approx 1.98
(p value
loosen 8 . In seated position, hip ER is now
for 120=1.98) accompanied by a superior glide of the femoral head,
EXTERNAL ROTATION with the rotational movement being limited by the
SD 3.84 superior capsule and the iliofemoral ligament8. Hip
SE 0.384 IR, performed seated, is accompanied by an inferior
CAL T 7.083 glide of the femoral head and the rotational movement
TAB T Approx 1.98 would be limited by tension in the inferior capsule and
(p value superior ischiofemoral ligament8. The relative tension
for 120= 1.98)
of these capsuleoligamentous structures when moving
from the prone to the seated position is not known.
DISCUSSION
Based on our results, since IR was only minimally
In this study we have seen the amount of hip active affected by the change in measurement posi- tion, the
ROM in Internal rotation & External rotation of males capsuloligamentous structures limiting IR would have
and Females College aged students in two positions a similar relative tension. For ER, the
prone and seated these positions were chosen since capsuloligamentous structures limiting ER would be
they are most commonly used to measure Hip rotation in greater tension in the seated position. In addition to

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 28 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

the passive tension of the capsule, passive tension of ACKNOWLEDGMENTS

the musculature surrounding the hip must also be
The authors would like to acknowledge all the
considered. A 90" change in the hip flexion position
voluntaries for their help with the data collection.
will undoubtedly change the available length of many
of the hip muscles which would passively limit motion Conflict of Interest: In this study BMI is not taken into
in rotation if already placed in a stretched position by consideration. Future studies can be done by taking
the flexed or extended hip. Active insufficiency of the anthropometric measurements into consideration.
hip rotators and the influence of gravity must also be
considered as possible explanations for the change in Source of Funding: Self
active range of motion at the hip between the seated
and prone positions. Moving the hip from a near 90" REFRENCES
flexed position to a near neutral anatomical position
1. Gajdosik RL, Bohannon RW: Clinical
in the sagittal plane changes the length and orientation
measurement of range of motion: Review of
of the muscles which surround the hip. Excessive goniometry emphasizing reliability and validity.
shortening of any number of muscles participating in Phys Ther 67(72):1867- 1872, 1987
hip rotation could result in their decreased ability to 2. Miller PJ: Assessment of joint motion. In:
generate a torque and rotate the hip. The fact that hip Rothstein JM (ed), Measurement in Physical
rotation measured prone is gravity-assisted and hip Therapy, pp 103-135. New York, NY: Churchill
rotation measured seated is performed against gravity Livingstone, 1985
could compound this factor. In this study, efforts were 3. Norkin CC, White Dl: Measurement of Joint
made to control for measurement errors that could be Motion: A Guide to Goniometry (2nd Ed),
associated with unwanted movement of the hip in Philadelphia, PA: F.A. Davis Company, 1985
flexion, abduction, or adduction. Adequate 4. American Medical Association: Guides to the
Evaluation of Permanent lmpairment (3rd Ed),
stabilization of the lower extremity was judged
Milwaukee, WI: American Medical Association,
necessary to improve both the reliability and accuracy
7 990
of the measurements. For this purpose, external 5. American Academy of Orthopedic Surgeons:
stabilization with the use of straps and manual contact Joint Motion: Method of Measuring and
were used. While such stabilization is unlikely to be Recording, Chicago, IL: American Academy of
common practice in the clinical setting (due to time Orthopedic Surgeons, 1965
constraints), clinicians should pay close attention to 6 Walker JM, Sue D, Miles-Elkousy N, Ford G,
possible substitutions which may affect their Trevelyan H: Active mobility of the extremities
measurements. in older subjects. Phys Ther 64(6):9 1 9-923, 1984
7. James B, Parker A W: Active and pas- sive
CONCLUSION mobility of the lower limb joints in elderly men
and women. Am J Phys Med Rehabil68(4): 162-1
This study provides information as to the difference 67, 1989
in hip active 8. Fuss FK, Bacher A: New aspects of the
morphology and function of the human hip joint
range of motion in rotation mea- sured seated vs. ligaments. Am J Anat 192: 1- 13, 1991
prone, the two most common measurement positions
used in the clinic. In general, women had greater total
hip rotation than males, with most of this difference
being attributable to an increase in hip IR.

6. amit agrawal--25--28.pmd 28 8/1/2013, 8:31 AM

 DOI Number: 10.5958/j.0973-5674.7.3.060
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 29

Electrophysiological Assessment of Clinically Diagnosed

Patients of Carpal Tunnel Syndrome in Western
Maharashtra (India)

Joshi A G1, Gargate A R2, Patil S N2

1
Professor, Department of Physiology, 2Associate Professor, Department of Physiology, Krishna Institute of Medical
Sciences Deemed University, Karad, Maharashtra, India

ABSTRACT
Objective: To find out most sensitive electrophysiological indictors of carpal tunnel Syndrome.
Materials and method: 45 normal subjects and 125 clinically diagnosed patients of carpal tunnel
syndrome (CTS) were studied. Sensory and motor conduction of Median nerve was studied bilaterally.
Sensory and motor conduction of Ulnar nerve was studied bilaterally.
Results: Compared to controls, in patients following changes were observed on both the sides:
Distal sensory latencies (DSL) and distal motor latencies (DML) of median nerve were
increased.
Sensory nerve conduction velocity (SNCV) of median nerves was reduced.
Differences between DSL of median and ulnar nerves were increased.
Differences between DML of median and ulnar nerves were increased.
Compound Muscles Action Potentials (CMAP) and Sensory nerve action potentials
(SNAP) were not significantly reduced.
Median nerve conduction abnormalities were also observed in asymptomatic hands.
Conclusion: Difference between DSL of median and ulnar nerves, difference between DML of median
and ulnar nerves and SNCV of median nerve are very sensitive indicators for diagnosis of CTS.
CTS is bilateral disorder.
Keywords: Carpal Tunnel Syndrome, Median Nerve Conduction, Ulnar Nerve Conduction

INTRODUCTION CTS has also been reported to be the commonest

entrapment neuropathy in western countries. In
Carpal tunnel syndrome (CTS) is most common
Rochester, Minnesota, the prevalence of CTS was
entrapment neuropathy in upper extremity. The carpal
estimated at 125 per 100,000 in 1976-80. Earlier hospital
tunnel is bounded by carpal bones and transverse
based studies from India reported CTS rarely. In recent
ligaments which are attached to Scaphoid, trapezoid
study from South India CTS accounted for 7% of
and Hamate bones. The diameter of carpal tunnel is 2
patients with peripheral nerve disorders and 84% of
to 2.5cm and median nerve passes through it along
entrapment neuropathies referred for electro
with nine digital flexor tendons. Some degree of
diagnostic evaluation 3. Early diagnosis of CTS may
compression of median nerve and focal nerve
help to plan the treatment in early stage before
conduction slowing is common at this level which is
structural damage to median nerve occurs. The results
more pronounced 2-3 cm distal to the origin of the
of electro diagnostic studies have been found to be
ligament. Autopsy study has also confirmed focal
highly sensitive and specific 3. In Maharashatra,
abnormality in median nerve in 5 out of 12
especially in Western Maharashtra very little research
asymptomatic subjects.1, 2

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 30 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

work is available on electro diagnosis of CTS. Hence, Following parameters were measured: Motor
objectives for present study were: conduction

I) To find out the electrophysiological parameters Distal motor latency of Median nerve and ulnar
which are more sensitive for early detection of CTS. nerve Motor conduction velocity Amplitude of
compound muscle action potential.
ii) Most of our patients were having unilateral
symptoms. There was possibility that they may get Difference between distal motor latencies of
complaints suggestive of CTS in asymptomatic hand median and ulnar nerves.
later. So another purpose of the study was to find out Sensory conduction: Distal sensory latency of Median
whether there are electrophysiological changes of CTS nerve and ulnar nerve Sensory conduction velocity
in asymptomatic hands also. Amplitude of sensory nerve action potential.

In present study bilateral sensory and motor Difference between distal sensory latencies of
median nerve conduction studies were carried out in median and ulnar nerves.
clinically diagnosed patients of CTS to find out electro
physiologic changes in median nerve conduction. For recording sensory and motor nerve
Comparison of median palm-to-wrist latency with conduction, surface metal electrodes were used. For
ulnar palm-to-wrist latency is more sensitive indicator recording motor conduction of Median nerve,
for diagnosis of CTS 2, 4. So bilateral sensory and motor recording electrode was placed close to the motor point
ulnar nerve conduction studies were also carried out of Abductor Pollicis Brevis and reference electrode 3cm
and compared with that of median nerve. distal to it at first metacarpophalangeal joint. A
supramaximal stimulus was given at wrist and at
elbow near volar crease of brachial pulse.
MATERIALS AND METHOD

Nerve conduction study was conducted on 125 For recording motor conduction of Ulnar nerve,
(250 hands) patients referred to electrophysiology recording electrode was placed close to the motor point
laboratory of Department of Physiology in Krishna of Abductor Digiti Minimi and reference electrode 3cm
Institute of Medical Sciences Karad, Maharashtra distal to it at fifth metacarpophalangeal joint. A
(India) supramaximal stimulus was given at wrist and at
elbow in cubital tunnel behind medial epicondyle. For
Inclusion criteria :Patients having symptoms ulnar nerve stimulation at elbow arm position was
suggestive of CTS i.e.- aching pain in hand and arm maintained at 1350.1
(especially at night), parasthesia in thumb, index finger
and middle finger for more than 4 weeks 5, Phalan’s Care was taken to keep same distance between
test positive, Tinel’s sign positive. stimulating and recording electrodes for both median
and ulnar nerves at wrist so that distal latencies of
Exclusion criteria: Patients having clinical or Median and Ulnar nerves could be compared.1
laboratory diagnosis of radiculopathy, neuropathy,
diabetes, rheumatoid arthritis, trauma, For orthodromic sensory conduction of median
hypothyroidism and pregnancy were excluded from nerve, surface recording electrode was placed 3cm
the study 5 proximal to distal wrist crease and reference electrode
at 3cm proximal to recording electrode. For stimulation
Nerve conduction study was also performed on 45 ring electrodes were fixed on second digit.
age matched controls those were selected from medical
students and faculty members. For orthodromic sensory conduction of ulnar
nerve, recording electrode was placed 3cm proximal
Institutional ethical committee approval was taken to distal palmer crease and reference electrode at 3cm
for the study. Patients and subjects were informed the proximal to recording electrode. For sensory
detailed procedure of nerve conduction study and stimulation ring electrodes were fixed on fifth digit.
written consent was taken. Electro diagnostic study Cathode is placed at first interphalangeal joint and
included motor and sensory nerve conduction of anode at 3cm distal to cathode. For both median and
Median and Ulnar nerves on both sides by ulnar sensory conduction, 20 supramaximal stimuli
conventional method 1. were delivered and average was recorded. During both
median and ulnar sensory conduction recording,

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 31

ground electrode was placed between recording and parameters in patients and controls unpaired‘t’ test
stimulating electrodes. Care was taken to keep same was applied. The difference was considered to be
distance between stimulating and recording electrode highly significant when p value was <0.001 and
for both median and ulnar nerves at wrist. significant when p was < 0.05.

During nerve conduction study, laboratory 95% normality range (Mean ±2 S.D.) was
temperature was maintained between 21o C to 230C. determined for each study parameter from
When skin temperature of limb was below 340C, the observations made on controls. In patients number of
limb was immersed in a warm water to correct the observations for each study parameter lying outside
temperature.1 this normality range were measured and its percentage
was calculated.
For nerve conduction studies, Recorder and
Medicare System (RMS) machine from Chandigarh RESULTS
(India) was used.
125 patients and age matched 45 normal subjects
Statistical Analysis were subjected to bilateral median and ulnar, sensory
To compare difference between various study and motor nerve conduction.

Table 1. Sensory Nerve Conduction Study

Parameter Mean ± SD Control n=45 Mean ± SD Patients n=125 T value P value

Median Rt.SNCV Lt.( m/s) 54.92 ± 4.52 53.61 ± 5.86 39.80 ± 9.63 44.14 ± 9.3 10.0786.310 < 0.0010.000987
Median Rt.DSL Lt. ( ms) 2.38 ± 0.242.45 ± 0.35 3.24 ± 0.77 2.90 ± 0.64 7.1614.275 < 0.001< 0.001
Median Rt.SNAP Lt.( uV) 30.92 ± 8.7927.82 ± 12.82 13.66 ± 10.3919.83 ± 12.82 9.6545.631 0.1965270.043069
Difference Rt.In DSL Lt. 0.12 ± 0.18 0.18 ± 0.23 1.12 ± 0.780.83 ± 0.61 8.4956.873 < 0.001< 0.001

SNCV: Sensory nerve conduction velocity; DSL- Distal sensory latency of median nerve was
Distal sensory latency; SNAP- Sensory nerve action prolonged. It was statically highly significant with p
potential value <0.001.

Compared to control group, in patients following SNCV of median nerve was reduced. Decrease was
changes were observed in sensory conduction on both highly significant with p value < 0.001 on Rt. Sides
the sides (Table No. 1): and p < 0.05 on Lt. side.

Difference between DSL of median and ulnar In 24% of patients sensory response from median
nerves was increased. It was statistically highly nerve was absent.
significant with p value < 0.001.

Table 2. Motor Nerve Conduction Study

Parameter Mean ± SD Control(n=45) Mean ±SD patients (n=125) T value P value

Median Rt.DML Lt.( ms) 2.98 ± 0.335 2.90 ± 0.453 3.92 ± 1.31 3.57 ± 0.90 5.0044.778 < 0.0010.000005
Median Rt.CMAP Lt.(mv) 15.13 ± 3.39 16.40 ± 3.929 10.98 ± 4.82 12.41 ± 4.56 5.3205.222 0.0079580.240942
Difference Rt.in DML Lt. 0.83 + 0.30 0.76 ± 0.30 1.76 ± 1.24 1.45 ± 0.91 4.9364.927 < 0.001< 0.001

MNCV: Motor nerve conduction velocity; DML- nerves was increased. It was statistically highly
Distal motor latency; CMAP- Compound muscle significant on both the sides with p value < 0.001
action potential
DML was prolonged in patients. Increase was
Compared to control group, in patients following highly significant with p value < 0.001.
changes were observed in motor conduction on both
the sides (Table No. 2): Changes in amplitude of CMAP and SNAP were
not statistically significant.
Difference between DML of median and ulnar

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 32 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Table No:3 Percentage of patients with electrophysiological abnormalities

Parameter Right Left

1) No. of Patients having Median DML > Normality range 62 (49.6%) 33 (26.4%)
2) No. of Patients having Median MNCV < Normality range 16 (12.8%) 20 (16%)
3) No. of Patients having Median CMAP amplitude < Normality range 36 (28.8%) 22 (17.6%)
4) No. of Patients having difference in DML of Med.& Uln. > Normality range 66 (52.8%) 46 (36.8)
1) No. of Patients having Median DSL > Normality range 60 (48%) 35 (28%)
2) No. of Patients having Median SNCV < Normality range 64 (51.2%) 38 (30.4%)
3) No. of Patients having Median SNAP amplitude < Normality range 57 (45.6%) 38 (30.4%)
4) No. of Patients having difference in DSL of Med. & Uln. > Normality range 64 (51.2%) 50 (40%)

51.2% of patients were having increased difference across the carpal tunnel (Table No. 2). In severely
between DSL on Rt. side and 40% were having on Lt. affected patients sensory response was absent (24%).
side. 48% of the patients on Rt. side and 28% on Lt. There was significant decrease in SNCV of the patients,
side were having prolonged median nerve DSL. 51.2% on both sides. The previous reports from researchers
of patients were having reduced SNCV on Rt. side and show same results.2, 7
30.4% were having on Lt. side.
Distal sensory latencies and distal motor latencies
52.8% of patients were having increased difference of median nerve across the carpal tunnel were
between DML on Rt. side and 36.8% were having on prolonged significantly on both sides as they were
Lt. side. 62% of patients were having increased DML measured across the carpal tunnel. But this was
on Rt. side and 33% were having on Lt. side. observed in relatively less number of patients as shown
in Table no. 1, 2 & 3. Our finding are consistent with
DISCUSSION previous reports.1,6,11

For diagnosis of CTS electrophysiological studies Compared to controls, amplitudes of CMAP and
are more sensitive than clinical findings.3 SNAP of median nerve in patients were not reduced
significantly.
The electrophysiological diagnosis of CTS is based
on conduction abnormalities across carpal tunnel as To conclude, difference between DSLs of median
median nerve gets compressed in carpal tunnel 1, 3 and ulnar nerves is the most sensitive indicator of CTS.
Difference between DMLs of median and ulnar nerves
Characteristic findings in the electrophysiological is also the most sensitive indicator of CTS. Reduction
diagnosis of CTS were slowing sensory conduction of in SNCV of median nerve is sensitive indicator while
median nerve, decrease in SNAP amplitude, and DSL and DML are less sensitive indicators. Amplitudes
increase in DSL and DML in median nerve 6, 7, 8. As of SNAP and CMAP are not sensitive indicators. In
ulnar nerve does not pass through carpal tunnel and our study 80% patients were having complaints only
passes lateral to tunnel its DML and DSL are expected on Rt. Side. However, electrophysiological findings
to be normal. So difference between DML and DSL of showed bilateral changes. The high prevalence of
median and ulnar nerve may be considered as very abnormal median conduction without corresponding
sensitive indicator of CTS 2, 7, 9. The findings in our study symptoms may suggest presence of sub clinical CTS
also show that the difference between DML and DSL 12, 13
. If corrective measures are taken in time we would
of median and ulnar nerves was highly significant and be able to prevent progression of CTS in asymptomatic
also observed in maximum number of patients as hands.
noted in Table No.4
The present study has limitation that the number
The American Association of Electro diagnostic of patients is small. Larger studies are needed to
Medicine (AAEM) has concluded that median nerve strengthen the interpretations. For the present study
sensory transmission is also more sensitive indicator patients from Western Maharashtra were studied,
for diagnosis of CTS 10. In this study median nerve more patients should be evaluated from other parts of
sensory velocity was reduced as it was measured Maharashtra to generalise the interpretations.

7. Anand Joshi --29--33.pmd 32 8/1/2013, 8:31 AM

 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 33

ACKNOWLEDGMENT 7) Aydyn G., Keles I., Ozbudak Demir S., Baysal A.

Y. Sensitivity of median sensory conduction tests
The authors are thankful to vice chancellor, in digital branches for diagnosis of carpal tunnel
KIMSDU and Principal, KIMSDU, Karad for kindly syndrome. Phys. Med Rehabil 2004; 83: 17-21
providing laboratory and hospital facilities to carry out 8) Padua L., Lo Monaco M., Valente E.M., Tonali P.A.
this work. A useful electrophysiological parameter for
diagnosis of carpal tunnel syndrome. Muscle
REFERENCES Nerve 1996; 19
9) Jackson D.A., Cliford J.C. Electrodiagnosis of mild
1) Mishra U.K., Kalita J. Clinical neurophysiology, carpal tunnel syndrome. Phys.Med. Rehabil 1989;
2nd Ed. Reed Elsevier India Private Limited, 2008; 70: 199-204
32-40. 10) Tokcaer B Ayse, Gogus Feride, Gullap Sumer,
2) Gilliatt R.W. Sensory conduction studies in early Keles Isik, Gokce Mustafa. Role of sensory nerve
recognition of nerve disorders Muscle nerve 1978; conduction study of palmer cutaneous nerve in
1: 35 diagnosis of Carpal tunnel syndrome in patients
3) Murthy J.M.; Meena A.K., Carpal tunnel with polyneuropathy: Neurology India, 2007: 55,
syndrome- Electrodiagnostic aspects of fifty 17-21.
seven symptomatic hands. Neurology India, 11) Recep Aygul, Hizir Ulvi, Dilcan Kotan, Mtlu
1999: 47: 272-275. Kuyucu. Sensitivities of conventional and new
4) Atroshi I., Gummesson C., Johnson R, Ornsteir electrophysiologic techniques in carpal tunnel
E. Diagnostic properties of nerve conduction tests syndrome and their role in body mass index:
in population- based Carpal tunnel syndrome: Journal of Brachial Plexus And Peripheral Nerve
BMC Musculoskeletal Disorders, 2003,4:9 Injury, 2009: 4: 2-12
5) Oxford handbook of clinical medicine, Indian 12) Bagatur Erdem A., Merter Yalcinkaya. Unilateral
edition, 8th edition page:507 carpal tunnel syndrome caused by an occult
6) Thomus J.M., Xuan Kong, Shai N. Gozani. Utility palmer lipoma: ORTHOPEDICS, 2009; 32: 777
of nerve conduction studies for Carpal Tunnel 13) Bingham R.C., Rosecrance J.C., Cook T.M.
Syndrome by Family Medicine, Primary care and Prevalence of median nerve conduction in
Internal Medicine Physicians: The Journal of the applicants of industrial job: Am.J.Ind.Med., 1996
American Board of Family Medicine, 2007: 20: Sep;30(3): 355-61
60-64.

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 DOI Number: 10.5958/j.0973-5674.7.3.061
34 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Effectiveness of Core Muscle Stabilization Training on

Dynamic Balance in Mechanical Low Back Pain Patients

Apeksha O Yadav1, Ketaki G Deshmukh2

1
Asst. Professor, 2Intern. Ravi Nair Physiotherapy College, DMIMS (DU) Sawangi (M) Wardha

ABSTRACT
Objective: To assess & find the effect of core muscle stabilization training on dynamic balance in
mechanical low back pain patients.
Design: Prospective Experimental Study.
Participants and Outcome Measure: 30 Subjects with Mechanical Low Back Pain were selected and
Core Muscle Stability Training was given. Outcome measures were recorded pre & post training
program using STAR Excursion test.
Result: Data was collected & analysed using Student's paired t-test to determine changes in dynamic
balance, whereas correlation was done amongst right & left lower limb in each direction pre & post
training, it showed a significant difference in anterior, anterolateral, lateral, posterolateral, posterior
& anteromedial directions of right lower limb and anterior, anterolateral, lateral, posterolateral,
posterior, posteromedial and anteromedial directions of left lower limb.
Conclusion: Core stabilisation training is significantly effective in improving dynamic balance in
mechanical low back pain patients.
Keywords: Core muscle stabilization training, Dynamic balance, STAR Excursion Test

INTRODUCTION • Active system constitutes muscle and tendon

surrounding & acting on the spinal columns.
Back pain is the most prevalent condition affecting
adults and thus hampering their daily living activities. • Neural system constitutes nerves and CNS which
The incidence of back pain in adults has been estimated directly controls the active system in providing
to be as high as 60%–80% (1). dynamic stability (6).

Spinal instability is defined in terms of region of “Core stability” describes the ability to control the
laxity around the neutral resting position of spinal position and movement of central portion of the body.
segment called the “Neutral Zone” or “Neutral Spine”. It targets muscles deep within the abdomen which
This neutral zone is said to be larger with connect to the spine, pelvis and shoulders, assist in
intersegmental injury and intervertebral disc maintenance of good posture & provide foundation
degeneration and smaller with simulated muscle for all arm and leg movements and thus play vital role
forces across a motion segment. In this way, size of in maintenance of dynamic balance (5). The core can be
neutral zone is considered to be an important measure described as a muscular box with the abdominals in
of spinal stability (8). front, paraspinals and gluteals in back, diaphragm as
roof, and pelvic floor and hip girdle musculature as
It is influenced by the interaction between passive,
bottom to stabilize the spine, pelvis, and kinetic chain
active and neutral control systems:
during functional movements. The core is particularly
• Passive system constitutes the vertebrae, important in sports because it provides ‘‘proximal
intervertebral discs, zygoapophyseal joints and stability for distal mobility’’. It appears that a
ligaments. coordinated contraction of all deep and superficial core
muscles is needed for optimal spinal stabilization (5).

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 35

Good core stability can help maximize running a chosen excursion with the most distal part of their
performance and prevent injury. It helps reduce risk reach foot. Then they returned to a bilateral stance
of injury resulting from bad posture. Power is derived while maintaining their balance. Six practice sessions
from trunk region of the body and properly for each excursion followed by a minute rest & the
conditioned to control that power, allowing for farthest measurement was recorded. Additionally, leg
smoother more efficient and better co-ordinated length of the subject’s dominant extremity was used
movements in the limbs (5). to normalize their dynamic balance scores (excursion
length/leg length x 100 for a percentage of an excursion
Core functions to maintain postural alignment & distance in relation to the subject’s leg length) and used
dynamic postural equilibrium during functional for data analysis.
activities, which helps to avoid serial distortion
patterns. Core stability is the motor control and
muscular capacity of the lumbo-pelvic-hip complex. SEBT with Right limb stance SEBT with Left limb stance:
Normal function of the stabilizing system is to provide
sufficient stability to the spine to match the
instantaneously varying stability demands due to
changes in spinal posture, and static and dynamic
loads (3).

Core strengthening & stabilization training helps

to increase levels of functional strength and dynamic
balance leading to better control of balance and
improve athletic performance and prevent injuries to
alleviating low back pain(5).
A: anterior excursion; AM: anteromedial excursion;
M: medial excursion; PM: posteromedial excursion; P:
MATERIAL AND METHODOLOGY
posterior excursion; PL: posterolateral excursion; L:
This is a Prospective experimental study carried out lateral excursion; AL: anterolateral excursion.
in Physiotherapy OPD in Tertiary Care Hospital.
Materials used were Swiss Ball, Medicine Ball, Core stabilisation training programme exercises
Therabands, Coloured Tapes, Measuring Tape, Level 1: week 1
Sphygmomanometer as Pressure Biofeedback Unit. 30
Subjects were selected with Mechanical Low Back Pain. Day 1-3: Abdominal Muscle Contraction. Subject
Both genders were included. Patients with Radiating is in supine with knees bent so that feet lie flat on floor.
pain, Pregnancy, diagnosed Psychiatric illness, any They will be instructed to contract their abdominals,
abdominal surgery, history of lower limb fracture or drawing in their navel without rotating pelvis.
trauma and patients who have undergone Core muscle
Abdominal Muscle Contraction: Subject in
stabilisation training programme in past 6 months
quadruped position is instructed to contract their
were excluded. Study was explained & written consent
abdominals, drawing their bellybutton towards the
was taken from them to undergo treatment for four
ceiling without rotating their pelvis.
weeks. Observations were recorded by measuring the
excursion of each of the eight directions using STAR Abdominal Muscle Contraction: Subject in a
Excursion Balance test pre treatment and post sideways posture will bear their weight on right
treatment i.e. one week before and after the completion forearm and right foot. Then will maintain a straight
of training program. The SEBT involved a star pattern alignment while contracting the right oblique muscle.
with 8 projections each at 45 degrees from each other, Same will be repeated on other side.1x6/each side
on an even surface. Subjects placed their non-dominant (10sec holds).
foot on mid of the star pattern, while their dominant
foot reached as far as possible in each 8 excursions Dying Bug: Subject in supine with upper and lower
while maintaining a single leg stance & reaching with extremities facing straight toward the ceiling.
the opposite leg to touch as far as possible along a Instructed to maintain an abdominal contraction while
chosen excursion. They were then instructed to touch simultaneously moving their extremities toward the
the farthest point possible, & as light as possible, along torso in slow controlled movements (Figure 1).

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 36 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Fig. 1. Dying Bug.

Bridging: Subject in quadruped position, instructed Seated Medicine Ball Rotation: Subject sits upright
to contract their Abdominals while simultaneously on floor with knees bent at 45 degrees. Then will hold
extending one leg back as straight as possible in a slow a medicine ball in both hands and will rotate their
controlled manner, and then bringing it back to starting upper torso with the arms extended while maintaining
position. Continue same for opposite leg. abdominal contraction (Figure 2).

Fig. 2. Seated Medicine Ball Rotation.

Level 2:Week 3 Superman: Subject will lie on their stomach with

upper and lower extremities positioned straight out
Day 1-3: Abdominal Muscle Contraction. and fully extended. They will be instructed to raise
Seated on Swiss Ball: Subject sits on a Swiss Ball both extremities at the same time & not to exceed the
in an upright posture & will contract their abdominals onset of extreme low back arching. Return to the
without rotating their pelvis and simultaneously starting position in a controlled manner.
maintaining balance. Level 2: Week 4
Squat with Swiss Ball: Subject will squat with a Day 4-6: Abdominal Muscle Contraction.
Swiss Ball in between the subjects back and wall and
instructed to maintain a proper squatting posture while Multidirectional Lunge: Subject will stand in
contracting their abdominals during squat. upright posture with both hands on their hip. Then

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 37

they lunge with their right knee and hip flexed to 90 Twists on Swiss Ball: Subject will have both feet
degrees and their left knee flexed to 90 degrees and planted on floor while their upper back supported on
left hip at 180 degrees. The lunge will be directed a Swiss Ball with their arms extended toward the
straight ahead. After going back to the starting ceiling over their chest, holding a medicine ball. They
position, the lunge will be repeated with similar will then stabilize their lower body while moving their
posture 45 degrees to the right. The same movement extended arms to one side of the body, and then back
will be repeated for left leg. to the starting position, then repeat the same for
opposite side.
Oblique Pulley with Side Shuffles: A theraband
is tied at one end while the other end is held with both Core Stabilization: Training Program Protocol
hands in an extended position. Then the subject will
do side shuffles to the point of minimal resistance & Week 1 to Week 5
will then pull horizontally toward the tied up side, Specific prescribed sets and repetitions will be
and then will side shuffle back to the starting position. performed for each exercise with one minute rest in
Level 3:Week 5 between sets. Subjects will progress to next level of
core stabilization training program according to the
Day 1-3: Abdominal Muscle Contraction. exercise protocol.

Diagonal Curls on Swiss Ball: Subject will have Statistical Analysis: Data was assessed as follows-
both feet planted on floor while their upper back mean difference was taken for pre and post training
supported on a Swiss Ball and their arms crossed over measurements for each direction and student’s paired
their chest. They will be instructed to raise their upper t test was used to determine the changes in dynamic
body using their trunk muscles and turn towards balance, whereas correlation was done amongst right
opposite knee, then return to the starting position. The and left lower limb in each direction pre and post
same action will be repeated for the opposite knee. training.

RESULT
Table 1: Comparison of directions of pre and post treatment of Right Lower Limb

Direction Paired Differences t df p-value

Mean Std. Std. Error 95% Confidence
Deviation Mean Interval of
the Difference
Lower Upper
Anterior 0.82 1.29 0.23 -1.30 -0.34 3.48 29 0.002 S
Anterolateral 2.35 2.01 0.36 -3.10 -1.60 6.412 29 0.000 S
Lateral 2.06 4.79 0.87 -3.85 -0.27 2.356 29 0.025 S
Posterolateral 2.60 2.83 0.51 -3.66 -1.55 5.04 29 0.000 S
Posterior 0.90 1.08 0.19 -1.31 -0.50 4.58 29 0.000 S
Posteromedial 0.42 1.30 0.23 -0.91 0.05 1.795 29 0.083 NS
Medial 0.29 11.93 2.17 -4.15 4.75 0.13 29 0.892 NS
Anteromedial 0.49 1.52 0.27 -1.06 0.07 1.759 29 0.089 NS

Comparison of directions of pre and post treatment pre-treatment was 88.14 ± 8.46 and post-treatment
of right lower limb is: was 90.50 ± 8.90 with mean difference of 2.35 ±2.01.
Showing significant improvement in balance (t =
• The mean excursion for anterior direction at pre- 6.412, p= 0.000).
treatment was 81.30 ± 11.64 and post-treatment was
• The mean excursion for lateral direction at pre-
82.13 ± 11.68 with mean difference of 0.82 ± 1.29.
treatment was 85.85 ± 7.70 and post-treatment was
Showing significant improvement in balance (t =
87.91 ±11.23 with mean difference of 2.06 ±4.79.
3.48, p= 0.002). Showing significant improvement in balance
• The mean excursion for anterolateral direction at (t =2.356, p= 0.025).

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 38 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

• The mean excursion for posterolateral direction at of 0.42 ±1.30. Showing non-significant
pre-treatment was 82.96 ± 9.68 and post-treatment improvement in balance (t =1.795, p= 0.083).
was 85.57 ±9.64 with mean difference of 2.60 ±2.83.
Showing significant improvement in balance (t • The mean excursion for medial direction at pre-
=5.04, p= 0.000). treatment was 67.65 ± 14.45 and post-treatment
was 67.35 ± 10.16 with mean difference of 0.29
• The mean excursion for posterior direction at pre- ±11.93. Showing non-significant improvement in
treatment was 72.91 ± 18.42 and post-treatment balance (t =0.13, p= 0.892).
was 73.81 ± 18.67 with mean difference of 0.90
±1.08. Showing significant improvement in balance • The mean excursion for anteromedial direction at
(t =4.58, p= 0.000). pre-treatment was 79.21 ± 10.40 and post-treatment
was 79.70 ± 10.55 with mean difference of 0.49
• The mean excursion for posteromedial direction ±1.52. Showing non-significant improvement in
at pre-treatment was 68.87 ± 16.81and post- balance (t =1.759, p= 0.89).
treatment was 69.30 ±16.84 with mean difference

Table 2: Comparison of directions of pre and post treatment of Left Lower Limb

Direction Paired Differences t df p-value

Mean Std. Std. Error 95% Confidence
Deviation Mean Interval of
the Difference
Lower Upper
Anterior 2.08 1.78 0.32 -2.74 -1.41 6.397 29 0.000S
Anterolateral 4.67 7.45 1.36 -7.45 -1.89 3.43 29 0.002 S
Lateral 3.78 4.12 0.75 -5.32 -2.24 5.02 29 0.000 S
Posterolateral 4.04 5.03 0.91 -5.92 -2.16 4.397 29 0.000 S
Posterior 1.97 4.47 0.81 -3.64 -0.30 2.422 29 0.022 S
Posteromedial 0.88 1.79 0.32 0.21 1.54 2.69 29 0.012 S
Medial 0.51 3.28 0.59 -0.71 1.73 0.858 29 0.398 NS

Comparison of directions of pre and post treatment was 86.87 ± 11.12 with mean difference of 4.04 ±
of left lower limb is: 5.03. Showing significant improvement in balance
(t =4.397, p= 0.000).
• The mean excursion for anterior direction at pre-
treatment was 84.55 ± 7.18 and post-treatment was • The mean excursion for posterior direction at pre-
86.63 ± 7.85 with mean difference of 2.08 ± 1.78.
treatment was 79.01 ± 12.05 and post-treatment
Showing significant improvement in balance (t =
was 80.99 ± 14.70 with mean difference of 1.97 ±
6.397, p= 0.000).
4.47. Showing significant improvement in balance
• The mean excursion for anterolateral direction at (t =2.422, p= 0.022).
pre-treatment was 77.37 ± 8.52 and post-treatment
was 82.04 ± 10.04 with mean difference of 4.67 ± • The mean excursion for posteromedial direction
7.45. Showing significant improvement in balance at pre-treatment was 76.78 ± 10.40 and post-
(t = 3.43, p= 0.002). treatment was 75.90 ±9.33 with mean difference of
0.88 ± 1.79. Showing significant improvement in
• The mean excursion for lateral direction at pre-
balance (t =2.69, p= 0.012).
treatment was 87.56 ± 8.43 and post-treatment was
91.34 ±9.20 with mean difference of 3.78 ±4.12. • The mean excursion for medial direction at pre-
Showing significant improvement in balance treatment was 63.42 ± 8.26 and post-treatment was
(t =3.43, p= 0.002). 67.35 ± 10.16 with mean difference of 0.51 ±3.28.
• The mean excursion for posterolateral direction at Showing non-significant improvement in balance
pre-treatment was 82.83 ± 8.98 and post-treatment (t =0.858, p= 0.398).

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 39

• The mean excursion for anteromedial direction at Showing significant improvement in balance
pre-treatment was 85.23 ± 9.65 and post-treatment (t =2.46, p= 0.020).
was 82.81 ± 6.32 with mean difference of 2.42 ±5.38.

Table 3: Correlation between Right and Left Lower Limb Pre treatment

Directions Right Lower Limb Left Lower Limb Correlation ‘r’ p-value
Anterior 81.30 84.55 0.49 0.006S,p<0.05
Anterolateral 88.14 77.37 -0.43 0.31NS,p>0.05
Lateral 85.85 87.56 0.65 0.000 S,p<0.05
Posterolateral 82.96 82.83 0.25 0.18 NS,p>0.05
Posterior 72.91 79.01 0.55 0.002 S,p<0.05
Posteromedial 68.87 76.78 0.13 0.47 NS,p>0.05
Medial 67.65 63.42 0.66 0.000 S,p<0.05
Anteromedial 79.21 85.23 0.44 0.014 S,p<0.05

Table 4: Correlation between Right and Left Lower Limb Post treatment

Directions Right Lower Limb Left Lower Limb Correlation ‘r’ p-value
Anterior 82.13 86.63 0.51 0.004S,p<0.05
Anterolateral 90.50 82.04 0.33 0.06NS,p>0.05
Lateral 87.91 91.34 0.53 0.002 S,p<0.05
posterolateral 85.57 86.87 0.34 0.06 NS,p>0.05
Posterior 73.81 80.99 0.49 0.005 S,p<0.05
Posteromedial 69.30 75.90 0.06 0.73 NS,p>0.05
Medial 67.35 62.91 0.57 0.001 S,p<0.05
Anteromedial 79.70 82.81 0.29 0.11 NS,p>0.05

CONCLUSION Adaptation, and Enhancement. J Spinal Disord.

1992; 5:383-9.
Core stabilisation training is significantly effective 7. Jaana Suni, Marjo Rinne, Antero Natri, Matti
in improving the dynamic balance in mechanical low Pasanen, Jari Parkkari, and Hannu Alaranta.
back pain patients. Control of the Lumbar Neutral Zone Decreases
Low Back Pain and Improves Self-Evaluated
REFERENCES Work Ability. Spine. 2006; 31: E 611-20.
8. Alyson Filipa, Robyn Byrnes, Mark V. Paterno,
1. D.P. Rodriguez, T.Y. Poussaint. Imaging of Back Gregory D. Myer and Timothy E. Hewett.
Pain in Children. AJNR 2010; 31: 787-802. Neuromuscular Training Improves Performance
2. Anthony B. Piegaro, Jr., BS, ATC. The on the Star Excursion Balance Test in Young
Comparative Effects of Four-Week Core Female Athletes. J Orthop Sports Phys Ther. 2010;
Stabilization & Balance-Training Programs on 40:551-8.
Semidynamic & Dynamic Balance. 2003. 9. Hodges PW & Richardson CA. Core stability
3. Kimberly M. Samson, BS, ATC, PES. The Effects exercise in chronic low back pain. Orthop Clin N
of a Five-Week Core Stabilization Training Am. 2003; 34: 245-54.
Program on Dynamic Balance in Tennis Athletes. 10. Vezina MJ, Kozey CL, Muscle activation in
2005. therapeutic exercises to improve trunk stability.
4. Venu Akuthota, MD, Scott F. Nadler, DO. Core American Academy of Physical Medicine and
Strengthening. Arch Phys Med Rehab 2004; 85: Rehabilitation, 2000; 81:1370-9.
86-92. 11. Famin Farzaneh Hessari, Ali Asghar Norasteh,
5. Venu Akuthota, Andrea Ferreiro, Tamara Moore, Hassan Daneshmandi, Solmaz Mahdavi
Michael Fredericson. Core Stability Exercise Ortakand. 8 Weeks Core Stabilization Training
Principles. Curr. Sports Med. Rep. 2008; 7: 39-44. Program on Balance in Deaf Students. Medicina
6. Manohar M Punjabi. The Stabilizing System of Sportiva. 2011; 15: 56-61.
the Spine, Part I; Function, Dysfunction,

8. apeksha yadav--34--39.pmd 39 8/1/2013, 8:31 AM

 DOI Number: 10.5958/j.0973-5674.7.3.062
40 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Effect of Knee Chest Position in Primary Dysmenorrhea-

A Randomized Controlled Trial

Arati Mahishale1, Dinika Mascarenhas2, Shobhana Patted3

1
Assistant Professor, Institute of Physiotherapy, 2(MPT) OBG Physiotherapy, Institute of Physiotherapy, KLE
University, Belgaum, 3Professor, OBG Department, J.N. Medical College, KLE University, Belgaum, Karnataka

ABSTRACT
Background and objectives: Dysmenorrhea is a painful symptom that accompanies the menstrual
cycles. Although exercise is generally thought to alleviate the symptoms of menstrual pain the scientific
literature displays mixed evidence. The main objective of this research was to determine the effect of
knee chest position on primary dysmenorrhea.
Materials and method: 30 female participants were recruited from KLE's Institute of Physiotherapy,
Belgaum and randomly allocated to control and experimental group after obtaining an informed
consent and clearance from the institutional ethical committee. Visual analogue scale (VAS) and
Moos menstrual distress questionnaire (MMDQ) were used as primary and secondary outcome
measures. Control group received hot moist pack for 10 mins and the experimental group received
hot moist pack (HMP) for 10 mins and knee chest position for 10 repetitions with 20 seconds hold.
The intervention was carried out for 2 days beginning from the first day of menses. Outcome measures
were documented using VAS on both the days pre intervention and post intervention and MMDQ
on 1st day pre intervention and 2nd day post intervention respectively.
Results: The results showed statistically significant reduction in VAS and MMDQ scores in the
experimental group when compared to the control group with p<0.05.
Conclusion: Intervention with Knee chest position can be used in conjunction with HMP for reducing
pain and menstrual distress in primary dysmenorrhea.
Keywords: Primary Dysmenorrhea, Visual Analogue Scale, Moos Menstrual Distress Questionnaire, Knee
Chest Position

INTRODUCTION decreasing the efficiency and quality of life among

women. 1,4-11 The pain begins on the first day of
Dysmenorrhoea is defined as pain associated with menstruation and lasts for a few hours to even two
menstruation of sufficient magnitude so as to affect days. Pain is usually described as cramping in nature
day-to-day activities. 1 According to Dawood and pain is felt mainly in the hypogastrium and
dysmenorrhea is the common gynaecological radiates to the inner and front aspect of the thighs.3
complaint that can affect 50% of women with 10% of Women who exercise have a reduced incidence of
these women suffering severely enough to render them dysmenorrhea which could be due to exercise related
to incapacitate for one to three days of each menstrual hormonal effects on the lining of the uterus or increased
cycle .2 This condition not only has a significant impact level of circulating endorphins.12 Exercise acts as a non-
on personal health but also has a global economic specific analgesic for short-term relief of pain.13,14
impact.2 Pain is a subjective symptom and cannot be Dysmenorrhea is classified into three types namely
accurately estimated by an outside observer since Primary or spasmodic dysmenorrhea (essential/
different women perceive pain with different severity intrinsic/functional) which is defined as painful
and tolerance. 3 The incidence of primary menstruation in the absence of pelvic pathology.
dysmenorrhea is about 45-50%. It is the major cause Membranous dysmenorrhea is actually a type of
of absenteeism from work amongst women thus spasmodic dysmenorrhea characterised by the passage

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 41

of an endometrial or decidual cast. Secondary (experimental) receiving HMP and knee chest position.
dysmenorrhea is painful menses secondary to an
underlying organic disease of the pelvic organs.3 Inclusion Criteria

The management of primary dysmenorrhea Females aged between 18-35years, regular menses
includes various medical and surgical procedures. with complaint of primary dysmenorrhea and those
With the advent of oral contraceptives and non who were willing to participate in the study.
steroidal anti inflammatory drugs there is marked
Exclusion Criteria
relief in pain. Various exercises and positions have been
proposed which are targeted in between the menstrual Participants under medications like painkillers or
cycle but not evaluated during active menstrual period others, intermenstrual bleeding, subjects with urinary
although literature suggests that perimenstrual tract infection, postpartum women (during puerperal
exercises or positions are indicated for primary age), those with intrauterine contraceptive device and
dysmenorrhea, no specific therapy has been studied subjects who were breast feeding.
or recommended for clinical implication. To the best
our knowledge of literature search knee chest position Intervention
for primary dysmenorrhea has not been studied and
Intervention was given for two days beginning
hence the present study aims to evaluate the effect of
from the first day of menses. The control group
knee to chest position on pain and menstrual distress
received only HMP for 10 minutes. Those in
in primary dysmenorrhea.
experimental group received HMP for 10 minutes
which was placed on their lower abdomen and were
METHODOLOGY
made to perform alternate knee chest position. In this
Study Design position the subjects were made to lie in supine
position on the treatment table and alternate knee to
The present study is designed as a randomized
chest position was made to perform for duration of
controlled trial to evaluate the effect of knee chest
20seconds and frequency of 10 repetitions each twice
position in primary dysmenorrhea.
a day.
Source of data
Outcome measures
Primary data was collected from KLE’S DR.
VAS was used as primary and MMDQ was
Prabhakar Kore hospital and medical research centre,
secondary outcome measures. The Visual Analogue
Belgaum-Karnataka from September 2011 to
Scale is a 10cm horizontal line drawn on a paper where
November 2011.
start symbolizes no pain and end symbolizes the worst
PARTICIPANTS thinkable or tolerable pain and participants will be
asked to mark a point on this line as per severity of
30 female participants with complain of primary their pain which will indicate the pain level.15MMDQ
dysmenorrhea from the Institute of Physiotherapy was proposed by Rudolf H Moos. It is a standard
Belgaum and those referred to Physiotherapy O.P.D, method for measuring cyclical perimenstrual
KLE’S DR. Prabhakar Kore Hospital and Medical symptom. It is a 46-item self-report inventory for use
Research Centre, Belgaum were recruited for the study. in the assessment and treatment of premenstrual and
menstrual symptoms. MMDQ can distinguish cyclical
PROCEDURE from non-cyclical changes in physical symptoms,
Participants fulfilling the eligibility criteria were mood and behaviour and arousal. It identifies type and
considered for the study and informed consent was intensity of symptoms, mood and behaviour and
signed from the study participants prior to the arousal women experience during each phase of
commencement of study. Demographic details like menstrual cycle and can aid researchers and clinicians
name, age, height, weight, address and contact details in specifying effect of therapeutic interventions.16 Total
were recorded. The subjects were randomly allocated scores were calculated for this and then the pre and
to one of the two groups using envelope method to post test scores were compared. The primary outcome
Group A (control) receiving HMP and Group B measure VAS was taken on both the days before and

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 42 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

after treatment whereas the secondary outcome VAS Score

measure MMDQ was taken on first day pre
The pre-intervention VAS score in control group
intervention and second day post intervention.
on the 1st day was 8.3±1 and experimental group was
Data Analysis 8.2±0.88 and on 2nd day the control group was 7.4±1.13
and experimental group was 7±1.70. The post
Data was computed and analyzed using SPSS intervention VAS score in control group was 5.6±2.11
(statistical package for social sciences) software version and experimental group was 4.3±1.13 on the 1st day
16. For different quantitative parameters mean and SD whereas on the 2nd day it was 4.9±1.98 in the control
were calculated. Tests of significance namely Mann- group and 3.1±1.42 in the experimental group. There
Whitney Test and Wilcoxon signed-rank test were used was statistically significant difference in VAS score on
1st day as well as 2nd day post intervention with p=0.037
to compare between pre and post intervention and to
(day 1) and p=0.015 (day 2) suggesting better pain
compare between control and experimental group.
reduction in experimental group as compared to
control group. (Table 2)
RESULTS
MMDQ Score
The result of the study showed statistically
significant difference in pain and menstrual distress The pre-intervention MMDQ value was 133.2±30.49
as measured using VAS and MMDQ in experimental in control group and 138.8±34.32 in experimental
group as compared to control group. The demographic group on day 1 and 95.5±20.22 and 101.1 respectively
profile showed no statistical difference between the in the control and experimental group on day 2.
MMDQ values showed statistically significant
parameters like age, height, weight, BMI between the
difference within the groups in both control and
control and the experimental group which signifies
experimental group with p<0.05. (Table 3)
that the characteristics of participants in both the
groups were well matched. (Table 1)

TABLE: 1 (Demographic Profile)

AGE (yrs) HEIGHT (mats) WEIGHT (kgs) BMI

Control Group 23.4±4.62 1.61±.09 56.2±11 21.81±5.13
Experimental Group 23.2±4.62 1.62±.07 56.9±11.06 21.73±4.11
t 0.079 0.225 0.190 0.049
DF 28 28 28 28
P 0.938 0.824 0.850 0.961

No difference in mean of age, weight, height and BMI

TABLE 2. Visual Analog Scale

DAY -1 DAY-2
Groups Pre Post Diff Pre Post Diff
Control 8.3±1 5.6±2.11 2.7±1.47 7.4±1.13 4.9±1.98 2.5±1.05
Experimental 8.2±.88 4.3±1.31 3.9±1.82 7±1.70 3.1±1.42 3.9±1.47
Mann-WhitneyTest (p) 0.624 0.026 0.037 0.486 0.004 0.015

Significant differences in the VAS scores is seen between the groups and within the groups

TABLE: 3 (Moos Menstrual Distress Questionnaire)

Groups Pre Post Difference

Control 133.2±30.49 95.5±20.22 37.7±29.62
Experimental 138.8±34.32 101.1 37.7±25.72

The values of MMD are statistically significant within the groups for both control and experimental with p < 0.05

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 43

DISCUSSION potent vasoconstrictor and causes increased

myometrial contractility, whereas PGE2 increases
The present study results show that knee chest
sensitivity to the nerve endings. PGI2 is a vasodilator
position along with hot moist pack have significantly
which decreases prior to menstruation leading to
reduced pain and menstrual distress in subjects with
ischemia which further causes hypoxia and therefore
primary dysmenorrhea as shown by VAS and MMDQ.
results in pain.3 The hormonal effects of exercise act
A study where continuous, low level, heat wrap
on the lining of the uterus as well as leads to an increase
therapy was used as a non medical self help therapy
in the level of circulating endorphins. An interesting
applied over suprapubic region was significantly
element of relationship between exercise and
superior to acetaminophen.17 Topically applied heat
dysmenorrhea is the involvement of stress. Exercise is
has proved subjective relief of pain in primary
widely accepted as a mean of moderating stress and
dysmenorrhea. Thermotherapy works by increasing
biochemical changes in the immune system. A
the blood flow thereby supplying protein, nutrients
mechanism by which exercise may improve the
and oxygen at the site of injury. Increased blood flow
symptoms of dysmenorrhea has been articulated by
facilitates tissue healing by increase in metabolism.
Gannon in 1986.14 The experimental group received
This increase in metabolism aids the healing process
both HMP and knee chest position and has shown
by increasing both catabolic and anabolic reactions
significant reduction in pain as compared to the control
needed to degrade and remove metabolic by-products.
group which signifies the cumulative effect of both
The reduction in pain in the control group of our study
HMP and exercise. This combined effect can be used
who received HMP could be consistent with the
in clinical practice to overcome the discomforts of
physiological basis as explained above.18
primary dysmenorrhea .
Exercises are recommended in primary
dysmenorrhea with supporting literature since more CONCLUSION
than 15-20 years. These exercises are recommended
Knee chest position along with hot moist pack is
even during perimenstrual period19. Several exercises
effective in reducing pain and relieving the discomforts
such as Cat stretch, lower trunk rotation, buttock/hip
of primary dysmenorrhea aiding in pain free menses.
stretch, abdominal strengthening and bridge position
have been stated in literature but not implemented
LIMITATIONS
clinically and lacks literature support.20 It has also been
said that at least 15minutes of exercises done daily as Sample size was small, data was collected only at
well as between menstrual periods relieve pain during one menstrual cycle and no follow up was done.
dysmenorrhea. These exercises include floor polishing
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pp.26-31,2006. postural defect. Archives of Surgery 1943;46:611.
13. Bonen A, Keizer H. Athletic menstrual cycle 20. R Baranitharan, V Mahalakshmi, V Kokila.
irregularity endocrine response to exercise and Physiotherapy Care For Women’s Health. 2010
training. Physician Sports Med. 1984;12:78-93 1st ed. Jaypee Brothers Medical Publishers Ltd.
14. Ganon. L. The potential of exercise in the pp.37-41
alleviation of menstrual disorders and 21. Golub Lm, Solidum. A, Warren M. Primary
menopausal symptom. Women Health. 1986; dysmenorrheal and physical activity. Sport Exc
142(2):105-7.A. Med. 1998;30: 906-9

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 DOI Number: 10.5958/j.0973-5674.7.3.063
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 45

The effect of Strength Training on Normalizing the Tone

and Strength of Spastic Elbow Flexors in Subjects with
Stroke

Bharath Kumar P V S R1, V Sri Kumari2, K Madhavi3

1
Post graduation student, Master of physiotherapy in Neurology, 2Assistant Professor, College of Physiotherapy,
3
Professor & Principal, College of Physiotherapy, SVIMS, Tirupati

ABSTRACT
Objectives: This study is designed to find out whether strength training can normalize the tone in
spastic upper extremity muscles and improve the strength of the spastic upper extremity muscles.
Materials and Method: The study was conducted on 30 subjects with elbow flexors spasticity and
were divided into experimental and control groups. Both the groups received conventional
physiotherapy and Experimental group received strength training in addition. The parameters like
strength and spasticity were measured isokinetically.
Result: The strength training program had no statistical significant effect on tone of the spastic elbow
flexors between the two groups. t value 0.48 at p value 0.636(not significant)
There is a statistically significant difference between two groups in the strength with the improvement
in the experimental group. t value 6.03 at p value <0.05(significant)
Conclusion: This study concludes that strengthening program has minimal effect on spasticity &
effective in improving the strength without deleterious effect on spasticity.
Keywords: Stroke, Spasticity, Strength, BIODEX, Active torque, Passive torque

INTRODUCTION of intensive therapeutic efforts5. This unfortunate state

calls for renewed efforts to examine the theoretical
Stroke is the 3rd most common cause of death in
basis of the factors impeding upper-limb recovery and
the western world and the most common cause of long
their clinical implications
term adult disability1. A study by the World Health
Organisation (WHO), which was released in June 2009, Strength training is necessary after stroke to
says that the incidence of stroke in India is around 130 improve the force generating capacity and efficiency
per 100,000 people every year. of weak muscles to improve functional motor
performance6.
Petrasovits and Nair2 reported that stroke is a major
cause of disability and economic cost. It is recognized The potential risk of an increase in muscle tone in
that the negative motor impairments following stroke, patients with pre-existent muscle spasticity is still a
e.g. loss of strength and dexterity, contribute most to major point of contention. As a result, muscle weakness
disability3 . It now appears that weakness i.e. the loss of central origin is mainly treated by physiotherapy,
of ability to generate normal amounts of force is the i.e., by different functional approaches like the Bobath
major contributor to limitation of physical activity4. techniques or proprioceptive neuromuscular
facilitation (PNF). These techniques are thought to
One of the most devastating and common
empower patients in activities of daily living by
consequences of stroke is loss of the use of the arm
improving normal motor patterns. But motor functions
and hand. Only about 5% of individuals paralyzed by
in activities of daily living require both strength and
stroke regain full arm and hand function, and about
endurance7, so that strength building exercises appear
20% regain no functional use5. The prognosis for upper
to be well justified.
limb recovery following stroke remains dismal in spite

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 46 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

However, it is even more important that both the METHODOLOGY

evaluation of the severity of spasticity and the
measurement of possible pathophysiological
mechanisms are far from optimal with the techniques
currently available. A detailed quantification of
spasticity is difficult to obtain clinically and the
available Modified Ashworth scale appears not to
provide a very accurate and reproducible measure of
the severity of spasticity8,9,10 .

In our opinion, a correlation between change in

activity in any of the mechanisms that have been
implicated in the pathophysiology of spasticity and
the severity of spasticity should not be ruled out until
more optimal techniques for evaluation of spasticity
have been developed. Biomechanical dynamometers,
which permit standardized muscle stretches at
sufficiently high velocities to elicit stretch reflex
activity, seem promising as a basis for such a
technique11,12.

There is some concern among clinicians that

strength training may not be appropriate in the
presence of spasticity or elevated muscle tone. Such
training may enhance the spastic restraint and thus
interfere with coordination and reinforce abnormal
muscle activation patterns. Thus the relationship
between spasticity and strength training after stroke Conventional treatment
is an area of continued interest.
• Cryotherapy : Duration: 10-15 min

MATERIALS AND METHOD • Stretching

30 subjects with unilateral stroke who had residual • Position of patient: Supine lying, arm held out of
spasticity of their affected upper limb were recruited the couch
from department of physiotherapy, SVIMS, Tirupati,
Andhra Pradesh. Subjects of age group 45years to 65 • Stretch for elbow flexor muscles
years were screened to ensure that they can perform • Number of repetitions: 4 – 5
antigravity movement of elbow flexion of the affected
side, modified ashworth score not more than 3, without • Active movements: 30 repetitions in 3 sets with 10
affected elbow contractures, deformities or fractures, of each
stable hemodynamics, without sensory perceptual and
psychosomatic disorders were randomly divided into Strengthening program
control group and experimental group with 15 each Progressive resistance training
by simple random sampling. Subjects who undergone
any invasive anti-spastic therapy were excluded for Position of patient: Half lying
the homogeneity among the subjects. The written
informed consent was taken from successive patients/ Macqueen protocol
patient attendants whom cannot give a written 10 lifts with 10 RM
consent.
10 lifts with 10 RM

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 47

10 lifts with 10 RM Peak value of extension torque (ET) recorded from

5 repetitions.
10 lifts with 10 RM
Value derived from difference between 90°/sec &
40 lifts, 3 times weekly, 30°/sec
Progress 10 RM every 1-2 weeks
FINDINGS
The outcome measures
Statistical analysis was done using software ‘SPSS
During initial evaluation both active torque and 16.0 version’. For this purpose the data was entered
passive torque were measured comparing at various into Microsoft excel spread sheet, tabulated and
angular velocities. All the measures are objective subjected to statistical analysis.
measures.
Of the 30 subjects, 15 were randomized into
Active torque: experimental group and 15 were randomized into
control group. All the subjects completed the entire
Measurement in N-M for strength assessment with
study protocol as defined, by 8 weeks in the training
BIODEX System4pro (Isokinetic analyzer)
sessions.
Test conducted in isokinetic mode at 60°/sec
Pretest – posttest values of passive torque are
angular velocity.
measured on BIODEX for spasticity grading.
Peak torque value recorded from 5 repetitions.
Pretest – posttest values of active torque are
Passive torque measured on BIODEX for strength assessment.

Measurement in N-M for spasticity grading with To compare the pre and post treatment effect within
BIODEX System4pro (Isokinetic analyzer) the group paired sample t-test was used to compare
the pre and post treatment effect between the groups,
In isokinetic mode at 30°/sec & 90°/sec angular unpaired t-test was used.
velocities.

Table 1: Analysis of Control group with Pre and Post intervention

Parameter N Mean SD t value Df p value
Passive torque(spasticity) Pre 15 2.08 0.76 10.267 14 0.0013*
Post 15 1.76 0.69
Active torque(strength) Pre 15 3.97 0.72 10.664 14 0.001*
post 15 4.46 0.82

*indicates significant at 5% level

To test the significance of the pre and post p value of the parameters is < 0.05, there is a notable
intervention of the parameters Spasticity and Strength, significance. It is observed that the post intervention
the paired t-test has been used. Since the corresponding had shown significant impact on the subjects.

Table 2: Analysis of Experimental group with Pre and Post intervention

Parameter N Mean SD t value Df p value
Passive torque(spasticity) Pre 15 2.22 0.76 6.237 14 0.001*
Post 15 1.66 0.51
Active torque(strength) Pre 15 3.9 0.67 13.263 14 0.001*
post 15 6.24 0.79

*indicates significant at 5% level

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 48 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

To test the significance of the pre and post p value of the parameters is < 0.05, there is a notable
intervention of the parameters Spasticity and Strength, significance. It is observed that the post intervention
the paired t-test has been used. Since the corresponding had shown significant impact on the subjects.

Table 3: Comparison of both Passive torque & Active torque between the groups

Torque N Mean SD t value Df p value

Passive(spasticity) Exp post 15 1.66 0.51 0.48 28 0.725
Cont Post 15 1.76 0.69
Active(strength) Exp Post 15 6.24 0.79 6.03 28 0.001*
Cont post 15 4.46 0.82

*indicates significant at 5% level

To test the significance of the pre and post The results revealed significant difference in
intervention mean values between the groups, the strength in the experimental group when compared
unpaired t-test has been used. Since the corresponding with control group. There also existed a minimal
p value of the active torque is < 0.05, there is a notable difference in elbow flexor spasticity in both the groups,
significance. It is observed that the post intervention where experimental group shown slightly higher
had shown significant impact on the subjects. difference compared to control group.

Chart 1: Mean differences between Experimental & Subjects who received strength training and
Control groups conventional physiotherapy showed improvement in
the strength and spasticity. But on comparing these
two, strength training seems to be beneficial.

The positive results with strength training might

have occurred because of the underlying physiology
that, the repetitive strengthening exercises might
decrease spastic stiffness both by improving the neural
control of muscle and by maintaining the extensibility
of muscle.

Nativ stated that, dynamic or isokinetic resistance

training invokes both autogenic and reciprocal
inhibition and it should therefore, lengthen stiff,
RESULTS shortened spastic muscles. He points out that the
process of repeatedly contracting a muscle against
After a 8 week treatment period, the subjects in resistance then stretching it should help increase rather
control group (conventional physiotherapy) and than decrease the range of motion around the targeted
experimental group (conventional and strength joint. He explains that, it occurs by way of reciprocal
training) had shown improvement with the out come inhibition to the antagonist muscle, followed by
measures; but on comparing experimental group with autogenic inhibition to the eccentrically working
control group, experimental group had shown a agonist.
statistically significant improvement at 0.05 level with
the out come measures – spastic elbow flexors strength Otis et al also states that, the dynamic stretching
(p=0.001), and a statistically non significant and that occurs during active exercise may play a part in
minimal improvement in elbow flexors spasticity decreasing reflex hyper excitability and increasing
(p=0.725). muscle compliance.

These results strongly support the earlier findings

DISCUSSION of Teixeria – Salmela et al13 (1999) who examined the
This study was to determine the effect of strength effect of strengthening in subjects with chronic stroke
training on normalizing tone and strength of spastic and found a significant improvement in strength in
elbow flexors in subjects with stroke. the affected muscle groups, as well as an increase in

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 49

gait speed and rate of stair climbing after training. 3. Burke D (1988) Spasticity as an adaptation to
Improvements in strength were not associated with pyramidal tractinjury. Advances in Neurology 47:
an increase in either quadriceps or ankle flexor 401–418.
spasticity 4. Louise Ada, Simone Dorsch and Colleen G
Canning, Strengthening interventions increase
Inaba et al14 in their randomized study on 176 strength and improve activity after stroke: a
patients in 3 groups of functional training and systematic review Australian Journal of
stretching; active exercise plus functional training and Physiotherapy 2006 Vol. 52 pg 241-248
stretching; and progressive resistive exercise plus 5. Basmajian JV, Gowland C, Brandstater M, et al.
EMG feedback treatment of upper limb in
functional training and stretching, has concluded that,
hemiplegic stroke patients: a pilot study. Arch phys
the resistive exercise group improved significantly
Med Rehabil. 1982;63:613-615
more in strength and gross motor function . 6. CARR, J & SHEPERD, R (1998) Neurological
15
Sharp and Brouwer in their pretest-posttest cohort Rehabilitation: Optimising Motor Performance
Butterworth Heinemann, Oxford pp
study of 15 individuals with stroke of more than 6
7. M. Radlinger, Krafttraining, Stuttgart – N.Y. 1998,
months in duration, given isokinetic strength training
G-Thieme Verlag.
for 6 weeks. They found statistically significant 8. Haas, B.M., Bergstrom, E., Jamous, A. & Bennie,
changes in peak torque of the knee extensors and the A. 1996. The inter rater reliability of the original
knee flexors,walking speed, and the Human Activity and of the modified Ashworth scale for the
Profile (a subjective measure of activity). This study is assessment of spasticity in patients with spinal
important because it found that spasticity did not cord injury. Spinal Cord 34, 560–564.
increase with muscle strengthening exercises. 9. Blackburn, M., van Vliet, P. & Mockett, S.P. 2002.
Reliability of measurements obtained with the
This study and also the clinical research has shown modified Ashworth scale in the lower extremities
that effort applied in strength training does not increase of people with stroke. Phys Ther 82, 25–34.
spasticity, associated movements, co-contraction and 10. Platz, T., Eickhof, C., Nuyens, G. & Vuadens, P.
resistance to passive movement. Strength training 2005. Clinical scales for the assessment of
results in increased muscle strength and decreased spasticity, associated phenomena, and function:
spasticity. a systematic review of the literature. Disabil
Rehabil 27, 7–18.
The result of the present study indicates that 11. Knutsson & Martensson 1976, Action of
strength training has higher beneficial effects over dantrolele sodium in spasticity with low
conventional physiotherapy on elbow flexor spasticity dependence on fusimotor drive. J Neurol Sci 29,
in subjects with stroke. 195-212
12. Burridge, J.H., Wood, D.E., Hermens, H.J. et al.
2005. Theoretical and methodological
ACKNOWLEDGEMENT
considerations in the measurement of spasticity.
The authors are thankful to Director, Dr. B. Disabil Rehabil 27, 69–80.
Vengamma. Sri Venkateswara Institute of Medical 13. Luci Fuscaldi Teixeira-Salmela, Effects of muscle
strengthening and physical conditioning training
sciences (SVIMS), Tirupati for kindly providing all the
on temporal, kinematic and kinetic variables
facilities to carry out this work.
during gait in chronic stroke survivors. J Rehab
Med 2001; 33: 53–60
REFERENCES 14. Inaba M, Edberg E, Montgomery J, Gillis MK.
Effectiveness of functional training, active
1. Bath PMW (2005) Prostacyclin and analogues for
exercise and resistive exercise for patients with
acute ischaemic stroke [Systematic Review].
hemiplegia. Phys Ther 1973;53:28-30.
Cochrane Stroke Group Cochrane Database of
15. Sharp SA, Brouwer BJ. Isokinetic strength training
Systematic Reviews 1.
of the hemiparetic knee: effects on function and
2. Petrasovits A, Nair C. Epidemiology of stroke in
spasticity. Arch Phys Med Rehabil 1997;78:1231-6.
Canada. Health Rep 1994;6:39-44. Comment in:
Health Rep 1994;6:9-12.

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 DOI Number: 10.5958/j.0973-5674.7.3.064
50 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Comparison of Supervised Rehabilitation vs. Home Based

Unsupervised Rehabilitation Programs after Total Knee
Arthroplasty: A Pilot Study

Bijender Sindhu1, Manoj Sharma2, Raj K Biraynia3

1
Research Scholar, Singhania University, 2MS (Ortho), Research Supervisor, 3D. Ortho, DNB(Ortho), Singhania
University

ABSTRACT
Objective: The purpose of the current study was to compare two rehabilitation programs post primary
total knee arthroplasty (1) Supervised rehabilitation delivered by qualified physiotherapist and (2)
home-based unsupervised rehabilitation monitored by a physiotherapist via periodic telephone calls.
Method: Twenty patients having primary total knee arthroplasty were assigned randomly to two
rehabilitation program (1) supervised rehabilitation program group (2) home-based unsupervised
rehabilitation program group. Outcome measures used to assess the outcome were (1) Knee Society
Knee score for knee integrity (2) ILOA for level of assistance (3) Goniometry for ROM and (4) VAS
Scale for pain.
Results: The significant difference were observed in the score of all outcome scale used for assessment.
The subjects in supervised rehabilitation program group performed better compared to home-based
unsupervised rehabilitation program group.
Conclusions: This pilot study shows that the supervised rehabilitation after total knee arthroplasty
having better prognosis than home-based unsupervised rehabilitation program on range of motion
and functional ability and pain.
Keywords: TKA, Home Based Exercises, Supervised Exercises

INTRODUCTION assess the effectiveness of both are lacking thus there

is need to assess the most effective model of exercises
Home-based unsupervised rehabilitation programs program for post-operative rehabilitation after total
typically do not require the patient to attend clinic knee arthroplsty.
sessions or attendance to minimum number of
outpatient sessions, thus provide fewer opportunities OBJECTIVE OF THE STUDY
for monitoring or program modification. Although
home-based unsupervised exercises rehabilitation The purpose of current study was to compare two
program developed and taught to patients by rehabilitation programs after total knee arthroplasty
physiotherapists and typically completed (1) supervised rehabilitation program delivered by
independently by the patient at home. In contrast the qualified physiotherapist (2) home-based
supervised rehabilitation program provides better unsupervised rehabilitation program monitored by a
opportunities for monitoring or program modification. physiotherapist via periodic telephone calls.
Various previous studies have examined the effects of
these exercise program but the comparative study to MATERIAL AND METHOD

Inclusion and Exclusion Criteria

Corresponding author:
Bijender Sindhu Patients having primary unilateral total knee
Ph.D (Research Scholar) arthroplasty as a result of osteoarthritis, both male and
139/14, Sector-20, Rohini, Delhi-86 female who had a primary unilateral TKA, age 50-85
Telephone: +919871487673 were included in study. Patients who had rheumatoid
Email: [email protected] arthritis or major neurologic conditions were excluded.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 51

Randomization to Groups improve ROM and facilitate walking pattern. All

exercises were done in supervision and assistance of a
20 patients were randomly assigned to two qualified physiotherapist, therapists were permitted
rehabilitation program (1) supervised rehabilitation to modify or add exercises, use therapeutic modalities
program group (2) home-based unsupervised (such as ice, heat, and ultrasound) or other measures
rehabilitation program group. as they deemed appropriate.
Intervention
OUTCOME MEASURES
Home based unsupervised rehabilitation program
group The following tests were completed (1) Knee
Society Knee score (2) ILOA level of assistance (3)
The Home based unsupervised rehabilitation Goniometry; (4) VAS scale.
program was targeted to strengthen the lower limb
muscles, to improve ROM and facilitate walking Findings
pattern. We provided a booklet consisted of pictorial
and written descriptions of each exercise and necessary RESULTS
instructions about precaution, using ice and controlling 32 subjects were recruited among the patient
swelling. All patients were instructed to complete the discharge from hospital postoperatively and randomly
home exercises three times daily until their 6-week divided into supervised rehabilitation program group
follow up. A physiotherapist familiar with the home and home based unsupervised rehabilitation program
exercises made telephone to each patient of home- group. 8 patients do not fulfilled the inclusion criteria
based unsupervised rehabilitation group at least two thus excluded from study. 3 patients excluded from
times in a week asked whether the patient was having study due to prolonged hospital stay for medical
any problems with the exercises, to remind them the reasons and 1 patient refused to be tested was also
importance of completing exercises, and to provide excluded. Total 20 patients were available for final
advice on wound care, scar care, and pain control. assessment.
Patients were also provided with a contact telephone
There was significant difference observed in the
number to call if additional questions arise.
score of three outcome scale used for assessment.
Supervised rehabilitation program group Subjects in supervised rehabilitation program group
performed better compared to home based
The supervised rehabilitation program was unsupervised rehabilitation program group. The
targeted to strengthen the lower limb muscles, to numerical data are mentioned below in table 1

Table 1: Showing mean and p value of ILOA score, KSKS score, goniometry score of two groups.

ILOA KSKA Goniometry

Mean p=value Mean p=value Mean p=value
Home based unsupervised rehabilitation program group 11.94 0.018 74.72 0.017 88.06 0.05
Supervised rehabilitation program group 10.01 76.78 95.52

DISCUSSION rehabilitation program post TKA may have

advantageous outcome.
The subjects in supervised rehabilitation program
group performed better compared to home based The current pilot study compared two
supervised rehabilitation program group. Score of all rehabilitation programs, where in home based
outcome measures in the current study suggests that unsupervised rehabilitation program was a series of
the supervised rehabilitation program is better when exercises to be completed independently by patients
considering a spectrum of functional variables. at home. These exercises were developed and taught
Overall, the additional patient monitoring, adjustment to the patients by physiotherapists, supervised
of program and motivational support available rehabilitation program was targeted to strengthen the
through supervised rehabilitation may had an lower limb muscles, to improve ROM and facilitate
advantage. For these reasons the supervised walking pattern. All exercises were done in supervision

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 52 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

and assistance of a qualified physiotherapist, therapists had advantage of regular monitoring and appropriate,
were permitted to modify or add exercises, use timely and customised progression. One of measure
therapeutic modalities (such as ice, heat, and limitation in this study was a very small subject
ultrasound), or other measures as they deemed population other limitation may be that the booklet
appropriate. provided to patient were in English language. We
conclude that this pilot study gives very strong ground
for future randomised study with more specific
methodology and more number of subjects.

ACKNOWLEDGMENTS

The authors thank Dharam Pandey (MPT), Deepa

Dabas MSc (Psychology) for assistance throughout the
study.

Conflict of Interest

Authors declare that they have no conflict of

Fig. 1. (A) Showing means score of ROM of Knee Flexion interest.

Source of Funding

This study was self-finance and authors have no

financial interest.

REFERENCES

1. Manual of Orthopedics, 6th Edition- Editors:

Swiontkowski, Marc F.; Stovitz, Steven D. page
No. 342, 345, 346.
2. Physiotherapy in Orthopedics -A problem-
solving approach Karen Atkinson MSC M C S P
Fig. 1. (B) Showing means score of ILOA level of assistance Cert.Ed. DipTP Senior. Page No. 233, 253, 255,
measures. 258.
3. Catherine Jane minns lowe, the university of
Birmingham, 2009: The effectiveness of
physiotherapy following discharge from hospital
after primary total knee arthroplasty for
osteoarthritis. Page No. 25, 33.
4. John F. Kramer, PhD, 2003 Lippincott Williams
& Wilkins: Comparison of Clinic- and Home-
Based Rehabilitation Programs After Total Knee
Arthroplasty. Clin Orthop Relat Res. 2003
May;(410):225-34.
5. Neeta Khandoo, Johannesburg, 2008: The
postoperative status of total knee arthroplasty
(TKA) patients on discharge from an acute setting
Fig. 1. (C) Showing means score of (KSKS) knee society knee score in Johannesburg hospitals, South Africa. URI:
http://hdl.handle.net/10539/7391
CONCLUSIONS 6. Candace Lally, Johannesburg, 2007: The
relationship between knee integrity and function
This pilot study shows that the group of supervised post total knee replacement. URI: http://
rehabilitation after total knee arthroplasty having hdl.handle.net/10539/5743
better prognosis than home based exercise group i.e. 7. Beard DJ, Dodd CAF: Home or supervised
rehabilitation following anterior cruciate
range of motion and functional ability and pain. We
ligament reconstruction: A randomized
believe that patients in supervised rehabilitation group

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 53

controlled trial. J Orthop Sports Phys Ther 27:134– 10. Mahomed NN, Koo See Lin MJ, Levesque L, Lan
143, 1998. S, Bogoch ER: Determinants and outcomes of
8. Insall JN, Dorr L, Scott RD, Scott WN: Rationale inpatient versus home-based rehabilitation
of the Knee Society clinical rating system. Clin following elective hip and knee replacement. J
Orthop 248:13–14, 1989. Rheumatol 27:1753–1758, 2000.
9. Jokl P, Stull PA, Lynch JK, and Vaughan V: 11. Operative Orthopedics – Eleventh Edition by
Independent home exercise versus supervised Campbell’s Page No. 259, 262, 278.
rehabilitation following arthroscopic knee 12. Orthopaedics Rehabilitation by Dr.Brotzmen.
surgery: A prospective randomized trial. Page No. 251, 253.
Arthroscopy 5:298–305, 1989. 13. Research Methodology Practice by Petter Laake,
Haakon Breien Benestad. page No. 93-99.

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 DOI Number: 10.5958/j.0973-5674.7.3.065
54 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Supervised V/s Unsupervised Constraint Induced

Movement Therapy in Improving Upper Extremity
Function in Spastic Hemiparetic Cerebral Palsy Children

Charu Chopra1, Jaskirat Kaur2

1
Astt. Professor at Banarsidas Chandiwala Institute of Physiotherapy, New Delhi, 2Astt. Professor at ISIC, Institute of
Rehab Sciences, NewDelhi

ABSTRACT
Objective: Constraint Induced Movement Therapy has been found to be a promising treatment for
substantially improving the use of extremities affected by neurologic injuries such as stroke and
traumatic brain injury in adults. The purpose of this study was to determine the applicability of a
child friendly form of CI Therapy on young children with cerebral palsy.
Method: Thirty Children with hemiplegic Cerebral Palsy age 4-8 years received CI Therapy and
completed evaluations. They were randomized to either Group A or Group B. In both the groups
children wore mitt as restraint on their non-involved upper extremity and the involved upper extremity
was engaged into play & functional activities for six hours per day for ten week days. In Group A all
the activities done by children were under the supervision of therapist where as Group B was more
of home based program although activities were therapist guided. Changes in upper extremity
function were evaluated with Quality of Upper Extremity Skills Test. The evaluations took place at
the onset of intervention and after completing two weeks of intervention.
Results: Children in both the groups demonstrated significant improved functional efficiency of
their involved upper extremity (p<0.05). However, children in Group A had improved significantly
more than the children in Group B (p<0.05).
Conclusion: Results suggest that the CI Therapy can improve motoric function among children with
hemiparesis and that this efficacy is more in a therapist supervised CIMT program.
Keywords: Cerebral Palsy, Constraint Induced Movement Therapy, Restraint, Hemiparesis

INTRODUCTION intervention originated from the observation that

unilaterally deafferented monkeys normally do not
Hemiplegic Cerebral Palsy is the result of early make use of the deafferented limb, but can be induced
brain damage, including brain malformations, to do so by restricting movement of intact limb, and
periventricular brain lesions, Middle cerebral artery they will continue to use the limb even when the
infarctions and non-progressive postnatal injuries.1 The movement restriction ceases.2, 3 CIMT in humans is
resulting movement impairments are largely based on the hypothesis that in hemiplegia, disuse of
lateralized to one side, with the upper extremity the affected arm can occur as a result of learned ‘Non
usually being affected more than lower extremity.1 Use’.4 The Nonuse, in turn, leads to contraction of the
Often the integrity of the motor cortex and cortical representation of the affected extremity in the
corticospinal pathways, necessary for precision chronic phase of a patient’s recovery. So CIMT was
grasping & fine control of the fingers and hand are developed to help patients overcome this nonuse.5
compromised. Consequently skilled independent Neuroimaging and Transcranial magnetic stimulation
finger movements and hand skills do not develop (TMS) studies of the brain prior to and after CIMT have
normally. In addition, there may be reduced strength demonstrated differences in cortical organization
as well as tactile & proprioceptive disturbances which around the infarct site after the intervention.6 However,
may further impact on fine motor skills.1 Constraint unlike adults a child with hemiplegic cerebral palsy
Induced Movement Therapy (CIMT) was developed may have neural tissue that is underutilized, although
in 1986, by Edward Taub & associates. 2 The

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 55

the mechanisms for this underutilization may differ A or Group B, with 15 subjects in each group. This
from the mechanism in adults i.e. rather than learned was achieved by assigning subjects according to
Nonuse, for example a child may not develop neural the group designation indicated on a folder piece
pathways involved in movement because of lack of of paper, taped closed and drawn from a jar set up
ability to experience age appropriate sensorimotor before the beginning of subject enrollment.10
stimuli that lead to development of upper extremity
skills.5 Recent evidence suggests that children with INTERVENTION
hemiplegic cerebral palsy may improve motor
performance if provided with sufficient opportunities GROUP A: The intervention was carried out in a
to practice.6 Taub & Crago first hypothesized in 1995 child-friendly environment in which the therapy
that CIMT might be especially well suited for use with included play/functional activities 3,11.During the
children because of great capacity for plasticity in the intervention children wore a mitt on the unaffected
developing Nervous System & may result in an even hand and the affected upper extremity was engaged
better outcome.5 Taub et al (2004) randomly assigned in structured practice (Shaping and Repetitive task
eighteen children aged between 7 months & 96 months Practice) under the supervision of the Therapist.3 The
to treatment & control groups. In the treatment group total treatment protocol consisted of six hours of
a bivalved plaster cast was applied to the unaffected training per day for ten weekdays over a period of
arm for 21 days and functional training was given to two weeks.3, 12 During the therapist directed period the
the affected arm for six hours a day. Results
child’s affected upper extremity was engaged into play
demonstrated improvements in both amount of use &
and functional activities like playing card game (Uno),
functional abilities in the treatment group.4 Hence the
releasing Puzzles, arts and crafts (Paintings with
purpose of this study was to find the effects of CIMT
brushes on paper), gross motor (shoulder flexion and
on spastic hemiparetic cerebral palsy children and to
abduction), eating, playing connect four game,
see whether the Supervised or Unsupervised program
was effective in improving upper extremity function bowling, cleaning table, and drawing.3, 12. The activities
in these children. were appropriate for the age of the child and all could
be perform unimanually. The tasks were made
progressively more difficult as the child improved in
METHOD
performance by requiring greater speed, accuracy,
Subjects and Recruitment increased movement repetition, or performance
sensitive adaptations.3 The tasks constraints were
30 subjects with spastic hemiparetic cerebral palsy adapted to allow success and were removed as one’s
who met the inclusion criteria were selected for the skill improved. Only positive reinforcement was used
study. The subjects were taken from ESI Hospital, in the form of primary verbal praises, smiles, cheers,
Basaidarapur, New Delhi and Meena child clapping and supportive gestures. When the child
rehabilitation centre, New Delhi. The inclusion criteria showed signs of fatigue or reduced interest, the
was activities were adapted but not stopped. 10 The time
(1) Subjects with a diagnosis of spastic hemiparetic spent on each activity was approximately 15-20
cerebral palsy.4Age between 4-8 years.7 minutes.

(2) Ability to follow verbal instructions8. GROUP B: The intervention was carried out in a
child- friendly environment in which the therapy
(3) Ability to extend the wrist at least 20o and the included play/functional activities 11. During the
fingers at least 10 o from full flexion at the intervention children wore a mitt on the unaffected
metacarpophalangeal joints.3,9 hand and the affected upper extremity was engaged
in structured practice (Shaping and Repetitive task
(4) Spasticity not more than 3 on Modified Ashworth
Scale.9 Practice).3 This Group B was more of home based
program i.e. supervised by parents although activities
(5) Sensory integrity intact. Children were excluded were therapist guided. The Parents were instructed to
who had encourage the use of mitt at home and were responsible
for accomplishing these activities on a daily basis for
(1) Any other neurological condition leading to spastic ten weekdays over a two weeks period.8, 13 Parents kept
hemiplegia except cerebral palsy.4 on maintaining logs to monitor compliance.4 Children
(2) Any other impairment e.g. Visual or auditory.9 in this group were treated with similar number of
Children were randomly assigned to either Group hours, approach and activities as that of Group A.

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 56 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Pre and Post intervention Assessment

Assessment was done at the beginning of the study

and after completing two weeks of intervention. Upper
limb function of the subjects was assessed using quality
of upper extremity skills test (QUEST).4

QUEST supplies information related to fine motor

function, movement, postural responses as well as
quality of upper limb function. The test has four
domains:-a) Dissociated movements, b) Grasps, c)
Weight bearing, d) Protective extension.

Fig. 1 Mitt used as Restraint RESULTS

Thirty subjects with spastic hemiparetic cerebral

palsy, 16 males and 14 females with mean age of 5.95
years, 17 right hemiparetics and 13 left hemiparetics
were included. Independent t-test was used for
analyzing post treatment scores of QUEST for group
A and group B which showed that, tstat (2.27) > tc (1.70).
[at 5% level of significance and degrees of freedom
28]. In both the Groups, post treatment mean QUEST
score (Group A-67.69 & Group B-61.31) was better than
pre treatment mean score (Group A-42.01 & Group B-
39.93). Likewise Post Treatment mean QUEST score of
Group A (67.69) was better than post treatment mean
QUEST score of Group B (61.31).

Fig. 2 A Child playing Uno game

Fig. 4. Comparison between Post Treatment QUEST Score for

Group A and Group B.
Fig. 3 A Child painting on a paper

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 57

DISCUSSION

Rehabilitation Techniques for hemiplegic

cerebral palsy have focused on teaching and

reinforcing compensatory strategies that encourage
use of the noninvolved upper extremity to decrease
functional limitations.6 However, recent studies have
suggested that promoting early motor activity through
intensive practice may enhance the development of
corticospinal tract, and thereby optimize
developmental motor skill potential.7 This intensive
practice could be provided with CIMT. In this study
the approach was made child friendly by reducing the
number of hours that children were restrained, by
incorporating the movements in the context of games
or age appropriate functional tasks and by combining
home practice under the supervision of parents, yet
maintaining two major elements of adult CIMT namely
repetitive task practice and shaping to improve motor
performance of the involved upper extremity. 3,8
Children initially had difficulty using the involved
hand during the intervention period. For e.g. it took
them time to initiate and coordinate the grasp to drop
the disk into the slot in Connect four game. But this
Fig. 5 Comparison between Pre and Post treatment mean QUEST became easier with practice & once they were efficient
score for Group A.
or their performance improved the task was made
more challenging taking into consideration his/her
abilities by varying temporal, spatial and/or accuracy
constraints.3 Practice at home was advantageous, since
it was a child friendly environment in which number
of new variables introduced could be reduced and also
parents could continue the regime. The results of this
study showed that in Group A post treatment mean
value (67.69) was better than pre treatment mean value
(42.01), likewise in Group B post treatment mean value
(61.31) was better than pre treatment mean value
(39.93). This might be presumably due to large use-
dependent cortical reorganization. The use of restraint
has been debated over time since it may have
disadvantages like breakdown of skin integrity, muscle
wasting, reduced range of motion, and falls due to
imbalance. The type of restraint used for the
noninvolved hand in pediatric population is extremely
important. Mitt was chosen in this study because it
has few advantages like it is less restrictive than other
restraints, cost effective, easy donning and doffing and
also addresses concerns about the loss of balance and
falls by allowing the wearer to be able to use the
noninvolved upper extremity for protective extension.6
The results of this study also showed that the post
Fig. 6 Comparison between Pre and Post treatment QUEST score treatment mean value of Group A (67.69) was better
for Group B.
than that of Group B (61.31) and furthermore, t-test

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 58 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

analysis of post treatment QUEST scores of Group A 3. Gordon et al: Methods of Constraint induced
and Group B revealed that tstat (2.27) was more than tc movement therapy for children with hemiplegic
(1.70), showing that Group A performed better than cerebral palsy: Development of a child-friendly
Group B. These results might have been due to the Intervention for improving upper extremity
reasons that active practice is the important variable function. Arch Phys Med Rehabil 86:837-844,
2005.
in the treatment efficacy; it is related to the intensity of
4. CE Naylor: Modified Constraint Induced
practice. Since the study involved home practice in
Movement Therapy for young children with
Group B i.e. therapist guided activities supervised hemiplegic cerebral palsy: a pilot study. Dev Med.
under parents so there might have been a possibility and Child Neurol 47:365-369, 2005.
that the children in this group were not adequately 5. De Luca et al: Pediatric constraint induced
supervised by their parents during the performance movement therapy for a young child with
of activities as compared to the children in the Group cerebral palsy: Two episodes of care. Phys ther
A in which the children were supervised by the 83:1003-1013, 2003.
therapist while performing the activities. Although the 6. Charles et al: A critical review of constraint
parents maintained the logs to monitor compliance and induced movement therapy and forced-use in
the study was designed to know about the feasibility children with hemiplegia. Neural plasticity
of this unsupervised method of CIMT by the therapist 12:245-261, 2005.
7. Charles et al: Efficacy of a child friendly form of
where in all children were in a friendly home
Constraint- Induced Movement Therapy in
atmosphere under parents guidance for activities, still
hemiplegic cerebral palsy: a randomized control
it can be of research further to club this supervised trial. Dev Med and Child Neurol 48:635-642, 2006.
and unsupervised so that the children can do some 8. Eliasson et al: Effects Constraint- Induced
activities under therapist supervision and rest as home Movement Therapy in young children with
based program and therefore benefited from both the hemiplegic Cerebral Palsy: an adapted model.
protocols. Dev Med and Child Neurol 47:266-275, 2005.
9. Andrew M et al: Efficacy of Constraint induced
CONCLUSION movement therapy on involved upper extremity
use in children with hemiplegic cerebral palsy is
The application of CIMT with children with CP has not age dependent. Pediatrics 117:363-373, 2006.
only recently been investigated. This study suggests 10. E. Taub et al: Efficacy of Constraint induced
that CIMT may be effective in improving upper movement therapy for children with cerebral
extremity impairments in this population and that palsy with asymmetric motor impairment.
supervised CIMT application is beneficial for the Pediatrics 113:305-312, 2004.
children. 11. Lavinder et al: Effects of constraint induced
therapy on hand-function in children with
hemiplegic cerebral palsy: Ped Phys Ther 13:68-
REFERENCES
76, 2001.
1. Andrew M Gordon: Development of hand arm 12. Kelly et al: Case report: a modified constraint
bimanual intensive training (HABIT) for induced movement therapy program for upper
improving bimanual coordination in children extremity of person with chronic stroke. Phys
with hemiplegic cerebral palsy. Dev Med and Ther and Prac 21:243-256, 2005.
Child Neurol 48:931-936, 2006. 13. Pierce et al: Constraint induced therapy for a child
2. Elizabeth A. Noser: Constraint induced with hemiplegic cerebral palsy: A case report.
movement therapy. Stroke 35:2699-2701, 2004. Arch Phys Med Rehabil 83, 1462-1463, 2002.

12. charu Chopra--54--58.pmd 58 8/1/2013, 8:31 AM

 DOI Number: 10.5958/j.0973-5674.7.3.066
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 59

Effect of Proprioceptive Neuromuscular Facilitation in

Hemiplegic Gait a Randomized Trial of 4 Weeks and a
Follow up after 2 Weeks

Damaneek Kaur Mann1, N A Ramasubramia Raja2, Nidhi Bhardwaj2, Jagmohan Singh3

1
Student, M.P.T (Neurology), 2Associate Professor, 3Professor & Principal, Gian Sagar College of Physiotherapy,
Ram Nagar, Rajpura (Punjab), India

ABSTRACT
Background and Objectives: Stroke is the most disabling condition with 30% to 66% of individuals
lose their functional ability and gait is the most occurred motor impairment in stroke. Gait is a major
determinant of independent living, therefore, walking function is the most commonly stated priority
of stroke survivors. Proprioceptive Neuromuscular Facilitation technique is a motor learning approach
used in neuro-motor development training to improve motor function and facilitate maximal muscular
contraction. The present study aimed to evaluate the effect of Proprioceptive Neuromuscular
Facilitation & its sustained improvement in hemiplegic gait. And the objective is to improve the gait
pattern in hemiplegic gait.
Keywords: Hemiplegic gait, Proprioceptive Neuromuscular Facilitation, Spatial parameters of gait, Wisconsin
Gait Scale

INTRODUCTION Gait is a major determinant of independent living,

therefore, it is not surprising that improvement of
Worldwide incidence of Stroke has been quoted as
walking function is the most commonly stated priority
2/1000 population per annum about 4/1000 in people
of stroke survivors6.
aged 45-80 years. In India the incidence of Cerebro-
Vascular accident was found to be 13/100,000 In persons with hemiplegia, posture tone and
population per year conducted at Rohtak1. coordinate reciprocal movements, which are required
for normal gait, are usually impaired. Normal
Stroke is associated with the highest odds of
reciprocal pelvic movement is often replaced by a fixed
reporting severe overall disability2.
pelvic retraction, which makes it difficult for patients
Stroke is the most disabling condition with 30% to to swing the affected lower extremity forward. The
66% of individuals lose their functional ability3. resulting gait is slow, with short step length and
asymmetric steps, often called “Hemiplegic gait”7,8.
Gait is the most Motor impairment in stroke This slow gait can be observed in clinical settings as a
typically involves paresis of the side of the body decrease in gait speed and cadence. Improvement of
opposite to the site of the brain lesion. Gait is one of the quality of gait is often a major goal of physical
the most common and complex of human movements4. therapy for patients with hemiplegia. Proprioceptive
Neuromuscular Facilitation (PNF) is one approach
Ability to walk is generally associated with the
commonly used to improve the gait of patients with
achievement of four related tasks: maintenance of
hemiplegia 9. Various PNF procedures have been used,
upright posture; balance or stance stability during the
depending on the affected site10. Among these PNF
stance phase of the gait cycle; clearance of the swinging
techniques is facilitation of pelvic motion to improve
foot during the swing phase of the gait cycle; and the
control of the pelvis, because the pelvis has been
supply of sufficient energy to the body with each stride
described as a “key point of control” for maintaining
to ensure efficient forward progression5.
a gait pattern, techniques designed to affect the pelvis

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 60 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

are widely used very few studies however, have 30 subjects suffering from hemiplegic gait were
documented the therapeutic effects of facilitation of selected, following random sampling method from a
pelvic motion in patients with hemiplegia. finite population.

Proprioceptive Neuromuscular Facilitation Duration of study

Is a motor learning approach used in neuro-motor 6 months

development training to improve motor function and
facilitate maximal muscular contraction. It was Inclusion criteria
developed by Dr. Herman Kabat and Maggie Knot in Diagnosis of hemiplegia secondary to
late 1940’s and early 1950’s. cerebrovascular accident, with symptoms lasted from
Basis of PNF philosophy is the idea that all human less than 12 months from the incidence of stroke, The
beings, including those with disabilities have untapped ability to walk at least 60 ft (18.3 m) without manual
existing potential11. assistance with or without an assistive device, at ones
preferential speed, No previous PNF treatment could
The PNF approach to treatment uses the principle have been given to the pelvic region, The patients have
(based on early phylo-genetic and embryologic intact kinesthesia for the Hip, Knee, and Ankle as
observations) that control the motion proceeds from determined by the evaluator, Patients having
proximal to distal body regions. Facilitation of trunk hemiplegia and suffering from Hemiplegic Gait on the
control, therefore is used to influence the extremities. basis on Brunnstorm Stages of Recovery of lower
If this paradigm is valid, gaining control of and extremities, Both males and females included, Age (45-
strengthening “normal” pelvic motions should 65 years), Patients who are able to follow simple
improve lower extremity function. instructions, Patients who have suffered from first time
stroke with right or left side involvement.
PNF exercises are based on the stretch reflex which
is caused my stimulation of the golgi tendon and Exclusion criteria
muscle spindles. This stimulation results in impulses
being sent to the brain, which leads to the contraction Patients with a history of visual and auditory
and relaxation of the muscles. When a body part is deficits, Patients with a history of lower limb
injured, there is a delay in the stimulation of the muscle pathology, Patients with a history of Previous knee and
spindles and the golgi tendons resulting in weakness Hip surgeries, Patients with a history of recent
of the muscle. PNF exercises help to re-educate the significant injury to the Hip, knee or ankle, Patients
motor units which are lost due to the injury/ with a history of Brain tumor, Patients with a history
impairment. of more than one stroke incident, Patients with
contracture and deformities of the lower limb, Patients
Proprioceptive Neuromuscular Facilitation is one taking anti-spastic medication.
approach commonly used to improve the gait of
patients with hemiplegia. Various PNF procedures Procedure
have been used, depending on the affected side. 1. After the approval from the ethical committee of
Among these PNF techniques is facilitation of pelvic Gian Sagar Medical College and Hospital.
motion to improve the control of the pelvis. Because
the pelvis has been described as the key point of control 2. 30 hemiplegic patients suffering from
for maintaining a gait pattern, techniques designed to circumduction gait in case of hemiplegia secondary
affect the pelvis are widely used12. to cerebrovascular accident were selected on the
basis of brunnstrom’s stages of recovery for lower
MATERIALS AND METHOD extremities (Stage 3, 4 and 5)9.

Type of Study 3. The patient’s ability to walk at least 18.3 m (60 ft.)
without manual assistance, with or without an
Experimental group study, assistive device, at ones preferential speed.
Comparative in nature. 4. The patient’s intact kinesthesia is evaluated before
Sample Size the selection.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 61

5. For the evaluation of kinesthesia-.The patient’s hip, 9. They received a total of 12 sessions of PNF (three
knee, and ankle are tested three times. times a week) with each treatment session lasting
for 30 minutes.
• The therapist places the patient’s hip in medial or
lateral rotation, asking the patient whether the toes 10. Readings at week 0 and readings at week 4 were
are “in” or “out.” recorded by Wisconsin Gait Scale and Spatial
parameters (foot prints were taken and the changes
• The therapist places the patient’s body region to between both the readings were measured).
be considered as knee in flexion or extension,
asking the patient whether the lower extremity is 11. In a follow up after 2 weeks the readings at week 6
“bent” or “straight.” were measured and recorded to determine the
sustenance in the improvement from functional
• To test the ankle, the therapist places hemiplegic ability in circumduction gait.
patient’s foot in dorsi-flexion or plantar flexion and
asks the patient whether the foot is “up” or 12. The PNF sessions were given for 4 weeks. 3
“down.” sessions weekly, cumulative of 12 sessions.

To carry out these tests, the physical therapist Outcome measures

always puts one hand around the patient’s knee
and the other hand around the patient’s ankle. The WGS is a useful tool to rate
patient must give correct response, on all three Qualitative alterations of post-stroke hemiplegic
trials for each body region to be considered as subjects and assess changes over time during
having intact kinesthesia. rehabilitation training13.

6. After the selection process was completed the total Documented gait improvement at walking
of 30 subjects were selected, these patients were performance and to point out the correlations between
duly informed about the treatment protocol and patterns in patients with hemi paresis using the
informed consent was taken from them. Wisconsin gait scale (WGS) which is a visual gait
analysis system that examines 14 observable variables
7. PNF techniques were administered on the patient’s related to the hemiplegic gait deviations. Rodrigues
for 4 weeks. provided validation for the newly developed scale, an
instrument of gait measurement that may assist in
8. Techniques of PNF administered on the patients comparing outcomes14.
were Rhythmic Initiation, Slow Reversal, and
Agonistic Reversals. The sequence was rhythmic Footprint method involves the application of ink
initiation first for 10 minutes, followed by slow to the soles of the patient’s shoes or feet and walking
reversal and agonistic reversal each again for 10 along strips of paper. This method is easy to apply, is
minutes4. not time consuming and has high reproducibility.
Quantitative analysis of movements in specialized gait
• Rhythmic initiation- The position of the patient laboratories is expensive and unaffordable in most
was in side lying, neck slightly flexed and the clinics in Africa15.
pelvis was moved through the available range of
motion of anterior elevation and then to return the RESULTS
pelvis through the posterior depression pattern.
Statistical analysis of data using paired t-test
• Slow reversal- The patients body part moved to comparing the week0 & week 4 and week 4 & week 6
the lengthened range of the anterior elevation later and week0 & week6 values of Spatial parameters of
switching the manual contacts to the posterior gait analysis (Step length, Stride length, Toe-out angle,
depression. Base of support) and one way ANOVA to compare the
• Agonistic reversal- The therapist moves the values of week0, week 4 and week 6 of the
subjects body part to the point at which the muscle experimental group. Similarly non parametric
will be lengthened in the desired pattern (anterior Wilcoxon signed rank test for week0 & week4 and
elevation) week 4 & week 6 and Friedman’s test for comparing
the interrelation of week0,4& 6.

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 62 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Wisconsin Gait Scale- Gait Improved. Wilcoxon test

– for 0 week & 4 weeks= 4.7 (p<0.05), 4weeks & 6
weeks= 1.4 (p>0.05), 0 week & 6 week = 4.5 (p<0.05)
Friedman test (0 weeks, 4 weeks & 6 weeks)= 39.7
(p<0.05). Spatial Parameter of gait analysis- Step
length- t-test for 0 weeks & 4weeks= 20.7 (p<0.05),4
weeks & 6 weeks=.273 (p>0.05), 0 week & 6 week =
22.0 (p<0.05) ANOVA (0 weeks, 4 weeks & 6
weeks)F=72.5 (p<0.05), Stride length- t-test for 0 week
& 4 week =18.9 (p<0.05), 4week & 6 week =1.4 (p>0.05),
0 week & 6 week = 19.62 ( p<0.05) ANOVA- F=102.42
(p<0.05), Toe out angle- t-test- for 0 week & 4 week =
10.20 (p< 0.05), 4 weeks & 6 weeks=.44 (p>0.05), 0
weeks & 6 weeks = 9.8 (p<0.05), ANOVA-F=26.0
(p<0.05), Base of support- t-test for 0 weeks & 4 weeks
=2.2 (p<0.05), 4 weeks & 6 weeks =.29 (p>0.05), 0 weeks Fig. 3. Mean of stride length
& 6 weeks = 1.6 (p>0.05) ANOVA- F= .64 (p>0.05).
Paired t-test was applied to examine the changes in
dependent variable from base-line to after completion
of intervention in the group. Level of significance was
defined at p< 0.05 and confidence interval of 95% was
taken.

Fig. 4. Mean of Toe out angle

Figure 1: Mean of Wisconsin gait scale

Fig. 5. Mean of Base of support

DISCUSSION

It is found from the present study that the PNF

procedures for the pelvic region are highly beneficial
Fig. 2. Mean of Step length for patients suffering from hemiplegic gait. This study

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 63

aimed at evaluating the effect of Proprioceptive amount of improvement from the treatment protocol
Neuromuscular Facilitation in subjects with the reason for that could be inability to assess the
hemiplegic gait after 4 weeks and also to evaluate the patient in the premorbid conditions. The patients in
sustained improvement on the gait pattern in a follow this study presented with highly variable base of
up after 2 weeks from the cessation of the support.
Proprioceptive Neuromuscular Facilitation treatment
protocol. CONCLUSION

The following discussion intends to explain the It is concluded statistically from the research that
observations made and the results obtained through Proprioceptive Neuromuscular Facilitation techniques
this study in the light of the available scientific when applied on the patients with hemiplegic gait,
evidence. The subjects who suffered from hemiplegic improves the gait pattern, leading the patient one step
gait following an incidence of cerebrovascular accident closer to functional independence. Also after the
(Stroke) symptoms lasted less than 12 months from cessation of the treatment the effect of the technique is
the incidence of stroke were taken in this study with maintained by the patient’s lower extremity. The
accordance to brunnstrom stages of recovery, as the difference in week 4 and week 6 was not statistically
improvement of gait is a major goal of physical therapy significant hence suggesting sustenance in the
for patients with hemiplegia. improvement of hemiplegic gait, prior to cessation of
treatment.
Gait is one of the most common of all human
movement’s. It exists to transport the body safely and Conflict of Interest
efficiently across ground level4.
There is no conflict of interest amongst authors to
Hence, retraining of walking is a major goal in a prepare this manuscript.
rehabilitation program for persons with stroke 5.
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neuromuscular re-education for paralysis. hemiparetic patients. East African Medical
Permanente Fdn med. Bull., 8, 121. Journal, 79, (8), 420-422.
12. Assunti Pizzi, Giovanna Carlucci, Catuscia
Falsini, Francesco Lunghi, Sonia Verdesca and

13. Damneek kaur-59--64.pmd 64 8/1/2013, 8:31 AM

 DOI Number: 10.5958/j.0973-5674.7.3.067
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 65

Comparison of effects of Sitting-up using Rope Ladder

versus Manual Supported Sitting-up on Haemodynamic
Variables in Patients after Coronary Artery Bypass
Grafting

Deepti Garnawat1, Faizan Ahmed2, Muhammed Abid Geelani3

1
Physiotherapist, Dr.R.M.L Hospital, New Delhi, 2Assistant Professor, Faculty of Rehabilitation Science, Jamia
Hamdard, New Delhi, 3Professor, Department of CTVS, G.B.Pant Hospital, New Delhi

ABSTRACT
Objective: To evaluate haemodynamic effects of using rope ladder for sitting-up by patients after
Coronary Artery Bypass Graft(CABG) surgery.
Background: Rope ladders are provided to patients to sit-up after cardiac surgery. Sitting-up using
rope ladder requires a combination of isotonic and isometric efforts. Combined isotonic and isometric
activities cause some cardiovascular/hemodynamic alterations.
Method: Study was conducted on 2nd post-operative day. Measurement of Heart Rate (HR), Systolic
Blood Pressure(SBP), Diastolic Blood Pressure(DBP), Rate Pressure Product(RPP) and Post-operative
pain were obtained for all subjects in supine, immediately on sitting-up, after 5 minutes and 10
minutes of sitting with either using rope ladder or manual support.
Results: Sitting-up using rope ladder immediately resulted in an increase in DBP, HR and Post-
operative pain scores and decrease in SBP and RPP. The significance level was set at p< 0.05.
Conclusion: Sitting-up using rope ladder results in slightly greater alterations in hemodynamic
variables.
Keywords: Isometric, Isotonic, Haemodynamics, Coronary Artery Bypass Grafting

INTRODUCTION move and change positions without excessively

putting the load on the upper extremities during
Coronary Artery Bypass Surgery is a mainstay of
transfer activities 2,5. It also reduces the patient’s
therapy for patients with severe coronary artery
reliance on nursing or medical staff to be mobile when
disease1. Post-operative physiotherapeutic regimen
confined to the bed2.
includes emphasis on frequent and regular change in
body position while the patient is in bed to promote Sitting-up using rope ladder requires a combination
early recovery after surgical procedure2,3. During early of both dynamic(isotonic) and static (isometric) efforts.
post-operative period, it is also difficult for patient Both isotonic and isometric activity causes some
himself, to change position, get out of bed because of cardiovascular/ haemodynamic alterations. Various
post-operative pain, chest tubes and lines in situ, and studies have shown that the circulatory responses to
fear of increasing pain associated with movement4. dynamic exercises are characterized by increase in
Rope ladders are provided to patients to properly oxygen consumption, HR, SBP with maintenance or
slight decrease in DBP6,7. Thus dynamic exercises
Corresponding author: impose primarily a volume load on myocardium6. In
Deepti Garnawat contrast an isometric action has been shown to impose
MPT (Cardio-Pulmonary), Physiotherapist, Dr. R.M.L a pressor response on myocardium which is
Hospital, New Delhi. characterized by a marked increase in SBP, DBP, HR,
Email: [email protected] Mean Arterial Pressure and a moderate increase in

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 66 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

oxygen consumption7,8. But a combination of both PROCEDURE

dynamic and static exercise results in a predominant
Preoperative CABG patients were assessed on a
pressor response9.
standard institutional Performa which included
Patients are encouraged to use rope ladders for examination of the muscle strength and range of
sitting-up in the immediate post-operative period by motion so as to rule out any orthopedic or neurological
staff of many hospitals2,5. In contrast certain hospitals impairment which could limit the gripping of rope
do not encourage the use of rope ladder in the ladder. Sitting-up using rope ladder and with manual
immediate post-operative period. As it is well support was demonstrated and explained to the
documented that isometric and dynamic exercises are patients preoperatively. After surgery the patients were
associated with an increase in BP and HR6,7,8. For this again examined on second post-operative day. All
reason, some health care professionals question the subjects were requested to sign the written informed
safety of using rope ladder in immediate post- consent forms. The study and consent form were
operative phase as they are cautious about the approved by the institutional ethics review committee.
isometric and dynamic responses which could be
Nursing staff were trained to give manual support for
evoked during sitting-up using rope ladder. There is
sitting-up and were blind to the procedure as they were
lack of evidence regarding the use of static and
not aware of the research hypothesis.
dynamic exercise in the immediate post-operative
period in CABG patients. The safety of using rope On the second post-operative day, sitting-up using
ladder in the immediate post-operative phase is also rope ladder or with manual assistance was again
unknown. Pure isometrics are not recommended by explained to the patients. First fifteen patients were
American Heart Association guidelines for patients made to sit-up with manual support on second post-
with cardiovascular disease & post CABG surgery operative day initially & after 2 hours with using rope
within 3 months of surgery as the safety and efficacy ladder on the same day. Next fifteen patients were
of pure isometric exercise have not been established
made to sit-up using rope ladder on 2nd post-operative
in such patients10. Thus it was important to evaluate
day initially & after 2 hours with manual assistance
the physiological effects of isometric and isotonic
on the same day. The resting SBP, DBP, HR, RPP &
efforts of upper extremities which inadvertently occur
Post-operative pain level were recorded in supine
during rope pulling task which often goes unnoticed.
position (the head end of bed was elevated to 10
degree) and then patient’s were made to sit (90 degree
METHOD
upright position with legs horizontal) either with the
SUBJECTS help of nursing staff or using rope ladder. The pressure
transducers were zeroed and aligned to the
This was same subject study with 30 male post
midthoracic level (angle of Louis) in the supine
CABG surgery. Characteristics of sample are described
position and at the level of 4th inter-costal space in
in Table.1. On second post-operative day all subjects
sitting position. After recording the supine
were on intravenous infusion of inotropes,
hemodynamics, the patient position was changed to
vasodilators, nitrates, oral administration of diuretics,
the upright position. Hemodynamic measurements
antibiotics and diabetic patients were on insulin. All
patients underwent Off-pump CABG surgery. Subjects were again repeated immediately on sitting-up, after
were excluded if they showed unstable cardiovascular five minutes and after 10 minutes of sitting. HR and
condition as defined by a Mean Arterial Pressure <65 BP were measured directly from the bed side Philips
mmHg11,12 and/or HR >130.13 (Intillivue MP40,Netherland) monitors since all the
patients had an intra-arterial line in situ. Continuous
Table.1 Patient Characteristics monitoring (HR, BP and ECG) was ensured
Characteristics Mean±Standard Deviation throughout the procedure so that sitting activity could
Age(yrs) 52.73±7.23 be terminated before any alarming sign. Visual
Height(mtr) 1.67±0.04 Analogue Scale (VAS) was the tool used for self
Weight(kg) 64.73±9.65 reporting of post-operative pain which was a
Body Mass Index(kg/m2) 23.03±3.25 horizontal line scale of 0 to 10 cm. Zero was defined as
Ejection Fraction(%) 49.33±8.78 “no pain” & 10 was referred as “worst pain
imaginable”. Patients were asked to rate their pain

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 67

levels in supine position, immediately on sitting-up Sitting-up using rope ladder immediately resulted
with either rope ladder or manual support, after 5 and in significant fall in SBP, significant rise in HR and
10 minutes of sitting. The subjects were also instructed nonsignificant rise in DBP and Post-operative pain
to breathe throughout the sitting procedure and not to
scores. After 5 min of sitting SBP and DBP showed
perform breath holding to avoid valsalva maneuver.
The ACSM guidelines were followed to terminate the significant rise, RPP showed nonsignificant rise
activity 14. Patients were continuously monitored whereas HR, showed a significant fall and post-
during both type of sitting-up for any ST segment operative pain showed nonsignificant fall. After 10
depression/elevation, premature ventricular minutes of sitting SBP, DBP and RPP were found to be
contraction, atrial ectopics. Neither type of sitting decreased with no changes in HR and pain scores.
produced ST segment elevation/depression, any
significant ectopics which could compromise the Whereas sitting up using manual assistance
cardiovascular system. immediately resulted in significant rise in DBP, HR,
Descriptive statistics (Mean and Standard RPP & Post-operative pain scores. SBP also showed a
Deviations of variables) were computed for all nonsignificant rise immediately on sitting-up. After 5
demographic variables of the 30 patients. Paired t–test minutes of sitting SBP and DBP nonsignificantly
was used for comparison of dependable variables increased while HR significantly decreased towards
between the two interventions. Changes within the the base line values, RPP was also decreased and pain
group were analyzed using repeated measures scores remained same. After 10 minutes of sitting SBP,
ANOVA (Analysis of Variance) with Bonferroni
DBP, HR and RPP were significantly decreased.
adjustments. The significance level for this study was
set at p<0.05. Sitting-up using rope ladder resulted in slightly
greater alterations in hemodynamic variables (without
RESULTS
any immediate complication/adverse effects on
Mean values and Standard Deviations of the cardiovascular system) in comparison to manually
outcome variables during both type of sitting-up are assisted sitting-up.
displayed in Table.2 and Table.3.

Table 2. Mean±Standard Deviation values of outcome variables during sitting-up using rope ladder

Dependable Baseline Immediately After 5 minutes After 10 minutes

Variables (Supine position) After sitting-up of sitting-up of sitting-up
SBP(mmHg) 131.47±12.77 123.03±12.27(*) 133.0±13.58(*) 129.20±12.16(*)
DBP(mmHg) 67.23±11.1 68.73±11.13 71.73±9.86(*) 69.90±10.27(*)
HR(bpm) 102.37±15.76 109.40±14.83(*) 102.53±16.19(*) 102.23±15.31
RPP 134.96±25.12 134.43±21.36 136.72±26.43 132.31±24.18(*)
Pain(cm) 0.90±0.71 1.47±0.81(*) 1.43±0.77 1.43±0.77

(*)- The mean difference is significant at p< 0.05.

Table 3. Mean±Standard Deviation values of outcome variables during sitting-up with manual assistance

Dependable Baseline Immediately After 5 minutes After 10 minutes

Variables (Supine position) After sitting-up of sitting-up of sitting-up
SBP(mmHg) 130.17±14.32 133.87±15.87 136.57±15.87 132.90±14.31(*)
DBP(mmHg) 66.80±10.63 71.83±10.85(*) 72.97±10.09 71.33±10.07(*)
HR(bpm) 102.97±15.11 109.03±15.37(*) 104.93±15.52(*) 104.03±15.76
RPP 134.20±25.12 146.37±28.45(*) 143.84±29.86 138.61±27.20(*)
Pain(cm) 0.83±0.87 1.07±0.86(*) 1.07±0.86 1.07±0.86

(*)- The mean difference is significant at p<0.05.

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 68 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

DISCUSSION very brief period of combined isometric and isotonic

effort simultaneously with change of posture from
Rope ladders are given to patients in post-operative
supine to upright might have resulted in fall in BP. In
period to aid mobility2,5. Since literature is unclear
the present study sitting-up using rope ladder required
about effects of using rope ladder in the immediate
muscular effort in comparison of the manually assisted
post-operative phase after CABG, the present study sitting-up so one of the possible reasons for the fall in
was undertaken to investigate the physiological BP could be activation of afferent nerves in the
responses of isometric and isotonic efforts elicited contracting muscles or the Central Nervous System17.
during pulling of rope ladder. The mean DBP was increased immediately during both
the type of sitting procedures but significant (p=0.001)
The results of sitting-up using rope ladder showed rise was observed during manually supported sitting-
that there was a significant fall (p=0.01) in mean SBP up.
of about 6.41% immediately on sitting, which
significantly (p=0.01) increased after 5 minutes of Both type of sitting-up procedures resulted in
sitting and after 10 minutes it decreased significantly immediate increase in HR. The difference between the
(p=0.04). These findings are in contrast to previous two was found to be non-significant but mean HR of
studies of Louhevaara et al7, Bezucha et al9, Lind et rope ladder supported sitting-up was greater than
al15, done on isometric and isotonic exercises with manual assisted sitting-up. An initial increase to HR
diverse patient population which mainly showed an response during isometric and isotonic exercise was
increase in SBP response with exercises. They observed also observed by Petro et al19 and Borst et al20. In the
an increase in HR which solely increased the cardiac light of previous studies the possible reason for
output which was accompanied by widespread increase in HR could be an increase in sympathetic
vasoconstriction resulting in an increased BP activity19,20. The use of rope ladder produced less
response7,9,15. Whereas, Sprangers et al16 observed an demand on heart as measured by RPP, than manual
immediate fall in BP during active work than passive supported sitting. The lower RPP observed during
head up tilt. He postulated that the fall in BP was rope pulling task is primarily due to lower SBP
perhaps due to the metabolic effect in the active response.
muscles by direct activation of afferent nerves in the
contracting muscles or by central nervous system i.e. The post-operative pain levels were increased
muscular effort was responsible for the fall in BP. during both type of sitting-up procedures. The patients
During manual supported sitting-up the mean SBP reported more pain with the use of rope ladder in the
was non-significantly increased. This result was similar immediate post-operative period but none of the
to findings of Dean et al17 & Prakash et al18. The non- patient had difficulty in sitting-up using rope ladder.
significant changes found were probably due to little The increase in pain level was transient as patients
or no gravitational pooling of blood in the legs. As legs reported decreased pain after 5 and 10 minutes of
of patients were in horizontal position and not sitting-up with either type of sitting. An analogy to
substantial hemodynamics responses were observed19. our finding of greater post-operative pain during
mobility activities was also observed by Migrom et al4.
We speculate that the differences in responses in
present study in sitting-up using rope ladder were due The present study showed that sitting-up using
to the timing of measurement or the clinical status of rope ladder resulted in slightly greater changes in
the subjects, as previously none of the researchers have haemodynamic variables in comparison to manually
studied the effect of isometric and isotonic exercises assisted sitting. It was found that the changes observed
in patients immediately after CABG surgery. In the did not produce any haemodynamic instability or
previous studies7,15 all the exercises were done at a compromise cardiovascular system. Also decreased
particular maximum voluntary contraction and for RPP indicate decreased myocardial oxygen
particular duration of time ranging minimally from a consumption. Since the changes observed in sitting-
period of 1 minute to the limit of fatigue or a particular up using rope ladder did not produce any
number of contractions were performed. Whereas the haemodynamic instability, rope ladders can be a used
maximum time to sit-up using rope ladder was 5 as mobility aid for patients during immediate post-
second and the strength of contraction of various operative period. Thus, sitting-up using rope ladder
muscles during rope pulling was also not known. This is a better alternative than manually supported sitting-up.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 69

Fig.3 Between intervention comparisons for HR

Supine- HR in supine position.

Fig.1 Between intervention comparisons for SBP. Sitting- HR immediately after sitting-up.

Supine- SBP in supine position. After 5 min- HR after 5 minutes of sitting.

Sitting- SBP immediately after sitting-up After 10 min- HR after 10 minutes of sitting.

After 5 min- SBP after 5 minutes of sitting-up.

After 10 min- SBP after 10 minutes of sitting-up.

Fig.4 Between intervention comparisons for Post-Operative Pain

Scores

Supine- Post-operative pain in supine position.

Sitting- Post-operative pain immediately after

sitting-up.

Fig.2 Between intervention comparisons for DBP After 5 min- Post-operative pain after 5 minutes of
sitting.
Supine- DBP in supine position.
After 10 min- Post-operative pain after 10 minutes
Sitting- DBP immediately after sitting-up. of sitting.
After 5 min- DBP after 5 minutes of sitting.
ACKNOWLEDGEMENT:
After 10 min- DBP 10 minutes of sitting.
The author acknowledges the mentorship of Dr.
M.A.Geelani and support of other staff of G.B. Pant
Hospital.

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 70 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Conflict of Interest: There is no conflict of interest. 12. Savian C, Paratz J, Davies A. Comparison of the
effectiveness of manual and ventilator
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O, Shen N. Cardiorespiratory Responses to 18. Prakash R, Parmley W, Dikshit K, Forrester J,
Fatiguing Dynamic and Isometric Handgrip Swan H. Hemodynamic Effects of Postural
Exercise. Eur J Appl Physiol. 2000;82:340-344. Changes in Patients With Acute Myocardial
8. Marjorie G, Susan D, Stephanie B. Heart Rate and Infarction. Chest. 1973;64:7-9.
Blood Pressure Response to Several Method of 19. Petro J, Hollander A, Bouman L. Instantaneous
Strength Training. Physical Therapy. 1984; Cardiac Acceleration in Man Induced by a
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9. Bezucha G, Lenser M, Hanson P, Nagle F. 1970;29(6):794-798.
Comparison of Hemodynamic Responses to 20. Borst C, Hollander A, Bouman L. Cardiac
Static and Dynamic Exercise. J Appl Physiol. acceleration Elicited by Voluntary Muscle
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 DOI Number: 10.5958/j.0973-5674.7.3.068
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 71

Electrical Muscle Stimulation (EMS) Preserve Muscle

Strength in Critically ill Patients- A Pilot Study

Dharam Pani Pandey1, Ram Babu2, Uday Shanker Sharma3

1
Ph.D Scholar, Singhania University, Pacheri, Rajasthan, India, 2Research Supervisor, Sr. Consultant Internal
Medicine, Jaipur Golden Hospital, Rohini, New Delhi, 3Sr. Consultant Neurologist, Jaipur Golden Hospital,
Rohini, New Delhi

ABSTRACT
Introduction: Weakness that is acquired during hospitalization for critical illness is increasingly
recognized as common and important clinical problem. Weakness acquired in the intensive care unit
(ICU) and related acquired neuromuscular dysfunction occur in a large percentage of critically ill
patients and are associated with increased morbidity and mortality.
Objective: This study was designed to investigate the effects of electrical muscle stimulation (EMS)
on strength of muscle groups stimulated in critically ill patients.
Method: 134 subjects were recruited among the patient admitted in multidisciplinary intensive care
units and randomly divided in to control and EMS group. Patients unable to understand or speak
English and or Hindi due to language barrier or cognitive impairment prior to admission, unable to
independently transfer from bed to chair at baseline prior to hospital admission, Patient with known
history of primary systemic neuromuscular disease, vascular events, organ transplant, intracranial
process that is associated with localizing weakness, transferred from another ICU after >2 consecutive
days of mechanical ventilation, amputation of lower extremities were excluded from study.
Results: EMS group patients achieved higher MRC scores than controls in knee extensors
(left ≤ 0.018), (right P ≤ 0.038) and ankle dorsiflexors (left ≤ 0.04), (right P ? 0.05)
Conclusions: EMS has beneficial effects on the strength of critically ill patients mainly affecting muscle
groups stimulated, it can be considered as a potential effective means of muscle strength preservation
and early mobilization in this patient population.
Keywords: Electrical Muscle Stimulation, Muscle Strength, CIPNM, CIM, ICU-AW

INTRODUCTION Critical illness polyneuromyopathy (CIPNM) is an

acquired neuromuscular disorder observed in
Weakness that is acquired during hospitalization survivors of acute critical illness. It is characterized by
for critical illness is increasingly recognized as common profound muscle weakness and diminished or absent
and important clinical problem. Weakness acquired in deep tendon reflexes 1 and is associated with delayed
the intensive care unit (ICU) and related acquired weaning from mechanical ventilation 2 suggesting a
neuromuscular dysfunction occur in a large percentage possible relation between limb and respiratory
of critically ill patients1–3 and are associated with neuromuscular involvement. In addition, the
increased morbidity and mortality.4,5 syndrome is associated with prolonged hospitalization
and increased mortality 3. The diagnosis of CIPNM
Corresponding author: requires a reliable bedside muscle strength
Dharam Pani Pandey examination and depends on patient’s cooperation and
Ph.D Scholar, Singhania University, Pacheri, maximal effort 4 . Several risk factors have been
Rajasthan, India identified including systemic inflammatory response
Physiotherapy & Rehabilitation and sepsis5, medications such as corticosteroids6 and
BLK Super Speciality Hospital neuromuscular blocking agents7, inadequate glycemic
Pusa Road, New Delhi- 110085. (India) control8, protracted immobility 4, hypoalbuminemia 9,
Telephone: +911130653154 (Off) +919818911195 (Mob) Gram-negative bacteremia 9 and severity of organ
Email: [email protected] dysfunction 10.

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 72 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

A very few of studies available suggesting the admission (based on detail history taken from
treatment and prevention of critical illness myopathy caregivers. Patient with known history of primary
these includes intensive insulin therapy, optimal systemic neuromuscular disease, vascular events,
glycemic control and minimized use of neuromuscular organ transplant, intracranial process that associated
blocking agents, high dose and prolong use of with localizing weakness, transferred from another
corticosteroids. ICU after >2 consecutive days of mechanical
ventilation, amputation of lower extremities, any
OBJECTIVE OF THE STUDY limitation of life support, pregnancy, age under 18
years, obesity, technical obstacles that did not allow
The objective of this study was to investigate the implementation of EMS such as bone fractures, skin
whether electrical muscle stimulation (EMS) would lesions and, end-stage malignancy were excluded from
decrease the incidence of ICU-associated muscle our study.
weakness

Our experimental Hypothesis was that “EMS DESIGN OF STUDY

would beneficially affect muscle functional status and The study employed a randomized single blind
preserve muscle strength in the critically ill patients. controlled experimental study design consisting of two
group experimental group and control group, Subjects
MATERIAL AND METHOD were randomly assigned ether to experimental group
Subjects: The 134 subjects were recruited among or to control group everyday the ICU patient
the patient admitted in multidisciplinary intensive care admission register were observed and with in 24 hour
units during the study period. the assessment were done , each time when a patient
met the criteria for inclusion a random number were
Exclusion criteria picked up between 1 to 10 using sealed envelop
method if it were an odd number than the subject were
Unable to understand or speak English and or assigned to experimental group similarly if even
Hindi due to language barrier or cognitive impairment number were obtained the subjects were assigned to
prior to admission, unable to independently transfer control group.
from bed to chair at baseline prior to hospital

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 73

INTERVENTION FINDINGS

EMS was implemented on knee extensors, tibialis Data analysis and Results
anterior and of both lower extremities. Patients
All continuous variables were presented by mean.
received daily sessions. After skin cleaning, rectangular The statistical significance of P value was set at 0.05.
electrodes (90 × 50 mm) were placed on motor point
of targeted muscle. The stimulator (Unistim, HMS One-way repeated measures analysis of variance
(ANOVA) was made to compare MRC Grading
medical system) delivered biphasic, symmetric
Between-group
impulses of 50 Hz, 100 ìsec pulse duration, 12 seconds
at intensities able to cause visible contractions. The Two hundred and thirty-eight patients were
duration of the session was 30 minutes each muscle admitted to our multidisciplinary ICU during the
eight-month of study period. 104 patients fulfilled the
group. EMS sessions were continued until ICU
exclusion criteria or stayed in the ICU less than 48
discharge, both group were getting routine hours. The study population consisted of 134 patients
physiotherapy included the passive movements, active of which of 70 were randomly assigned to the EMS
assisted movements and chest physiotherapy. group and 64 to the control group. 6 patients from EMS
group and 1 patient from control group died or were
OUTCOME MEASURES discharged from the ICU before the second
measurement.
Primary Outcome Measures were lower extremity
The final results shows significant difference (MRC
strength, at discharge from ICU, of 2 bilateral muscle muscle grading score of muscle being stimulated)
groups which were stimulated measured by MMT between two groups, EMS group showed preserved
using a composite Medical Research Council (MRC) muscle strength at time of discharged from ICU as
score. compared to control group. Numerical data is
summarized in table 1 below.

Table:1 Showing numerical values of results

Knee extensors Ankle dorsiflexors

Left Right Left Right
Mean p Mean p Mean p Mean p
EMS Group 3.91 0.018 3.87 0.0387 3.91 0.04 3.46 0.058
Control Group 3.49 3.69 3.78 3.37

Graph 1: Showing the mean and significance level of two group Graph 2: Showing the mean and significance level of two group
of left and right knee extensor. of left and right ankle dorsiflexors.

DISCUSSION as assessed with MRC muscle strength grading system

. EMS of lower extremities applied to critically ill
The main finding of our randomized controlled patients upon admission is associated with a lesser
study is that EMS to lower extremities seems to degree of muscle strength loss of these patients as
preserve the muscle strength in critically ill patients assessed with MRC muscle strength grading system.

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 74 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Electrical stimulation has been used to increase and preventing CIPNM in critically ill patients and to
strength and endurance in partially and fully define which patients would benefit most from this
paralyzed muscle. It has been used for peroneal nerve intervention.
stimulation 10,11 the restoration of shoulder movement
12
, recovery of tendonesis grip 13, and in the use of an ACKNOWLEDGEMENTS
upper arm prosthesis 14. Electrical muscle stimulation
(EMS) has been used as an alternative to active exercise We would like to acknowledge the support of all
in patients with chronic heart failure (CHF) 15 and intensive care unit staff, consultants and all the patients
chronic obstructive pulmonary disease (COPD) 16,17. caregivers.
Many of these patients, even those who are clinically Conflict of Interest
unstable, experience severe dyspnea on exertion,
which can prohibit the regular application of Authors declares that they have no conflict of
conventional exercise training, considered necessary interest.
for an integrated therapeutic approach. In a recent
Source of Funding: This study was self-finance
systematic review, EMS implementation in most of the
and authors has no financial interest.
selected controlled clinical trials produced significant
improvements in muscle strength, exercise capacity
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and disease-specific health status 18. Recently, an study
identified an acute systemic effect exerted by EMS on 1. De Jonghe B, Sharshar T, Lefaucheur JP, Authier
peripheral microcirculation of critically ill patients 19. FJ, Durand-Zaleski I, Boussarsar M, et al; Groupe
Specifically, after performing a 45-minute session of de Reflexion et d’Etude des Neuromyopathies en
EMS on the lower extremities, an improvement in the Reanimation. Paresis acquired in the intensive
microcirculation of the thenar muscle as assessed by care unit: a prospective multicenter study. JAMA
near infrared spectroscopy technique was observed. 2002;288(22):2859–2867.
2. de Letter MA, Schmitz PI, Visser LH, Verheul FA,
EMS, as a possible substitute to aerobic and
Schellens RL, Op de Coul DA, van der Meche
resistance exercise training in severe CHF and COPD
FG. Risk factors for the development of
patients, has been shown to improve muscle
polyneuropathy and myopathy in critically ill
performance, aerobic exercise capacity, and disease-
patients. Crit Care Med 2001;29(12):2281–2286.
specific health status 9–11.
3. Coakley JH, Nagendran K, Yarwood GD,
Honavar M, Hinds CJ. Patterns of
CONCLUSIONS
neurophysiological abnormality in prolonged
EMS exercise induces beneficial effects in muscle critical illness. Intensive Care Med
strength of ICU patients. These effects mainly concern 1998;24(8):801–807.
muscle groups directly stimulated, but there is also 4. Garnacho-Montero J, Madrazo-Osuna J, Garcia-
evidence of effects in muscle groups not stimulated. Garmendia JL, Ortiz- Leyba C, Jimenez-Jimenez
EMS application constitutes a promising means of FJ, Barrero-Almodovar A, et al. Critical illness
muscle strength preservation and early mobilization polyneuropathy: risk factors and clinical
in critically ill patients. consequences: a cohort study in septic patients.
Intensive Care Med 2001;27(8): 1288–1296.
Clinical relevance & limitation 5. Spitzer AR, Giancarlo T, Maher L, Awerbuch G,
Bowles A. Neuromuscular causes of prolonged
EMS is an alternative method of exercise causing
ventilator dependency. Muscle Nerve
minimal discomfort to patients who are not able to
1992;15(6):682–686.
perform any form of physical exercise, as is often the
6. Rudis MI, Guslits BJ, Peterson EL, Hathaway SJ,
case in critically ill patients. It is a limitation of this
Angus E, Beis S, Zarowitz BJ. Economic impact
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of prolonged motor weakness complicating
functional recovery related Further studies are needed
neuromuscular blockade in the intensive care
to explore the possible role of EMS as a tool for
unit. Crit Care Med 1996;24(10):1749–1756.
preserving the muscle strength, the muscle properties

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7. Latronico N, Peli E, Botteri M. Critical illness 14. Knox AJ, Mascie-Taylor BH, Muers MF. Acute
myopathy and neuropathy. Curr Opin Crit Care hydrocortisone myopathy in acute severe asthma.
2005;11(2):126–132. Thorax 1986;41(5):411–412.
8. Bednarik J, Lukas Z, Vondracek P. Critical illness 15. Hund E, Genzwurker H, Bohrer H, Jakob H,
polyneuromyopathy: the electrophysiological Thiele R, Hacke W. Predominant involvement of
components of a complex entity. Intensive Care motor fibres in patients with critical illness
Med 2003;29(9):1505–1514. polyneuropathy. Br J Anaesth 1997;78(3):274–278.
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Verwaest C, Bruyninckx F, Schetz M, et al. Kamler M, et al. Sepsis and catecholamine
Intensive insulin therapy in the critically ill support are the major risk factors for critical
patients. N Engl J Med 2001;345(19):1359–1367. illness polyneuropathy after open heart surgery.
10. Tennila A, Salmi T, Pettila V, Roine RO, Varpula Thorac Cardiovasc Surg 2000;48(3):145–150.
T, Takkunen O. Early signs of critical illness 17. Garnacho-MonteroJ, Amaya-Villar R, Garcia-
polyneuropathy in ICU patients with systemic Garmendia JL,Madrazo- Osuna J, Ortiz-Leyba C.
inflammatory response syndrome or sepsis. Effect of critical illness polyneuropathy on the
Intensive Care Med 2000;26(9):1360–1363. withdrawal from mechanical ventilation and the
11. Rabuel C, Renaud E, Brealey D, Ratajczak P, length of stay in septic patients. Crit Care Med
Damy T, Alves A, et al. Human septic myopathy: 2005;33(2):349–354.
induction of cyclooxygenase, heme oxygenase 18. Bolton CF. Sepsis and the systemic inflammatory
and activation of the ubiquitin proteolytic response syndrome: neuromuscular
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12. MacFarlane IA, Rosenthal FD. Severe myopathy 1408–1416.
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1977;2(8038):615. Tomelleri G, Tonin P, et al. Critical illness
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nerve function in sepsis and multiple organ
failure. Chest 1991;99(1):176–184.

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 DOI Number: 10.5958/j.0973-5674.7.3.069
76 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Effect of Core Stability Exercises Versus Conventional

Treatment in Chronic Low Back Pain

Dheeraj Lamba1, Suneeti Kandpal2, Monika Joshi2, Mamta Koranga2, Neeta Chauhan2
1
Incharge, Dept of Physiotherapy, 2Interns, Dept of Physiotherapy, IAHSET,Govt. Medical College Haldwani

ABSTRACT
Aims and Objectives: To determine whether the use of core stability exercises on Swiss ball for
LBPgives better results.
Hypothesis: Core stability exercises on Swiss ball will be more effective in long term improvement in
chronic low back pain.
Study Design: Experimental.
Subjects: 30 subjects with chronic low back pain participated in the study.
Methodology: Based on the inclusion and exclusion criteria subjects were included in the study.
Convenient samplings was done for patients with random allocation into the following two groups:
GROUP A : (Experimental Group) exercises on the Swiss ball (15 patients).
GROUP B : ( Control Group) conventional treatment (15 patients).
Conclusion: The present study reported significant rate of improvement with exercises done on the
Swiss ball. Hence the study concludes that core stabilization exercises on Swiss ball are safe and
effective in long term management of chronic low back pain.
Keywords: LBP, Low Back Pain, VAS, Visual Analogue Scale, ODI, Oswestry Disability Index

INTRODUCTION Various etiological factors leading to LBP include

prolapsed disc, disc degeneration, osteoarthritis of
Low back pain (LBP) is the most common health
apophyseal joints, fractures and dislocations of
problems in the industrialized world and in adult
vertebrae, osteoporosis, spondylolisthesis, lumber
working age population 2. Epidemiological studies
canal stenosis and previous back surgery. General level
have shown that 50% to 80% of the population is
of physical activity, diet, heredity, posture, body build,
affected by low back pain at least once in a lifetime.
presence of other disease, previous use of medications
Prevalence among adults in different studies ranges
and autoimmune mechanism have been suggested as
from 15% to 30%. About 2% to 5% of the population
predisposing agents in these various diseases.
receives medical care or loses time from work every
year as a result of back pain. The peak age shown for The recent evidences suggest that patients with
adults was between 45-65 years secondly only to chronic low back pain exhibit deficits in proprioception
arthritis. Across sectional study done on Danish and trunk motor control. LBP is thought to occur when
population of individuals of 12-14 years of age, more spinal load exceeds the tissue tolerance 6. Dysfunction
than 50% had experienced at least one episode of LBP. of ventral and dorsal muscle of the trunk have been
The overall incidence was higher in women compared studied in low back pain. Insufficiency of muscle
to men. function leads tostress and undue load on the joints
and ligaments of the spine, because of inherent
Studies suggest that LBP is associated with heavy
instability of the lumbar spine, failure of
manual occupations in which repeated forward
intersegmental rotation is required to produce micro
bending and lifting may induce pain for patients 4
trauma of the structures of the lumbar spine.
.There is also evidence suggesting that jobs requiring
manual material handling, frequent bending/ twisting, Stability of lumbar spine require both passive
and static work posture are associated with back pain.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 77

support trough the osseous and ligamentous structures 3. Age group : 25-40 years.
and active trough muscles. Spinal instability occurs
4. Weight: 50-100 kg.
when either of these components is disturbed. Gross
instability is true displacement of vertebrae while 5. A traumatic Origin.
functional instability is due to relative increase in range
of neutral zone 1 .Active stability can be achieved Exclusion Criteria
through muscular contraction. By recruiting 1. Patients with neurological deficit.
antagonists cocontractions of trunk muscles ,spinal
stability can be improved thus allowing the structure 2. Spondylolysis.
to withstand extreme compressive loads safely. 3. Spondylolisthesis.
Cocontractions may add protection against low back
disorders by improving spinal stability. This 4. Spinal fracture.
cocontractions significantly influences spinal load 5. Spinal tumors.
accounting for 26% to 45% of local compressive load.
6. Spinal surgery.
Core strengthening has been discovered in
rehabilitation. This term has come to define lumbar 7. Pregnancy.
stabilization and other therapeutic exercise regimes. 8. Disc prolapsed.
The “core” has been described as a box with the
abdominals anterolaterally , paraspinal and gluteals 9. Scoliosis.
in the back, the diaphragm as the roof and pelvic floor
Instrumentation
and hip girdle musculature as the bottom.
Rehabilitation of chronic low back pain using a 1. Swiss Ball.
multidimensional approach has achieved wide
2. Visual Analogue Scale.
acceptance since 1970’s.
3. Oswestry Disability Index.
Core stability is a recent generic description for
training transverse abdominis and lumbar multifidus 4. Measuring Tape.
which are local stabilizers, but no focus has been
carried out yet on inclusive of global muscles in core PROTOCOL
stabilization training on long term management of
chronic LBP 2.

STUDY DESIGN

METHODOLOGY

Sample size

30 subjects with chronic low back pain participated

in the study. The subjects were recruited from
Department of physiotherapy, Sushila Tiwari Govt
Hospital Haldwani. Subjects were randomly allocated
into two groups. The mean age, height and weight of
the subjects in Group A were (34.3 + 1.19) yrs. (166.8+
1.93) cms, (68.4+ 1.59) kgs respectively, likewise in
Group B it was (31.5+1.02) yrs, (162.9+1.75) cms,
(64.7+1.25) kgs respectively.

Inclusion Criteria PROTOCOL

1. Patients with chronic low back pain ( duration of Based on the inclusion and exclusion criteria
3 months or more). subjects were included in the study. Convenient
samplings was done for patients with random
2. No radiation to leg.
allocation into the following two groups:

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 78 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

GROUP A : (Experimental Group) exercises on the extended. Patient were asked to tuck in tummy for
Swiss ball (15 patients). about 3/4th of the maximum extent. Progression of this
exercise was done by asking the patient to take out
GROUP B : ( Control Group) conventional treatment one upper extremity with the tummy in. Furthermore,
(15 patients). progression was made the by asking the patient to
simultaneously take out one upper extremely and
PROCEDURE contra lateral leg.

UPPER BODY ROLL OUT

All the patients in group A were demonstrated with
abdominal hallowing exercises to make them aware In prone roll position, the subject was made to lie
of the procedure. The maximum extent of patients with the lower leg and feet contact with the surface of
ability to hold the tummy in was recorded for each the ball. The hands were positioned in line with the
patient and they were asked hold the tummy in for shoulders, with the fingers facing forward. The trunk
about 3/4th of maximum extent in all the following was perpendicular to upper extremity (manually
exercises. The patient were instructed to maintain measured with goniometer).
normal breathing pattern while doing the exercises.
INCLINED PRESS UP
GROUP A: (Experimental Group)
The top position of the inclined press up was the
Full examination of posture, movement of lumbar starting point in which hands were placed on the ball,
spine, confirmatory tests were done and recorded. elbow was extended and trunk was inclined on the
Patients were made to fill VAS and ODI on the starting floor. Hands were about shoulder width apart. Position
day, 2nd week, 4th week and 6th week without any of each subject’s feet was marked. Then the patient
intervention given 4th and 6th week. was asked to lower the trunk by flexing the elbow joints
to approximately 90degree to hip and knee flexion.
All the patients in group A received abdominal
Then the patient was asked to extend the knee, and
hallowing exercises in supine lying , crook lying and
then extend the hip inline with the trunk.
quadruped position during 1st week. From 2nd week
onwards core stabilization exercises were given on Contralateral Single Leg Hold
Swiss ball. The exercises were performed once a day
with 10 repetitions, 6 times a week for a total duration Subject was made to lie supine on high surface with
of 4 weeks. The height of the ball differed for each only trunk supported. Right foot was kept on the floor
individual . at 90 degrees to trunk throughout the task. Left leg
was assisted manually to approximately 90 degree to
Selection of ball height: Patients were asked to stand hip and knee flexion. Then the patient was asked to
and the distance between posterior aspect of heel of extend the knee, and then extend the hip in line with
the foot and the popliteal crease was measured using the trunk.
measuring tape.
Quadruped Exercises
SUPINE LYING Patient was kept in quadruped position with hips
Patient was made to lie supine and tuck in the 90 degrees flexed, knees and hands on the floor i.e.
tummy for about 3/4th of the maximum extent. hip 90 degrees and beneath the shoulder joint. Then
the patient was instructed to take out one arm and
CROOK LYING contra lateral leg simultaneously until both upper and
lower body segments were parallel to the trunk.
Patient was in supine lying with hip 45 degree
flexed and knee 90 degree flexed and instructed tuck Group B (Control Group)
in the tummy for about 3/4th of the maximum extent. Full examination of posture, movement of lumbar
spine, confirmatory tests were done and recorded.
QUADRUPED EXERCISES Patients were made to fill VAS and ODI on the starting
Patient was made to lie in all four positions, knee day, 2nd week, 4th week and 6th week without any
was kept at shoulder width apart and elbow was intervention given 4th and 6th week. In this group

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 79

patients received conventional treatment in the form Multiple comparisons within groups for ODI was
of modalities and spinal exercises. performed showed significant improvement between
starting day and 2nd week, starting day and 4th week,
a) Ultrasound: starting day and 6th week, 2nd and 4th week, 6th week,
Patient Position: Prone starting day and 6th week but there was insignificant
differences between 4th and 6th week for group A . In
Ultrasound was applied with intensity of 1.5 to 2w/ group B, results showed significant improvement
cm square on lower back for 7 minutes. between starting day and 2nd week starting day and
4th week, starting day and 6th week , 2nd and 6th week
b) Transcutaneous electrical nerve stimulation
but the results were insignificant between 4th and 6th
(TENS) week.
Patient Position: Prone
Improvement in VAS and ODI was calculated in %
Tens was applied along the site of pain with for both the groups from starting day to the 6th week.
frequency of 2-4 Hz, output intensity of 50M A , pulse Group A showed 70.78% improvement in VAS and
rate at 2 pulse/ sec and pulse width between 30-60 79.71% improvement in ODI whereas Group B showed
minutes. 48.56% improvement in VAS and 60.25% improvement
in ODI.
c) Diathermy: Drum electrodes or induction
electrodes can be used, continuous mode was used DISCUSSION
patient position- supine, duration – 10 minutes.
Low back pain is the commonest problem in
d) Spinal Traction: Intermittent lumbar traction was industrialized world. Till date lot of treatment method
used, traction force 10-25lbs is adequate for pain have been introduced and successfully practiced. The
relief. principle of core stabilization exercises on and off Swiss
ball is well known 8 . Its applicability to relief of chronic
e) Spinal Exercises: Patient position- prone back
low back pain has been generally overlooked. Previous
extensor exercises were done by the patient 10
studies have been done to see the effect of core
times a day.
stabilization exercises on chronic LBP. O’ Sullivan et
al 5 found that specific training of deep abdominal
DATA ANALYSIS
muscles, with co contractions of lumbar multifidus
The data analysis was done using SPSS software there is significant reduction in pain intensity and
version 11.0. functional disability. The significant results for VAS in
group A are supported by the study done by Natasa
RESULTS Kavcic et al . They quantified tissue load and spine
stability while performing low back stabilization
The results of VAS showed insignificant difference exercises. Higher the compression, higher the stability.
at starting day but significant differences were seen at
2nd week, 4th week and 6th week. For ODI the results Georgory J Lehmann et al recorded the EMG
were insignificant at starting day, 2nd week, 4th week activity of trunk muscles during bridging exercises on
but showed significant improvement at 6th week. and off Swiss bal, they stated that stability is achieved
through the co contraction of trunk muscles therefore
Multiple comparisons within groups for VAS in endurance training is beneficial in training trunk
group A showed significant improvement between muscles to provide stability .A physio ball also
starting day and 2nd week, starting day and 4th week, improves proprioception, which provides increased
starting day and 6th week, 2nd and 4th week, 2nd and balance and stability. As this study included only
6 th week but there was insignificant differences young chronic LBP patients, this can also be the reason
between 4th and 6th week. In group B, VAS showed for significant improvement.
insignificant results between starting day and 2nd week
and 4 th and 6 th week but there was significant Further significant improvement in group A can
improvement between starting day 4th week, starting also be attributed to the study done by G.D Maitland
day and 6th week, 2nd and 4th week 2nd and 6th week and Richerdson et al 7 found that co contraction of
respectively. multifidus and transverse abdominis tenses the

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 80 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

thoracolumbar facia and leads to increased intra 3. Kinser C, Colby L.A. Therapeutic exercise
abdominal pressure. This provides segmental stability foundation and techniques, 3rd edition, Jaypee
to the spine hence improves LBP. The above reasons Brothers Medical Publishers (P) Ltd.
are also responsible for significant improvement in 4. Miller R.S. Exercises ball therapy for low back
disability up to 4th week in both the groups A and B. pain. JAMA October 22, 2003.
5. O’ Sullivan et at, Evaluation of specific stabilizing
The insignificant result at 6th week can be due to the
exercise in the treatment of chronic low back pain
continuation of occupation without any exercise
with radiology diagnosis of spondylolysis and
sessions. spondylolisthesis. Spine 22,24,2959-2967, 1997.
6. Foster N, Thompson K Baxter G, Allen J.
Paul Marshall et al stated that the long term
Management of non specific low back pain by
relevance of core stability exercise programs is not
physiotherapists in Britain and Ireland, a
neglected the synergistic relation between the muscles descriptive questionnaire of current clinical
of the global and local stability systems, for any practice. Spine 1999; 24: 1332-42.
movement task that involves trunk region, only one 7. Chiradejnant A, Maher C, Latimer J. Efficacy of
specific muscle system is not actively involved. One therapist selected versus randomly selected
single muscle cannot be identified as being more mobilization techniques for the treatment of low
important for lumbar stability than the other. This can back pain: a randomized controlled trail. Aust J
also be the reason for significant improvement in group Physiotherapy 2003; 49: 233-41.
A, insignificant improvement in group B. 8. Rasmussen-Barr E, Nilsson-Wikmar L, Arvison
I. Stabilizing training compared with manual
CONCLUSION treatment in sub-acute chronic low back pain.
Manual Therapy 2003; 8(4): 233-41.
The present study reported significant rate of 9. Cairns M, Foster N, Wright C. Randomized
improvement with exercises done on the Swiss ball. controlled conventional physiotherapy for
Hence the study concludes that core stabilization recurrent low back pain. Spine 2006; 31(19): E6
exercises on Swiss ball are safe and effective in long 70-81.
10. Hurwitz E, Morgenstern H, Harber P et al. Second
term management of chronic low back pain.
prize the effectiveness of physical modalities
among patients with low back pain randomized
REFERENCES to chiropractic care: findings from the UCLS low
1. Punjabi M.M, The stabilizing systems of the spine, back pain study. J. Manipulative Physio Therapy
part II, neutral zone and instability hypothesis. 2002; 25(1): 10-20.
Journal of Spinal Disorders, 5,4,390-397,1992.
2. Tesh K.M. et at, The abdominal muscles and
vertebral stability, Spine 12,5,1987.

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 DOI Number: 10.5958/j.0973-5674.7.3.070
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 81

Efficacy of Electromyography Biofeedback Training on

Trunk Stability in Chronic Low Back Pain

Hashim Ahmed1, Amir Iqbal2, Md Abu Shaphe3

1
Head Department of Physiotherapy, Shreya Hospital,Shalimar Darden Extension, Ghaziabad,U.P., 2Head Department
of Physiotherapy, Taneja Hospital, Preet Vihar, Delhi, 3Associate Professor, Faculty of Applied Medical Sciences, Jazan
University, KSA

ABSTRACT
Objectives: The purpose of this study was to investigate the effect of trunk stabilization exercise
using a gym ball with or without electromyography biofeedback for people with chronic low back
pain.
Design: Pretest-posttest Experimental - control group design.
Method: 30 subjects were randomly assigned into two groups. Experimental group received trunk
stabilization exercise along with the electromyography biofeedback whereas control group received
trunk stabilization exercise without electromyography biofeedback. Endurance and Pain was
measured at 0 week, 2nd week, 4th week and 6th week.
Results: Trunk stabilization exercise along with Electromyography biofeedback significantly improves
the endurance and reduces pain.
Conclusion: from the result we may conclude that trunk stabilization exercise along with the
electromyography biofeedback is more effective than trunk stabilization exercise without
electromyography biofeedback in rehabilitation of patient with chronic low back pain.
Keywords: Trunk Stabilization Exercise, Electromyography Biofeedback, Endurance, Pain

suffering from low back pain are between the age of

INTRODUCTION
20 and 55(11). Out of occupational factors like heavy
Low back pain(LBP) is one of the most common physical work, lifting, stooping, bending or static work
musculoskeletal disorder(1) and is closely related to postures (e.g. prolong sitting, standing), pushing ,
functional disability of the trunk muscles, such as the pulling ,carrying etc have been found to be
back extensor and abdominal muscles (2,3,4). The deep significant(12,13).
abdominals, in particular the transversus abdominis
There are various treatment techniques available
(TA) are primarily involved in the maintenance of intra
in treating low back pain, includes the correct body
abdominal pressure, while imparting tension to the
mechanics and ergonomics training, postural
lumbar vertebrae through the thoracolumbar fascia(6).
awareness training, strengthening exercise, trunk
The trunk muscles are vital to the maintenance of stabilization exercise, stretching exercise. Activities of
the spinal stability (5, 6). The spinal column is unable to daily living (ADL) training, therapeutic massage, joint
carry normal physiological loads without the support mobilization and manipulation, McKenzie, Williams
of trunk muscles (7). Such functions of the trunk muscles Flexion exercises, mechanical traction, EMG-
such as strength, endurance, and coordination provide biofeedback, (TENS), superficial and deep thermal
this stability. modalities, and work hardening(15).

Epidemiologic studies have indicated that about In 90% of patients LBP resolves within 6 weeks. In
80% of population experience low back pain during other 5% of patients the pain resolves by 12 weeks after
their active lives (8, 9, 10). Patient with low back pain have initiation (14).
weaker trunk muscles then the normal population.
Trunk stabilization Exercise is those exercises that
It has been noted that the majority of patients activate the stabilizing muscles of trunk.

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 82 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

EMG biofeedback is to enable the patient to STUDY DESIGN

reacquire voluntary control over striated musculature.
A different subject pretest-posttest experimental
In clinical EMG biofeedback training a patient is made
group design was selected for testing the hypothesis.
aware of minute or over exaggerated muscle
Data were collected pre intervention at 0 week, and
contractions through visual and auditory feedback
post intervention on 2nd, 4thand 6th week. The outcome
from muscle.
measure selected for this study was endurance and
In the last several years a numbers of authors have pain.
reported the use of EMG biofeedback in the treatment
of LBP by relaxation training of frontalis or Para PROCEDURE
vertebral muscles(16, 17).
The Subjects were screened first according to
There is number of experiment suggested that EMG inclusion and exclusion criteria. All the subjects who
biofeedback significantly work as add on therapy in met the inclusion criteria were included in the study.
various relaxation training to reduce the standing level Prior to participation all subjects were given consent
of Para vertebral muscle tension and exercise form. On the basis of the inclusion criteria mentioned
programme to strengthen the back muscles. above the subjects were randomly assigned to group
A and group B, and their baseline measurement were
So, far no previous study had been done on specific carried out for pain by VAS and endurance by pressure
topic, thus it inspired me to look deeper in to various biofeedback.
aspect of the utility of EMG biofeedback in increasing
lumbar muscles stability along individual with chronic Group A: Experimental group (trunk stabilization
low back pain and thereby reduce their pain and exercises with EMG Biofeedback)
improve endurance.
Group B: Control group (trunk stabilization exercises
The rational for employing biofeedback is to without EMG Biofeedback)
provide visual feedback to the patient exercise
performance in the form of maximum voluntary INTERVENTION
contraction of Para vertebral muscles during exercises.
Interventions were conducted over 6 weeks, twice
I focus my study to evaluate the effectiveness of a week, each session lasting 40 minutes. Sessions was
EMG biofeedback as add on therapy, thereby to supervised by the investigator, and participants were
standard stabilization training in increasing the instructed to report any adverse event, whether it was
stability of trunk muscles in chronic low back pain. related to the exercises or not. Participants were
instructed not to participate in any other physical
METHOD program during the study.
30 subjects were randomly assigned into two Warm up exercise component
groups. The criteria for inclusion were Gender –Male,
age 30- 40 years, Subject to low back pain as a primary Aerobic work: exercise bicycle for 5 minutes at
complaint, due to mechanical cause, Low Back Pain moderate pace.
of more than 3 months. Subjects were excluded if they
Stretching exercises
are diagnosed as having a tumor, infection, or
inflammatory disease affecting the spine,have spinal Back stretches
or lower limb surgery,have spinal fractures or
structural deformities such as spondylolisthesis, have Leg stretches: Hip flexor, Hamstring, Calf,
contradictions to exercise therapy) e.g: uncontrolled Adductor Stretch.
hypertension, previous myocardial infarction,
Electrode placement: A disposable silver/silver
cerebrovascular disease, peripheral vascular disease,
chloride electrode with a recording diameter of 1 cm
respiratory disorder), have sign of nerve root
was used. The EMG signals was recorded from the
compression, defined as decreased tendon reflexes,
upper & lower rectus abdominals, The upper rectus
sensory loss and motor deficits, Severe
abdominis (3 cm lateral and 5 cm superior to to the
osteoporosis.,Lumbar canal stenosis, acute disc
umbilicus), the lower rectus abdominis (3 cm lateral
herniation, and Lack of motivation.
and 5 cm inferior to the umbilicus), the upper back

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 83

extensors (2 cm lateral to the midline running through 10. Subjects control sitting posture on the gym ball
the T9 spinal process), the lower back extensors (2 cm while rhythmically extending alternate legs.
lateral to the midline running through the L5 spinal
process). 11. Subjects did a curl-up on the gym ball in half sitting
position while one leg extended.
For Group A: After the electrode placement all the
subjects were made to perform activities with the gym 12. Subjects lifted the body up to the push up position
ball in different positions. Before doing these activities and held it, while supporting themselves with their
in any of the positions, they were instructed to draw hand on the gym ball and their toes on the floor in
the abdomen inwards to activate the deep muscles. prone position.
The activities performed by subjects in stage 1 and 2 The patient was instructed that during muscular
in various positions are as under: contraction a beep sound appear, so the contraction
1. Subjects lifted the gym ball up and held it between was performed with its maximum volume as he can
their legs with both knees flexed in supine position. perform.

2. Subjects lifted the pelvis up to the bridged position For each exercise subjects perform 10 repetitions
and held it, while supporting themselves with both (10 second holds and 5 second rest).
legs on the gym ball and with the knees extended Patient was given 1 to 2 minute rest in between each
in supine position. type of exercise.
3. Subjects placed both the hand on the gym ball and Group B: The same exercise was performed
their knees flexed on the floor, maintaining four- without EMG biofeedback.
point kneeling position.

4. Subjects control sitting posture on the gym ball. DATA ANALYSIS

5. Subjects did a curl-up on the gym ball in half sitting Statistical analysis was performed by using SPSS
position. 16 version software. Repeated measure ANOVA
(multivariate test) was done to find differences within
6. Subjects lifted the body up to the push up position group A and B for all variables i.e. VAS and END. Post
and held it, while supporting themselves with both hoc Boneferrion was done to find pair wise differences.
legs on the gym ball and hands on the floor in Independent T test was done to compare difference
prone position. for all variables.

Stage 2 of the exercise program involved increasing The alpha (probability) level has been taken as 0.05
the complexity of the exercise by progressing and
exercises targeting coordination of trunk and limb RESULT
movement, maintenance of optimal trunk stability,
and improvement of posture and movement Endurance
patterns. Within Group analysis
7. Subjects lifted the gym ball up and held it between Endurance was significantly improved at the end
their legs with knee extended in supine position. of the second week in both the groups, (p=0.00) which
8. Subjects lifted the pelvis up to the bridged position was maintained till end of treatment (p=0.00) in both
and held it, while supporting their head on the gym the groups
ball and with their feet on the floor, with both knees Between Group analysis
flexed in supine position.
Endurance was significantly improved in Group A
9. Subjects in four -point kneeling position with one as compared to Group B at end of 2nd week (p= 0.00),
arm and leg in extension. 4th week (p=0.00) and the end of 6th week (p= 0.00)

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 84 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Table.1: Between groups comparison of endurance

Variables Group A Group B Mean difference t value p valve

END0-END2 6.29+2.30 3.39+1.13 2.89 4.53 0.00
END0-END4 11.39+2.60 5.80+1.39 5.58 7.46 0.00
END0-END6 15.19+2.69 7.54+1.23 7.69 9.87 0.00

PAIN

Within group analysis

VAS score was significantly decreased at the end

of the second week in both the groups, (p=0.00) which
was maintained till end of treatment (p=0.00) in both
the groups.

Between group analysis

Pain was significantly reduce in Group A as

Fig. 1.Comparison between pre-test and post-test value of
compared to Group B at end of 2nd week (p= 0.032), 4th
endurance between the groups(0 to 2, 0 to 4 and 0 to 6 weeks). week (p=0.042) and the end of 6th week (p= 0.025)

Table.2: Between groups comparison of pain

Variables Group A Group B Mean difference t value p valve

V0 – V2 1.29+0.69 0.80+0.56 0.52 2.19 0.028
V0 – V4 2.49+0.64 1.93+0.76 0.59 2.12 0.038
V0 – V6 4.42+0.78 3.73+0.70 0.65 2.27 0.027

stabilization exercise brought greater gains in all

outcome measures, including endurance and pain
intensity.

The analysis showed that the 6 weeks of

intervention period brought significant improvement
in both the groups. The experimental group shows
more improvement than control group which was
statistically significant.

Within Group, Improvement in endurance

Fig. 2. Comparison between pre-test and post-test value of pain
between the groups (0 to 2, 0 to 4 and 0 to 6 weeks). According to Kines and Hollusuzy et al (1994),
within group improvement in endurance is due to
DISCUSSION effect of exercise which increases the capillary density
(6)
and oxidative capacity of muscle fibres (7) which
The study was designed to determine the efficacy then enhance oxygen unloading resulting in increased
of trunk stabilization exercise with or without EMG VO2 diffusion by 7%.
biofeedback in patient with chronic low back pain. The
purpose of study was to assess the effectiveness of Mole, Holloszy et al revealed that muscle
EMG biofeedback as an adjunct to trunk stabilization mitochondria undergoes major adaptive changes in
exercise in order to increase the endurance and response to exercise and they increased respiratory
decreasing pain. control, hypermia, oxidative phosphorylation and
more ATP production,(7) so that the supply of energy
The result of study demonstrated that a is for longer duration which could lead to
combination of EMG biofeedback and trunk enhancement of endurance.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 85

Grieves et al (2000) showed that exercises leads to Barr K.P, Griggs et al stated that improvement in
increase in major glucose transporter (GLUT-4) and endurance and lumbar stability reduced pain. (20)
lipoprotein lipase (LPL) in skeletal muscles, these
GLUT-4 and LPL act as source of energy fuel.(17,18) This Hartingan et al concluded that exercise reduce
can leads to increase in blood flow and help in the anxiety and fear which help in reduction of back
reduction of lactate level. This can leads to reduction pain.(20)
in muscle fatigue and hence improve endurance and The experimental group shows more improvement
muscle work, than control group which was statistically significant.
Between Group, improvement of endurance A possible explanation for this improvement may be
due to EMG biofeedback can make the patient feel
The data showed that 6 weeks of training period more in control of the experienced pain, since there
brought significant improvement in both the groups. appears to be a way to influence and thus reduce pain
In between group analysis the improvement of levels. Thus, biofeedback promotes active participation
endurance in EMG-biofeedback group was greater and motivates the patient, which is arguably the most
than those of control group at the end of training critical element for pain management.
period. Difference in endurance gains by EMG-
biofeedback group may be explained by the following CONCLUSION
complimentary theories:
From the result we can concluded that the addition
Basmajian has demonstrated that with the help of of electromyographic biofeedback to trunk
auditory and visual cues, subjects could control the stabilization exercise programme has shown greater
recruitment as well as the frequency of discharge of gains in endurance and reduction of pain intensity.
motor units.10 in terms of the present study, one might Future research is needed to look for long term follow-
hypothesize that the visual and auditory cues from ups.
the biofeedback unit enabled Group A to consciously
and precisely control the exercise at submaximal REFERENCE
thereshold level. Therefore increase firing rate of small
motor units, or the frequency of discharge of the active 1. Liebenson C Rehabilitation of the spine Baltimore
Williams and Wilkins 1996 Churchill Livingstone
motor neurons. Therefore, one could hypothesize from
2. R A McKenzie, the lumbar spine: mechanical
the work of Brasmajian that because more fibres were
diagnosis and therapy spinal publication New
firing and possibly faster rate, Group A produced Zealand 1983
greater gains in endurance. 3. Claus Manniche,et al. Clinical trial of intensive
muscle training for chronic low back pain. The
Neural factor have been described by Moritiani and
Lancet, 31 december 1988 volume 332, issue 8626.
Devries, (19) as a facilitation or disinhibitation occuring Pages 1473-1476
as a result of neurological reorganization. Although 4. D Gute, C. et al. Regional changes in capillary
not yet clearly understood, this may be hypothesized supply in skeletal muscle of high- intensity
that persistent recruitment of increased number of endurance trained rats. Journal of applied
motor units via biofeedback causes a reorganization physiology 1996: 81 (2) 619-626
of facilitation pattern. This reorganization may be 5. Laughlin M H. cardiovascular response to
responsible for either the increase firing rate of slow exercise. Advance in physical education 1999;
motor neuron or the increase number of motor units 22:1:5244-5259
recruited, as demonstrated by the significant increased 6. Bente Kiens, et al. Skeletal muscle substrate
in endurance. utilization during submaximal exercises in man.
Journal of physiology 1993:469:459-478
Pain intensity 7. Holloszy J O biochemical adaptation in muscle.
Effect of exercise on mitochondrial oxygen uptake
The data revealed that 6 th weeks intervention and respiratory enzymes activity in skeletal
brought significant reduction in pain in both the muscle. Journal of biochemical chemistry 1967;
groups. This significant improvement in both the 242:2278-2282
groups may be attributed to improvement in back 8. Panjabi MM. The stabilizing system of the spine,
endurance and there by spinal instability which leads part I: function, dysfunction, adaptation, and
to reduction in pain. enhancement. J Spinal Disord. 1992; 5: 383-389

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9. Rozemberg S, low back pain: Deffinition and 16. Moffroid MT. Endurance of trunk muscles in
treatment, Rev Prat,2008, 15; 58:265-72 persons with chronic low back pain: assessment,
10. Basmajian JV, ed. Biofeedback: Principles and performance, and training. Journal of Rehab.
Practice for Clinicians. 2nd ed. Baltimore, MD: Research and Development 2006: vol.34, no.4, oct-
Williams and Wilkins; 1983. 1997, page 440-52.
11. Nielson WR, Weir R. Biopsychosocial approaches 17. Greiwe J S, Holloszy JO et al Exercise induced
to the treatment of chronic pain. Clin J Pain. 2001; lipoprotein lipase and GLUT-4 protein in muscle,
17(4 suppl):S114-127. independent of adrenergic receptor signalling.
12. Middaugh SJ, Kee WG. Advances in Journal of applied physiology 2000; 89:1:176-181
electromyographic monitoring and biofeedback 18. Houmard J, Hickey M et al. Seven days of
in the treatment of chronic cervical and low back exercise increase GLUT-4 protein content in
pain. Adv Clin Rehabil. 1987; 1:137-172. human skeletal muscle. Journal of applied
13. Neblett R, Gatchel RJ, Mayer TG. A clinical guide physiology 1995; 97:1936-1938
to surface-EMG-assisted stretching as an adjunct 19. Moritani T, Davries H A neural factor in
to chronic musculoskeletal pain rehabilitation. hypertrophy in the time course of muscle strength
Appl Psychophysiol Biofeedback. 2003; 28(2):147-610. gain. Am. Jr. Of Physi. Med. 1979; 58:115-130
14. Arokoski JP, Valta T, Airaksinen O et al (2001) 20. Barr KP, Griggs M et al. Lumbar stabilization. A
Back and abdominal muscle function during review of core concept and current literature. Part
stabilization exercises. Arch Phys Med Rehabil 2 American Journal of Phys Med Rehabil. 2007;
82:1089–1098 86:1:72-78
15. Silfies SP, Maurer P et al (2005) Trunk muscle
recruitment patterns in specific chronic low back
pain populations. Clin Biomech 20:465–473

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 DOI Number: 10.5958/j.0973-5674.7.3.071
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 87

A Comparative Study between the effects of Static

Somatosensory Balance Training and Static Vestibular
Balance Training on Dynamic Balance and Fear of Fall in
Institutionalized Elderly

Jyoti Laroia1, Nusrat Hamdani2, Majumi Mohammad Noohu3

1
Master of Physiotherapy, Student, 2Assistant Professor, Jamia Hamdard, New Delhi, 3Assistant Professor, Jamia Milia
Islamia, New Delhi

ABSTRACT
Purpose: To determine carry over effects of static somatosensory balance training or static vestibular
balance training on dynamic balance and fear of fall in institutionalized elderly.
Subjects: Forty subjects aged 60 to 80 years.
Method: Subjects were selected according to inclusion and exclusion criteria and were divided into
two groups. Group 1 underwent static vestibular balance training and group 2 underwent static
somatosensory balance training. The subject's dynamic balance was measured with the help of
functional reach test (FRT) and Timed Up and Go test (TUG) and fear of fall was measured by Activities
Specific Balance Confidence Scale (ABC). Measurements were taken at baseline, immediately after
four weeks of intervention and after four weeks of follow up from intervention. Frequency of falling
was also determined by noting the number of falls that occurred during the follow up period.
Independent t-test was used to compare the difference between the group as well as one-way Anova
and Post hoc bonferroni were used to compare the outcomes within the two groups.
Results: The results documented that static balance training has carry over effects on dynamic balance;
this was justified by significant difference in the scores of functional reach test when between groups
comparison was done. Also there was significant improvement in fear of fall in elderly subjects, as
evidenced by statistically significant difference in the scores of activities specific balance confidence.
The p-value of ABC was 0.01 in group 1 and group 2 when between groups comparison was done.
Conclusion: Static balance training has carry over effect on dynamic balance this was documented
by statistically significant scores of FRT and ABC. The significant results between the two groups
hypothesize that static balance training could be an effective part of rehabilitation settings. Despite
the many age-related changes occurring in the multiple systems that contribute to good balance and
mobility, growing evidence suggests that we can reverse, or at least slow, the rate of decline occurring
in some or all of these systems.1
Keywords: Balance, Fear of Fall, Institutionalized elderly, Activities Specific Balance Confidence

INTRODUCTION popular country in the world has 76.6 million people

at or above the age of 60, constituting above 7.7 % of
The number of persons above the age of 60 years is
total population. In a Multi – centric Community study,
fast growing, especially in India. The problems faced
evaluating Health Problems in the Elderly, in 10 states
by this segment of population are numerous owing to
across India covering a total population of 10200
the social and structural changes that are taking place
elderly with, the incidence of falls was found to
within the Indian society. Falls are one of the major
be 14 %.2
problems in the elderly and are considered one of the
“Geriatric Giants”.2 The highest fall incidence occurs Myers et al identified more than 130 different fall
in the institutional long-term-care setting where 50% risk factors. History of falls is associated with increased
to 75% of the 1.63 million nursing-home residents risk. Carter et al., suggested that most of the falls risk
experience a fall yearly.2 India as the second most associated with advancing age can be attributed to

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 88 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

changes in three sensory systems: the vestibular, the The purpose of this study is to find out the carry
visual and the somatosensory.3 Fallers tend to be less over effect of static balance training on dynamic
active and may inadvertently cause further atrophy balance and to compare the two interventions of static
of muscle around an unstable joint through disuse.4 balance training that is vestibular and somatosensory
Exposure to risk is also one of the factors contributing in institutionalized elderly aged 60 to 80 years of age
to falls. One trial found that brisk walking may increase having a fall history within 6 months. That if training
the risk of falls5 others found that increased physical one aspect of balance (static) has effect on other aspect
activity was associated with a decreased risk of falls, then why spending time in offering complex time
but an increased risk of suffering a serious injury.6 consuming dynamic training protocols in
institutionalized elderly. This time could be entailed
Poor balance is a known risk factor for falls, in other domains of balance problems or offering
investigating methods to improve balance and prevent services for limiting disability by throwing light on
falling among older people is a high priority issue.7 other important risk factors. This research involves
Balance function has been reported to decline with age, determining fear of falls in institutionalized elderly as
as evidenced by increased postural sway and well as reduction in the number of falls as the
decreased stability.8 The age – related changes in secondary aim, as subjects who have a fall history have
subsystems involved in balance control contribute to a greater prevalence of fear of falling
the poorer balance performance of older adults
compared with younger people.7 Improvement of
METHOD
balance may be a desired functional outcome for many
patients, for this proper assessment plays an important Subjects: 40 institutionalized elderly aged 60 to 80
role.8 The high prevalence of dysmobility in older years were taken.
individuals requires that geriatric assessment include
a reliable, easily administered measure of balance9. Inclusion Criteria

A study done by Shimada H determined the 1. Institutionalized elderly

effectiveness of treadmill gait training in 2. Male /Female between 60-80 years of age.
institutionalized disabled elderly. The study seemed
to be beneficial in improving balance and reaction 3. Cognitively intact (MMSE>24)
time.1
4. Berg Balance Scale 35-40
Fear of falls has been recognized as a negative
consequence of falls.Tinetti and Powell defined fear 5. Able to walk independently at least 10 meters.
of falling as an ongoing concern about falling that 6. At least 1 fall in the previous 6 months (not
ultimately limits the performance of daily activities.10 resulting from a violent blow; loss of
Assessment of falls is considered equally important consciousness, paralysis, or seizure).
as balance. Many fall risk screening tools have been 7. Independent in ambulation.
introduced into clinical practice in the United Kingdom
in recent years.11 Clinically, the Tinetti Gait and Balance Exclusion Criteria
Assessment (TGBA) have been widely used to assess
1. Uncooperative patients.
the risk of falls in elderly by examining balance and
gait.12.Questionnaires such as the Activities Specific 2. Patients with any neurological deficit or cerebellar
Balance Scale provide self- report information dysfunction.
regarding functional status.
3. Patients with severe cardiac or pulmonary disease
Prescribing the right treatment requires an terminal illness, dementia, medical unresponsive
understanding of the processes which lead to falls, and depression.
knowledge of the modifiable risk factors.13 The key 4. The subjects with visual problems or severe
message revealed to us is that falls are not just due to auditory problems.
age, many falls can be prevented, and some simple
questions about presence of common falls risk factors 5. Elderly who used assisted walking devices or who
should be reviewed that indicate the need for a health were unable to walk independently at least 10
practitioner review. meters.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 89

Instruments both the groups 1 and 2. Then group 2 was subjected

to somatosensory exercises i.e. anterior-posterior tilts
Stop watch , Chair , Yard stick , Wobble Board
on wobble board, medial lateral tilts, knee flexion,
,Foam Roller and Marker
tandem stance and standing on roller and hard surface.
Similarly group 1 was subjected to static vestibular
PROCEDURE
exercises17 namely looking straight ahead on the target,
Institutionalized elderly subjects who were willing turning head 45 degrees towards right and then
and fulfilling inclusion criteria were taken for the towards left, active eye-head movements between two
study. The subjects were selected by sample of targets, and visualization of imaginary targets.
convenience and were randomly allocated into two Dynamic balance measurements were taken by FRT
groups. Group 1 underwent static musculoskeletal and and TUG test and fear of fall was measured by
static vestibular balance training and group 2 was activities specific balance confidence scale immediately
subjected to static musculoskeletal and static after the four week intervention period and again after
somatosensory balance training. Their dynamic four weeks of follow-up period. Frequency of falls was
balance measurements were obtained by (TUG) and reassessed by taking record of subjects through phone
(FRT) as well as fear of fall scores were taken by 8 weeks after baseline measurements.
activities-specific balance confidence questionnaire
(ABC) before the commencement of the training. Their DATA ANALYSIS
frequency of falls was also noted. The Balance Training
Independent t-test was used to compare the
Program consisted of 40 minutes of exercises per
differences between the two groups. One-way Anova
session, 5 days a week for 4 weeks. Group 1 and group
was used to compare the outcomes of each variable at
2 were given static musculoskeletal exercises namely
baseline, after intervention and after follow-up. A post
one foot standing balance, one foot standing balance14
hoc comparison was made by post hoc bonferroni with
with hip flexion and side lateral raise for balance15,
a significant level at p<0.05.
these exercises targeted on ankle strategy. These
exercises were preceded by two foot standing balance
RESULTS
with forward bending and two foot standing balance
on foam roller. These exercises targeted on improving The demographic data shows insignificant
ankle strategy. Then static strengthening exercises16 like difference between group 1 and group 2 in terms of
ankle plantar flexion, dorsiflexion, knee flexion, hip age and weight. P-value has been taken as <0.05 which
flexion, hip extension and side leg raise were given to is considered significant.

Table 1: Between group comparison of PI (TUG, FRT & ABC) i.e. post- intervention (After 4 weeks from baseline)
and FU (TUG, FRT & ABC) i.e. follow up intervention (After 8 weeks from baseline) in group 1 & group 2.

Variable Group 1 Group 2 t-value p-value

PI TUG(Mean + SD) 11.01+1.01 10.95+0.56 0.21 0.82
FU TUG(Mean + SD) 11.86+1.03 11.65+0.74 0.71 0.48
PI FRT(Mean + SD) 8.30+1.30 7.05+1.73 2.58 0.01
FU FRT(Mean + SD) 7.25+0.85 6.10+1.48 3.00 0.005
PI ABC(Mean + SD) 66.54+5.48 71.97+7.35 -2.64 0.01
FU ABC(Mean + SD) 61.71+3.77 66.69+7.81 -2.56 0.01

Table 2: Between group comparison of pre intervention and follow-up intervention of falls.

PRE FALLS (Mean + SD) 1.35+0.81 1.20+0.69 0.627 0.53

FU FALLS(Mean + SD) 0.100+0.30 0.100+0.30 0.00 1.0

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 90 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

DISCUSSION

The results of the study indicate that static balance

training forms an important and essential component
that needs to be highlighted in the rehabilitation
settings when designing protocols for balance training
mainly for the “specific age group’ i.e. older adults.

The primary objective of this study was to ascertain

the carry over effects of static balance training on
Graph 1: The graph compares the timed up and go scores between dynamic balance. It is useful to us because the foremost
the two groups before intervention (Pre), after intervention (PI worry for any health professional working with
TUG) and after follow-up (FU TUG).
unstable older adult is that the person falls whilst
exercising or taking part in any activity. Physical
activity generally involves the use of large movements
that displace the body’s center of gravity and therefore
taxes balance.18 In the present study participation in a
4 week static balance training exercise programme
(both vestibular and somatosensory) is effective and
had significant carry-over effect on dynamic balance
as indicated by the changes in the scores of functional
reach test between the two groups. Although we are
aware that balance training serves a very essential and
Graph 2: The graph compares FRT before intervention (Pre FRT),
after intervention (PI FRT) and after follow-up (FU FRT). significant role in the rehabilitation of older adults and
subjecting older adults to either strength training or
flexibility interventions could not impart the benefit
equivalent to balance interventions. This view was
supported by Melzer et al., where the subjects who
participated in the balance training obtained 64%
improvement in 3 months in comparison to the group
subjected to muscular strength training.19

Consistent with the above findings, in the present

study static balance exercises formed the main frame
of intervention in older subjects who were the part of
Graph 3: The above graph illustrates comparison of ABC before
intervention (Pre ABC), after four weeks of intervention (PI ABC) the study. To document the effect of balance training
and after four weeks of follow-up (FU ABC). in elderly aged 60 to 80 years having a fall history, both
the groups 1 and 2 were subjected to a similar static
musculoskeletal training protocol. This was consistent
with the findings from other studies that hypothesize
that programs that emphasize balance training are
more effective at improving balance than other
interventions that emphasized on muscular strength
or flexibility exercises.20Taking in view the role of work
done earlier on standing balance training as evidenced
by earlier researches, 21 the present study utilized static
balance training as the only means to document its
effect on dynamic activities. Most of the studies that
Graph 4: The graph shows comparison of falls between groups 1
and 2 prior to intervention (PRE FALLS) and after four weeks
were done earlier, highlighted on a generalized balance
follow-up (FU FALLS). The p-values were not significant. training protocol.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 91

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on postural control of elderly. Harefuah 2005, 114: group exercise improves balance and reduces falls
839-844. in at-risk older people: A randomized controlled
20. Rogers ME, Fernandez JE; Training to reduce trial. Age and Ageing 2003; 32: 407-414.
postural sway and increase functional reach in
the elderly. J Occup Rehabil 2001, 11:291-298.

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 DOI Number: 10.5958/j.0973-5674.7.3.072
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 93

Efficacy of Eccentric Training and Muscle Energy

Technique on Hamstring Flexibility in Sedentary College
Students

Gurpreet Kaur1, M Kashif Reza2

1
MPT Student, 2Lecturer, College of Applied Education and Health Sciences, A-122 Gangotri Colony,
Roorkee Road, Meerut, UP, India

ABSTRACT
Purpose of study: Muscular flexibility is an important aspect of normal human function . Limited
flexibility has been shown to affect a person's level of function. Purpose of the study is to investigate
the effectiveness of Eccentric Training and Muscle Energy Technique on hamstring flexibility in
sedentary college students and to compare the effect between the boys and girls.
Methodology: 40 healthy college students between the age groups of 18- 25 years were selected and
were randomly assigned to two study groups. Group 1 (n= 20) subjects were treated with Eccentric
Training where as Group 2 (n= 20) subjects were treated with Muscle Energy Technique. And each
Group comprising of equal ratio of boys and girls. Treatment was given for 14 consecutive days and
a follow up measurement was done one week after cessation of intervention. The outcome was
measured in terms of Active knee extension test and Sit and reach test. Each intervention was
performed for duration of 30 sec.
Results: There was a significant difference in range of motion in Active knee extension test between
both the groups with (p= 0.005) in right side and left side (p=0.10), whereas in Sit and reach test there
is no significant difference between both the groups with (p= 0.219) according to the paired and
unpaired t- test.
Conclusion: Results indicate that muscle energy technique is significantly improving hamstring
flexibility. But there is no statically significant difference in muscle flexibility between boys and girl.
Keywords: Active knee extension, Sit and reach, Static Stretch

INTRODUCTION Inadequate hamstring muscle length has

historically been thought of as a possible cause of
The ability of an individual to move smoothly hamstring injury. 6 Hamstring strain injuries are
depends on his flexibility, an attribute that enhances common in sporting arena, and frequently occur in
both safety and optimal physical activities. 1 Most activities which involve running, sprinting, jumping
medical professionals, coaches and athletes consider or kicking. Incidence rates of hamstring strain range
aerobic conditioning, strength training and flexibility between 7.7% and 30% with relatively high recurrence
are integral components in any conditioning program.2 rates between 18% and 34%.3
Limited flexibility has been shown to predispose a Gajdosik and Lusin designed a test to measure
person to several musculoskeletal overuse injuries and hamstring length by the angle of knee flexion after knee
significantly affect a person’s level function.3 Muscle extension [AKE] while the hip was stabilized at 90
tightness is caused by a decrease in the ability of the degree flexion.6
muscle to deform, resulting in a decrease in the range
of motion at the joint on which it acts.4 Static stretching of hamstring muscle has been
shown to be efficient for gain in flexibility.7
There are two ways to measure flexibility; by linear
or angular measurements to directly determine the Eccentric training that allows the muscle to elongate
extreme limits of range of motion. Linear measurement naturally and in its relaxed state this elongation is
measures length quantitatively, and angular measures achieved by having the subject eccentrically contract
angle such as with a goniometer is similar to protector.5 the antagonist muscle to move the joint through the

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 94 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

full available range in slow controlled manner to SAMPLE DESIGN

stretch the agonist muscle group.8 Eccentric strength
training resulted in improving the hamstring flexibility, Convenient sampling
producing a gain of 12.8 degree in range of motion.9 CRITERIA FOR SAMPLING
One such approach which targets the soft tissues INCLUSION CRITERIA
primarily although it makes a major contribution
towards joint mobilization has been termed as muscle • Age group- 18-25 years
energy technique and is also known as active muscular
relaxation technique.2 • Both Males and females

Muscle energy technique is a form of manual • Clinical Diagnosis of hamstring flexibility

therapy frequently used, herein the patient voluntarily confirmed by history, physical examination.
contracts specific muscles against the resistance of the • Tight hamstring of 30 degree knee extension deficit
clinician.10
• Subjects had no warm up before data collection
It is defined as resistive duction, which is defined
as a series of muscle contraction against resistance. • Extremity had no history of impairment to knee,
Muscle energy technique is used to lengthen a thigh, hip.
shortened or spastic muscle, to strengthen a
EXCLUSION CRITERIA
physiologically weakened muscle.11
• Subject unwilling to be a part of the study.
The theory behind muscle energy technique
suggest that the technique is used to correct an • Patient with weakness around articular joint.
asymmetry by targeting a contraction of the hamstring
and moving the innominate in a corrected direction.10 • Acute or chronic low back pain.

• Acute or chronic hamstring injury.

AIMS AND OBJECTIVES
• Visible acute swelling in the region of hamstring
To compare the Efficacy of Eccentric Training and
muscle.
Muscle Energy Technique on hamstring flexibility in
sedentary college students. TOOLS FOR DATA COLLECTION
NULL HYPOTHESIS (H0): There will be no 1. Stop watch
significant difference between the Eccentric training
and Muscle energy technique on hamstring flexibility 2. Theraband
in sedentary college students.
3. Sit and reach box

4. Double arm Goniometer

ALTERNATE HYPOTHESIS (H1): There will be a
5. Cross bar
significant difference between the Eccentric training
and Muscle energy technique on hamstring flexibility 6. Treatment table
in sedentary college students.
PROCEDURE
MATERIAL AND METHOD
The research work has been approved by the
STUDY DESIGN research committee of the College of Applied
Education Health Sciences.
Experimental design comparative in nature.
Subjects were selected from the College of Applied
SOURCE OF DATA
Education and Health Sciences and were screened for
The subjects were recruited from the College of the inclusion and exclusion criteria. Subjects were
Applied Education and Health Sciences. oriented about the procedure and intervention.
Informed consent was obtained from each subject.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 95

The subjects were randomly assigned into two Table 2- Table comparing the pre, post and retention
groups as Group 1 and Group 2. values of knee extension deficit of right side between
the Eccentric training and Muscle energy technique
Group 1: Eccentric training with static stretch only. group.
Group 2: Muscle energy technique with static The analysis by SPSS 15 software shows that there
stretch only. is no significance difference in sit and reaches values
Pre and post measurements were collected on the between Eccentric training and Muscle energy
0 day and on the 14th day, followed by measurement technique groups as shown in table 3.
after one week of cessasation of intervention.Following Sig.(2-tailed),
investigations were performed. p-value
STRPRE Equal variances assumed 0.797
1. Active knee extension test with double arm Equal variances not assumed 0.797
goniometer. STRPOST Equal variances assumed 0.554
Equal variances not assumed 0.554
2. Sit and reach box test with a measuring scale
STRRET Equal variances assumed 0.218
Findings: Equal variances not assumed 0.219

The data analysis was done by using software SPSS Table 3: Table comparing the pre, post and retention
15, using the paired t- test and unpaired t- test. values of sit and reach between the Eccentric training
The statistical analysis shows that there is a and Muscle energy technique group
significant improvement in knee extension deficit The statistical analysis shows that there is no
range of motion in left side retention with a p value significant difference in knee extension deficit values
(p= 0.005) between Eccentric training and Muscle of both left and right side and sit and reach values in
energy technique group as shown in table 1. both boys and girls between the Eccentric training and
Sig.(2-tailed), Muscle energy technique group.
p-value
Sig.(2-tailed),
KEDLTPRE Equal variances assumed 0.407
p-value
Equal variances not assumed 0.408
KEDLTPRE1 Equal variances assuwmed .855
KEDLTPOST Equal variances assumed 0.070
Equal variances not assumed .855
Equal variances not assumed 0.070
KEDLTPOST1 Equal variances assumed .540
KEDLTRET Equal variances assumed 0.005
Equal variances not assumed .540
Equal variances not assumed 0.005
KEDLTRET1 Equal variances assumed .768
Equal variances not assumed .768
Table 1. Table comparing the pre, post and retention
KEDRTPRE1 Equal variances assumed .847
values of knee extension deficit of left side between
Equal variances not assumed .847
the Eccentric training and Muscle energy technique
KEDRTPOST1 Equal variances assumed .776
group.
Equal variances not assumed .776
The statistical analysis shows that there is a KEDRTRET1 Equal variances assumed .302
significant improvement in knee extension deficit Equal variances not assumed .302
range of motion of right side in retention period with STRPRE1 Equal variances assumed .809
the p value (p= 0.010) between Eccentric training and Equal variances not assumed .810
Muscle energy technique group as seen in table 2. STRPOST1 Equal variances assumed .605
Sig.(2-tailed) Equal variances not assumed .606
p-value STRRET1 Equal variances assumed .396
KEDRTPRE Equal variances assumed 0.973 Equal variances not assumed .397
Equal variances not assumed 0.973 KDLTPRE2 Equal variances assumed .192
KEDRTPOST Equal variances assumed 0.415 Equal variances not assumed .192
Equal variances not assumed 0.415 KEDLTPOST2 Equal variances assumed .935
KEDRTRET Equal variances assumed 0.10 Equal variances not assumed .935
Equal variances not assumed 0.10

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 96 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Sig.(2-tailed), Hence the active knee extension test showed a

p-value statistically significant improvement after 2 weeks of
KEDLTRET2 Equal variances assumed .725 treatment between both the rehabilitation groups and
Equal variances not assumed .725 there is no significant difference in the sit and reach
KEDRTPRE2 Equal variances assumed .493 values between the groups. But there is a significant
Equal variances not assumed .494 difference in the values of sits and reaches in centimetre
KEDRTPOST2 Equal variances assumed .433 within the groups that is in the pre, post and retention
Equal variances not assumed .433 values.
KEDRTRET2 Equal variances assumed .619
Equal variances not assumed .620 The study is in agreement with Odunaiya N.A et al
STRPRE2 Equal variances assumed .831 investigated the static stretch duration on the flexibility
Equal variances not assumed .831 of hamstring muscle. The study showed a significant
STRPOST2 Equal variances assumed .089 reduction in the knee extension deficit (KED) after 6
Equal variances not assumed .090 weeks.1
STRRET2 Equal variances assumed .163
Mack D Rubley et al examined the flexibility
Equal variances not assumed .164
retention 3 weeks after a 5- day training regime. The
Table 3 : Table shows the comparision of knee study showed that gains in flexibility are retained for
extension deficit and sit and reach values between the at least 3 weeks after a stretching program. 12
boys and girls.
It is believed that this form fascilitates the golgi
tendon organ which produces an autogenic inhibition
CONCLUSION
of muscle that is being stretched.5
A total of 40 subjects completed the 2 weeks of
The study is in contrast with Depino GM, Webright
rehabilitation program with the retention of 1 week.
et al investigated the duration of maintained hamstring
According to the analysis there is a statistically flexibility after cessation of an acute static stretching
significant difference between the groups in post and protocol.13
retention values of knee extension deficit (KED) in left
Study is in agreement with Mohd. Wassem et al
and right side both, where as there is no statistically
did a study to compare the effect of static stretching
significant difference between the groups in sit and
and eccentric training on popliteal angle and revealed
reach test in post and retention values in sedentary
that these techniques are effective individually in
college students.
improving flexibility of hamstrings. As the skeletal
The p: value of active knee extension in group 1 muscle has a large adaptation potential induced by
receiving eccentric training of left side is (p<0.05) and eccentric contraction and morphological changes are
for the right side, p value is (p< 0.05) and for the group related to addition of sarcomeres in series. On repeated
2 receiving muscle energy technique of left side and contraction (eccentric) leads to disruption and
right side, p value is (p>0.005) in the post period where membrane damage, this lead to uncontrolled ca+
as in the pre and retention period p value is (p<0.05), movements and the development of localized
however the patients reported a significant increase contracture, this could be a reason in improvement of
in their flexibility subjectively. hamstring flexibility. 8

The p: value for sit and reach in group 1 receiving Study is in accordance with Madelaine Smith et al
the eccentric training is (p<0.05) and that for group 2 investigated the comparison of two muscle energy
receiving muscle energy technique is (p> 0.05). Both techniques for increasing flexibility of the hamstring
of which are non – statistically significant in subjects muscle group. 14 When a muscle contracts, the length
with hamstring tightness. and tone is altered, which influences biomechanical,
biochemical and immunologic function, muscle
According to the independent sample test there is contraction requires energy and the metabolic process
no statistically significant difference between the results in carbon dioxide, lactic acid and other
effects of Eccentric training and Muscle energy metabolic waste products that must be transported and
technique on both the boys and girls. metabolized.15

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 97

There is a statistically significant difference between Faheem Ahmed. A comparative study : static
both the groups in improvement in active knee stretching versus eccentric training on popliteal
extension range of motion in retention period in angle in normal health Indian collegiate males.
hamstring flexibility. Whereas there is no statistically Internation journal of sports science and engineer
significant difference between both the groups in sit 2009 ;03(03): 180-186.
and reach test performed in college sedentary students. 9. Luiz Antonio Moreira Junior, Elder Lopes
Bhering Henrique C. Peixoto, Juliana Castro
Conflict of Interest: NIL Bergamini, Hans- Joachim Menzel, Antonio
Eustaquio Pertence, Mauro Heleno Chagas.
REFERENCES Range of motion and strength tolerance after
1. Odunaiya N.A., Hamzat T.K., Ajayi O.F. The eccentric strength training. XXV ISBS Symposium
effects of static stretch duration on the flexibility 2007.
of hamstring muscles.African journal of 10. Noelle M. Selkow, Terry L. Grindstaff, Kevin M.
biomedical research 2005; 8( 2): 79-82 Cross, Kelli Pugh,Jay Hertel, Susan Saliba. Short
2. Mohd. Waseem, Shibill Nuhmani, C.S. Ram. – term effect of muscle energy technique on pain
Efficacy of muscle energy technique on hamstring in individuals with non – specific lumbopelvic
muscles flexibility in normal Indian collegiate pain : a pilot study. J Man Manip Ther. 2009; 17(1):
males. Calicut medical journal 2009; (7): e4 E14-E18.
3. Nagarwal A.K., Zustshi K, Ram C.S., Zafar R. 11. Grubb ER, Hagedom EM,Inous N, Leake MJ,
Improvement of hamstring flexibility: A Lounsberry NL, Love SD,Matus JR, Morris LM,
comparision between two PNF stretching Stafford KM, Staton GS,Waters CM. Muscle
techniques. 2010(04);1:025-033. energy. University of Kentucky, 2010
4. Influence of age on hamstring tightness in 12. Mack D Rubley, Jody B Brucker, Kenneth L
apparently healthy Nigerians. Journal of Nigeria Knight,Mark D Richard and David O Draper.
society of physiotherapy,2005 October Flexibility retention 3 weeks after a 5 – day
5. The effect of static stretching on a of sample 18- training regime. journal sports rehabilitation,
25 year – old students at Saint Martin’s University. 2001 ; 10: 105- 112.
Saint Martin’s university biology journal, 2006 13. Glen M. Depino, William G. Webright and Brent
may; 1. L. Arnold. Duration of maintained hamstring
6. Andrew rolls, Keith George. The relationship flexibility after cessation of an acute static
between hamstring muscle injuries and stretching protocol. Journal of athletic training,
hamstring muscle length in young elite 2000; 35(1):56-59.
footballers. Physical therapy in sports 5 (2004) : 14. Madeleine smith, B. Clin. Sc.(osteo) a, Gary
179 – 187 Fryer.A comparison of two muscle energy
7. Daniela nice Ferreira, Janaina Luciano Labanca, techniques for increasing flexibility of the
Michelle Figueiredo Silva, Aikelton Figueiredo hamstring muscle group.2008 october, ;12 (4) :
Silva, Marco dos Anjos Cristiane Guimaraes 312 - 317.
Pessoa, Geraldo Fabiano Moraes, Natalia 15. Ballantyne F, Fryer G, McLaughlin P. The effect
Bittencourt. Analysis of the influence of static of muscle energy technique on hamstring
stretching and eccentric training on flexibility of extensibility : the mechanism of altered flexibility.
hamstring muscles. XXV ISBS Symposium 2007. Journal of osteopathic medicine. 2003; 6(2):
8. Mohd. Waseem, Shibili Nuhmani, C.S. Ram, 59-63

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 DOI Number: 10.5958/j.0973-5674.7.3.073
98 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Efficacy of Taping in Bell's Palsy

Kaushal M1, Saini S S2, Singh N3, Ghotra P K4

1
Physiotherapist, 2Assoc. Prof., 3Prof. Medicine, 4Asstt. Prof.,COP,CMCH, Ludhiana

ABSTRACT
Objectives: To study &compare the efficacy of taping protocol/Technique over Conventional
treatment technique protocol in Bells Palsy.
Materials and Method: The study was conducted on 30 subjects. Subjects were divided into two
groups. One group was given Electrical stimulation and exercises and other group was given electrical
stimulation , facial exercises and taping.
Results- There exists significant difference between post-treatment scores of both the groups. The
study concluded that the treatment of Es+facial exercise+tapping is effective in curing bell's palsy
Conclusion: Group B protocol is more effective for functional retraining than conventional treatment
in subjects with Bells Palsy.
Keywords: Bell's Palsy, Taping, Electrical Stimulation, Facial exercises

INTRODUCTION 1. Rapid recovery group

Bell’s palsy, also known as acute idiopathic facial 2. Delayed / partial recovery
paresis, is an idiopathic neuropathy of the facial nerve
(cranial nerve VII). It is a rapid onset facial paralysis The treatment options available for Bell’s palsy
that is not life-threatening. While acute immune includes (Medical & Surgical Management)
demyelination triggered by a viral infection may be • Eye drops & Eye lubricants or viscous ointments,
responsible for Bell’s palsy, its exact cause is still
unclear. Bell’s palsy is usually self-limiting with the • Therapeutic injections of botulism toxin & vitamin
majority of patients recovering spontaneously without B12 supplements,
treatment within 6 months of onset of the disorder.
However, a recent study by Kanazawa et al (2007) • Anti-inflammatory & Antiviral medication,
reported that recovery from Bell’s palsy in diabetics is • Alternative treatment,
delayed, and the facial movement score remains low
in comparison with non-diabetics.1Facial paralysis has • Facial massage and exercises,
been primarily considered a cosmetic inconvenience
with associated functional problems such as speech, • Acupuncture,
eating, facial asymmetry, drooling, and an inability to • Chiropractic manipulation,
close the eye on the paralyzed side .The patient with
facial paralysis cannot convey the normal social signals • Surgery.
of interpersonal communication. Incidence of Bell’s
Palsy is about 23/100000/annum. The diagnosis of Bell’s palsy is primarily one of
exclusion, however certain features in the history and
Facial nerve is responsible for voluntary facial physical examination can aid in distinguishing it from
movements,& can be tested by asking a patient to facial paralysis as a consequence of other conditions.
perform movements such as wrinkling the brow, These clinical features include abrupt onset with
showing teeth, frowning, closing the eyes tightly, complete, unilateral facial weakness at 24 to 72 hours,
pursing the lips and puffing out the cheeks & noticing and, on the affected side, numbness or pain around
asymmetry. The recovery phases of Bell’s palsy tends the ear, a reduction in taste, and hypersensitivity to
to follow one of two pathways2 sounds.3

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 99

The objectives of facial retraining therapy are: (i) rice or pasta, one-half cup cooked cereal or 1 oz
to normalize movement of facial muscles, (ii) to (28 g) of ready-to-eat cereal.
increase symmetrical movement patterns of the face,
(iii) to increase volitional movements of the face, (iv) • Vegetable group: Three servings per day. Includes,
to inhibit undesired movements and synkinesis, and per serving, one-half cup of chopped raw or
(v) to normalize muscular tone. cooked vegetables, one cup of raw, leafy
vegetables.
Most cases of Bell’s palsy resolve uneventfully in
children, some do not. It is possible that rehabilitation, • Fruit group: Two servings per day. Includes, per
including retraining the brain through facial exercises serving, one piece of fruit or melon wedge, three-
or even surgical correction for weakened facial muscles quarters cup of fruit juice, one-half cup of canned
can be necessary in extreme cases. In the early stage of fruit, onequarter cup of dried fruit.
Bell’s palsy, when facial muscles are the most flaccid, • Milk group: Two servings per day. Includes, per
it is desirable to allow the muscles to simply rest and serving, one cup of milk or yogurt, or 2 oz (57 g) of
recover on their own. Gentle massage and moist cheese.
warmth may provide pain relief and improve
circulation, but stronger interventions should wait. • Meat group: Two servings per day. Includes, per
Usually facial exercises will not be necessary for serving, 2–3 oz (57–85 g) of cooked lean meat,
children with Bell’s palsy unless the paralysis does not poultry or fish, one-half cup of cooked dry beans,
resolve itself and there is long-term damage to nerves. one egg, or two tablespoons of peanut butter.
However facial exercises such as wrinkling the
forehead, flaring and sniffling the nostrils, curling and • Fats and sweets group: Should be limited as much
as possible.
puckering the lips, and several others may be used to
retrain the brain’s messages to facial muscles. Even Prognosis
younger children can often be taught to do these
exercises, and they can be presented by parents or The potential outcome from Bell’s palsy is quite
therapists as playing a game—making faces in the hopeful. NINDS notes that the majority of all Bell’s
mirror. Sessions of facial exercise should be brief and palsy sufferers improve dramatically, with or without
performed two to three times a day. A surgical treatment, within two weeks. The Bell’s Palsy
procedure involving decompression of the facial nerve Information Site notes that half of all people
through extremely delicate microsurgery has, in severe contracting this condition recover completely within
cases, also been done. But its effectiveness in Bell’s “a short time,” and another 35 percent have “good
palsy remains at issue among child health-care recoveries within a year.” The outlook for children is
providers. Benefits of this surgery are considered by better. Eighty-five percent of children with this disease
some child health specialists to be insufficient recover completely. Ten percent of the children who
compared to the risks involved. contract Bell’s palsy will have mild weakness
remaining afterward, and 5 percent will have severe
Nutritional concerns residual facial weakness. Statistically, 7 percent of all
children that develop Bell’s palsy will have a recurrent
Because compromise of the immune system is so
often a facet of children contracting Bell’s palsy, good episode in the future.4
nutrition is necessary to rebuild and strengthen that AIMS AND OBJECTIVES
immune system. This involves following the American
Dietetic Association (ADA) nutritional guidelines for To study& compare the efficacy of taping protocol/
children, and possibly the addition of a multivitamin Technique over Conventional treatment protocol.
if the pediatrician feels it is advisable. Semi-solid foods
such as yogurt, jello, pudding, or ice cream may be HYPOTHESIS
easier to take in than liquids if the child is experiencing
Null Hypothesis (Ho)
swallowing difficulty.
Both taping protocol/Technique and Conventional
ADA nutritional guidelines for children include
treatment protocol are equally effective in subjects with
• Grain group: Six servings per day. Includes, per Bell’s palsy .
serving, one slice of bread, one-half cup cooked

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Alternate Hypothesis (Ha) into two groups Group A: Electrical Stimulation and
Facial Exercises Group B: Conventional (Group A
(1) Taping protocol/Technique is more effective than Protocol) and Taping. Subjects were taken from
Conventional treatment protocol in subjects with Christian Medical College and Hospital, Ludhiana and
Bell’s palsy consent form was signed by them.

(2) Conventional treatment protocol is more effective Inclusion criteria: Subjects with age group 15-45
than Taping protocol/Technique in subjects with years, Acute onset (1-3 week), Diagnosed case of Bells
Bell’s palsy. palsy, Non-traumatic onset, No other neurological
deficit.
Review of Literature
Exclusion Criteria: Psychiatric illness, UMN lesion,
Vijay Batra and Meenakshi Batra 2007 study Neurotmesis, Skin infection & open wounds
conducted on 30 subjects with diagnosis of bells palsy Hypersensitive skin, Skin Allergy to micropore.
showed VM functional dynamic taping protocol is
more effective functional retraining then conventional PHYSIOTHERAPY TREATMENT
treatment in subjects with bells palsy.
A. ELECTICAL STIMULATION
Ross, et al (1991), compared two treatment groups
with a third control group received no treatment. After Facial muscles and nerve trunks are stimulated at
their motor points.
comprehensive evaluation, one group was trained with
EMG and mirror feedback, while the second group B. FACIAL STRAPPING
used mirror feedback alone. Patients were re evaluated
after one year of treatment .A significant difference was It is a procedure to correct the deviation of the angle
found between the treatment groups and the control of the mouth by correcting the hyper action of
group.7 antagonistic commonly used technique.

Cederwall E, Olsen MF, Hanner P, Fogdestam PROCEDURE

(2006) I did a study on evaluation of physiotherapeutic
treatment intervention in Bell’s facial palsy.In Two strips of adhesive tape are cut and one is
sticked near to chin below the lower lip and is pulled
conclusion, patients with remaining symptoms of Bell,s
unto lower part of ear whereas the other strip is taken
palsy appear to exterience positive effects from a
part of the ear.
specific training program.5

Dalla Toffola, BossiD,BuonocoreM,Montomli C, MATERIAL USED

Petrucci L, Alfonsi E(4) did a study on Usefulness of
• SURGICAL TAPE
BFB/EMG infacial palsy rehabilitation. The objective
of study was toanalyze and to compare the recovery • MICROPORE TAPE
and the development of synkinesis in patients with
idiopathic facial palsy (Bell’spalsy) following treatment • ELASTOPLAST
with two methods ofrehabilitation, kinesitherapy (KT) C. FACIAL MASSAGE
and biofeedback/EMG (BFB/EMG). It was concluded
that BFB/EMG seems to bemore useful than KT in The patients often derive great comfort from
Bell’s palsytreatment.6 massage. The following manipulation can be
given:
METHODOLOGY 1. STROKING
Design: Randomised Controlled trial It should be given from the chin upward to the
temple from middle of the forehead downward
SUBJECTS toward the ear.
Subjects taken were 30 with age group 18-45 years 2. FINGER KNEADING
with a diagnosis of bell’s palsy of non-traumatic onset.
Subject pool was taken from CMC & Hospital Small circular all over the affected side of the face
&consent form signed by them. Subjects were divided ,care being taken not to stretch the muscles.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 101

3. TAPOTEMENT Although Both taping protocol/ technique &

Conventional treatment protocol were effective for
May be administrated in the from of tapping with functional retraining but subjects in Group B showed
the finger tips quickly & lightly. better recovery than Group A.
D. FACIAL EXERCISES TEST 1: Ex+Facial Exercises
1. Drink all liquids through a straw. You’ll be Ho: There exists no significant difference between
dribbling all over yourself for a few days. But it pre-treatment and post treatment scores of group I
does help the muscles around the mouth.
H1: There exists no significant difference between
2. Sniff strongly. Wrinkle nose. Flare nostrils. pre-treatment and post treatment scores of group I
3. Curl upper lip up and raise and protrude upper Applying t-test we get
lip. Try to touch nose.
Pre Post
4. Using your index finger and thumb pull the Mean 117.8667 143.2
corners of your lips in toward the center. Variance 155.2667 184.7429
Observations 15 15
5. Chew gum. Pearson Correlation 0.333768

6. Chew and suck on ice. Hypothesized Mean Difference 0

Df 14
For the eye t Stat 6.512843
P(T<=t) one-tail 6.86E-06
1. Placing 4 finger tips on the eyebrow rub using a
t Critical one-tail 1.761309
firm slow stroke up to the hairline. Return
P(T<=t) two-tail 1.37E-05
downward to the eyebrow.
t Critical two-tail 2.144789
2. Using finger tips placed on the cheek tap lightly The test reveals that the calculated value is higher
and slowly along the bone under the eye to the
than the table value. Hence, the Ho is rejected. Thus,
face. there exists significant difference between pre-
3. Try to close the eye slowly. treatment and post-treatment scores of group I. The
treatment of Es+facial exercise is effective in curing.
RESULTS TEST 2: Ex+Facial Exercises+Tapping
Student t test was used to compare quantitative Ho: There exists no significant difference between
characteristic & baseline outcome variables. Statistical pre-treatment and post treatment scores of group II
analysis was done & P value (< .05) was found to be
significant for group B H1: There exists no significant difference between
pre-treatment and post treatment scores of group II

Applying t-test we get

Variable 1 Variable 2
Mean 142.2 172.0667
Variance 309.3524 370.8857
Observations 15 15
Pearson Correlation 0.879939
Hypothesized Mean Difference 0
Df 14
t Stat 12.61168
P(T<=t) one-tail 2.46E-09
t Critical one-tail 1.761309
P(T<=t) two-tail 4.93E-09
t Critical two-tail 2.144789

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 102 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

The test reveals that the calculated value is higher 69 78

than the table value. Hence, the Ho is rejected. Thus, 72 78
there exists significant difference between pre- 72 74
treatment and post-treatment scores of group II. The 90 100
treatment of Es+facial exercise+tapping is effective 95 88
in curing Bell,s Palsy
85 98
Comparative Results of Group I and Group II
DISCUSSION
The objective of the study was to examine whether
Es+facial exercise + tapping is more effective in On the basis of analysis of result the alternating
curing the Bell’s Palsy. For this purpose, the hypothesis stating that Group B taping protocol is more
hypothesis was framed and then post treatment effective than conventional treatment protocol subjects
results of group I and that of group II were compared with bell’s palsy. Although both Group B taping
and t-values were calculated. protocol & conventional treatment protocol were
Ho: There exists no significant difference between effective for retraining but subjects in group b showed
post-treatment scores of both the groups better recovery than Group A in term of facial
symmetry & ability to perform functional activities
H1: There exists significant difference between post- such as chewing, balloon blowing & speech. But taping
treatment scores of both the groups protocol being more effective , sequential & systematic
show better results. Also the intricacy of the movement
Applying t-test we get
that can be achieved by the facial muscles should
Group I Group II preclude the use of maximum effort, gross exercises
Mean 143.2 172.0667 where motor units other than those targeted are
Variance 184.7429 309.3524 recruited due to overflow. Basically taping help to
Observations 15 15 retrain paralyzed facial muscle maintaining symmetry
Hypothesized Mean Difference 0 & facilitating the paralyzed muscle thereby preventing
Df 28 over activity of normal muscle and act as a normal
t Stat 5.02964 mechanism by promoting the desired symmetrical
P(T<=t) one-tail 1.55E-05 movement pattern that need to be repetitively
t Critical one-tail 1.705616 reinforced before it will be learned.
P(T<=t) two-tail 3.11E-05
Conflict of Interest: No conflict of study is reported
t Critical two-tail 2.055531
for this study.
The test reveals that the calculated value is higher
than the table value. Hence, the Ho is rejected. Thus, Source of Funding: No source of funding is reported
there exists significant difference between significant for this study
difference between post-treatment scores of both the
groups. Ethical Clearance: Approved had been taken.

From the above analysis, it can be concluded that REFERENCES

the treatment of Es+facial exercise+tapping is effective
in curing bell’s palsy 1. Kanazawa A, Haginomori S, Takamaki A, et al.
Prognosis for Bell’s palsy: A comparison of
Comparison results of Group 1 and Group 2 diabetic and nondiabetic patients. Acta
Otolaryngol. 2007;127(8):888-891
2. Batra V and Batra M, (2007) To Study and
compare the efficacy of taping protocol /
technique over conventional treatment protocol
in Bell’s Palsy .2007;39(2):35-40
3. Ahmed A. When is facial paralysis Bell palsy?
Current diagnosis and treatment. Cleve Clin J
Med. 2005;72(5):398-401, 405.
4. Schonbeck, joan 2006,Gale Encyclopedia of
children health: Infancy through adolescence.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 103

5. Cederwall E, Olsen MF, Hanner P, Fogdestam I EMG in facial palsy rehabilitation, Disabil
Department of Physiotherapy, Skene lasarett, Rehabil. Jul 22; 27(14): 809-15.
Skene, Sweden (2006); Evaluationof a 7. Ross B, Nedzelski JM, McLean JA (1991): Efficacy
physiotherapeutic treatment intervention in of feedback training in long- standing facial nerve
“Bell’s” facial palsy.Physiotherapy Theory Pract. paresis. Laryngoscope 101:744-750.
Jan 22(1): 43-52.
6. Dalla Toffola, Bossi D, BuonocoreM, Montomli
C, Petrucci L, AlfonsiE (2005); Usefulness of BFB/

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 DOI Number: 10.5958/j.0973-5674.7.3.074
104 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Effect of Aerobic Exercises on Plasma Lipid Profile and

Cardiorespiratory Fitness in Obese Women

Aisha A Hagag
Lecturer at Department of Physical Therapy for Cardiovascular/Respiratory Disorders and Geriatrics, Faculty of Physical
Therapy, Cairo University, Egypt

ABSTRACT
Purpose: The present study was designed to evaluate the effects of aerobic training on metabolic
parameters like cholesterol, high density lipoprotein (HDL)and triglycerides and cardiorespiratory
fitness parameters including maximum oxygen consumption, minute ventilation, systolic and diastolic
blood pressures in obese women.
Method: This study was performed as an experimental study, in which subjects were randomly
selected. There were sixty obese women, aged between 35-45yrs with body mass index (BMI) of
above 30. Subjects were grouped into control (n=30) and aerobic training (n=30). Aerobic training
was given for four days a week at 60-70% of maximum HR for 12weeks. blood lipids and
cardiorespiratory fitness parameters were measured before and after study period in both groups.
Results: The findings of the study indicate statistically significant differences in lipid profile including
total cholesterol, very low-density lipoprotein(VLDL), serum triglycerides(TG), and high density
lipoproteins(HDL) levels in aerobic training group . body mass index (BMI) and cardio respiratory
fitness parameters showed significant improvements in aerobic group.
Conclusion: Aerobic training is an effective method in improving lipid profile and cardiovascular
fitness in obese women and can be used as a preventive measure in patients who are at risk of
developing cardiovascular diseases due to obesity.
Keywords: Obesity, Cardiorespiratory Fitness, Lipid Profile, Aerobic Exercises

INTRODUCTION Being obese refers to an excess accumulation of

body fat, which is defined by a Body Mass Index of 30
Obesity refers to excess of body fat. It is due to
and above. Body mass index (BMI) is the method used
greater energy intake compared with energy
to assess the body fat content which is defined as a
expenditure. It has also been reported that with
person’s weight in kilograms divided by the square of
massive obesity there is an increased prevalence of
height in meters(1)
cardiovascular disease, hypertension, diabetes
mellitus, pulmonary disorder and Gall stones(1). Weight reduction in obesity brought about by
physical training has been associated with numerous
The metabolic defects that ensue in obesity include
metabolic adaptations including preservation of lean
increased levels of free fatty acids resulting from
body mass (LBM), improved muscle endurance,
insulin resistance, increased LDL-cholesterol, VLDL
increased insulin sensitivity, improved high-density
and triglycerides and decrease in HDL-cholesterol(2)
lipoprotein cholesterol, low-density lipoprotein
According to WHO estimation in 2005, 400 million cholesterol ratio and improved ability of the muscle
adults (9.8%) are obese, with higher rates of obesity cell to take up glucose and metabolize fat(4).
among women than men. Increased weight gain,
Moderate to high intensity aerobic training results
which is associated with increased lean and fat mass,
in an improvement in the blood lipid profile(5). The
along with the associated increase in total blood
most recent studies in patients with established heart
volume may be accompanied by an increase in stroke
disease suggest that a relatively high intensive, yet
volume, cardiac output and circulatory preload and
aerobic exercise training improves the intrinsic pump
afterload that can lead to left ventricular hypertrophy
capacity of the myocardium.
and sustained rise in blood pressure(3)

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 105

Aerobic training is characterized by the execution Estimation of Lipid Profiles

of cyclic exercises that carried out with large muscle
groups contracting at mild to moderate intensities for Fasting blood samples were collected from both
a long period of time.(6) exercise and control groups for a series of laboratory
investigations using standard protocols for estimation
AIM OF THE STUDY of lipid profiles. The lipid profile was done using
standard kit method in the semi auto analyzer.
The main objective of the present study was to
assess the efficacy of aerobic training in improving Blood samples for lipid analysis (10 ml) were drawn
cardiovascular parameters as maximum oxygen only at baseline (fasting). After the sample was drawn,
consumption (VO2max) , anthropometric parameters it was centrifuged at 3000 rpm for 5 min. Subsequently,
as BMI and percent body fat percentage and blood the serum was drawn off and placed in a small tube
lipid profile as high density lipoprotein (HDL), and then was kept at 4 degrees Celsius. Serum
cholesterol and triglycerides in obese women. The cholesterol and triglyceride concentrations were
hypothesis of the study was that aerobic exercise may measured with an automated analyzer using standard
prove to be beneficial method in improving plasma enzymatic techniques. HDL was measured after
lipid profile and cardiovascular fitness of obese removal of very low density lipoprotein (VLDL) and
women. low density lipids (LDL) from samples.

Lipid profile testing was done before starting the

METHODOLOGY training program and then after the three months of
Subjects training.

Sixty obese female with mild obesity were recruited Cardiopulmonary exercise test procedure
from out patient’s clinic of Elkasr Elini teaching Before conducting the exercise tolerance test, all
hospital, their ages ranged from 35-45 years old. They subjects had to visit the laboratory to be familiarized
were randomly divided into exercise (n=30) and with the equipment in order to be cooperative during
control (n=30) groups. The study had local research conducting the test. Each subject underwent
and ethics committee approval and all subjects gave continuous progressive exercise tolerance test
written consent . according to Bruce standard protocol which consists
Inclusion and exclusion criteria of warming up phase and five active phases and
recovery phase in order to determine the maximum
Only healthy subjects without any history of oxygen consumption (VO2max).
pathologic or orthopedic limitation were included in
the study. No subject was currently engaged in any of Systolic blood pressure (SBP), diastolic blood
the other exercise programs. Subjects with a body mass pressure (DBP), heart rate (HR), minute ventilation
index of above 30 were chosen and instructed not to (VE) and Maximum oxygen consumption (VO2max)
take fried products and foods with high sugar content. obtained for both groups before and after the exercise
program.
All patients underwent anthropometrical
measurements, and cardio respiratory fitness testing. The aerobic exercise training program

The measurements for weight, height and other The aerobic treadmill-based training program was
anthropometrical indexes were taken pre and post- started with a 5-minute warm-up phase performed on
study. Body weight and height were measured with a the treadmill at a low load, Active phase of the training
standard physician’s scale and a stadiometer, session was gradually increased from 20 to 40 minutes
respectively when subjects were in a fasting state when in the form of walking/running on electronic treadmill
the participant had thin clothes on and was wearing with zero inclination four times per week for twelve
no shoes. Body mass index (BMI) was calculated using weeks, its intensity gradually from 60% to 70% of the
weight divided by squared height. maximum heart rate (HRmax) achieved in a reference
exercise testing performed according to a modified

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 106 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Bruce protocol. This rate was defined as the training Table 3. Mean, standard deviation and significance of
heart rate (THR) and ended with 5-minute recovery cardiorespiratory fitness parameters.
and relaxation phase. All patients performed four Variable Exercise group Control group #p
weekly sessions over a 3-month period.(7) VO2max(ml/kg/min)
Pre 21.8±0.16 20.9±0.13 Ns
Statistical analysis
Post 26.7±0.14** 20.8±0.11 P <0.05
The mean values of data ob-tained for both groups VE(ml/min)
before and after the study period were compared using Pre 51±9.1 52±9.1 Ns
paired “t” test. Independent “t” test was used for the Post 60±11.5** 51±8.7 P <0.05
comparison between the two groups (p<0.05). HR(beat/min)
Pre 82.14±2.78 83.22±3.4 Ns
RESULTS Post 73.25±3.76** 85.43±5.6 P <0.05
SBP(mmHg)
Table 1. Mean, standard deviation and significance of
Pre 136.11±5.97 137.33±4.5 Ns
anthropometric measurements.
Post 124.32±6.3** 138.11±2.2 P <0.05
Variable Exercise group Control group #p DBP (mmHg)
Weight(kg) Pre 87.4±4.4 88.3±4.5 Ns
pre 76.30±5.87 77.00±5.53 Ns Post 88.9±3.7** 89.5±6.2 P <0.05
post 72.40±6.22** 78.76±4.49 P< 0.05
**p 0.05 within group between pre- and post-training (paired t
BMI(kg/m2) -test); #p value between exercise and control group.
Pre 31.93±1.46 31.82±1.503 Ns
VO2max:maximum oxygen consumption, VE: minute ventilation,
Post 30.32±1.53** 32.11±1.378 P <0.05
HR: heart rate, SBP: systolic blood pressure, DBP: diastolic blood
**p 0.05 within group between pre- and post-training (paired t pressure.
-test); #p value between exercise and control group.
DISCUSSION
BMI: Body Mass Index\

Table 2. Mean, standard deviation and significance of Obesity is a serious public health problem in both
plasma lipid profile. developed and developing countries. According to
world health organization, Overweight and obesity,
Variable Exercise group Control group #p
had taken the fifth rank of leading risk factors cause
Chol(mg/dl)
of death in 2004(8)
Pre 241.70±21.1 243.70±11 Ns
Post 229.00±17.4** 244.30±13 P <0.05 Obesity is considered to be one of the primary risk
TG(mg/dl) factors in chronic diseases including cardiovascular
Pre 140.00±7.07 143.90±6.226 Ns diseases, hypertension, and non-insulin dependent
Post 134.30±3.80** 145.0±7.659 P <0.05 diabetes mellitus(9). It is known that physical exercise
HDL(mg/dl) is of benefit to the treatment of obesity.
Pre 45.40±3.53 44.80±4.54 Ns
post 53.60±3.13** 44.50±5.31 P <0.0
In view of hyperlipidemia and
VLDL(mg/dl)
hypercholesterolemia that occur in obesity, it is a risk
Pre 28.10±1.41 28.78±1.24 ns
factor for atherosclerosis. In fact, obesity is associated
Post 26.86±0.73** 29.00±1.53 P <0.05
with an increase in the incidence of coronary heart
disease, congestive heart failure and strokes(2)
**p 0.05 within group between pre- and post-training (paired t
-test); #p value between exercise and control group Physical inactivity is one of the factors for the
Chol: Cholesterol; Trig-Triglycerides; HDL: High Density Lipids; increases of obesity and its complications. Physical
VLDL: Very Low Density Lipids inactivity levels are rising in many countries with
major implications for increases in the prevalence of

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 107

non-communicable diseases and the general health of body mass index, plasma lipid profile, systolic and
the population worldwide(8) diastolic blood pressure and aerobic performance
capacity in obese women. . Based on our study results,
Sedentary lifestyle is one of the risk factors for it is therefore recommended that obese individuals
obesity epidemic. Many studies revealed that physical should perform regular physical training in form of
activities made significant improvement on aerobic aerobic exercises so that the body improves both
performance and strength capacity.(9) In the present cardio-respiratory fitness and metabolic parameters
study significant improvement in cardiovascular simultaneously. Further studies need to be done on
fitness including VO2max was observed in exercise how the combination of aerobic exercise training and
group at the end of training. Independent studies have diet restriction affects body weight, plasma lipid profile
conducted to examine the effect of aerobic and and cardiorespiratory fitness on obese individuals.
resistance exercise training(10). In these studies, aerobic
training group showed greater VO2max record than ACKNOWLEDGMENTS
the resistance group.
The author is grateful for the cooperation and
The role of aerobic exercise training on support of all subjects who participated in this study.
cardiovascular diseases is well documented Studies
have conducted to examine the effect of physical Ethical clearance
activities on blood pressure and metabolic variables.
Independently the effect of aerobic training and All subjects were informed about the study
resistance training on these variables was assessed. procedure and signed consent forms approved by the
After intervening independent aerobic and resistance local research ethical Committee for the Protection of
training a significant reduction is reported in systolic Human Subjects, at Faculty of physical therapy, Cairo
(p=0.004) and diastolic (p=0.002) blood pressure in University.
aerobic group and systolic (p=0.002) and diastolic Conflict of Interest
(p=0.007) blood pressure in resistance group after the
intervention(11). A consistent result was observed in our There is no conflict of interest with any
study. At the end of the training a significant reduction organization, and this research is not funded.
in systolic (p<0.05) and diastolic (p<0.05) blood
pressure was resulted. Moreover, we assessed the REFERENCES
effects of the intervention on metabolic variables. Pre
and post training test was done on these metabolic 1. Surajit Kumar MukhopadhyayStudy of Lipid
variables. The result showed Significant (p<0.05) Profile in Obese Individuals and the Effect of
reduction change on total cholesterol , triglycerides Cholesterol Lowering Agents on Them, Al Ame
and very low density lipoproteins at the end of the en J Med S c i (2 012 )5 (2 ) :1 4 7 -1 5 1.
intervention. The result supports the previous studies 2. Equsa G, Beltz WF, Grundy SM, Influence of
that advocate the preventative and/or curative effects obesity on metabolism of apolipoprotein B in
of regular physical training. humans. J Clin Invest. 1985; 76: 596-600
3. Peter G. Kopelman Obesity as a medical problem.
Our results showed significant reduction in BMI
Nature. 2000; Pp:404
after training. Related studies showed significant
4. Thomas DP, Belko AZ, Mulroy GL, et al.
changes on these variables. Even though, the duration
of intervention is different significant changes was combined effects of exercise and restriction of
observed. A related previous study reported a 4.07 %( energy intake on moderately obese Women. Br J
p<0.001) and 3.35 %( p=0.002) decrease on BMI in Sports Med. 1986;20:84-8.
aerobic group (10). On another previous study a 5.04% 5. Leon AS, Sanchez OA. Response of blood lipids
and 2.24% reduction on BMI in aerobic and resistance to exercise training alone or combined with
group respectively was observed(12) dietary intervention. JAm College of Sports Med.
2001;33:S502-515.
CONCLUSION 6. Kemi, OJ, Wisloff U. High-intensity aerobic
exercise training improves the heart in health and
Intervening aerobic training for three months
disease. J Cardiopulm Rehabil Prev. 2010;30:2-11.
resulted in significant improvement on body weight,

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 108 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

7. Perna F, Bryner R, Yeater R. Effect of diet and 11. Mengistie Alemayehu Belay1, Reddy R.C.1 and
exercise on quality of life and fitness parameters Syam Babu M, The Effects of Combined Aerobic
among obese in¬dividuals. J Exercise Physiol and Resistance Exercise Training on Obese,
1999;2:125-31. Adults, Northwest Ethiopia Res.J.Recent Sci,
8. World health organization. Global health risks: 2013; Vol. 2(1), 59-66, January
Mortality and burden of disease attributable to 12. Chaudhary Sarika, Manpreet Kaur Kang and
selected major risks, (2009). Sandhu J.S., The Effects of Aerobic Versus
9. Junichi K, masarou K. evaluation of physical Resistance Training on Cardiovascular Fitness in
fitness on cycle ergometer in obese patients. Obese Sedentary Females, Asian J. Sp. Med., 2010;
J.phy.ther.sci. 1995, 7:53-55. 1(4), 177-184
10. Sarsan A., Ardic F., Ozgen M., Topuz O. and
Sermez Y., The effects of aerobic and resistance
exercises in obese women, Clin.Reh., 2006; 20,
773-782.

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 DOI Number: 10.5958/j.0973-5674.7.3.075
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 109

Effect of Postoperative Ambulation on the Quality of Life

in a Transtibial Amputee

Amit Saraf1, Ankita Gupta2, Jeewan S Prakash3, Jedidiah S Prakash4

1
Assistant Professor, Dept. of Orthopaedics, 2Resident, Dept. of Medicine, 3Principal, Dept. of Physiotherapy, 4Resident,
Dept. of Surgery, Christian Medical College, Ludhiana

ABSTRACT
Background: Quality of life of a transtibial (TT) amputee is not only determined by his functional
rehabilitation but also social, economical and psychological rehabilitation. A number of studies have
analyzed the influence of lower limb amputation on these factors. This study analyses the effect of
functional recovery on other parameters of quality of life in a TT amputee.
Material and method : The present study followed 160 patients of TT amputation. Their postoperative
ambulatory status was calculated using Pinzur's ambulatory level. Their quality of life was determined
on the basis of answers to five point questionnaire. These parameters were correlated to assess the
influence of functional recovery on quality of life.
Results: All the amputees with Pinzur's 0-1 level of ambulation suffered loss of income consequent
to loss of job. All of them felt increased level of depression and anxiety after amputation. 50% of them
felt socially neglected. Comparatively much less percentage of amputees with 5-6 level of ambulation
suffered economic, social and psychological crisis.
Conclusions: Postoperative ambulation level directly affects the quality of life of a TT amputee.
Keywords: Ambulation Level, Quality of Life, Transtibial Amputee

remainder had to change occupation. Bruins et al

INTRODUCTION
(2003) reported that 50% patients had to change their
Lower limb amputation is carried out for a variety occupation after amputation.
of reasons including peripheral vascular disease,
diabetes, trauma, tumour, infections etc1. TT or below Hawamdeh et al (2008) reported that 55.4% of
knee (BK) amputation is the most common major amputees in their study did not get social support.
amputation (51.2%) followed by transfemoral (17.5%)2. They reported that patients who lost social support,
Trauma is the leading cause of leg amputation in had more/deeper psychological involvement.
developing countries and is second only to peripheral These studies 1,4,5,6 suggest that any major
arterial disease in developed countries3. amputation generally influences the quality of life of
Most patients who lose a limb as a result of trauma the patient. This study makes an attempt to find out if
or surgical procedure encounter a number of social, ambulation level of a TT amputee has any effect on
economical and psychological problems along with other parameters of quality of life of the amputee.
physical inactivity1. All these factors together reflect
on the quality of life an amputee leads. MATERIAL AND METHOD

Shukla et al (1982) noted that depression is the most This was a 10 year retrospective and two year
common psychological reaction and 50% of all prospective study done between 1996-2007 in
amputees need some sort of psychological Department of Orthopaedics, Christian Medical
intervention. College, Ludhiana. A total of 190 patients between 18-
60 years were enrolled in this study. Of these 190
Burger et al (2007) reported 66% return to work rate patients, 16 were lost to follow up and 14 patients
after a lower limb amputation. Between 22% and 67% expired before 6 months. These patients were excluded
of the subjects retained the same occupation, while the thereby leaving us with a study of 160 patients. Patients

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 110 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

with amputation of ipsilateral / contralateral upper point questionnaire (Table 2). These outcome/answers
limbs, contralateral lower limbs, neurological deficit, were in turn correlated with the ambulatory level of
physical disability hampering mobility were also each patient to assess the influence of functional
excluded from this study. rehabilitation on the quality of life of a TT amputee.

All the patients were followed upto a minimum Table 1 : Pinzur et al (1993) ambulatory scale
period of 6 months after stump closure. The mean Level Walking capacity
duration of follow up was two and half years. During 6 Independent community ambulator
this period ambulatory level of the amputees was 5 Limited community ambulator
graded by using Pinzur et al (1993) ambulatory scale 4 Unlimited household ambulator
(Table1). Patients were assessed for their quality of life 3 Limited household ambulator
on psychological, economical and sociological aspects. 2 Supervised household ambulator
This assessment was based on their answers to a five 1/0 Transfer- bedridden

Table 2 : Five point questionnaire for quality of life

Question Answer
Have you changed your occupation/lost job after amputation? Yes No
Is there an income declineafter amputation? Yes No
Do you feel socially neglected? Yes No
Do you feel more depression after amputation? Yes No
Has your anxiety increased after amputation? Yes No

RESULTS Out of 56 patients with Pinzur ’s level 2-4

ambulation, 75% (42) lost or changed their jobs. 83.9%
Of 160 patients who were followed up, 83 (51.9%) (47) amputees suffered an income decline after
amputees suffered a loss of occupation/ change in amputation. 57.1% (32) patients complained of loss of
occupation. 98 (59.4%) patients suffered an income social support during post surgery rehabilitation.
decline during rehabilitation. 48 (30%) patients Increase in depression and anxiety level was 51% (49)
reported loss of social support. 109 (68.1%) patients and 31.3% (30) in this group.
were observed to have increased depression and 84
(52.5%) increased anxiety after amputation. 34.4% (33) out of 96 patients with Pinzur’s level 5-
6 of ambulation needed to change their job after
It was observed that 8 patients with Pinzur’s level amputation. 41.7% (40) amputees in this group suffered
0-1 ambulation suffered a 100% loss of income an income loss. 12.5% (12) of these patients lost their
consequent to loss of job. 50% (4) of these patients felt social support. Increase in depression level was 51%
socially neglected. All patients in this group felt that (49) and anxiety level 31.3% (30) in this group
their anxiety and depression level had increased postoperatively (Table 3).
following amputation.

Table 3 : Correlation of ambulatory scale and quality of life

Questionnaire Answer Ambulation level

0-1(n=8) 2-4(n=56) 5-6(n=96) Total(N=160)
Occupation change/lost job Yes 100% (8) 75% (42) 34.4% (33) 51.9% (83)
No 0% (0) 25% (14) 65.6% (63) 48.1% (77)
Income decline Yes 100% (8) 83.9% (47) 41.7% (40) 59.4% (95)
No 0% (0) 16.1% (9) 58.3% (56) 40.6% (65)
Loss of social support Yes 50% (4) 57.1% (32) 12.5% (12) 30% (48)
No 50% (4) 42.9% (24) 87.5% (84) 70% (112)
Increase in depression Yes 100% (8) 92.9% (52) 51% (49) 68.1% (109)
No 0% (0) 7.1% (4) 49% (47) 31.9% (51)
Increase in anxiety Yes 100% (8) 82.1% (46) 31.3% (30) 52.5% (84)
No 0% (0) 17.9% (10) 68.7% (66) 47.55 (76)

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 111

DISCUSSION ambulation could do most of their work themselves.

This group thus neither needed social support nor did
Health is defined as “a state of complete physical,
they face so much of social neglect.
mental, and social well-being and not merely the
absence of disease or infirmity”8,9. Thus quality of life
of a TT amputee is determined not only by his
functional rehabilitation but also social, economical
and psychological factors.

Economic aspect

Of 160 patients, 51.9% changed/ lost their jobs after

amputation. This change was in 100% patients in poor
ambulatory level of 0-1 as compared to only 34.4% in
level 5-6 of ambulation which was significant
(Figure 1). This proves that after TT amputation,
ambulatory level had a significant effect on the job
status of the patient. Patients with poor ambulatory
level often had to quit their jobs.
Fig. 2. Social effect of ambulatory level on amputees

Psychological aspect

There was increase in depression and anxiety

feelings in all the patients with ambulatory level of 0-
1 as compared to 51% and 31.3% respectively in those
with ambulatory level of 5-6 (Figure 3). Patients with
poor ambulation could not involve themselves actively
in social activities. Further they were dependent on
others for most of their activities of daily living.
Together this led to an omnipresent feeling of
depression and anxiety. Thus there was a higher level
of depression and anxiety in TT amputees with poor
ambulatory level.
Fig. 1. Economical effect of ambulatory level on amputees

It was also noted that all the patients with 0-1 level
suffered a loss of income as compared to 41.7% patients
with 5-6 level of ambulation. This is because patients
with poor ambulatory level had to either quit their
job or change it to a low profile job with less income.

Social aspect

50% of patients with 0-1 level lost social support

after amputation as compared to 12.5% patients with
level 5-6 (Figure 2). Reason for this finding was that
amputees with poor functional level were fully
dependent on others and thus in general people Fig. 3. Psychological effect of ambulatory level on amputees
around them gradually started shirking their
responsibilities. This aspect of quality of life is CONCLUSIONS
especially important in a developing country like India
where there is a dearth of social welfare or security From this study we thus conclude that post
system. On the other hand patients who had better operative functional outcome significantly affects the

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 112 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

quality of life of an amputee. An amputee with better 3. Perkins, Z.B., De'Ath, H.D., Sharp,G., Tai,N.R.M.
ambulation level fares better economically, (2012). Factors affecting outcome after traumatic
psychologically and socially in comparison to an limb amputation. Br J Surg, 99, S1, 75-86.
amputee with poor ambulatory outcome. 4. Shukla,G.D., Sahu,S.C., Tripathi,R.P., Gupta,D.K.
(1982). A psychiatric study of amputees. Br J
Conflict of Interest: None Psychiatry, 141, 50-3.
Ethical Adherence: Yes 5. Burger,H., Marincek,C. (2007). Return to work
after lower limb amputation. Disabil Rehabil,
Disclaimers: None 15,29(17), 1323-9.
6. Bruins,M., Geertzen,J.H., Groothoff,J.W.,
Source of Funding: None Schoppen,T. (2003). Vocational reintegration after
a lower limb amputation: a qualitative study.
REFERENCES Prosthet Orthot Int, 27(1), 4-10.
1. Hawamdeh,Z.M , Othman,Y.S., Ibrahim,A.I. 7. Pinzur,M.S., Larsen,J., Smith,D. (1993). Functional
(2008). Assessment of anxiety and depression outcome of BK amputation in peripheral vascular
after lower limb amputation in Jordanian insufficiency. Clin Orthop Relat Res, 286, 247- 249.
patients. Neuropsychiatr Dis Treat, 4(3), 627-33. 8. WHO. (1978). Health for All, Sr.No.1
2. AL- Worikat. (1996). Amputees referred to the 9. WHO. (1979). Health for All, Sr.No.2
royal medical services- Jordan. JCRPO, 2, 129-36.

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 DOI Number: 10.5958/j.0973-5674.7.3.076
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 113

Effect of High Power Pain Threshold Static Ultrasound

Combined with Transverse Friction Massage and
Stretching on Upper Trapezius Myofascial Trigger Point

Hari Haran R1, Singh Anand Kumar2

1
Assistant Professor, 2M.P.T, Orthopaedics, Department of Physiotherapy, Maharishi Markandeshwar University,
Mullana, Ambala

ABSTRACT
Objective: To investigate the additional effect of HPPT static ultrasound when combined with TFM
and stretching on myofascial trigger point of upper trapezius muscle fibre.
Materials and method: This study was done on the 30 subjects who were divided randomly into 2
groups. 15 subjects were included in each group and treated as follows:
Group A - HPPT Static Ultrasound + TFM + Static Stretching of upper trapezius muscle.
Group B - TFM + Static Stretching of upper trapezius muscle.
Group A and B were given intervention 2 times per week for 4 weeks. Only pre-test, after 2 week and
post-test measures were taken of LFROM, NPRS and NPDI.
Results: Study shows that there is significant difference in group A and group B in reducing trigger
point, pain and improving function. Group A shows greater significant difference in outcome measure
in comparison to group B.
Conclusion: Physical therapy interventions focusing on high power pain threshold static ultrasound,
transverse friction massage and static stretching exercise should be indicated for patients presenting
with myofascial trigger points as it relieves pain, improves the ROM and function.
Keywords: HPPT (high power pain threshold), LFROM (lateral flexion range of motion), TFM (transverse
friction massage), NPRS (numeric pain rating scale), NPDI (neck pain disability index)

INTRODUCTION response, or by jumping away from the examiner.

Muscle without TPs, or normal muscle, is not tender
Travell defined a TrP as “a hyperirritable spot in
upon palpation and does not produce a “jump
skeletal muscle that is associated with a hypersensitive
sign8, 9, 7.
palpable nodule in a taut band1, 2, 3, 4, 5, 6. The spot is
tender when pressed and can give rise to characteristic Trigger points are classified as being active or latent,
referred pain, motor dysfunction and autonomic depending on their clinical characteristics. An active
phenomena”1, 5, 7. trigger point causes pain at rest. It is tender to palpation
with a referred pain pattern that is similar to the
A myofascial TP has been described as an area of
patient’s pain complaint. This referred pain is felt not
hyperirritability located in a taut band of muscle,
at the site of the trigger-point origin, but remote from
variously described as resembling a small pea or as a
it. The pain is often described as spreading or radiating.
rope-like nodular or crepitant (crackling, grating) area
Referred pain is an important characteristic of a trigger
within the muscle that is painful upon palpation and
point. It differentiates a trigger point from a tender
refers pain, tenderness, and an autonomic (functionally
point, which is associated with pain at the site of
independent) response to a remote area. Some authors
palpation only2.
contend that when pressure is applied to a TP, a “jump
sign” or “jump response” is elicited whereby the The energy crisis theory is the earliest explanation
patient reacts with facial grimacing, by a verbal of trigger point formation. This theory postulates that

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 114 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

increased demand on a muscle (increased neural MATERIALS AND METHOD

input), macro trauma, or recurrent micro trauma leads
30 subjects were selected by means of convenience
to increased calcium release from the sarcolemma and
sampling based on inclusion and exclusion criteria,
prolonged shortening of the sarcomeres. Prolonged
with signs and symptoms of myofascial trigger point.
shortening compromises the circulation, with the
subsequently reduced oxygen supply leaving the cells Myofascial trigger point was confirmed by the
unable to produce enough ATP to initiate the active following diagnostic criteria16.
process of relaxation. Ischemic by-products of
metabolism accumulate being in part responsible for Primary criteria (all 5 needed)
some of the pain produced, by sensitisation and direct
1. Regional pain complaint.
stimulation of sensory nerves. Unfortunately, there are
no studies to date that can confirm such muscle injury 2. Pain complaint or altered sensation in the expected
as the initiating factor3, 11. distribution of referred pain from a trigger point.
The concept of altered muscle metabolism 3. Taut band palpable in an accessible muscle.
underlying the changes at trigger point sites was
investigated by Bengtsson. Muscle energy stores can 4. Exquisite spot tenderness at 1 point along the
be measured by the levels of various phosphate length of the taut band.
containing compounds. Adenosine triphosphate,
5. Some degree of restricted range of motion.
phosphocreatine, and adenosine di-phosphate are
compounds capable of donating their phosphate Secondary criteria (1 of 3 needed)
moiety and releasing energy for muscle activity.
Adenosine monophosphate and free creatine are the 1. Reproduction of clinical pain complaint, or altered
remaining compounds after this process and are, sensation, by pressure on the tender spot.
therefore, low energy molecules. In a biopsy study of
2. Local twitch response elicited by snapping
patients with fibromyalgia, it was found that the levels
palpation at the tender spot or by needle insertion
of high-energy phosphates were reduced and low
into the tender spot.
energy phosphates increased at trigger point sites in
patients when compared to non-tender muscle points 3. Pain alleviated by elongating (stretching) the
in both patients and controls. This supports the idea muscle or by injecting the tender spot.
of a metabolic derangement at trigger point sites.
However, lactate and pyruvate are the products of Patients are included in the study with following
anaerobic muscle metabolism, and their levels were inclusion criteria: Age between 18 and 45, both genders
not increased. Therefore, although a pure ischaemic are included, Unilateral upper trapezius myofascial
cause is unlikely, there is some evidence to suggest a trigger point, Trigger points in the course of upper
metabolic abnormality at trigger point sites3, 10. The trapezius muscle fibre and having duration more than
energy crisis theory could well co-exist with the motor 3 months with an intensity disturbing normal daily
end plate hypothesis. activity, Reproduction of pain complain by palpation
of trigger points, The number of trigger point less than
Ultrasound is being used in physical medicine to 10, The patient shall be capable of following the
relieve pain and increase joint mobility. Many papers demands inherent in the trial and patient are excluded
have been published on the issues of the effect of with following exclusion criteria: Signs of cervical disc
ultrasound in musculoskeletal disorders. Many prolapse, systemic disorder or migraine, Patients on
researches has been done on trigger point in which medication for trigger point or physiotherapy
massage, stretching and static ultrasound is used as treatment taken for myofascial trigger point 3 weeks
interventions alone and two interventions combined prior to the participation in the study, Pregnancy.
with each other but in this study all these interventions
are combined for the treatment of myofascial trigger Design: Prospective Randomized clinical trial.
point, to see the combined effect of these intervention
Independent Variable: HPPT static Ultrasound,
and additional effect of static ultrasound.
TFM, Static stretching and Conceptual dependent

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 115

variable: Pain, LF ROM of the cervical spine, Function C. Stretching

and Operational Dependent variables are: NPRS,
goniometer, NPDI. All the patients were given passive stretching of
the upper trapezius muscle in supine lying. It is
STUDY PROTOCOL given to muscle tendon unit by slowly placing it
in a maximal position of stretch and sustaining it
30 subjects were divided randomly into 2 groups. there for an extended period of time this maximal
15 subjects were included in each group and treated stretching position is determined by discomfort
as follows: and/or pain that patient experience. 15 This
procedure was repeated three times with 30-
• Group A – HPPT + TFM + Static Stretching of second rest intervals in between. This is given 2
upper trapezius muscle. days a week for 4 week.
• Group B - TFM + Static Stretching of upper Data Analysis
trapezius muscle.
SPSS 17 is used for the statistical calculations,
PROCEDURES MANOVA was used to compare the between group
values and repeated measure ANOVA was used to
Group A was given high power pain threshold calculate the within group values. Level of significance
static ultrasound, transverse friction massage and was set at 5% (p < 0.05).
stretching of upper trapezius muscle and group B was
given transverse friction massage and static stretching RESULTS
of upper trapezius muscle.
Demographic data of subjects in group A and
A. High Power Pain Threshold Static Ultrasound Group B at baseline are summarized in table 1. There
Technique was no significant difference in demographic
It is applied in watts/cm2 in continuous mode to characteristics between groups at the baseline.
treat the patients of group A, with the probe placed Table 1: Demographic characteristics of subjects in
directly on the trigger point and held motionless. group A and B
To elicit threshold pain, the ultrasound probe must
Group A Group B
be kept static on the trigger point. Intensity will
Age ± S.D 23.93±4.23 26.00±4.55
be gradually increased to the level of maximum
Side affected 10 Right & 5 Left 9 Right & 6 Left
pain the patient could bear. It is kept at that level
Gender 7 Male & 8 Female 6 Male & 9 Female
for 4-5 seconds and then reduced to half- intensity
level for another 15 seconds. This procedure is Within group analysis: There was a significant
repeated 3 times. Each patient will receive the difference within both the groups in NPRS, NPDI, and
treatment 2 days a week for 4 week. Patients were LFROM at 2 weeks and 4 weeks when compared with
instructed to continually reporting their pain level, the baseline measure.
its localization and nature11.
Between group analysis: Result obtained after 2
B. Transverse friction massage weeks was not significant but after 4 weeks there was
significant difference but in comparison to group B
Transverse friction massage is followed by HPPT
there was more improvement in group A and result
Static ultrasound. The maximum duration of this
was significant at p < 0.05 (Table 2)
was 2 minutes for each trigger point16.

Table 2: Within group and between group comparisons

Group A Group B
Baseline 2 week 4 week baseline 2 week 4 week
NPRS 6.8±0.94 4.6±0.81 3.0 ±.65 6.8±.774 5.1±.639 3.5±.516
NPDI 34.3±4.51 38.8±3.44 41.4±2.29 34.2±3.97 37.4±2.69 39.8±1.5
LFROM 67.0±3.53 37.4±4.92 20.6±3.97 67.0±3.53 41.6±2.29 26.2±3.9

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 116 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

DISCUSSION The two groups had equal number of subjects and

there were no significant differences with respect to
Findings of this trial indicate that subjects in both
their gender distribution and age which could have
the groups had significant decrease in pain, increase
altered the results of the study. As transverse friction
in function and ROM at cervical spine. However, out
massage and stretching was given in both the groups
of two groups, the group received high pain threshold
& there was a significant decrease in pain & increase
static ultrasound as a supplement to transverse friction
in function and ROM in both groups after 4weeks of
massage and stretching had a higher percentage of
intervention. The significant improvement in the
change in pain intensity, function and ROM at cervical
Group A can be attributed to physiological and
spine, as compare to transverse friction massage and
therapeutic effects of high power pain threshold static
stretching alone. The results obtained after the data
ultrasound.
analysis did not support the null hypothesis and thus
it was rejected and the alternate hypothesis was Clinical Implication
accepted.
The results of the present study enlighten the use
Result of this study goes with the accordance with of combination therapy approach (HPPT+TFM+Static
previous studies, which tells that the high power pain stretching) as more effective approach than the either
threshold static ultrasound is helpful in decreasing the intervention alone in the clinical settings for the
pain and breaking of adhesion which are formed due management of myofascial trigger point patients.
to trigger points. Care must be taken not to apply high-
power, static ultrasound on trigger points in the Limitations of the study
vicinity of bony and neural structures. Patients will
Objective outcome measure (pressure algometer)
report discomfort and unbearable pain and burning was not used for trigger point and follow up was not
when ultrasound waves meet periosteum, sympathetic
done. Another limitation of the study was blinding of
chains and peripheral nerves, good knowledge of patient was not done because of ethical concern.
anatomy is very useful for this assessment14.
Future Research Suggestions
According to Michelle H and Cameron 14 High
power, pain threshold, static ultrasound increases the Future research can be done using objective
temperature of soft tissues temporarily to increase their outcome measures and the blinding of both the patient
extensibility, increasing the length gained for the same and researcher should be done to overcome the bias
force of stretch while also reducing the risk of tissue effect. There should be long term follow up of the
damage. The increase in soft tissue length is also patient to determine the sustained effects of
maintained more effectively if the stretching force is combination therapy (HPPT+TFM+Static stretching).
applied while the tissue temperature is elevated. This
increased ease of stretching is thought to be the result CONCLUSION
of altered viscoelasticity of collagen and alteration of
collagen matrix. This study describes the management of patients
with complaints and findings consistent with
High-power, pain-threshold, static ultrasound myofascial trigger point of upper trapezius muscle
technique resolves trigger points more rapidly than fibre, who responded favourably to an intervention
does treatment with conventional ultrasound program focused on high power pain threshold static
technique. Someday it may be found more cost ultrasound, transverse friction massage and static
effective because it significantly decreases the number stretching exercise.
of PT treatment sessions13.
REFERENCES
High-power, static ultrasound, technique applied
to trigger points before stretching the muscle was more 1. Simons DG, Travell JG, Simons LS.Travell and
effective than conventional ultrasound and it also Simons’ Myofascial pain and dysfunction: The
significantly decreased the length of therapy. They trigger point manual, vol 1, Upper half of body.
reported that no patient reported any short or long 2nded, Pennsylvania,Baltimore, Md: Williams and
term adverse effects17. Wilkins;1999.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 117

2. Alvarez J David, Rockwell G Pamella. Trigger 10. Dommerholt Jan, Baron Caral. Myofascial trigger
point: Diagnosis and management. American point: An evidenced-informed review. The
family physian.2002 Feb; 65:653-660. journal of manual and manipulative
3. Huguenin K Leesa. Myofascial trigger point: The therapy.2006; 14(4):203-221.
current evidence. Physical therapy in sports.2003 11. Huijbregts Peter A. Myofascial trigger point and
Nov; 5:2-12. myofascial pain syndrome:a critical review of
4. Shah J. P, Danof J. V. Biochemical associated with recent literature an introduction by the editor in
pain and inflammations are elevated in sites near chief. The journal of manual and manipulative
to and remote from active myofascial trigger therapy.2006; 14(4):124-171.
points. Arch phys med rehab.2008 Jan; 89(1): 12. Simons David G. Understanding effective
157-159. treatment of myofascial triggers point. Journal of
5. Lavelle ED,Lavelle W, Myofascial trigger point. bodywork and movement therapy.2002; 6(2):
Anesthesiology clinics.2007; 25:841-851. 81-88.
6. Hoyle Jeffrey A, Marras William S. Effect of 13. Javed Majlesi, MD, HalilUnalal, MD. High-power
postural and visual stressor on myofascial trigger pain threshold Ultrasound technique in the
point development and motor unit rotation treatment of active Myofascial trigger points: a
during computer work. Journal of randomized, double-blind, case- control study.
electromyography and kinesiology.2011; 21:41-48. Archives Physical Medicine Rehabilitation.2004;
7. Balbis Peter, Pollard Henry. Neuroemotional 85:833-6.
technique for the treatment of trigger point 14. Michelle H. Cameron. Physical agents in
sensitivity in chronic neck pain sufferers: A Rehabilitation -2nd Edition, 1999:196.
controlled clinical trial. Chiropractic and 15. Kisner Carolyn, Colbey Lynn Allen. Therapeutic
osteopathy.2008; 16(4). exercise foundation and techniques.4th edition.
8. Hanten P William, Oslon L Sharon, Butts L Nicole. New delhi: Jaypee brothers medical publisher.
Effectiveness of a home program of ischaemic 16. Gamn Arne N, Warming S. Treatment of
pressure followed by sustained stretch for myofascial trigger-points with ultrasound
treatment of myofascial trigger point.2000 Oct; combined with massage and exercise – a
80:997-1003. randomized controlled trial. Pain.1998; 77(1):
9. Hong Chang-zern. Myofascial trigger point: 73–79.
Pathophysiology and correlation with
acupuncture points. Acpuncture in
medicine.2000; 18(1):41-47.

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 DOI Number: 10.5958/j.0973-5674.7.3.077
118 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Efficacy of Muscle Energy Technique in Combination

with Strain-counterstrain Technique on Deactivation of
Trigger Point Pain

Amir Iqbal1, Hashim Ahmed2, Md Abu Shaphe3

1
Head Department of Physiotherapy, Taneja Hospital, Preet Vihar, Delhi, 2Head Department of Physiotherapy, Shreya
Hospital, Shalimar Garden Extension, Ghaziabad, U.P, 3Associate Professor, Faculty of Applied Medical Sciences, Jazan
University, KSA

ABSTRACT
Objective: To establish the best possible long term effective choice of treatment program for
deactivating MTrP's by using the combination of muscle energy technique with strain-counterstrain
technique
Design: Pretest-Posttest control group design
Setting: Outpatient physiotherapy department, Taneja Hospital, Preet Vihar New Delhi.
Patients: Fourty five subjects (only male) with Myofascial Trigger Points Pain. Subjects were randomly
placed into three groups: Experimental group A (n=15), Experimental group B (n=15) and a Control
group C (n=15).
Intervention: The experimental group A received muscle energy technique in combination with strain-
counterstrain technique and experimental group B received muscle energy technique alone whereas
control group received conventional treatment only.
Main Outcome Measures: Pain pressure threshold was assessed with the pressure threshold meter
(PTM). Pain and functional status of the patients were measured by a visual analogue scale (VAS)
and the Neck Disability Index scores respectively.
Results: Within group analysis revealed significant improvement in pain pressure threshold, functional
status and reduction in pain intensity in all groups. Between group analysis revealed significant
difference between group A, group B and group C. Further post hoc analysis revealed significant
difference between group A and B, group A and C and group B and C for all variables even after one
week of follow up after the termination of intervention.
Conclusion: The combination of muscle energy technique with strain-counterstrain has been shown
to produce greater improvement in pain pressure threshold on pressure threshold meter, function
status on neck disability index scores and reduction in pain intensity on visual analogue scores even
after one week of the termination of intervention. This shows the long term effectiveness of
combination of two manual techniques deactivating the myofascial trigger point's pain.
Keywords: Myofascial Trigger Points Pain, Pain Pressure Threshold, Pressure Threshold Meter, Muscle
Energy Technique, Strain-Counterstrain Technique

INTRODUCTION The spots are painful on compression and can

produce referred pain, referred tenderness, motor
Musculoskeletal disorders are the main cause of
dysfunction, and autonomic phenomena.(4)
disability in the working-age population and are
among the leading causes of disability in other age Trigger points are classified as being active or latent,
groups.(1) Myofascial pain syndrome is a common depending on their clinical characteristics. (5) An active
painful muscle disorder caused by myofascial trigger trigger point causes pain at rest. It is tender to palpation
points.(3). with a referred pain pattern that is similar to the

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 119

patient’s pain complaint. (6) The pain is often described Although muscle energy technique used in various
as spreading or radiating. (7) It differentiates a trigger studies has been proven to be effective in the
point from a tender point, which is associated with management of trigger points, but only short-term
pain at the site of palpation only. (8) effects have been established with this manual
technique. Also no research till date has been
Many researchers agree that acute trauma or
attempted to reveal the combined effectiveness of
repetitive micro trauma may lead to the development
muscle energy technique with any other manual
of a trigger point. Lack of exercise, prolonged poor
technique for the complete resolution of trigger points.
posture, vitamin deficiencies, sleep disturbances, and
Therefore the study has designed to establish the best
joint problems may all predispose to the development
possible long term effective choice of treatment
of trigger points.(5)
program for deactivating MTrPs by using the
There are many treatments approach are available combination of muscle energy technique with strain-
in physical therapy to deactivate the MTrPs (12) such as counterstrain technique.
Ischaemic compression technique, spry and stretch
technique, Strain -Counter strain technique, Trigger METHOD
point pressure release technique, Ultrasound deep heat
Total 45 male subjects those met the inclusion
therapy, Thermo Therapy, Laser Therapy, Needling
criteria were recruited from the Taneja hospital, Preet
Therapies, Transverse Friction massage, Post isometric
Vihar, Delhi. Inclusion criteria was limited to male only
relaxation (MET), Electrical muscle stimulator,
having age 19-38 years, maximum 3-5 active MTrPs
Stretching etc.
which when palpated replicated their chief complaints
Muscle Energy Technique (MET) is claimed to be in the upper trapezius muscle (unilateral), subjects
effective for a variety of purposes that includes didn’t receive any treatment for their trigger points
lengthening of shortened or contractured muscle, before one month prior to the study. Patients were
strengthening of muscles, as a lymphatic or venous excluded when they had diagnosed case of
pump to aid the drainage of fluid or blood, and fibromyalgia syndrome according to American college
increase the range of motion (ROM) of a restricted joint. of Rheumatology (Wolf et al 1990), presented active
Muscle energy technique emphasizes on the relaxation MTrPs in bilateral Upper trapezius muscles, history
of the contractile component of the muscles.(2) of whiplash injury, history of cervical spine surgery,
diagnosis of cervical radiculopathy or myelopathy
Strain-Counterstrain (S-CS) is a gentle, indirect determined by the primary health care physician, had
manipulative technique for the treatment for the undergone myofascial pain therapy within the past one
treatment of somatic dysfunction. It is one of several month before the study, exhibited inadequate co-
treatment approaches where positioning of the body operation.
is used to evoke a therapeutic effect. These approaches
have been categorize and “positional release” and STUDY DESIGN
include “functional technique” and “facilitated
positional release”. Pretest: Posttest control group design was used in
the study.
Simon and Travell suggested that a therapeutic
approach which effectively deactivates tender points PROCEDURE
should beneficially influence the other trigger points
also. Therefore, Leon Chaitow(13) suggested that clinical Prior to participation each subject were required to
evidence also support this supposition, especially read and sign an informed consent form. The entire
when the positional release method is combined with subject who met the inclusion criteria was assigned
other approaches such as ischaemic compression, MET, randomly into any of the three groups. Pressure Pain
etc. which have good track record in trigger point Threshold (PPT), and Visual Analogue Scale (VAS)
deactivation.. scores were taken pre-intervention and after 2 min. of

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 120 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

post-intervention at day 1, day 3 and day 5 and one by 3 Seconds of relaxation. The technique was repeated
week of follow up after the termination of intervention. four times in each session.
Neck Disability Index (NDI) score assessment were
taken but limited to pre intervention at day 1 , post Strain counter-strain technique
intervention at day 5 day and one week of follow up The part (upper trapezius muscle) was exposed and
after the termination of intervention.
the subject was in supine position with the cervical
spine in neutral position. The Physiotherapist located
MEASUREMENTS
the active MTrPs in the Upper Trapezius muscle using
The pressure threshold meter (“WAGNER FORCE “pincer palpation” method. A mechanical Pressure
DIAL) FDK 20” was used to assess the pain pressure Threshold Meter was used to find out the most active
sensitivity of myofascial trigger point pain as trigger point among all MTrPs. Once located, the
suggested by Fischer.17 The trigger point with lowest Physiotherapist applied gradually increasing pressure
pressure pain threshold value was designated the to the MTrP until the sensation of pressure became one
primary trigger point. Subjects were advised that they of pressure to one of pain. Followed by subject was
would feel some pressure over the trigger points and then passively placed in a position that reduced the
that they should indicate when the sensation changed tension under the palpating fingers and caused a
from one of pressure to one of pain by saying ‘there’ / subjective reduction of pain by around 75%. In the
‘yes’. Three consecutive measurements were obtained present study, the position that reduced pain was
by the same assessor and the mean was considered in usually ipsi-lateral side-flexion of the cervical spine in
further analysis. At least 1 minute elapsed between addition to a slightly contra lateral cervical rotation
the 2 consecutive measurements, as suggested by i.e. 5–80. The subject upper extremity was previously
Fischer.17 After the pre-treatment data of the PPT, a passively positioned in 900 of abduction. That position
second application of 2.5 kg/cm2 of pressure was was maintained for 90seconds. Finally, the subject was
applied by the physiotherapist. Subjects were told to slowly passively placed in a neutral position (13).
rate their pain on the VAS, assessing local pain evoked
by the application of that amount of pressure. A DATA ANALYSIS
functional questionnaire “Neck Disability Index
(NDI)” was provided to the subjects to assess their Statistical analysis was done using SPSS 15.0
functional limitations due to myofascial trigger points Software. Repeated measure ANOVA was used for
pain. within group analysis and one way ANOVA was used
for between group analysis for all the variables.
INTERVENTION
RESULTS
All the three groups received Hot Packs (750C for
20 minutes) and Active Stretching (Slow, 5 repetition Within group: All the three group showed the
per session, 10 seconds hold and 10 seconds relaxation significant improvement for all variables at day 1
between two repetition) followed by group A was postintervention and final day 5 postintervention
treated with muscle energy technique along with strain when compared with their respective baseline. Only
counter-strain technique, and group B was treated only group C showed insignificant improvement after one
with muscle energy technique and group C was treated week of follow up when compared with their baseline
with only conventional treatment. value.
Muscle energy technique Between group analysis revealed significant
The patient will lie supine with cervical spine in difference between group A, group B and group C.
opposite lateral flexion to the treating part so that the Further post hoc analysis revealed significant
upper trapezius muscle fibers will be in a lengthen difference between group A and B, group A and C and
position. 13 The moderate isometric contraction group B and C for all variables even after one week of
(approximately 75% 0f maximal) of upper trapezius follow up after the termination of intervention. Further
muscles was elicited for a period of 5 Seconds followed details are given in following tables:

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 121

Table 1: Between group post hoc Bonferroni analysis for PPT

PPT 0 'p' PPT 1 'p' PPT 3 'p' PPT 5 'p' PPT 6 'p'
Group A
Vs Group B 1.000 0.108 .000 .000 .000
Group B
Vs Group C 1.000 .379 .007 .000 .000
Group A
Vs Group C 1.000 .002 .000 .000 .000

Table 2: Between group post hoc Bonferroni analysis for VAS

PPT 0‘p’ PPT 1‘p’ PPT 3‘p’ PPT 5‘p’ PPT 6‘p’
Group A Vs Group B 1.000 0.108 .000 .000 .000
Group B Vs Group C 1.000 .379 .007 .000 .000
Group A Vs Group C 1.000 .002 .000 .000 .000

Table 3: Between group post hoc Bonferroni analysis for NDI

Variables NDI0‘p’ NDI5‘p’ NDI6‘p’

Group A Vs Group B 1.000 0.006 .001
Group B Vs Group C 1.000 .002 .003
Group A Vs Group C 1.000 .000 .000

Figure.3: Between group comparison of NDI.

Fig.1. Between group comparison of VAS
DISCUSSION

The study was designed to find out the efficacy of

muscle energy technique in addition to strain-
counterstrain in managing upper trapezius myofascial
trigger point pain. The inter group comparison of the
study reveal that trigger point sensitivity was
significantly reduced when muscle energy technique
was combined with strain-counterstrain technique
than muscle energy technique alone.

The results of this study can be discussed with the

previous studies done by Hong et al., 1993; Hanten et
al 2000; Freyer and Hodgson, 2005. The results
obtained by these authors are similar to those obtained
Fig. 2. Between group comparison of PPT in this present study.

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 122 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Muscle energy technique (MET) emphasizes on the reducing trigger point sensitivity and pain intensity,
relaxation of the contractile component of the muscles without the use of vapocoolant spray (20). Jaeger and
which play a role in improving the flexibility of the Reeves, who reported the effectiveness of spray and
muscles thus reducing pain and improving function stretch in decreasing pain intensity and increasing
of the muscles.
pressure pain threshold, indicated that vapocoolant
The study explained that muscle energy technique spray could not produce anesthesia in the
may bring flexibility which results in analgesia and subcutaneous tissues or muscle because of the depth
increase pressure pain threshold by following of the tissue.
mechanism.
They hypothesized that decreasing MTrPs pain
Pain relief from muscle energy technique may utilizing spray and stretch is due to the elongation of
result from a spinal reflex mechanism for the relief of the muscle to its full normal length. (12) Moist heat tend
muscle spasm. (21). It may equalize the length of
to relax the underlying muscles and to diminish the
sarcomeres in the involved MTrP and consequently
tension on the TrPs, thereby reducing referred pain and
decrease pain. (18 )and offer effective stretching and
local tenderness to pressure(12).
mobilization of the taut bands.(20)

Fryer and Hodgson (2005,) who recently Since, the group A received all the techniques such
demonstrated that decreased local MTrPs tenderness as muscle energy technique, strain-counterstrain, so
was due to a change in tissue sensitivity rather than the higher gain in pain relief and increase pain pressure
any unintentional release of pressure by the threshold may be attributed to the above mechanism
practitioner.(12) explained and supported by different previous
studies.(12, 13, 18, 19, 20)
The muscle energy technique can also be explained
by the concept of the “barrier release” in which the
therapist gradually applies counter force to the muscle CONCLUSION
until a definitive increase in resistance is perceived,
The study concluded that “muscle energy
i.e. the barrier, which is usually perceived as not being
technique in combination with Strain-counterstrain
painful by the subject.(20)
technique is more effective than muscle energy
Hence it can be concluded that muscle energy technique alone in deactivating upper trapezius
techniques might be helpful in reducing pain, myofascial trigger point pain.
increasing pain pressure threshold and in turn
improving functional status in subjects with myofascial Future research is required to support the
trigger points. hypothesis of pain relief by quantifiable histochemical
analysis.
The mechanism relief of pain and increased pain
pressure threshold by Strain-Counterstrain technique
REFERENCES
is also thought to achieve its benefits by means of an
automatic resetting of muscle spindles which would 1. Imamura ST, Fischer AA, Imamura M, Teixeira
help to dictate the length and tone into the affected
MJ, et al. Pain management using myofascial
tissues (13) . Finally, there is emerging evidence
approach when other treatment failed. Phys Med
supporting the activation of descending inhibitory
pathways with the application of manual interventions Rehabil Clin North Am 1997; 8:179-96.
(Ferna´ndez-de-las-Pen˜as et al., 2007; Skyba et al., 2. Ballantyne, F., Fryer, G., McLaughlin, P., The
2003). Hence, different mechanisms would probably Effect of Muscle Energy Technique on Hamstring
act at the same time. Extensibility: The Mechanism of Altered
Flexibility. Journal of Osteopathic Medicine, April
The improvement in the control group is attributed
6 (1), 37; 2003.
to the effects caused by stretching and hot packs.
3. Hong CZ, Hsueh TC. Difference in pain relief
Stretching of the affected muscle is believed to be an
integral part of trigger point therapy. Lewit and Simons after trigger point injections in myofascial pain
demonstrated that “muscle lengthening” utilizing patients with and without fibromyalgia. Arch
post-isometric relaxation appears to be effective in Phys Med Rehabil 1996; 77:1161-6.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 123

4. Simons DG, Travell JG, Simons LS. Travell & 14. Hou, C.R., Tsai, L.C., Cheng, K.F., Chung, K.C.,
Simons' Myofascial pain and dysfunction: the Hong, C.Z., 2002. Immediate effects of various
trigger point manual. 2d ed. Baltimore: Williams therapeutic modalities on cervical myofascial and
& Wilkins, 1999: trigger point pain sensitivity; Archives of Physical
5. Han SC, Harrison P. Myofascial pain syndrome Medicine and Rehabilitation 1982,1406-14.
and trigger-point management. Reg Anesth 15. Meseguer A.A, Ferna´ndez-de-las-Pen˜as C,
1997;22:89-101. Navarro-Poza J L,. Immediate effects of the
6. Ling FW, Slocumb JC. Use of trigger point strain/counterstrain technique in local pain
injections in chronic pelvic pain. Obstet Gynecol evoked by tender points in the upper trapezius
Clin North Am 1993;20:809-15. muscle; Clinical Chiropractic: 2006 vol. 9, 112-118.
7. Mense S, Schmit RF. Muscle pain: which receptors 16. Jensen, M.P., Turbner, J.A., Romano, J.M., Fisher,
are responsible for the transmission of noxious L.D., 1999. Comparative reliability and validity
stimuli? In: Rose FC, ed. Physiological aspects of of chronic pain intensity measures. Pain 83,
clinical neurology. Oxford: Blackwell Scientific 157-162.
Publications, 1977:265-78. 17. Fischer, A., pressure algometry over normal
8. Hopwood MB, Abram SE. Factors associated with muscle, standard values, validity and
failure of trigger point injections. Clin J Pain 1994; reproducibility of pressure threshold, pain 1987,
10:227-34. 30; 115-126.
9. Fricton JR, Kroening R, Haley D, Siegert R. 18. Simons, D., Hong, C.-Z., 2002. Endplate potentials
Myofascial pain syndrome of the head and neck: are common to mid fiber myofascial trigger
a review of clinical characteristics of 164 patients. points. American Journal of Physical Medicine
Oral Surg Oral Med Oral Pathol 1985;60:615-23. and Rehabilitation 81, 212-222.
10. Simons DG, Travell JG, Simons LS. Travell & 19. Jaeger, B., Reeves, J.L., 1986. Quantification of
Simons' Myofascial pain and dysfunction: the changes in myofascial trigger point sensitivity
trigger point manual. 2d ed. Baltimore: Williams with the pressure algometer following passive
& Wilkins, 1999:94-173. stretch. Pain 27, 203-210.
11. Rachlin ES. Trigger points. In: Rachlin ES, ed. 20. Hou, C.R., Tsai, L.C.,2002. Immediate effects of
Myofascial pain and fibromyalgia: trigger point various physical therapeutic modalities on
management. St. Louis: Mosby, 1994:145-57. cervical myofascial pain and trigger-point
12. Simons DG, Travell JG, Simons LS. Travell & sensitivity. Archives of Physical and Medical
Simons' Myofascial pain and dysfunction: the Rehabilitation 82, 1406-1414.
trigger point manual. 2d ed. Baltimore: Williams
& Wilkins, 1999:11-93.
13. Sola A E, Bonica JJ, Myofascial pain syndrome:
the management of pain. 2 ed, Philadelphia: Lea
and Febiger,1990,352-57.

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 DOI Number: 10.5958/j.0973-5674.7.3.078
124 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

A Case Review of Perceptual Deficit in PRES: Detailed

Perceptual Evaluation is a Key to Definite Goal Achieving
Techniques

Moushami S Kadkol
Assistant Professor (Occupational Therapy), Seth GSMC & KEMH, Mumbai

ABSTRACT
In an average adult, visual, perceptual and cognitive skills are highly developed. Following a cerebro
vascular accident, because of the damage to the brain at its integrative level, certain perceptuo-
cognitive deficits may result depending on whether the affectation is in only the right or left hemisphere
or in both of them. These integrative affectations may be present in absence of any gross physical
impairment in the form of Apraxias, Body scheme and Image deficits, Spatial relation syndrome,
Agnosias or a combination. The resultant of these deficits is seen as difficulties in performing the
ADL (Activities of Daily Living) to variable intensities. This affects not only the lifestyle of the
individual but severely affects his confidence to be a productive member of the society. There are a
variable battery of tests used for evaluation of these deficits that may or may not be standardized but
are adequate for the clinician to understand the impact and specify the deficit so that the rehabilitative
management is goal oriented and specific. Depending on the nature of the deficit is the treatment
approach decided. The specific the rehabilitation technique used earlier is the independence gained.
The present article discusses the use of OSOT (Ontario Society of Occupational Therapy) battery of
test to evaluate the deficits and how the exact evaluation and understanding of the problem area
would make the therapeutic intervention more definitive in terms of using appropriate technique for
rehabilitation.
Keywords: Perception, Rehabilitation, Apraxia, Activities of Daily Living (ADL)

INTRODUCTION between objects or between self and two or more

objects. This includes disabilities like figure ground,
The physical affectation following Cerebro vascular
form constancy, position in space, spatial relations,
accident may not as much maim an individual as the
topographical disorientation and depth and distance
cognitive perceptual disorders may. These
perceptual deficits.3,4
dysfunctions result probably from brain damage at the
cortical integrative level for sensory input.1 Agnosias deals with the patients lack of recognition
of familiar objects perceived by the senses like visual,
Apraxia is the inability to perform certain skilled
tactile, auditory and proprioceptive.3,4
purposeful movements in the absence of loss of motor
power, sensation or coordination. They may result
from lesions of either or both hemispheres and have METHODOLOGY
been described to take several forms like construction,
Case description and evaluation
motor, ideomotor, ideational, verbal and dressing. Two
or more types usually occur and it is less likely to find Client was a 25 year old female with history of
one in isolation.2 eclampsia. Postpartum over one year she observed
difficulty to dress, carry out her Activities of Daily
Body image and body scheme disturbances are
Living and perform her work as beautician although
thought to result in an alteration of the way a person
she could very well understand the concept of the
understands himself .i.e. his illness, his body or its
activity to be performed. She then underwent MRI
parts.3,4
scanning which revealed hyper intensities in bilateral
The Spatial relations syndrome poses varied parietal lobes. She was diagnosed as PRES (Posterior
problems in perceiving spatial relations and distances Reversible Encephalopathy Syndrome). She was then

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 125

referred to Occupational Therapy services for Score and findings post OSOT administration
rehabilitative management.
The client was subjected to the test and was
The Occupational therapist did a preliminary observed in terms of approach to the task, quantitative
evaluation of the client that included mental status, and qualitative response to the task. The total time
speech, vision, hearing, motor function, balance and taken to complete the test was also recorded.
ADL. It was observed that the client had no physical
deficits. Her motor power i.e. muscle strength was The client scored as follows
grade 5 according to Oxford method. She had good Sensory function : 33/40
voluntary control and did not exhibit any speech
deficit. She was observed for simple activities like Scanning : 2/8
coming in the department, removing footwear and
Apraxia : 9/20
pulling out the chair and sit. She seemed to look
puzzled and struggled when she had to sit. Also she Body Awareness : 11/16
reported moderate to severe difficulty in performance
of basic and instrumental ADL. Her cognitive Spatial Relations : 8/16
functions of attention, memory were not found to have
Visual Agnosia : 12/16
any affectation. She was then administered the OSOT
test for evaluation of her perceptual deficit. The total time required for the client to complete
the test was 1hour 15 minutes.
OSOT Test5:
It was inferred from the test that the client had
This battery is developed for study of the brain
major affectation in the area of apraxia; especially the
damaged adults. It evaluates perception and the
motor type that was affecting her performance
battery includes tests in following areas:
wherever use of kinaesthetic patterns or motor
Sensation planning and execution were concerned. She also
showed spatial neglect on right side. The body
Scanning awareness was affected for solving body puzzle in
which although the client knew where to place the
Apraxia
body parts of the puzzle she could not locate the exact
Body awareness space to put them. She had difficulty in manipulating
peg board design, drawing, and figure ground
Spatial relations perception. But significantly did not exhibit body
Visual Agnosia neglect, body part recognition and laterality deficits.

Scoring system of the test Interpretation and Discussion

It has a 4 part scoring system to measure perceptual It was observed that the client had poor score on
dysfunction through certain predetermined constructional component of apraxia and motor
performance tasks. Initially this test was more planning component of apraxia. She scored well on
subjective but was subsequently reported to be ideational and ideomotor component where she was
standardized and reliable. It is suggested that a normal asked to imitate gestures, make purposeful use of tool
individual would take the test in half an hour. The and imitate it. Constructional apraxia is the
structure of the scoring system is: impairment in producing designs in two or three
dimensions, by copying, drawing or constructing
4. Intact perceptually for basic functioning whether upon command or spontaneously. It results
from lesions in either cerebral hemisphere and limits
3. Minimal dysfunction the clients’ ability to perform purposeful acts while
2. Moderate dysfunction using objects in their environment. They lack the
perspective of exact location of a figure in space and
1. Severe dysfunction the ability to analyze parts in relation to each other.
They overall exhibit an execution or planning
problem6. Therefore irrespective of whether they are

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 126 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

able to see things in correct perspective, they have Chaining (forward or backward): the task is broken
trouble initiating a planned sequence of movement down into its component parts. Using backward
when trying to construct. The impact of this deficit chaining the task is completed with facilitation from
was magnified when the client was subjected to tests the therapist apart from the final component, which
for scanning, body awareness and spatial relation. the patient carries out unaided. If successful next time
Performance was affected on the tests like scanning further steps are introduced. Forward chaining is the
for a specific alphabet on the sheet, drawing a man, reverse of backward chaining
fixing body parts puzzle, peg board design activities,
completing the clock face. Interestingly, the client did Normal movement approaches: the therapist
not exhibit body neglect, affectations in body part facilitates the body through normal movement
recognition and laterality. The occurrence of omissions patterns.
on the scanning sheet would otherwise suggest In light of the evaluation and the inference it would
unilateral neglect related to ignorance of any stimuli be advisable to make use of the last 3 techniques to
or input from the side to which the omissions are get goal specific rehabilitation and enable the client to
present i.e. right side in this case. But with the client achieve early independence. The therapist can make
scoring adequate on all other tests of body scheme and use of normal movement as a preparatory strategy so
spatial relation the deficit could be understood under that the transfer of training occurs smoothly. Cueing
light of peripersonal neglect which is a form of or providing a physical prompt for the task can ease
unilateral neglect of spatial relation that deals with the the performance of the client as the understanding of
behavior manifested in reaching space 7. the concept is unaffected .e.g. labeling the back of the
Also the client showed affectation in the area of dress so that the right side is put in front.
visual agnosia further suggesting that visuospatial Chaining can be taught for activities like sitting on
impairments can selectively disrupt the ability to chair, cooking, walking on road, crossing etc. where
represent visual information in a body centered the task is broken in to sequences and the client goes
reference frame in the absence of any defect of visual from one step to other. Also imitation can be used
exploration.7,8 which is unaffected in the patient. In case of the
All these findings supported the view that the client ideomotor component being present it would have
exhibited more of planning, sequencing and execution been advisable to go for strategy training approach
problem i.e. praxis without affectation of the ability to with use of sensory stimulation to get an enhanced
understand the purpose of the activity and imitate the adaptive response.
tool use.
CONCLUSION
The different techniques that are suggested in
rehabilitation literature are9,10,11,12. The use of OSOT (Ontario Society of Occupational
Therapy) battery of test allows for the exact evaluation
Strategy training in daily living activities: this and understanding of the problem area that would
technique teaches internal (for example, the patient is make the therapeutic intervention more definitive in
taught to verbalize and implement the task steps at terms of using appropriate technique for rehabilitation.
the same time) or external (for example, when aids Thus it is a worthwhile exercise to go in for a detailed
are used to overcome a functional barrier) evaluation of the cognito perceptual components to
compensatory strategies that enable a functional task offer efficient rehabilitation.
to be completed.
ACKNOWLEDGEMENTS
Sensory stimulation: Stimulations including deep
pressure, sharp and soft touch are applied to the I would like to thank the Dean, Seth G.S. Medical
patients’ limbs (Butler 1994) College and my students for their cooperation.

Proprioceptive stimulation: The patient leans on Statement for conflict of interest

and puts weight through their upper and lower limbs
I, Moushami S. Kadkol, am taking full
Cueing, verbal or physical prompts: Given to responsibility for the data, the analyses and
enable each stage of the task to be completed interpretation, and the conduct of the research and that

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 127

I have full access to all of the data; and have the right 5. Boys M, Fisher P, Holzberg C, Reid DW.: The
to publish any and all data separate. I declare no OSOT Perceptual Evaluation: a research
conflict of interest. perspective: Am J Occup Ther. 1988 Feb;42(2):
92-8.
Financial disclosure statement 6. Giuseppe Vallar: Constructional Apraxia and
This is to state that the above mentioned study, “A Spatial Disorders of Drawing: CNS Spectr.
Case Review of Perceptual Deficit in PRES : Detailed 2007;12(7):527-536
perceptual evaluation is a key to definite goal 7. Prudence Plummer, Meg E Morris and Judith
achieving techniques”, is not funded or sponsored by Dunai: Assessment of Unilateral Neglect: PHYS
any financial resources. THER. 2003; 83:732-740.
8. Zoltan B: Vision, Perception and Cognition Ed.3
Ethical clearance (rev), Thorofare, NJ, 1996 Slack
9. West C, Bowen A, Hesketh A, Vail A:
This is to state that patient consent is obtained for Interventions for motor apraxia following stroke
the concerned evaluation. As it was a case review,
(Review): The Cochrane Library 2008, Issue 1
according to the Institutional Ethics Board ethics 10. Susan D. Ryerson : Hemiplegia: Neurological
clearance was not required. Rehabilitation, Darcy Umphred, 5th ed. , Mosby
2007
REFERENCES 11. Carol J. Wheatley : Evaluation and Treatment of
1. Burt M: Perceptual Deficits in Hemiplegia : Am J Perceptual and Perceptual Motor Deficits :
of Nursing 70:1026-1029, 1970 Occupational Therapy Practice Skills for Physical
2. Hopkins HL : Occupational Therapy Dysfunction, Pedretti, Early; 5th Edition 2001 ,
management of Cerebro Vascular Accidents and Mosby
Hemiplegia. In Willard H, Spackman C: 12. Quaintana Lee: Remediating Perceptual
Occupational Therapy (10 th Edition). Impairments: Occupational Therapy for Physical
Philadelphia, J. B. Lippincott Company,2003 Dysfunction, 4th Edition: William & Wilkins, 1997
3. Zoltan B, Siev E, Freishtat B : Perceptual and
Cognitive dysfunction in the adult stroke patient
Ed.2, Thorofare NJ, 1986, Charles B Slack
4. Golisz Kathleen, Toglia Joan: Perception &
Cognition: Willard & Spackmans Occupational
Therapy 10 th Edition, Lippincott William &
Wilkins, 2003.

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 DOI Number: 10.5958/j.0973-5674.7.3.079
128 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Perceived Stress, Sources and Severity of Stress among

Physiotherapy Students in an Indian College

Tushar J Palekar1, M G Mokashi2

1 2
Principal, Professor Emeritus, Padmashree Dr. D. Y. Patil College of Physiotherapy, Dr. D. Y. Patil Vidyapeeth, Pune

ABSTRACT

Objective: To study the Perceived stress in physiotherapy students as per questionnaire along with
assessment of corroborative clinical parameters and perceived stress score.

Method: A cross-sectional, questionnaire based survey was carried out among undergraduate
physiotherapy students of Padmashree Dr. D. Y. Patil college of physiotherapy, Pune, India. Perceived
stress was assessed using the perceived stress scale (PSS 10). A 27-item questionnaire was used to
assess sources of stress and their severity. Another 11-item questionnaire was used to find possible
institutional stress reducing factors.

Results: Of the physiotherapy students who were administered the questionnaire, 71 (74%)
respondents participated in this study. The mean age ± standard deviation (SD) of the study
participants was 19.39 ± 1.12 years, with a range of 18-23 years. Out of the 71 students, 57 (80.3%)
were female students and 14 (19.7%) were male students. The mean PSS score was 20.50 (SD 5.96).
The main sources of stress were found to be related to physical, emotional and academic factors. The
main institutional stress reducing factors were picnics (59.2%), vacations (56.3%), interaction with
friends (52.1%), and personal hobbies (54.9%).

Conclusion: High levels of perceived stress were found in Physiotherapy students. The physical,
emotional and academic factor causes stress in little to great extent.
Keywords: Stress, Undergraduate physiotherapy students, Institutional stress reducing factors, Stress inducing
factors

INTRODUCTION rarely tendency of suicide9,10 among medical students.

The presence of emotional distress affects student’s
Stress is defined as the body’s non-specific response
performance in class room as well as in their clinical
to demands made upon it, or to disturbing events in
practice.11,12 It also increases the risk of stress-induced
the environment.1,2 It is not just a stimulus or a response
disorders and deteriorating performance.11,12 Presence
but rather, it is a process by which we perceive and
of current mental distress and further health problems
cope with environmental threats and challenges.3
was found to be high in those having perceived
Personal and environmental events that cause stress
medical stress.13,14
are referred to as stressors.4 Recently incidence of stress
during professional courses is increasingly being The present curriculum of the Physiotherapy course
reported in published articles.5 ,6 is comprehensive and large. The course is demanding
in terms of students’ effort. Competition for post
Previous studies have shown fairly high incidence
graduate seats in best clinical setups as well as other
of distress, such as symptoms of depression7,8 and even
social and emotional factors influences students’
mental health. Hence the student undergoing this
Corresponding author: course is predisposed to stress. The purpose of present
Tushar J Palekar study is to find out Stress in Physiotherapy students
Principal by using self-reported questionnaires, clinical
Padmashree Dr. D. Y. Patil College of Physiotherapy,
parameters and perceived stress score.
Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune-18
Email: [email protected]

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 129

METHOD perceived stress scale (PSS 10).15 We also assessed

clinical parameters which include Pulse rate,
Setting and Participants
Respiratory rate, Blood Pressure and Body Mass Index.
The present study was undertaken at Padmashree
Dr. D.Y. Patil Physiotherapy College, Dr. D. Y. Patil DATA ANALYSIS
Vidyapeeth, Pune. Each year 60 students have taken
The data was analyzed using SPSS 15.0 version. The
admission in Bachelor of Physiotherapy (BPT). As per
mean scores of perceived stress were calculated. The
their curriculum, the students have to appear for two
number and percentage of response of each stress
internal examinations namely the Terminal and the
factors were calculated. Descriptive statistics were
preliminary examinations. Therefore, they are likely
considered for severity of stressors.
to undergo stress twice in an academic year, beginning
from entry level throughout the physiotherapy course.
RESULTS
The students of second, third and fourth year BPT were
invited to participate in this study. Demographic characteristics and perceived stress
score of the respondents
PROCEDURE
Of the physiotherapy students who were
The design of this study was a cross-sectional administered the questionnaire, 71 (74%) respondents
survey using self-administered questionnaire. This participated in this study. The mean age ± standard
study has approval of Institutional ethical committee deviation (SD) of the study participants was 19.39 ±
of Dr. D. Y. Patil Vidyapeeth, Pune. A total of 95 1.12 years, with a range of 18-23 years. The majority of
Physiotherapy undergraduate students were participants were female (80.3%). Mean PSS score in
participants in this study. The students were asked to the study population was 20.50 (SD 5.96) (Table 1).
complete a 27-item questionnaire to assess sources of Mean PSS score in II BPT was 20.02 (SD 6.68), III BPT
stress and their severity. Another 11-item questionnaire 23.80 (SD 3.94) and IV BPT it was 18.62 (SD 4.48)
was used to find possible institutional stress reducing (Table 2).
factors. Perceived stress was assessed using the
Table 1: Demographic Data

Class Number Percent Gender Number Percent

BPT II 40 56.3 MALE 14 19.7
BPT III 15 21.1 FEMALE 57 80.3
BPT IV 16 22.5

Table 2: Clinical Data and Perceived Stress Score

Pulse RR BP (Systolic) BP (Diastolic) Weight (Kg.) Height (cm) BMI PSS

Mean 84.26 19.78 114 70 60.59 166 24.32 20.50
SD 12.53 4.23 9.02 8.10 11.44 17.61 6.56 5.96

Stress inducing factors [28(39.4%)], ‘Other students performances being better

than mine’ [27(38%)], ‘Competition for postgraduate
The most frequent [number of respondents seats’ [26 (36.6%)]. (Table 3, 4, 5, 6)
(percentages)] contributing factors for the sources of
stress reported by the students as “great extent/ Stress reducing factors
considerable extent” were, ‘Unpredictability of
examinations’ [40 (56.6%)], ‘Fear of failure’ [35 (49.3%)], The most frequent [number of respondents
‘Staying away from family’ [32(45.1%)], ‘High (percentages)] contributing factors for reducing stress
expectations of parents for my performance’ reported by the students as “very much/considerable”
[30(42.3%)], ‘Shortage of equipment/ lab. Facilities, were, ‘Interaction with friends and group members’
[30(42.3%)], ‘Change in the methods of study from 12th [64 (90.1%)], ‘Personal hobbies like music, sports’ [55
standard’ [29(40.8%)], ‘Staying away from friends’ (77.4%)], ‘field visits’ [52 (73.3%)], ‘Vacations and

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holidays’ [50(70.4%)], ‘Free time during college hours’ ‘Teacher’s affection and care, [36 (50.7%)], ‘Beautiful
[45 (63.4%)], ‘Help from senior students’ [44 (62%)], campus of the college’ [(34 47.9%)] (Table 7).

Table 3: Response pattern of Academic factors

Great extent Considerable Moderate Little None

extent extent
N % N % N % N % N %
Change in the methods of study 3 4.2 26 36.6 25 35.2 10 14.1 7 9.9
from 12th standard
Unpredictability of examinations 20 28.3 20 28.3 13 18.2 8 11.3 10 14.1
Too many mid-term and unit tests 2 2.8 19 26.8 22 31 22 31 6 8.5
Too many lectures and clinics 14 19.7 11 15.5 23 32.4 17 23.9 6 8.5
Inability/ difficulty to cope with 2 2.8 4 5.6 2 2.8 28 39.4 35 49.3
English medium
Other students performances 13 18.3 14 19.7 13 18.3 23 32.4 8 11.3
being better than mine
Competition for postgraduate seats 13 18.3 13 18.3 7 9.9 9 12.7 29 40.8

Table 4: Response pattern of Physical factors

Great extent Considerable Moderate Little None

extent extent
N % N % N % N % N %
Living conditions in hostel 8 11.3 11 15.5 7 9.9 24 33.8 21 29.6
Noisy classrooms and surroundings 7 9.9 13 18.3 14 19.7 29 40.8 8 11.3
Shortage of equipment/ lab. Facilities 12 16.9 18 25.4 12 16.9 16 22.5 13 18.3
Every day travel to college and back 6 8.5 9 12.7 12 16.9 28 39.4 16 22.5
Food in canteen and hostel 9 12.7 6 8.5 19 26.8 14 19.7 23 32.4
lack of quiet surroundings / environment 9 12.7 8 11.3 21 29.6 15 21.1 18 25.4
Inadequate library facilities 12 9.9 16 18.3 8 12.7 18 42.3 17 16.9

Table 5: Response pattern of Social factors

Great extent Considerable Moderate Little None

extent extent
N % N % N % N % N %
Inability to speak in group or public 7 9.9 13 18.3 9 12.7 30 42.3 12 16.9
High expectations of parents for 11 15.5 19 26.8 15 21.1 15 21.1 11 15.5
my performance
Interference in study by parents 2 2.8 9 12.7 6 8.5 34 47.9 20 28.2
Staying away from family 19 26.8 13 18.3 10 14.1 14 19.7 15 21.1
Trouble from senior students 2 2.8 5 7 9 12.7 20 28.2 35 49.3
Having to do household work after 3 4.2 5 7 13 18.3 23 32.4 27 38
returning from college
Inadequate social/ financial support 1 1.4 5 7 6 8.5 29 40.8 30 42.3

Table 6: Response pattern of Emotional factors

Great extent Considerable Moderate Little None

extent extent
N % N % N % N % N %
Feeling that you do not have time 14 19.7 10 14.1 15 21.1 20 28.2 12 16.9
for personal hobbies and sports
Getting involved in love affairs 3 4.2 0 0 6 8.5 20 28.2 42 59.2
Not accepted by other students 1 1.4 4 5.6 7 9.9 20 28.2 39 54.9
Conflicts with colleagues 3 4.2 6 8.5 15 21.1 24 33.8 23 32.4
Fear of failure 19 26.8 16 22.5 6 8.5 21 29.6 9 12.7
Indifferent behavior of teachers 9 12.7 10 14.1 10 14.1 12 16.9 30 42.3
Staying away from friends. 14 19.7 14 19.7 11 15.5 16 22.5 16 22.5

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 131

Table 7: Response pattern of stress reducing factors

Very much Considerable Some what little None

N % N % N % N % N %
Beautiful campus of the college 11 15.5 23 32.4 15 21.1 17 23.9 5 7
Teachers’ affection and care 17 23.9 19 26.8 13 18.3 16 22.5 6 8.5
Interaction with your friends 37 52.1 27 38 5 7 2 2.8 0 0
and group members
Vacations and holidays 40 56.3 10 14.1 14 19.7 7 9.9 0 0
Field visits 42 59.2 10 14.1 4 5.6 12 16.9 3 4.2
Student - mentor programme 9 12.7 11 15.5 14 19.7 27 38 10 14.1
Personal hobbies like music, sports 39 54.9 16 22.5 6 8.5 7 9.9 3 4.2
Help from senior students 20 28.2 24 33.8 7 9.9 16 22.5 4 5.6
Free time during college hours 33 46.5 12 16.9 8 11.3 16 22.5 2 2.8
Attending Workshops/Conferences 8 11.3 13 18.3 18 25.4 18 25.4 14 19.7
outside the college campus
Educational tours 17 23.9 13 18.3 18 25.4 12 16.9 11 15.5

DISCUSSION chose the PSS 10 since this scale has been documented
for its reliability and validity.15
In our study, we evaluated perceived stress among
physiotherapy students including its sources and Most students had experienced academic, social
severity, which may be of importance to both and emotional stressors. Among academic stressors,
physiotherapy teachers and a psychologist. To our ‘Unpredictability of examinations’ and ‘Change in the
knowledge such a detailed study has not been reported methods of study from 12th standard’ were the chief
in physiotherapy students in the country. sources of stress. Although examinations are important
in the health care training as a standard for evaluation/
In our study, physiotherapy students reported a
assessment, examinations also facilitate student’s
higher level of perceived stress, which was higher
learning and give feedback to the teachers. Yet,
among second and third year BPT students. Academic
previous studies have also reported that examinations
and social stressors were reportedly more common
are frequent sources of stress among medical
both in terms of frequency of occurrence and severity.
students.19,20,21
The main institutional stress reducing factors were
field visits (59.2%), vacations (56.3%), interaction with There may be a need to study the examination
friends (52.1%), and personal hobbies (54.9%). Life of system to make it less stressful to the students. It is
health care professional can be very stressful. Mild, obvious that most of the students feel that ‘Change in
moderate and high levels of stress and even burnout the methods of study from 12th standard’ is one of the
have been reported amongst medical students and sources of stress. Lack of command over English
healthcare professional from different countries.16, 17,18 language did not pose any problem in almost 90%
students. Those students whose method of study in
The amount and severity of stress experienced by
12th standard was not English may put to stress. Other
health professional students may vary according the
important source of stress was related to social and
settings of the college, the curricula, examination
emotional factors. This may be due to lack of time for
pattern etc. Previous studies from medical schools in
self, family, friends and entertainment owing to
different countries have reported varying levels of
demands of physiotherapy curriculum. Another
stress. A study from Pakistan University has reported
reason could be high expectation from the parents
that more than 90% of its students experienced stress
(62.9%) and fear of failure as reported by the students
during their course.19 Similarly 73% students had
(57.8%).
perceived stress at Indian medical college during
medical schooling.20 In Thai medical school 61.4% of Present study also investigates institutional stress
Students had reported incidence of stress as calculated reducing factors. The main institutional stress reducing
by the Thai stress test.21 These studies have used factors were field visits, vacations, interaction with
different instruments to assess stress. This limits the friends, and personal hobbies. Similarly study done
comparability among these studies. However, we by A N Supe reported that friends, Gymkhana and

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 132 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

personal hobbies were the most common stress 2. Rosenham DL, Seligman ME. Abnormal
relieving factor in medical students.20 Psychology, (2nd ed.). New York: Norton. 1989.
3. Myers DG. Stress and Health. In: Exploring
Limitations Psychology (6th ed.). New York: Worth
The information provided by the students was Publishers. 2005;p. 402.
based on self-reported questionnaire in this cross- 4. Lazarus RS. Theory-Based Stress Measurement.
sectional survey. Therefore, there is some potential for Psychology Inquiry. 1990;1(1): 3–13.
reporting bias which may have occurred because of 5. Aktekin M, Karaman T, Senol YY, Erdem S,
the respondents’ interpretation of the questions or Erengin H, Akaydin M. Anxiety, Depression and
desire to report their emotions in a certain way or Stressful Life Events among Medical Students: A
simply because of inaccuracies of responses. In Prospective Study in Antalya, Turkey. Med Educ.
addition, the study took place at only one college, 2001;35(1):12–17.
which could differ in the generalizability to other 6. Guthrie EA, Black D, Bagalkote H, Shaw C,
institutions. Campbell M, Creed F. Psychological Stress and
Burnout in Medical Students: A Five-year
CONCLUSION Prospective Longitudinal Study. J R Soc Med.
1998;91(5):237–243.
High levels of perceived stress were found in 7. Dahlin M, Joneborg N, Runeson B. Stress and
(60.5%) Physiotherapy students. The Academic, social depression among medical students: a cross
and emotional factors causes ‘No to little stress in sectional study. Med Educ 2005;39:594-604.
(28.03%) students while Moderate stress in (16.3%) 8. Zocolillo M, Murphy GE, Wetzel RD. Depression
students. ‘Considerable to a great extent’ stress was among medical students. J Affect Disord
found in (13.78%) students. We encourage building up 1986;11:91-96.
and adopting institutional stress reducing factors to 9. Tyssen R, Vaghum P, Gronvold NT, Ekeberg O.
relieve stress among these students. Especially, Suicide ideation among medical students and
‘Teachers’ perceived affectionate attitude has scope for youth physicians: a nationwide and prospective
improvisation since almost 40% students felt of prevalence and predictors. J Affect Disord
‘Indifferent behavior of teachers’. Similarly forming 2001;64:69-79.
self-support groups within the students has great scope 10. Tyssen R, Hem E, Vaghum P, Gronvold NT,
since only 22% felt trouble from Sr. students, while over Ekeberg O. The process of suicidal planning
70% had help from them. This aspect should be among medical doctors: predictors in a
improved to reduce stress by including good senior longitudinal Norwegian sample. J Affect Disord
students in ‘Student Mentor programme’ which 2004;80:191-198.
appeared to be appreciated by less than 50% students. 11. Malathi A, Damodaran A. Stress due to exams in
There is need that examinations must be perceived as medical students-role of yoga. Indian J Physiol
student-friendly and parental support should be Pharmacol 1999;43:218-24.
healthier. 12. Bramness JA, Fixdal TC, Vaglum P. Effect of
medical school stress on the mental health of
ACKNOWLEDGEMENT medical students in early and late clinical
curriculum. Acta Psychiatr Scand 1991;84:340-5.
We are very thankful to Dr. Shahnawaz Anwer (PT), 13. Vitaliano PP, Russo J, Carr JE, Heerwagen JH.
Assistant Professor, Padmashree Dr. D. Y. Patil College Medical school pressures and their relationship
of Physiotherapy, Pune, for his valuable suggestions to anxiety. J Nerve Ment Dis 1984;172:730-736.
and contributions for making out this manuscript. 14. Tyssen R, Vaghum P, Gronvold NT, Ekeberg O.
Conflict of Interest: None Declared Factors in medical school that predict
postgraduate mental health problems in need of
Funding: None treatment: a nationwide longitudinal study. Med
Educ 2001;35:110-120.
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measure of perceived stress. J Health Soc Behav
1. Selye H. Stress without Distress. New York:
1983; 24:385-96.
Harper & Row. 1974.
16. Ortmeier BG, Wolfgang AP, Martin BC. Career

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commitment, career plans, and perceived stress: coping strategies: a case of Pakistani medical
a survey of pharmacy students. Am J Pharm Educ school. Educ Health (Abingdon) 2004;17:346-53.
1991;55:138-42. 20. Supe AN. A study of stress in medical students
17. Wolfgang AP. The health professions stress at Seth G. S. Medical College. J Postgrad Med
inventory. Psychol Rep 1988;62:220-2. 1998;44:1-6.
18. Lapane KL, Hughes CM. Job satisfaction and 21. Saipanish R. Stress among medical students in
stress among pharmacists in the long-term care Thai medical school. Med Teach 2003;25:502-6.
sector. Consult Pharm 2006;21:287-92.
19. Shaikh BT, Kahloon A, Kazmi M, Khalid H,
Nawaz K, Khan N, Khan S. Students, stress and

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 DOI Number: 10.5958/j.0973-5674.7.3.080
134 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Effect of High Frequency, Low Magnitude Vibration on

Bone Density and Lean Content in Children with Down
Syndrome

Naglaa A Zaky1, Amira E Elbagalaty1

1
Department of Physical Therapy for Growth and Development Disorders in Children and its Surgery, Faculty of Physical
Therapy, Cairo University, Egypt

ABSTRACT

Purpose: to examine the effects of high frequency, low magnitude vibration on bone density and
muscle content in children with Down syndrome.

Design: Experimental study (randomized control trial)

Subjects: Thirty children with DS from both sexes, ranging in age from 4 to 7 years. They were
divided randomly into two groups of equal number A (control) and B (study)

Procedure: Evaluation before and after three months of treatment for each child of the two groups
was conducted via using dual X-ray absorptiometry (DXA). Group A received a selected exercise
program, while group B received the same exercise program given to group A in addition to
proprioceptive stimulation in the form of whole body vibration (WBV) training.

Results: Significant improvement was observed in the two groups when comparing their pre and
post-treatment mean values. The mean ± SD of BMD post treatment for control group was 0.75 ± 0.03
and that for study group was 0.79 ± 0.03. The mean difference between both groups was -0.04. There
was a significant difference between control and study groups in BMD post treatment.

Conclusion: mechanical vibration seems to improve BMD and muscular content in DS children
making the treatment of osteoporosis possible.
Keywords: Down Syndrome (DS), Bone Mineral Density (BMD), Vibration

INTRODUCTION significant delays in the onset of motor skills, including

qualitative differences in movement patterns,
Peak bone mass, which is achieved soon after the
compared with the typical development in children
end of sexual development, is the most important
without DS.8-9
determinant of bone mass and osteoporosis later in
life 1-2. Children with disabilities such as cerebral palsy Most patients with Down syndrome require
(CP) and Down syndrome are particularly vulnerable treatment during childhood because of mental or
to deficits in bone mass accretion due to decreased growth retardation. Hypotonia, and nutritional and
mobility and weight-bearing which reduces hormonal deficiencies at critical times of bone-mass
mechanical loading of the skeleton. 3-4 accretion, namely in infancy and adolescence, have a
major role in the impairment of peak bone-mass
BACKGROUND accrual and correlate with osteoporosis.10

Down syndrome (DS) is one of the few disabilities Whole body vibration has shown promise as an
that carries with it the certainty of delays in all of the alternative method for stimulating both increases in
developmental domains.5 In the United States, DS bone mass and improvements in muscle
occurs approximately 1.36 times in every 1,000 live performance11-12. Animal studies have demonstrated
births. 6 Down syndrome is a common cause of that low-magnitude, high-frequency vibration can
cognitive deficits in childhood 7 and results in increase bone mass and bone strength and prevent

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 135

bone loss 13-14. Studies in humans have also shown a proprioceptive stimulation in the form of whole body
benefit to bone in post-menopausal women 11 and a vibration (WBV) training using a special device for 3
benefit to both bone and muscle in young women, ages months.
15-20 years, with low bone density 15. In children with
disabilities, a small pilot study found those 6 months
of low-magnitude; high-frequency (0.3g, 90 Hz) whole
body vibration increased in bone density and
prevented bone loss in the proximal tibias of a
heterogeneous group of participants 16.However whole
body vibration (WBV) seems to be beneficial to
improve BMD in disabled children13-14

The purpose of this study was to examine the effects

of high frequency, low magnitude vibration on bone
and muscle in children with Down syndrome. We were
interested in this group because they are at the age
which is considered critical period at which children
have the most potential to accumulate bone 17.
Fig. 1. Whole Body Vibration Device.
METHOD
Whole Body Vibration (WBV) Device (Fig.1) (serial
Participants
no. 0251460, manufactured in China 2005), designed
Thirty infants with DS of both sexes from the to provide vibration and proprioceptive stimulation.
Outpatient Clinic of The Faculty of Physical Therapy It enables the therapist to check the time and speed
and The National institute of Neuromotor disorders through display. It consists of the following parts:
were recruited to participate in the study. They were
(a) Transverse frame.
divided into two groups of equal numbers (control
group and study group). (b) Platform board.

Inclusion criteria: (c) Right and left handles.

The participants were children with DS ages 4-7 Each child in both groups was evaluated before and
years who were able to stand for 10 minutes without after three months of treatment by Dual Energy X-ray
handheld support. Absorptiometry (DEXA) (for measuring bone mineral
density of total body and total body lean content by
Exclusion criteria
using a standard technique for measuring bone
- The presence of a seizure disorder mineral content with very low dose of radiation of
acceptable precision using bone mineral content in
- Vision problems. grams (gm) by area of bone measured (cm2) and will
express density as grams/ cm2.
- Any other medical conditions that would severely
limit a child’s participation in the vibration
intervention.

INTERVENTION

Children in the control group received a specially

selected physiotherapy program for 3 months which
include: facilitation of equilibrium and protective
reactions, stimulatory techniques and muscle
strengthening & endurance training.

Children in the study group received the same

selected physiotherapy program in addition to Fig. 2. Bone mineral density testing apparatus (DXA)

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 136 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

RESULTS study group revealed significant improvement.(Table

1, figure 3).
Comparisons of pre and post treatment mean
values of BMD and lean content for control group and

Table (1)

Test Parameters Control group Study group

Mean P Mean P
Pre Post Pre Post
BMD 0.70 ± 0.01 0.75 ± 0.03 0.0001 0.71 ± 0.02 0.79 ± 0.03 0.0001
Lean content 5.79 ± 0.2 6.42 ± 0.3 0.0001 5.8 ± 0.17 6.67 ± 0.25 0.0001

Post treatment mean values of BMD for both groups DISCUSSION

(control and study) were compared .The mean value
In this study, the primary purpose was to
± SD of BMD post treatment for control group was
investigate whether the vibration intervention in
0.75 ± 0.03 and that for study group was 0.79 ± 0.03.
children with Down syndrome is beneficial to bone
The mean difference between both groups was -0.04.
mineral density and muscular content or not.
There was a significant difference between control and
study groups in BMD post treatment (p = 0.007). (figure 3). Low bone mass and the associated increased
fracture rates are clinical features that complicate
DS10.As the life expectancy of individuals with DS has
increased to greater than age 50 18-19, the bone health of
DS patients has become an important medical issue.
With the increasing life expectancy, many concerns
regarding the risk of osteoporosis have been raised 20-
21-22
. In fact, the accrual of bone mass during childhood
and adolescence may reduce osteoporosis risk later in
life and low bone mass in young adulthood is a strong
risk factor for later osteoporosis and fracture 23-24.

Several investigators reported that, adults (and

Fig (3): Post treatment mean values of BMD in control and study
groups.
children) with DS have lower bone mass, expressed
as BMD, especially in the lumbar spine, compared with
Post treatment mean values of Lean for both groups their peers without mental retardation or with mental
(control and study) were compared. The mean value retardation but without DS. 20-25-26-27-28
± SD of lean post treatment for control group was 6.42
± 0.3 and that for study group was 6.67 ± 0.25. The Dual radiograph absorptiometry (DXA) is the most
mean difference between both groups was -0.25. There widely used method for assessment of BMD and is
was a significant difference between control and study considered the “gold standard”. DXA uses 2 different
groups in lean post treatment (p = 0.02). (figure 4). radiographic energies to record attenuation profiles at
2 different photon energies. Attenuation is largely
determined by tissue density and thickness. At a low
energy, bone attenuation is greater than soft tissue
attenuation. At high energy, they are similar. This
allows the distinction between bone and soft tissue.
The energy absorption of the 2 different energy
radiographic beams is used to provide estimates of the
amounts of bone mineral29

The results of the current study at the end of

treatment period, showed a significant improvement
in the measuring variables in both study groups, but
Fig (4): Post treatment mean values of lean in control and study
in favor to study group. Also the percentage of
groups.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 137

improvement of the measuring variables was higher with Down syndrome exposed to vibration showed
in study group than control group. improvements in BMD and lean content as compared
to traditional exercise programs and that vibration
Mechanical vibration is a traditional and safe provides additional benefit to traditional exercise
physical therapy modality that is widely accepted in programs. Additional studies are needed to determine
diagnosis and treatment of the disease, rehabilitation safe and effective parameters for vibration training in
and sports medicine.30-31.In the skeletal system, the different age groups.
diagnosis and treatment is mainly based on cytological
and zoological research. Previous animal experiments
ACKNOWLEDGEMENT
showed that mechanical vibration with appropriate
frequency can affect energy metabolism, gene The authors would like to express their appreciation
activation, secretion of growth factors, and cell matrix to all children and their parents who participated in
synthesis of bone cells.32-33 Theoretically, mechanical this study with all content and cooperation.
vibration can increase bone mass in the human
skeleton as well. Ethical clearance

It was showed that the 8-month course of vibratory All subjects were informed about the study
exercise using a reciprocating plate is effective to procedure and signed consent forms approved by the
improve hip BMD and balance. A few studies have local research ethical Committee for the Protection of
shown recently the effectiveness of the up-and-down Human Subjects, at Faculty of physical therapy, Cairo
plate for increasing bone mineral density (BMD). 34 University.

With appropriate frequency, mechanical vibration Conflict of Interest

can affect energy metabolism of bone cell, gene There is no interest of conflict with any
activation and secretion of growth factors, and organization, and this research is not funded.
synthesis of other cell matrix.35-36.Under appropriate
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 DOI Number: 10.5958/j.0973-5674.7.3.081
140 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

A Comparative Study between Relaxation Technique and

Aerobic Exercise in Fatigue During Chemotherapy in
Acute Lymphoblastic Leukemia in Children

Bhatt Kaushal D1, Dhoriyani Narendra B2, Smitha D3

1
Physiotherapist & CEO, KIDS Paediatric Physiotherapy Clinic, Bhavnagar, 2Tutor Cum Physiotherapist, Government
Physiotherapy College, Jamangar, 3Assistant Professor, Shree Devi College of Physiotherapy, Mangalore

ABSTRACT

Background: Cancer is most common cause of death in children. Acute lymphoblastic leukemia
affecting around 83% of childhood cancer. Children receiving chemotherapeutic drug like Vincirstine,
Predisome and L-asparaginase are suffering from side effects like fatigue, peripheral neuropathy,
decreased in muscle strength etc. To reduce Fatigue, two method Aerobic exercise & Relaxation
technique can be given in different groups. So to compare the efficacy of Aerobic exercise and
Relaxation technique to reduce fatigue during chemotherapy in acute lymphoblastic leukemia in
children.

Materials and Method: 40 patients refereed by private oncologist, from government Wenlock hospital
were randomly divided in two groups: Group-A received Aerobic exercise, Group-B received
Jacobson's Relaxation technique. Each group received 20 min of intervention daily for a period of 3
weeks. Pre test fatigue level assessment done by Piper Fatigue Scale. After 3 weeks of Exercise protocol
given for both groups, fatigue level assessment was again done by Piper Fatigue Scale.

Results: There was a significant reduction in level of fatigue in both groups, but more reduction is
seen in group receiving Relaxation technique. So this study is highly significant in favor of Group B.
(p < 0.01).

Discussion and Conclusion: Relaxation technique helps them to reduce disease related or treatment
related stress and possibly Relaxation technique is easy to perform for children and children enjoy
doing that. This study concludes that Relaxation technique is more effective in reduction of fatigue
than Aerobic exercise in children.
Keywords: Acute Lymphoblastic Leukemia, Fatigue, Aerobic exercise, Relaxation technique

INTRODUCTION 375 BC Hippocrates of Cos coined the word

‘Carcinomas’. The Latin word ‘Cancrum’ which means
The incidences of malignant disease vary with age,
‘crab’ might have origin to the word “Cancer”.1 In
sex, and geographic locations. Both females and males
recent times in medical field the word cancer has been
have almost the same proportion of cancer. Pediatrics
replaced by Neoplasm; it indicates an abnormal type
cancers are far less than what is seen in adults, but it is
of new growth, not only evident in the intact animal,
growing in importance in terms of mortality. Cancer
but which can also be seen in tissue culture.
is a leading cause of death in children up to 14 years
in the developed world.1 In a historical sense, in 460- Acute Leukemia is a heterogeneous group of
neoplasm arising from clonal, neoplastic proliferations
of immature cells of the hematopoietic system, which
Corresponding author:
Dhoriyani Naredra B are characterized by aberrant or arrested
Tutor Cum Physiotherapist differentiation.2 Viral infection, Oncogens, like t(8;14)
Mahendranagar, Ta: Morbi , Rajkot, Gujarat, India. Ph: for Acute Lymphoblastic Leukemia ionizing radiation,
+91-987-971-8851 chemical agents like Benzene, Congenital
E-mail: Narendra41067@yahoo,com chromological abnormalities, Immunological

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 141

deficiency syndrome are some of the etiological factors Aerobic Exercise

responsible for Leukemia.3 Leukemia is regarded as a
condition in which there is clonal proliferation of Aerobic exercise is defined as sub maximal,
malignant stem cell in the bone marrow. Leukemia is rhythmic, repetitive exercise of large muscle group,
classified Chronic and Acute leukemia. Chronic during which the needed energy is supplied by
Leukemia is further classified as Chronic Myelocytic inspired oxygen. Main fuel source for aerobic exercise
Leukemia(CML) and Chronic Lymphoblastic are glycogen, fat and protein. ATP is resynthesized in
Leukemia(CLL) whereas Acute leukemia is further mitochondria of the muscle cell. The ability to
classified as Acute Myelocytic Leukemia(AML) and metabolize oxygen & other substrates is related to the
Acute Lymphoblastic Leukemia(ALL)2 number & concentration of the mitochondria & cells.
Maximal capacity of the aerobic system is great (90.0
Acute Lymphoblastic Leukemia is most common mol ATP) but maximal power of the system is small
in children with its highest incidence between 1 to 5 (1.0molATP/min). The system predominates over the
years 3 & it accounts for 80% of childhood leukemia.2 other energy systems after the second minute of
The phases of treatment are: Induction drug therapy, exercise.7 Activity that is of sub maximal intensity
consolidation therapy, CNS prophylaxis and remission lasting 30 minutes or more taxes a high percentage of
maintenance therapy. The side effects of chemotherapy the aerobic system & develops endurance. Other
are phlebitis or extravasations at injection site, acute benefit of exercise are increase endurance, improve
and chronic weakness and fatigue, hypoxia, myopathy, appetite improve heart’s pumping ability etc.7
peripheral neuropathy and cardiomyopathy. The late
side effects are pulmonary fibrosis and secondary Relaxation techniques: 8,9,10
malignancy. “State of consciousness characterized by feeling of
The most common complaints of people suffering peace and release from tension anxiety and fear.” In
from cancer are Fatigue, especially those who are 1970’s Herbert Benson, MD use word ‘relaxation
receiving chemotherapy. It is difficult to describe and response’. This response moderates sympathetic
patient express it in a variety of ways, using terms such arousal and produces health benefit like: Decrease
as tired, weak, exhausted, weary, worn-out, fatigued, heart rate and blood pressure, lowered lipid level,
heavy or slow. It is the condition characterized by decrease levels of circulating stress hormones,
distress and decreased functional status. Fatigue improved immune functioning. Various Relaxation
usually affects the physical performance and activity techniques are Jacobson’s Progressive muscle
of daily living. relaxation, Meditation, Guided imagery or
visualization. There are studies available which proved
Fatigue is the most important and often untreated effect of Aerobic exercise and Relaxation techniques
side effects in cancer today. Cancer related fatigue is in the management of fatigue for the cancer patients
largely a subjective experience, and relies on self receiving chemotherapy but as concluded in a study
reporting. Also, physician and patients alike many by P Jacobson, limited support available for these type
view cancer related fatigue as something to be of interventions.11
endured, rather than true symptoms that require an
intervention. It may be too easy to overlook a symptom There is lack of evidence in comparing both
such as fatigue when focusing on aggressive interventions to reduce level of fatigue in cancer
management of the tumor to ensure the patient’s patients who is receiving chemotherapy treatment.
survival. There are many factors, both physical and This study is proposed to compare the efficacy of
emotional, which can cause fatigue. This includes Aerobic exercise and the efficacy of Relaxation
disease itself, treatment, medications, pain, nutritional technique in fatigue during chemotherapy in Acute
deficits, anxiety and depression.6 Various physical Lymphoblastic Leukemia in children.
therapy interventions like Aerobic exercises,
Strengthening exercises, Stretching, and Relaxation MATERIALS AND METHODOLOGY
techniques are used to reduce fatigue in cancer A randomized control study was conducted at
patients. Among all these Aerobic exercises and Physiotherapy Department of Govt. Wenlock hospital
Relaxation techniques are preferred widely by the and Shree Devi College of Physiotherapy. 40 Acute
therapist. Lymphoblastic Leukemia patients of 8 to 16 years were
referred by an Oncologist to the Physiotherapy

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 142 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

department, who were screened using Oncology demonstrated. After the demonstration the
screening assessment for general health status and participants were instructed to follow the same.
Piper Fatigue Scale to assess fatigue. Patients who (Warm-up exercise for 5 minutes, cycling for 5 minutes
scored 4–6 and above in the Piper Fatigue Scale were and treadmill walking for 5 minutes.) Time was then
eligible for the study. The total number of eligible measured by stop watch. This session was followed
patients during the study was 36(31 Boys, 5 Girls) by cool down period for 5 minutes. All sessions were
based on the inclusion and exclusion criteria. The conducted under observation and in presence of
inclusion criteria were, Patient diagnosed with acute subject’s caretaker. Vital parameters were checked
lymphoblastic leukemia by the consulting oncologist during and after the study. In Group B (Relaxation
and who have already completed first dose of Technique Group) a well ventilated, quiet and peaceful
chemotherapy and complaining fatigue. The patients room was chosen. Jacobson’s relaxation technique was
were excluded if they had unstable cardio-vascular demonstrated to the subjects of this group. Then they
parameters, patients who have undergone recent were encouraged to perform same technique for 15
surgery or any cardiac disease-illness. Subjects were minutes. All sessions were conducted under
randomly divided into two groups using sealed observation and in presence of subjects care taker. Vital
envelope method. Both groups were explained about parameters were checked during and after the study.
their respective procedure which they would be
undergoing for a period of 3 weeks and were made to Post-intervention outcome measures were
sign a consent form. reassessed at the end of 3 weeks of exercise protocol.
Pre to post comparison of outcome measure of each
The subjects of both groups attended 1 session per group was done by students paired‘t’ test. Comparison
day for 5 days / week for 3 weeks. All vital parameters between the two groups i.e. group A and group B was
were measured to confirm that the subjects were stable. done using students unpaired‘t’ test. Mean and
Patients were called to department before their meal standard deviation were calculated and data were
or 2 hours after meal. Pre study fatigue level was subjected to statistical analysis using SPSS software.
measured by Piper fatigue scale in the wards if they
were in patients, or in oncologist’s clinic if on OPD RESULTS
basis.
From the table 1.1 and table 1.2 it is understood
Group A(Aerobic Exercise Group) subjects were that there was highly significant pre to post changes
explained general warm-up exercise, cycling on static was found in scores of Piper Fatigue Scales in both the
bicycle followed by walking on treadmill were groups.

Table 1.1. Comparison of level of fatigue from Pre to Post intervention for Group A (Aerobic exercise)

Aerobic exercise Mean Difference t-value p-value Result

PRE-POST 1.17 5.197 0.000 P<0.05 HS

In Group A mean difference of fatigue is 1.17 and t- exercise) there is highly significant difference in fatigue
value is 5.19 and p < 0.05, so in Group A (Aerobic level after aerobic exercise.

Table 1.2. Comparison of level of fatigue from Pre to Post intervention for Group B (Relaxation technique)

Relaxation technique Mean Difference t-value p-value Result

PRE-POST 1.98 12.94 0.000 P<0.05 HS

In group B mean difference of fatigue 1.98. t-value It shows that the interventions, Aerobic exercise and
12.94 and p< 0.05 so in Group B (Relaxation technique) Relaxation technique are good to decrease fatigue.
there is very highly significant difference in fatigue
level after relaxation technique.

Table 1.3. Comparison between Mean Difference of Group A (Aerobic exercise) and Group B (Relaxation technique)

Mean Difference t-value p-value RESULT

Aerobic exercise & Relaxation technique A 1.17B 1.98 2.96 0.005 P<0.001 VHS

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 143

In Group A the mean difference of pre to post is leads them to mental peacefulness. “The American
1.17 and in Group B the mean difference of pre to post cancer society’s” guideline to cope up with cancer
is 1.98. When this two groups mean difference were related fatigue; it is mentioned that relaxation
compared it is found that there is very highly technique may help to reduce stress in cancer
significant (P<0.001) difference between the groups. patients.30, 31
Group B (Relaxation technique group) had better
recovery from fatigue then the Group A (Aerobic Relaxation technique helps them to reduce disease
Exercise Group). related or treatment related stress and possibly
Relaxation technique is easy to perform for children
DISCUSSION AND CONCLUSION and we observed that children enjoy doing that. That
could be a reason for relaxation technique show better
According to Seattle Cancer Care Alliance, Physical result. Thus, from the study result it is concluded that
therapy department, Ease. cancer patients with Relaxation technique is better that the Aerobic Exercise
complain of fatigue and who need strength training to reduce fatigue in Acute Lymphoblastic Leukemia.
and cardio-vascular education is referred to physical
therapy department.12 Patients with cancer frequently The limitations of study were as it was done on
suffer from extreme stress over a long period of time, smaller sample size and treatment protocol was of
causing them to spend energy and experience high smaller duration and it is done on patients of 8-16 years
level fatigue. Other factors that causing fatigue are age group. There may be different result if Aerobic
anemia, medications, anorexia, metabolic exercise were given for longer duration and can be
disturbances, hormone deficiency, pain or infection. given after relaxation technique. This study can be
further extended by conducting on different types of
Anemia, a decrease in the red blood cells, which cancer with different types of physical therapy
leads to fatigue. An important part of red blood cells interventions.
is hemoglobin. When hemoglobin is low, oxygen
levels decrease and it becomes difficult to sustain its ACKNOWLEDGEMENTS
normal activity level.27 Aerobic exercise is helpful to
increase red blood cell counts which ultimately The authors are thankful to Principal and Board of
increase Hb level and oxygen carrying capacity of Trustee, Shree Devi College for providing laboratory
blood so that reduce fatigue after chemotherapy. facility and funding for study.
Cycling, home based or institute based walking on Ethical Clearance: The study was approved by
treadmill are ways to activate aerobic system of the Research and Development and Ethical committee of
body. 28 Exercise training can increase functional Shree Devi college of Physiotherapy.
capacity, leading to reduced effort and decreased
fatigue.29 This way aerobic exercise reduce fatigue, Source of Funding: The study was sponsored by Shree
improve physical performance and improve quality Devi College.
of life.
Conflict of Interest: The study was partly sponsored
The result of this study indicates that Group A’s by Shree Devi College, however it does not had any
level of fatigue was reduced from 4.36 to 3.19 with role in study design, in collection, analysis or
p<0.05. So reduction of level of fatigue is 1.17 and interpretation of the data; or in writing the manuscript
Group B’s fatigue level was reduced from 4.37 to 2.39 or the decision to publish the results.
with p<0.05. So reduction in level of fatigue for Group
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 DOI Number: 10.5958/j.0973-5674.7.3.082
146 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Predictors of Job Satisfaction among Physiotherapy

Professionals

Nidhi Gupta1, Shabnam Joshi2

1
Consultant Physiotherapist, Ayushman Hospital, Hisar, 2Incharge, Department of Physiotherapy, Guru Jambheshwar
University of Science & Technology, Hisar, Haryana

ABSTRACT

Background: The aim of the study was to find out the best predictors of job satisfaction and to
investigate the level of job satisfaction among physiotherapists.

Method: A self-administrated questionnaire survey was conducted in December 2008.

Data were collected from 196 physiotherapists in government and private health care settings,
institutions located in northern regions of India. The response rate was 77.55%.

Results: 72 women (51.43%) and 68 men (48.57%) participated in the study. The percentage of satisfied
physiotherapists was 56.4%. Logistic regression analysis showed that the most important predictors
of job satisfaction were: (1) Salary (OR=3.694, 95% CI 2.340-5.832), (2) Interesting (OR=1.937, 95% CI
1.009-3.719), (3) Fulfilling (OR=1.679, 95% CI 0.009-2.835). Job satisfaction dimensions indicate that
highest dissatisfaction levels occur in the area of salary and job security. The percentage of satisfaction
ratings was higher in men (65.3%) than in women (47.1%). Post graduate professionals were found to
be more satisfied (70.7%) as compared to their graduate counterparts.

Conclusion: This study concludes that salary, interest in work and fulfillment in job are important
predictors of job satisfaction among physiotherapy professionals. The result shows that a total of 79
(56.4%) physiotherapists were globally satisfied with their job. The percentage of satisfaction ratings
was higher in men (65.3%) than in women (47.1%).
Keywords: Physiotherapy, Job Satisfaction, Predictors

INTRODUCTION profession that is undergoing dynamic and sometimes

unpredictable changes can be especially susceptible
Physiotherapy is referred to as physical therapy,
to uncertainty and reduced professional satisfaction.
involves evaluating, diagnosing, and treating a range
of diseases, disorders, and disabilities using Behavioral and social science research suggests that
physical means. Employment opportunities for job satisfaction and job performance are positively
physiotherapists are tremendous as it is a career where correlated . [5] Job satisfaction and morale among
the demand exceeds supply. medical practitioners is a current concern
worldwide.[17,31] Poor job satisfaction leads to increased
In India the demand is rapidly increasing. It is
physician turnover, adversely affecting medical care
estimated that one physiotherapist is required per
.[7,26] Recent research into some determinants of job
10,000 people.[2]
satisfaction has examined individual factors as well
Satisfaction with one’s profession can affect as the organization’s role .[15] Calnan et al [9] showed
motivation at work, career decisions, personal health that people respond differently to similar working
and relationship with others. Those working in a conditions.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 147

Job satisfaction is one of the central variables in Procedure and Participants: The framed
work and organizational psychology and is seen as an questionnaire was presented to a group of
important indicator of working life quality. [14,35] physiotherapists for comments and criticisms. After
Satisfied employees tend to be more productive and that, the items were modified to improve the
creative. questionnaire and make it easier.

Job demands and job control have been reported 42 surveys out of total 196 were mailed to the
to have several interactive effects on employee well- participants with a letter of explanation concerning the
being and health in specific occupational groups.[11,12] purpose of the study with a stamped addressed reply
Karasek and colleagues observed that a level of high envelope. 98 surveys were collected in hand with
control over work is accompanied by positive health attached consent form copies.
characteristics, whereas heavy burdens at work lead
Scoring: In the questionnaire, the respondents were
to increased disturbances in health[20]. A few factors like
asked to rate their level of agreement or disagreement
autonomy, pay, task demands and organizational
for each statement on a five-point Likert-type scale on
policies are known to have a significant effect on job
a continuum from strongly disagree to strongly agree.
satisfaction.[8,30]
(1=strongly disagree, 2=disagree, 3= neutral 4=agree,
5=strongly agree). Agreement score of 5 indicated the
MATERIALS AND METHOD
highest degree of satisfaction and score of 1, the highest
A self-administrated questionnaire survey was dissatisfaction. Thus, the maximum possible
conducted in December 2008. 196 respondents were agreement score would be 75, and lowest disagreement
selected from physiotherapists practicing in Delhi, score would be 15.
Gurgaon, Haryana and Chandigarh by purposive
Reliability estimates: An alpha value of 0.70 or
sampling method.
higher was considered as acceptable reliability for
Physiotherapists who were in profession with the group comparisons [13,24]. The overall questionnaire had
minimum qualification of Bachelor ’s degree were a coefficient alpha value of 0.75.
included and those who were either diploma holders
Data Analysis: In this study SPSS version 15.0 for
or involved in research or were inactive at the time of
statistical analyses was used. The missing values were
the survey were excluded from the study.
checked prior to further statistical analysis. Missing
Instrumentation: A self-administered data analysis showed that 140 (71.42%) respondents
questionnaire survey was selected as the appropriate had no missing values. Nine (4.59%) respondents had
tool for data collection. The questionnaire consisted one missing value, three (1.53%) respondents had two
of two parts. In Part 1 of the survey sought missing values.
demographic information: gender, years of
The correlation coefficients were calculated to
professional experience and professional status. Part
evaluate the relationship between variables. Forward
2 consisted of fifteen statements which were
conditional logistic regression analysis was used to
considered important in the assessment of job
identify the most important predictor domains in
satisfaction in the professional practice of
global satisfaction. For this, those who indicated they
physiotherapy. A literature review was conducted to
were either satisfied or very satisfied in the global
create a list of dimensions and the fifteen most common
satisfaction question were re-coded as “1=satisfied”
were chosen for inclusion in the questionnaire. These
while all others were re-coded as “0=dissatisfied”.
included: leadership, mental stress, relationships with
co-workers and superiors, working conditions, Data were presented as the mean standard
achievement, recognition, salary, advancement deviation (SD) and percentage. The significant level
opportunities, interesting, fulfilling, autonomy, was set at P value less than 0.05.
paperwork, improvement in work, job security,
physical demanding and workload distribution.

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 148 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

FINDINGS
Table 1.1. Distribution of scores of various dimensions

N Minimum Maximum Mean Std. Deviation Variance

Interesting 140 1 5 3.84 .833 .695
Improving 140 1 5 4.16 .732 .536
Fulfilling 140 1 5 3.56 .954 .910
Autonomy 140 1 5 3.63 .984 .969
Advancement 140 1 5 3.76 .903 .815
Recognition 140 1 5 3.59 .857 .734
Security 140 1 5 2.67 .909 .827
Salary 140 1 5 2.61 1.180 1.391
Stress 140 1 5 3.09 1.017 1.034
Demanding 140 1 5 2.48 1.109 1.230
Workload 140 1 5 3.25 .841 .707
Paperwork 140 1 5 3.47 .860 .740
Relations 140 2 5 3.99 .725 .525
Conditions 140 1 5 3.83 .758 .575
Leadership 140 1 5 3.49 .971 .942
Valid N (listwise) 140

Table 1.2. Comparison of overall job satisfaction with gender

Overall1 Total
0 1 0
Gender F Count 36 32 68
Expected Count 29.6 38.4 68.0
% within Gender 52.9% 47.1% 100.0%
M Count 25 47 72
Expected Count 31.4 40.6 72.0
% within Gender 34.7% 65.3% 100.0%
Total Count 61 79 140
Expected Count 61.0 79.0 140.0
% within Gender 43.6% 56.4% 100.0%

TABLE 1.3. Comparison of overall job satisfaction with qualification

Overall1 Total
0 1 0
Qualification 0 Count 49 50 99
Expected Count 43.1 55.9 99.0
% within quali 49.5% 50.5% 100.0%
1 Count 12 29 41
Expected Count 17.9 23.1 41.0
% within quali 29.3% 70.7% 100.0%
Total Count 61 79 140
Expected Count 61.0 79.0 140.0
% within quali 43.6% 56.4% 100.0%

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 149

Table 1.4 Summary of logistic regression analysis for variables predicting job satisfaction

B S.E. Wald Df Sig. Exp(B) 95.0% C.I.

for EXP(B)
Lower Upper Lower Upper Lower Upper Lower Upper
Step 1(a) Salary 1.318 .223 35.029 1 .000 3.737 2.415 5.783
Constant -3.025 .573 27.868 1 .000 .049
Step 2(b) Fulfilling .680 .254 7.151 1 .007 1.973 1.199 3.248
Salary 1.283 .229 31.474 1 .000 3.609 2.305 5.650
Constant -5.334 1.118 22.751 1 .000 .005
Step 3(c) Interesting .661 .333 3.952 1 .047 1.937 1.009 3.719
Fulfilling .518 .267 3.764 1 .052 1.679 .995 2.835
Salary 1.307 .233 31.465 1 .000 3.694 2.340 5.832
Constant -7.370 1.640 20.204 1 .000 .001

a. Variable(s) entered on step 1: Salary.

b. Variable(s) entered on step 2: Fulfilling.

c. Variable(s) entered on step 3: Interesting.

RESULTS (0.000). The Hosmer and Lemeshow’s goodness of fit

test was greater than 0.05 (X=4.647, df=8, p =0.795).
The study population consisted of 72 women and Logistic regression analysis showed that the most
68 men. The ages ranged from 21 to 53 yr. the mean important predictors of job satisfaction were: (1) Salary
age was 27.02 ± 0.395. (OR=3.694, 95% CI 2.340-5.832), (2) Interesting
Kruskal-Wallis and chi-square tests revealed that (OR=1.937, 95% CI 1.009-3.719), (3) Fulfilling
total satisfaction scores significantly differ between (OR=1.679, 95% CI 0.009-2.835).
gender and professional qualification respectively.
47.1% were satisfied and 52.9 % females were DISCUSSION
dissatisfied with their profession while 65.3% were Job satisfaction is a complex phenomenon which
satisfied and 34.7 % males were dissatisfied and is measured to evaluate an individual’s attitude to his
constituting a total of 56.4% satisfied and 43.6% work. The primary objective of the present study was
physiotherapists dissatisfied with their job (c2 =4.721, to find the predictors which influence the job
P=0.03 i.e. P < 0.05). (Table 1.2) satisfaction among physiotherapy professionals. The
results revealed that among various factors- salary,
There was significant difference between the job
interesting work and fulfilling job constitutes the main
satisfaction and professional qualification (c2 = 4.824,
predictors of job satisfaction among physiotherapy
P= 0.028 i.e. p<0.05). Professionals with bachelor’s
professionals.
degree were less satisfied (50.5%) than the
professionals with masters degree (70.7%).(Table 1.3) Numerous studies carried out in several countries
showed that there is a significant correlation between
The participants scored lowest in the salary (2.61 ±
income and job satisfaction. [10,37] In a study Job
1.180) followed by job security (2.67 ± 0.909) but scores satisfaction of health care at health centres in Turkey’
were highest in learning and improvement in work conducted by Bodur in Turkey, it has been
(4.16 ± 0.732) and interpersonal relationships (3.99 ± demonstrated that income and working conditions
0.725). (Table 1.1) were the most important factors for dissatisfaction of
A total of 79 (56.4%) physiotherapists were globally health care providers working at public health centers.
Likewise, according to the study done by H. Sur et al
satisfied with their job. The percentage of satisfaction
on Factors affecting dental job satisfaction in Turkey,
ratings was higher in men (65.3%) than in women
monthly salary is one of the significant predictors of
(47.1%).(Table 1.2)
job satisfaction among Turkish dentists .[16] The results
A summary of the logistic regression analysis is of the study indicate that there was a significant
shown in Table 1.4. The Omnibus test in the model association between job satisfaction and salary which
row had a chi-square value (65.179) and a small p-value is consistent with the findings of previous studies.

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 150 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

A study conducted on Influence of working one’s abilities in his profession can positively affect
conditions on job satisfaction in anesthetists by J. F. the aspects of job satisfaction.
Kinzl et. al reveals that a job that is interesting and
that permits to contribute their skills and ideas is very CONCLUSION
important to anesthetists.[19] The study of Speakman
et al. on The Job Satisfaction of Physical Therapists also This study concludes that salary, interest in work
received high scores in the statement concerned with and fulfillment in job are important predictors of job
interesting job and fulfilling nature of the job. [34] satisfaction among physiotherapy professionals. The
Adetoyeje Y. Oyeyemi, in his study Nigerian Physical result shows that a total of 79 (56.4%) physiotherapists
Therapists Job Satisfaction: A Nigeria - U.S.A. were globally satisfied with their job. The percentage
Comparison, recorded a significantly higher of satisfaction ratings was higher in men (65.3%) than
importance scores on statements relating to physical in women (47.1%).
demand, fulfillment and interesting job. The statement Conflict of Interest
regarding the interesting nature of the job was rated
highest in importance by subjects. • There are currently no empirical data on job
satisfaction of Indian physiotherapists, therefore,
A second objective of this study was to assess it is recommended that this study be repeated in
whether physiotherapists were satisfied with their job. the future.
The analysis of the study reveals that more than fifty
percent of physiotherapists are satisfied with their jobs. • On the other hand, the findings should be
These findings are consistent with the results of interpreted with caution since the participants
previous study by APTA on Recruitment and Retention were physiotherapists from a particular region of
of Physical Therapists in Hospital Settings.[1] north India and do not represent all
physiotherapists in India.
In the present study there are significant differences
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conducted by Levent et al in 2004 there were no 4. Barnes M.R., and C.A. Crutchfield, Job
significant differences between gender and age Satisfaction-Dissatisfaction: A Comparison of
groups.[33] Private Practitioners and Organizational Physical
Therapists, Physical Therapy 5: 1997, pp. 35 41.
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job satisfaction showing a positive correlation with the satisfaction in a major metropolitan public EMS
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The positive correlation between overall of Allied Health Professionals, Journal of Allied
satisfaction and salary indicates that if the Health 7: 1994, pp. 281-287.
physiotherapists are not paid sufficiently can lead to 7. Buchbinder RN, Wilson M. Primary care
high levels of dissatisfaction among them. Areas of physician job satisfaction and turnover. Amer
dissatisfaction are signals for change. An interesting Jour of Managed Care 2001;7(7):701-13.
job as the sole factor would not suffice for adequate 8. Buessing A.Job satisfaction.Germany: Beltz
job satisfaction. Various other factors such as learning PsychologieVerlags Union, 1995-Cross ref
and improvement in the job, good interpersonal 9. Calnan M, Wainwright C. Mental health and
relationships at workplace and enablement to utilize stress in the workplace; the case of general
practice in the UK. Soc Sci Med 2001;52:499-507.

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10. D Grembowski, et al: Managed care and primary 23. Neuwirth ZE. An essential understanding of
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11. de Jonge J,et al. Job strain, effort-reward 24. Nunnally JC, Bernstein IH. Psychometric theory.
imbalance and employee well-being: a large-scale Third edition. New York: McGraw Hill, 1994
cross-sectional study. Soc Sci Med. 2000; 50: 1317– 25. Okerlund V.W., et al, “Factors Affecting
27[CrossRef] Recruitment of Physical Therapy Personnel in
12. de Jonge J, Dollard MF, et al. The demand–control Utah,” Physical Therapy 74 (2), 1994, pp.177-184.
model: Specific demands, specific control, and 26. Pathman DE, et al. Physician job satisfaction, job
well-defined groups. Int J Stress Management dissatisfaction, and physician turnover.Jour of
2000; 7: 269–87[CrossRef] Fam Prac 2002;5(7):16-21
13. DeVellis RF. Scale development: Theory and 27. Published online 2008 April 22. doi: 10.1186/1745-
applications. Newbury Park: Sage Publications, 6673-3-8.
1991,cron 28. Rozier, C.K., et al, “Gender and Physical Therapy
14. Dormann C, Zapf D. Job satisfaction: a meta- Career Success Factors,” Physical Therapy 78:
analysis of stabilities. J Organ Behav 2001; : 483– 1998, pp. 690-704.
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1999;48:1647-51. 30. Semmer N, et al. Instrument for Stress-related Job
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job satisfaction: a cross-sectional survey in Turkey. 31. Sibbald B, Enzer I,et al. GP job satisfaction in 1987,
Eval Health Prof 27, 152–164 (2004) 1990 and 1998: Fam Prac 2000;17:364-71.
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Prefecture , Japan, J.Phys . Ther.Sci.18:127-132 Health 2204;46,500-505
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on job satisfaction in anaesthetists ,British Journal Physical Therapists,” Physiotherapy Research
of Anaesthesia 2005 94(2):211-215 International 1 (4), 1996, pp. 247-254.
20. Karasek RA, Theorell T. Stress, Productivity, and 35. Warner TH. The effects of job satisfaction and
the Reconstruction of Working Life. New York: organizational commitment on intent to leave
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22. Migle Gamperiene et al. ,Self-reported work 37. Y Seo,et al: The determinants of job satisfaction
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 DOI Number: 10.5958/j.0973-5674.7.3.083
152 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Cervico-thoracic Mobilization to Address LBA for a

Patient with Lumbar Spondylolisthesis

P P Mohanty1, B Kuanar2, B K Behera3

1
Associate Professor, Head of the Department (PT), Swami Vivekananda National Institute of Rehabilitation Training and
Research, Olatpur, Cuttack, Orissa, 2Retired Professor & H.O.D, Department of Neurology, 3Professor & H.O.D,
Department of Orthopedics, SCB Medical College, Cuttack

ABSTRACT

Background and Purpose: This case report describes the examination, intervention and outcome of
a patient with lumbar spondylolisthesis. The patient was managed by myofascial release of levator
scapulae and cervico-thoracic central PA mobilization. There is no literature found describing these
interventions for lumbar spondylolisthesis.

Case Description: The patient was a 43 years old woman with LBA with radiating pain to left lower
limb due to lumbar spondylolisthesis. She received stretching of levator scapulae, piriformis & rectus
femoris, cervico-thoracic central PA mobilization, passive lumbar flexion mobilization, core
strengthening exercises. Treatment was given 5 days a week for 20 sittings.

Outcomes: Percentage of slippage.

Conclusion: Stretching of levator scapulae and cervico-thoracic central PA mobilization may help in
reducing forward slippage in lumbar spondylolisthesis.
Keywords: Mobilisation, Cervico-Thoracic Dysfunctions, Myofascial Pain Syndrome, Spondylolisthesis,
Muscle Energy Technique, Maitland

INTRODUCTION CASE DESCRIPTION

The term spondylolisthesis was first described in The patient was a 43 year old woman reported to
1854 by Kilian as a slow displacement of superior the physiotherapy outpatient Department of
vertebral segment over the inferior vertebra 1 . SVNIRTAR with the complaint of LBA radiating down
Approximately 2-5% of general populations have to left lower limb since about 3 months. Pain more on
spondylolisthesis, of which 50% are asymptomatic2. standing and walking relieved in lying with hips &
Spondylolisthesis in adult population is associated knees flexed. She lived with her husband & was a
with radiculopathy in 62%3, activity related lower back housewife. She wanted to perform her household
pain and neurological claudication4. Spondylolisthesis activities as usual.
can be diagnosed using plain radiography (oblique
and lateral view) and CT scan5. There are five types of Examination: The physical examination revealed
spondylolisthesis: dysplastic, isthmic, degenerative, pain score 9 by visual analogue scale 9, increased
traumatic and pathologic 6 . Severity of lumbar lordosis without any side deviation, lumbar
spondylolisthesis is graded on the basis of the flexion was grossly restricted; extension was terminally
percentage of translation of one vertebra on the caudal painful with segmental hypermobility at L4-5 level.
vertebra7. In low slip spondylolisthesis grade I (up to Bilateral pirifomis tightness was present (left greater
25%) and grade II (26 - 50%), conservative treatment than right), SLR left -70, right-75 with sciatic tension.
including physiotherapy is the first treatment of Myofascial pain syndrome as characterized by taut
choice8. band with trigger point was present in left levator

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 153

scapulae, compression of which reproduced the pressed the bent elbows and raised the upper trunk,
original low back & leg pain10, 11. Maitland’s central PA so that trunk flexion was obtained with the bent elbow
pressure over C7, T1, T2 reproduced the original in front of the chest acting as fulcrum15. 30 seconds
symptoms and segment hypomobility of cervico- mobilization followed by rest for 30 seconds were
thoracic spines were present12. X- ray lumbar spine applied for 4 times.
lateral view showed anterior slippage of L4 over L5
vertebral body. Percentage of vertebral slip was Stretching of levator scapulae was applied in prone
measured in lateral radiograph by using AutoCAD with the arms crossed across the chest. Physiotherapist
2006 software program. Meyerding classified the standing at head end with the thumbs inserted
grades of vertebral slip7; Tillard (1954) formulated a underneath the superior angles of scapulae to which
simple equation to calculate the percent slip. Percent levators are attached16, 34. Muscle energy technique
slip = the displacement of L4 on L5/width of L5 X 100. with resisted submaximal contraction of levators while
The percentage of slip was 35.2 %. There was no breathing in was followed by relaxation and further
neuromuscular deficit. stretching. 10 repetitions followed by 30 seconds
sustained stretch were applied to both the sides.
The physical diagnosis was L4 lumbar
spondylolisthesis with lumbar flexion dysfunction and Central PA pressure over C7, T1, T2, T3 & T4 with
cervicothoracic extension dysfunction. the amplitude that reproduced the patient’s original
symptom and tolerated by the patient were applied
The plan of Physiotherapy management was for 30 seconds each12.
developed to address the lumbar flexion and
cervicothoracic extension dysfunctions, tight The patient was advised to do static abdominal
piriformis, rectus femoris, levator scapulae and weak exercises at home, 5 seconds contraction followed by
abdominals. 10 seconds relaxation, 10 repetitions 5 times daily.

After 7th sittings no leg pain was reproduced while

INTERVENTIONS stretching levator scapulae and after 10 sittings no leg
The patient was treated with bilateral piriformis pain was reproduced while applying central PA
stretching in supine with hips and knees flexed, thighs pressure. After 10 sittings the pain score improved
crossed with the painful left thigh over the right11, 13. from 9 to 3. After 10 sittings all stretching, lumbar
Muscle energy technique with resisted hip adduction flexion mobilization were continued. Cervico-thoracic
while breathing in was followed by relaxation and central PA mobilization with greater amplitude was
stretching by adducting the thighs. 10 repetitions applied to all upper thoracic spines; those were found
followed by 30 seconds sustained stretch was applied11. to be hypomobile. After 20 sittings there was no
original pain, but soreness in the back due to
Rectus femoris was stretched in supine towards the mobilization was present. X rays LS spine lateral view
edge of the bed, so that the side to be stretched showed reduction of anterior slippage from 35.2 % (fig)
remained out of the bed. Patient was asked to hold to 15.63% .
the leg above the ankle and opposite hip & knee flexed
towards the abdomen by the other hand. Therapist
standing by the side of the patient pressed the thigh
towards the abdomen to obliterate the lumbar lordosis
and extended the thigh to be stretched to the end
range14. Muscle energy technique with resisted hip
flexion while breathing in was followed by relaxation
and stretching by extending the thigh. 10 repetitions
followed by 30 seconds sustained stretch were applied
to both the sides11.

Lumbar flexion was given in supine with hips and

knees flexed, fingers clasped and hands behind the
neck. Therapist standing by the side of the patient Fig. X-ray L-S (pre-intervention) X-ray L-S (post-intervention)

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 154 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

OUTCOMES extension may reduce compensatory hyperextension

at lower lumbar spine, so is helpful in LBA.
The patient received stretching of piriformis, rectus
Hypomobile spine must be mobilized so that an even
femoris, levator scapulae and strengthening of
distribution of movement is achieved21.
abdominals, passive physiological lumbar flexion
mobilization and cevicothoracic central PA Raymond & John Evans (1997) measured the
mobilization for 20 sittings. The initial anterior intervertebral movements of the lumbosacral spine
displacement of L4 on L5 was 35.2 %, after 20 sittings produced by PA mobilization - an in vivo radiographic
it was reduced to 15.63%. study, which strongly suggests that the spine is
subjected to 3-point bending under the application of
DISCUSSION mechanical loads. Under the mobilization load the
lumbar motion segments were found to extend. In a
The case was grade II spondylolisthesis with
series of cadaveric studies, Lee and Evans (1992, 1994)
radiculopathy. Laxity at L4, L5 results in hyper-
noted that spinal PA mobilization produced extension
extension and pain. Stabilisation at this level can reduce
moments and shear forces to lumbar motion segments.
the pain and improve the functions.
McCollam and Benson (1993) reported an increase in
The thoraco-lumbar fascia acts as nature’s “back extension range of movement following spinal PA
belt”. It spans the area from the iliac crest and sacrum mobilization22.
up to the thoracic cage. The superficial lamina gets
Drawback of myofascial release technique, central
tensed by contraction of various muscles, such as the
PA mobilisation of Cervicothoracic spine includes
Latissimus dorsi, Gluteus maximus and Erector
some found difficulty to tolerate the position and some
muscle. It has extensive attachments starting from
complained of shoulder pain.
posterior nuchal fascia, levator scapulae muscle
cephalically to the biceps femoris & soleus muscle In Conclusion Low back pain due to
caudally. It also helps in transference of load through spondylolisthesis associated with myofascial pain
the trunk to lower extremities and as a result effectively syndrome of periscapular muscles and cervicothoracic
deloads the spine if functioning appropriately.19 extension dysfunction may be benefited by stretching
of periscapular muscles and mobilisation of
Inefficient functioning of TL fascia can be due to
cervicothoracic spine.
many causes like weakness of muscles attached to
fascia, fibrotic changes of muscle with loss of elastic Conflict of Interest
properties. This leads to an increased load transferred
through the spine gradually leading to extension The researchers have not received or undertaken
loading & degeneration. Improving length of the or had no interest in any of the following from/for/of
fibrotic muscles will improve the mobility of the the study during the study period : Payment or receipt
lumbar spine and may help in pain relief. Stretching of honoraria, Research grant, travel grant or conference
of the levator scapulae helps in back pain with or expenses and other remuneration or benefit.
without radiating pain.
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Jones & Barlett Learning 3rd edition. Assoc; 43(2): 75-88.
15. Margaret Hollis, Phyl Fletcher, Cook : Practical 30. Mollar M, Oberg B, Ekstrand J (1985): Duration
Exercise Therapy, Wiley Blackwell,1999:4th Edn. of stretching effect on Range of motion in Lower
16. Martinez LM, Khalil TM (1992): Stretching in the extremities. Arch Phys Med Rehab; 66:171-173.
rehabilitation of low-back pain patients. Spine; 31. Potter L, Mc Carthy C, Oldham J (2006): Intra
17(3): 311-317. examiner reliability of identifying a dysfunctional
17. De Deyne PG. (2001): Application of passive segment in the thoracic and lumbar spine. J
stretch and its implication for muscle fibres. manipulative Physiological Therapeutics; 29: 203-
Physical Therapy; 82(2): 819-827. 207.
18. Oolaogun M, Kem IC (2004): Reliability of rating 32. White A, Panjabi M (1990): Clinical Biomechanics
low back pain a visual analogue scale and a of the Spine. 2nd ed. Lippincott Williams and
semantic differential scale. Physiotherapy theory Wilkins.
and practice; 20: 135-142. 33. Wilkinson A. (1992): Stretching the truth. A
19. Thomas E. Hyde - Conservative management of review of the literature on muscle stretching.
sports injuries 2007 Physiotherapy; 38(4): 283-285.
20. Huijbregts PA. HSC 11.2.3. Lumbopelvic region: 34. Robert A Donatelli, Physical therapy of the
Anatomy and biomechanics. In: Wadsworth C. shoulder, 2nd edition
HSC 11.2. Current Concepts of Orthopaedics

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 DOI Number: 10.5958/j.0973-5674.7.3.084
156 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Relationship of Cervicothoracic Curvature with Muscle

Strength and Endurance in Subjects with Neck Pain

Parminder Kaur1, Monalisa Pattnaik2, Patit Paban Mohanty3

1
Assistant Professor, Amar Jyoti Institute of Physiotherapy, Delhi, 2Assistant Professor, 3Associate Professor & HOD, Swami
Vivekanand National Institute of Rehabilitation Training and Research, Orissa

ABSTRACT

Purpose: The purpose of the study is to determine the changes seen in cervicothoracic curvature
with increasing age in normal and neck pain subjects and also to study, relationship of cervicothoracic
curvature with deep neck flexor muscle function and pain level.

Material & Method: A group of 10 normal subjects were recruited for reliability study of photographic
method. Age and sex matched 30 normal and 30 neck pain subjects were also recruited. Both the
groups were divided into three age groups i.e.31-40, 41-50 and 51-60 years with 10 subjects in each.
To determine cervicothoracic curvature, lateral profile photographs were taken for both the groups
and using AutoCAD software cervicothoracic kyphosis angles were measured at C6 (C4 - C6- T4), C7
(C4 - C7- T4) and T1 (C4 - C6- T4) levels. For neck pain subjects, the angle average (of all the 3 levels)
was compared with deep flexor muscle strength, endurance and pain level.

Results : The intraclass correlation coefficients for Interrater reliability indicated high reliability with
ICC at C6=0.86, at C7=0.80 and at T1=0.88. Statistical analysis was done using one-way ANOVA &
Tukey's HSD at all three levels for both the groups. Cervicothoracic kyphosis was increased with age
and the increase was more prominent in subjects with neck pain. At C7, angle showed early changes
i.e. in forth decade in neck pain subjects compared to normal. The pain intensity and muscle functions
were correlated with average cervicothoracic angle using Pearson's co-relation in neck pain subjects.
There was statistically significant positive correlation between cervicothoracic angle average and
deep flexor muscle strength (r=.598, p=.000). However, no statistically significant relationship was
established for muscle endurance and pain intensity.

Conclusion: It was concluded that degenerative changes at C7 vertebra were progressed early in
neck pain subjects and their deep flexors strength reduces as the cervicothoracic kyphosis increases.
Keywords: Cervicothoracic Angles, Deep Flexor Muscles, Forward Head Posture

INTRODUCTION are the levator scapulae, upper trapezius,

sternocleidomastoid and suboccipital and deep neck
The problem of neck pain in working people
flexor muscles. It was demonstrated that there are only
between the ages of 25-29yrs have been reported to
2 levels C6-7 & C7-T1 which demonstrate movement
range between 25-30% & for those older than 45yrs
during extension from neutral position. This forwardly
rises to 50%. The cervical structures can be affected by
placed position of the head puts increased stress in
degenerative disc diseases, trauma and/or
cervicothoracic region2.
inflammatory disorders, resulting into neck pain. The
commonest dysfunction involves loss of lower cervical Weakness of deep neck flexor muscles has been
extension1. It is proposed that atraumatic cervical proposed to contribute to neck pain. Harms –Ringdahl3
spondylosis in the presence of forward head posture showed that healthy volunteers who maintained
is the result of midcervical hypermobility & flexion of the lower cervical and upper thoracic
suboccipital / cervicothoracic hypomobility. The perceived pain within 2 – 15 minutes, forcing them to
muscles most often affected in forward head posture discontinue the posture. Very few studies have been

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 157

done regarding cervicothoracic posture. Boyle J 4 Exclusion Criteria

studied the influence of age on cervicothoracic spinal
curvature, in an ex vivo radiographic survey & found 1. Traumatic cervical spine injury
that the mean location of the cervicothoracic curve
2. Any previous spinal surgery
inflexion point moved from T3 towards C7-T1 with
increasing age. 3. Medical conditions affecting cervical spine
mobility
A review of literature revealed paucity of studies
that have seen effect of increasing age on 4. Infective & Neurological conditions
cervicothoracic curvature and also its association with
the neck muscles function. The purpose of the study 5. H/O low back pain in past 6 months.
thus, was to record the effect of increasing age over
cervicothoracic kyphosis in normal and neck pain Instrumentation
patients and its relation with deep neck flexor muscles
1. Photographs - Left sided profile photograph was
strength, endurance and pain intensity, if any in neck
taken to obtain measurement of cervicothoracic
pain patients.
kyphosis angle at 3 levels i.e. C6, C7 and T1 in
saggital plane. For taking photograph, spinous
METHODOLOGY
processes of C4, C6, C7, T1 and T4 were first
A group of 10 normal subjects (20-30 yrs) were palpated. Adhesive skin markers, light plastic rods,
recruited for reliability study of photographic method. 30mm in length were attached to these marked
A total 30 subjects with neck pain (15 M, 15F) with levels. Next, the subjects were made to stand on
mean age of 47.24 ± 8.98 and meeting the inclusion sheet of paper of 42×30cm and the distance
and exclusion criteria were recruited from the OPD of between the subject and the wall was also
the Swami Vivekanand National Institute of measured and was kept constant. A Cannon
Rehabilitation Training and Research. Age matched 30 3mpixel digital camera with 35 to 70mm zoom lens
normal subjects (15 M, 15F) with the mean age of 44.96 was mounted on a tripod, the camera was placed
± 9.56 were also recruited. Informed consent was
3m from the subject. The subject was
obtained from the recruited subjects. Both normal and
approximately in the centre of the lens. The camera
neck pain group were again divided into three age
was placed perpendicular to the ground and was
groups i.e.31-40, 41-50 and 51-60 years with 10 subjects
approximately leveled with the C7 level. 3
in each age group.
photographs were taken for every subject. Compaq
Group I: Normal subjects desktop system and AutoCAD software was used
to measure the cervicothoracic angle by drawing
Group II: Subjects with neck pain
lines from C4 to any one level (C6, C7 and T1) and
Inclusion Criteria then from that level to T4 (fig: 1).

1. Neck pain (with or without radiation) of more than 2. The Modified Sphygmomanometer- Maximal
3 months muscle strength of deep neck flexors was measured
using a modified sphygmomanometer. It was
2. Age range- 30-60yrs.
preinflated with 20 mmHg and placed
3. Forward head posture (grade1 & 2 according to suboccipitally. The subjects were taught to perform
Griegel-Morris measurement of Forward Head upper cervical flexion as pure nodding movement
Posture) with maximal strength (fig: 2).

4. Decrease in lower cervical extension with pain at 3. Stopwatch- Muscle endurance of the deep neck
the end range flexors was measured by stopwatch. In hook lying
position, with retracted chin subjects had to raise
5. Central PA over C7/T1reproduces original
their head 2cm from the plinth. Holding time was
symptoms
measured using stopwatch (fig: 3).

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 158 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

4. Visual analog scale (VAS) was used to measure

subjective pain intensity.

Fig. 3. Deep neck flexors endurance testing

PROCEDURE

A pilot study was done 10 normal subjects to

determine the interrater reliability for the photographic
method. 3 Lateral profile photographs were taken per
subject by 2 examiners at a gap of 1 week.

To determine the changes seen in cervicothoracic

curvature with increasing age (in all the age groups)
in normal and neck pain subjects. 3 Lateral profile
photographs were taken for each subject for both the
groups and mean cervicothoracic kyphosis angles were
measured at 3 different levels – C6, C7 &T1.

1. Angle at C6 level; is measured between

C4 – C6– T4

2. Angle at C7 level; is measured between

Fig. 1. Placement of markers for cervicothoracic kyphosis angle C4 – C7 – T4
measurement
3. Angle at T1 level; is measured between
C4 – T1– T4.

For neck pain group detailed examination was done

following which, 3 lateral profile photographs were
taken and this group was also assessed for pain level,
deep neck flexor muscles strength and endurance.

Data Analysis and Results

Data was analyzed using the SPSS statistical

package (version 11.5). Interclass correlation coefficient
(ICC) was measured for reliability group at 3 levels
C6, C7 and T1. The data were analyzed using a one-
way ANOVA with three levels: cervicothoracic
kyphosis angles at C6 (C4-C6-T4), C7 (C4-C7-T4) and
T1 (C4-T1-T4), for both normal and neck pain group.
Fig. 2. Deep neck flexors strength testing using modified The angles average of all the three levels were
sphygmomanometer

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 159

correlated with pain intensity, muscle strength and angle at T1 when compared to the 31-40 yrs age group.
endurance for neck pain group using Pearson ‘r’. There was however no significant difference between
41-50 and 51-60 yrs of age group.
Normal Subjects
The mean deep neck flexor strength was 29.392
Interrater reliability data indicated high reliability mmHg. The strength of deep neck flexor muscles had
of the photographic measurement procedures with a significant positive correlation with the angle average
ICC at C6= 0.86, ICC at C7= 0.80 and ICC at T1= 0.88. for neck pain group, r =.598 and p= .000 (Graph 3).
At all the angles there was progressive decline with The mean deep neck flexor endurance was 28.79567
increasing age i.e. 31-40, 41-50 and 51-60 yrs age groups seconds and the mean for pain level was 6 on VAS.
for normal subjects (graph 1). For cervicothoracic angle Both the deep neck flexor muscles endurance and pain
at C6, there was main effect for the group didn’t have a significant correlation with the angle
F(2, 27, .05) = 14.498, P<.000. Tukey’s HSD showed that average for neck pain group, r =.182 and p= .000 and
there was statistically lowered angle at 51-60 yrs age r= 0.057, p=0.764 respectively (graph 2 & 3).
group when compared with 31-40 and 41-50 yrs age
group. However, there was no significant difference
between 31-40 and 41-50 yrs age group. For
cervicothoracic angle at C7, there was main effect for
the group F (2, 27,.05) = 17.575, P<.000.Tukey’s HSD
showed that there was both 41-50 and 51-60 yrs of age
group had significantly lesser angle when compared
to the 31-40 yrs of age. However, there was significant
difference between 41-50 and 51-60 yrs of age group.
For cervicothoracic angle at T1, there was main effect
for the group F(2, 27, .05) = 10.878, P<.000.Tukey’s HSD
showed that both the groups (41-50 and 51-60 yrs) had
statistically significant lesser angle at T1 when
compared to the 31-40 yrs age group. There was
however no significant difference between 41-50 and
51-60 yrs of age group.

Neck Pain Subjects Graph 1. Mean peak and standard deviation of cervicothoracic
kyphosis angle (degrees) at C6, C7 and T1 level in different age
groups 31-40, 41-50, 51-60 for normal subjects.
At all the angles there was progressive decline with
increasing age i.e. 31-40, 41-50 and 51-60 yrs age groups
for neck pain subjects (graph 2). For cervicothoracic
angle at C6, there was main effect for the group
F(2, 27, .05) = 12.938, P<.000.Tukey’s HSD showed that
51-60 yrs age group had significantly lesser kyphosis
angle at C6 when compared with 31-40 and 41-50 yrs
age group. However, there was no statistically
significant difference between 31-40 and 41-50 yrs age
group. For cervicothoracic angle at C7, there was main
effect for the group F(2, 27,.05) = 19.700, P<.000.Tukey’s
HSD showed that both, 41-50 and 51-60 yrs of age
group had significantly lesser angle when compared
to the 31-40 yrs of age group and there was no
statistically significant difference between 41-50 and
51-60 yrs of age group. For cervicothoracic angle at
T1, there was main effect for the group F(2, 27, .05) = 11.308,
Graph 2. Mean peak and standard deviation of cervicothoracic
P<.000.Tukey’s HSD showed that both the groups (41- kyphosis angle (degrees) at C6, C7 and T1 levels in different age
50 and 51-60 yrs) had statistically significant lesser groups 31-40, 41-50, 51-60 for neck pain subjects.

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 160 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

DISCUSSION

The overall result of this study showed that

cervicothoracic kyphosis angle measured at C6
showed significant decline in late years i.e. after fifth
decade, in both neck pain and normal groups.
Cervicothoracic kyphosis angle measured at C7
showed significant progressive decline with increasing
age in normal subjects, however in neck pain subjects
the decline was seen significant somewhere after forth
decade and no significant changes were seen in later
years. In both the groups, cervicothoracic angle when
measured at T1 also showed significant decline
somewhere after 40yrs, but no significant changes were
Graph 3. Cervico-thoracic Kyphosis angle average at C6, C7 & T1
(ANAV) versus neck flexor muscle strength (NFSTR) in mmHg
seen in late years.
for neck pain patients.
In both groups cervicothoracic kyphosis angle at
C6 level started reducing after fifth decade i.e. 51-
60years age group. The change is more in neck pain
subjects. The cervicothoracic junction is the transition
zone between highly mobile cervical spine and very
stable thoracic spine. The facet relationship of C6 on
C7 allows C6 to be relatively mobile5. Moreover the
C5-C6 articulation is the most frequent site to show
transition in superior articular facet and the mean
segmental mobility at C5-C6 decreases after 55 yrs of
age. Neck pain is commonly associated with forward
head posture, producing early degenerative changes
which might be responsible for the more decline seen
in cervicothoracic angle measured at C6 level in neck
pain patients. The segmental mobility of C5-C6 is more
in earlier years and reduces movements in later years5.
Graph 4. Cervico-thoracic Kyphosis angle average at C6, C7 & T1 In normal subjects the cervicothoracic angle at C7
(ANGAV) versus deep neck flexor muscle endurance (DPNFXEN)
showed significant progressive decline with increasing
in seconds for neck pain patients.
age, however at T1 the decline occurred somewhere
after forth decade i.e. 41-50 yrs of age but no significant
changes observed in later years i.e. 51-60yrs of age.
The progressive decline in cervicothoracic angle at C7
might be due highly mobile C6-C7 segment and also
due to the change seen in posture with increasing age.
Moreover, it was found that there is a significant
tendency for a forward head posture to occur with
increasing age, occurring greatly in fourth and sixth
decade. It is possible that sustaining such postures
changes the length-tension relationship of the muscle
which control posture, leading to muscle imbalance.
Forward head posture is associated upper cervical
extension which may facilitate shortening of the
suboccipital connective tissues. As T1 is very stable
compared to lower cervical spine and introduction of
the ribs also significantly reduces the amount of motion
Graph 5. Cervico-thoracic Kyphosis angle average at C6, C7 & T1
(ANGVG) versus pain level on (VAS) for neck pain patients. available at this segment. It was also found that with

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 161

advancing age, at around 40yrs women exhibit an recruitment. This study showed no significant
increase in upper thoracic incline. Along with the correlation between the pain level and average angle
change in posture this might be reason for the decline of the cervicothoracic kyphosis in the neck pain group.
observed in cervicothoracic angle at T1 level in 41-50 The results could be attributed to factors like patient’s
yrs age group. occupation, body build, age, individual experience of
pain intensity and difficulty in pain quantification due
In neck pain subjects cervicothoracic kyphosis angle to its subjective nature affecting the degree of pain
at both C7 and T1 level showed significant decline in reported. There is no association of common postural
forth decade i.e. 41-50yrs age group, however no abnormalities in cervical, shoulder and thoracic region
significant decline observed in fifth decade, this might with severity and frequency of pain.
again be due to forward head posture, putting stress
on cervicothoracic junction. It was found that in neutral
REFERENCES
position the induced load moment of the C7-T1 motion
segment was 1.2Nm in a flexing direction forward 1. McKenzie RA. The cervical and thoracic spine:
head posture the load moment was 3.7Nm and there mechanical diagnosis and treatment. Spinal
was increase in myoelectric activity of trapezius and publications :( N. Z.) Ltd; 1990.
cervical erector spinae. The anterior vertebral neck 2. Harms-Ringdahl K. On assessment of shoulder
flexors remain in elongated position and show exercises & load elicited pain in cervical spine:
weakness6. biomechanical analysis of load EMG
methodological studies pain provoked by
This study shows that as the cervicothoracic extreme position. Scand J Rehab Med.1986; 14:1.
curvature reduces deep neck flexor strength also 3. Boyle J. Influence of age on cervicothoracic spinal
reduces. The impaired activation of the deep cervical curvature: an ex vivo radiographic survey.
flexor muscles, the longus colli and longus capitis is Clinical Biomechanics 2002; 17: 361-367.
found in people with neck pain and their strengthening 4. Phillip SE. Assessment of spine: the
reduces the neck symptoms7.The deep cervical flexors cervicothoracic junction. 1 st ed. Churchill
over time tends to get weaken, atrophied and inhibited Livingstone: 2004; 159-176.
due to the overactivity of the antagonists 5. Placzek JD. The influence of the cervical spine
(Sherrington’s law). This forwardly placed position of on chronic headache in women: a pilot study. J of
the head is commonly associated with either a localized manipulative and physiologic therapeutics.1999;
cervicothoracic kyphosis so puts increased stress in this 7: 33-39.
region. This study showed no significant correlation 6. Kendall, FP, McCeary EK. Muscle testing and
between the deep neck flexor endurance and average function with posture and pain. 5th ed. Williams
angle of the cervicothoracic kyphosis in the neck pain and Wilkins: Baltimore; 1982.
group. The neck flexor synergy in neck pain group had 7. Jull G, Trott P, Potter H. A randomized control
higher measures of EMG signal amplitude in the trial of exercise & manipulative therapy for
sternocleidomastoid compared to control subject, this cervicogenic headache. Spine 2002; 27: 1835 –43.
may be a measurable compensation for poorer active 8. Cholewicki J, Punjabi NM. A stabilizing function
contractile capacity of the deep cervical flexors8. It is of the trunk flexion-extension muscle around a
known that nociceptive inputs can alter motor neuron neutral spine. Spine 1997; 22: 2207-2212.
pool net excitability, which could modify motor unit

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 DOI Number: 10.5958/j.0973-5674.7.3.085
162 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

A Study on the Impact of Body Mass Index on Lower Back

Extensor Endurance in Apparently Healthy Subjects

V Pasupatham1, Mohan Vikram2, V Swaminathan3, S Reka Rani4

1
Lecturer in Physiotherapy, DPM&R, RMMC & H, Annamalai University, Annamalai Nagar, Tamil Nadu, 2Lecturer in
Physiotherapy, Faculty of Health Sciences, Universiti Teknologi MARA, Kampus Puncak Alam, Puncak Alam,
Selangor-42300, Malaysia, 3Reader in Physiotherapy, DPM&R, RMMC&H, Annamalai University,
Annamalai Nagar-608002, Tamil Nadu, India, 4Student (Final year BPT), DPM&R, RMMC&H, Annamalai University,
Annamalai Nagar 608002, Tamil Nadu, India

ABSTRACT

This study has been carried out with the objective of finding out whether the body mass index has
any influence on lower back extensor endurance in apparently healthy subjects. 180 healthy subjects
participated in the study and they were categorized into three groups based on the values of their
body mass index as underweight, normal weight and overweight. The lower back extensor endurance
was tested using prone double straight leg raise test, and the data collected were analyzed statistically
for correlation and the results were found to be -0.561,-0.557,-0.579 for overall, males and females
respectively and all of them were significant. The equality of the level of endurance for the three
groups namely under weight, normal weight and overweight was tested by ANOVA procedure and
the F statistic was found to be 34.619 with a corresponding p value 0. Therefore it has been inferred
that greater the BMI lesser will be the lower back extensor endurance and the average endurance
level of the three groups is not the same.
Keywords: Body Mass Index, Lower Back Extensor Endurance

negative impact on endurance of trunk muscles

INTRODUCTION
induces strains on the passive structures of the lumbar
Low back pain is one of the most common spine, leading eventually to low back pain and is
complaints in the society today, and the studies associated with prolonged or recurrent back pain.14,16
indicated that about 70-80% of the population had at Hence, the endurance training of the trunk extensor
least one episode of low back pain in their life time2, muscles in people with sub-acute low back pain is
17,18
. Though there are many factors which contribute effective in reducing pain and improving
to low back pain, muscle is a potential source of low performance 4,10 . Doymaz, et al. indicated that
back pain and endurance of those is one of the increasing age, mass; body mass index and waist hip
important parameters of health related physical ratio are important factors which cause decrease in the
fitness8. Muscle endurance is defined as the ability of trunk muscle endurance in healthy subjects 7 .
a muscle to perform repeated contraction at a certain Bayramoglu, et al. conducted a study on the
output or to sustain a contraction over time at a certain relationship among chronic low back pain and obesity
level. Static endurance of the trunk muscles is and trunk muscle strength and declared that the
important for mechanical support. These muscles must increase in body mass index and decrease in muscle
have the ability to sustain an isometric contraction to strength are directly associated with low back pain3.
support the trunk in any given position. The back However, only a few studies are available in the area
extensors are particularly important postural muscles of relationship between lower back extensor endurance
which function to help to stabilize the whole vertebral and body mass index as observed by the author of this
column9. Hence, poor endurance of the lumbar para article. So, this study has been initiated under the
vertebral muscles is one of the contributing factors in assumption that body mass index and lower back
acquiring idiopathic low back pain and a predictor for extensor endurance are inter-related and inversely
first time occurrence of low back injuries 11. The proportional to each other. Therefore the objective of

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 163

the present study is to find out whether the body mass It has been found that the co-efficient of correlation
index has any influence on lower back extensor between BMI and endurance is found to be r = -0.561,
endurance. and the correlation coefficient is significant since p=0.
The negative correlation indicates that as the BMI
METHODOLOGY increases, the level of endurance decreases.

For the purpose of experimental study, a stratified It is further proposed to examine the nature of the
random sample of 180 normal subjects in the two strata relationship and also its intensity by dividing the
namely males and females, who are the students of respondents into three groups viz., the BMI of those
the physical medicine rehabilitation division of who are under weight, the BMI of normal weight and
RMMC&H and the Faculty of Engineering of the BMI of overweight. The correlation coefficient
Annamalai University, were selected using the lottery between the two variables was computed separately
method. Students suffering from back pathology and for the three groups and the results are given in
musculoskeletal disorders were excluded from the table 1.
selection process. Out of the 180 respondents, 90 were
Table 1. Correlation Coefficients between BMI and
males and 90 were females of the age group 19- 25 lower back extensor endurance
years. They were divided into three groups based on
their body weight, under weight, normal weight and Groups Pearson’s Sig. (p)
correlation
overweight as recommended in the BMI classification. co-efficient
Each group consists of 60 members, 30 males and 30 Under weight -0.132 0.314
females. For all the 180 subjects, the lower back Normal weight -0.258* 0.046
extensor endurance was tested by prone double Over weight -0.265* 0.041
straight leg raise test, as followed by Chad E. Moreau,
et al.6 The superiority of this test has been discussed The correlation coefficient between BMI and
by Amir M. Arab, et al.1and Ismaeil Ebrahimi, et al.12 endurance level was negative, for all the three groups
and the correlation coefficients were significant except
For the prone double straight leg raise test, the in the case of underweight group. Hence, it implies
subject begins lying in prone position, hip extended, that as the BMI increases, the level of endurance
hands underneath forehead and arms perpendicular decreases. The magnitude of the negative correlation
to the body. The subjects were then instructed to raise coefficient is on the increase as the BMI increases. It
both legs until the knee clearance is achieved. The knee implies that greater the BMI less would be the
clearance has been monitored by sliding a hand under endurance level. To ascertain whether the correlation
the thighs. The time taken has been recorded in seconds between the two variables was the same between males
and the test has been terminated when the subject is and females, Correlation coefficients were computed
no longer able to maintain knee clearance. separately for males and females with no classification
under the three groups based on weight, and they are
Statistical methods used
given in table 2.
The statistical analysis has been made by using
Table 2. Gender wise correlation coefficient between
SPSS 11.5 for windows. To find out the intensity of BMI and lower back extensor endurance
relationship between body mass index and endurance
level, Karl Pearson’s product moment correlation co- Gender Pearson’s Sig. (p)
correlation
efficient was computed. Test for the equality of two co-efficient
correlation co-efficients for male and female was Male -0.557** 0
carried out using ‘Z’ test. To find out whether there is Female -0.579** 0
a significant difference in the average endurance time
for the three groups viz., under weight, normal weight Table 2 shows that there is a negative correlation
and overweight, ANOVA one way classification between the two variables as it has been observed
procedure was used. previously and also the correlation co-efficient was
more or less the same and significant in both the cases.
Data analysis and Results Further it was proposed to find out whether these two
With a view to examine the nature of relationship correlation coefficients differ significantly. For this
between body mass index and endurance, the purpose, the Z test for equality of correlation
correlation coefficient between them was computed. coefficients has been carried out and the Z statistic was

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 164 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

equal to 0.2148. Since this is less than 1.96, the 3 groups namely under weight, normal weight
correlation coefficients do not differ significantly. and over weight, ANOVA one way classification
procedure was made and the results are given in
In order to find out whether the level of lower back table 3.
extensor endurance differs significantly between the

Table 3. ANOVA for test of equality of means of lower back extensor endurance for three groups

Sum of squares df Mean square F Sig.

Between groups 11366.533 2 5683.267 34.619 0.00
Within groups 29057.217 177 164.165
Total 40423.750 179

The value of ‘F’ statistic was found to be 34.619 with A reliability and feasibility study carried out by
corresponding p=0. Hence the means of the three Ismaeil Ebrahimi, et al.12, on the five types of clinical
groups differ significantly. This implies that the tests such as Sorensen test, prone isometric chest raise
endurance levels of the three groups based on the BMI test, prone double straight leg raise test, supine
are not the same, on the average. isometric chest raise test and supine double straight
leg raise test to measure endurance of the trunk
The average lower back extensor endurance time muscles in subjects with and without low back pain,
in seconds and the standard deviation values for the shows that prone double straight leg raise test has more
three groups viz, under weight, normal weight and association with low back pain than other tests.
overweight are presented in the following table 4. Moffroid, et al.15 conducted a study on the endurance
Table 4. Descriptive Statistics training of the trunk extensor muscles and suggested
that the Sorenson test fatigues the biceps femoris more
Mean Std deviation
than lower erector spinae and that it indicates more
Under weight 63.41 13.65
about the endurance of the hip extensors than that of
Normal weight 56.18 12.51
trunk extensors. Another issue that should be
Over weight 44.15 12.22
considered in clinical use of the Sorenson test
From this table 4, it can be observed that the procedure is its difficulty. In Biering – Sorensen’s
endurance level is the highest for the underweight study5, 24 % of the sample could not complete the test
group and it is the lowest for the overweight group. and Latika, et al.13also reported a 50% of failure rate in
So as the BMI increases the average level of lower back doing the Sorenson test. Hence, in this study we
extensor endurance decreases. The standard deviations selected prone double straight leg raise test as an
are more or less equal for the three groups. outcome measure for testing the lower back extensor
endurance. Beverley Chok, et al. 4 suggested that
DISCUSSION muscle weakness causes decrease in muscle endurance
which may eventually lead to low back pain and found
The purpose of this study was to investigate the that endurance training of trunk extensor muscles was
influence of body mass index on lower back extensor effective in relieving low back pain and improving
endurance in 180 healthy subjects and the results show function. However, in this study the average level of
the correlation between the body mass index and the lower back extensor endurance was higher in
lower back extensor endurance was negative and underweight groups and there exists a relation
significant. This result is found to be in agreement with between body mass index and lower back extensor
that of the results of the study by Doymaz, et al.7 They endurance. Hence, it is obvious that keeping a control
investigated the effects of physical characteristics level of body mass index may be a preventive measure
including age, gender, mass, height, body mass index which may account in preventing back problem by
and waist hip ratio, on trunk muscle endurance in 200 enhancing lower back extensor endurance. The
healthy subjects. They concluded that increase in age, constraint about this methodology adopted in the
mass, body mass index, waist hip ratio is an important present study is that all the sampled respondents are
factor which causes a decrease in trunk muscle in the age group 19-25. But in selecting a sample of
endurance in normal subjects. respondents, the age restriction can be relaxed and the

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 165

impact of age on the lower back extensor endurance 4. Beverley Chok, Raymond Lee, Jane Latimer,
can be studied by taking persons in different age Seang Beng Tan, ‘Endurance training of the trunk
groups. It would be informative to investigate whether extensor muscles in people with subacute low
the BMI and low back pain are associated with each back pain’. Physical therapy; Nov. 1999 Vol 79,
other. If there is any association, then it would be No.11, Page 1032-1042.
interesting to examine their combined influence as well 5. Biering-Sorensen F. ‘Physical measurements as
as the intensity of relationship over the level of risk indicators for low- back trouble over a one-
endurance. Further this study can be extended by year period’. Spine; 1984, vol 9 No.2.
investigating the effects of lower back extensor Page 106-119.
endurance training on the obese as well as low back 6. Chad E. Moreau, Bart N Green, Claire D Johnson,
pain patients. Susen R Moreau, ‘Isometric back extension
endurance tests – A review of literature’. Journal
CONCLUSION of manipulative and physiological therapeutics;
Feb. 2001,Vol.24, No. 2.
The body mass index and lower back extensor 7. Doymaz F, Cavlak U, Kucuk M, Telli O, Bas Aslan
endurance are negatively correlated, that is as the BMI U. ‘Analyzing the effects of physical
increases, it has a negative impact on the level of lower characteristics on trunk muscles endurance in
back extensor endurance. Hence, if BMI is higher, the healthy Turkish subjects’. Medicine sportive;
level of endurance will be proportionally lower. Also 2006, No. 6
the impact of BMI on the endurance level of lower back 8. Gonzales E. ‘Physiological basis of Rehabilitation
extensor was not influenced by gender. The average Medicine’. Butter worth Hehemen Wasen USA,
level of endurance differs significantly between the 2001, Chapter 24 Page 563-264.
three groups’ viz., under weight, normal weight and 9. Greg McIntosh, Lynda Wilson, Michael Affleck,
overweight. Hamilton Hall,‘Trunk and lower extremity
muscle endurance: Normative data for Adults’.
ACKNOWLEDGEMENT Jour of Rehabilitation outcomes measurement;
The authors are thankful to Dr.P.G. 1998, Vol.2 No.4 Page 20-39.
Chandrashekaran Nair, Professor and Head, PM&R 10. Handa N, Yamamoto H, Tani T, Kawakami T,
division; DR.V.K. Mohandoss Kurup, professor PM&R Takemasa R, ‘The effect of trunk muscle exercises
division; and DR. R. Sathiyamoorthi , former Head of in patients over 40 years of age with chronic low
the department of statistics, Annamalai university, for back pain’. Jour. Orthop. Sci; 2000 Vol. 5(3) 210-6
their valuable suggestions. 11. Heyward VH. ‘Advanced fitness and exercise
prescription’. Third edition New mexico: Human
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1. Amir M Arab, Mahyar Salavati, Ismaeil Ebrahimi, on trunk muscles endurance in healthy Turkish
Mohammad E Mousavi, ‘Sensitivity, specificity subjects’. Medicine sportiva No.6 (2006).
and predictive value of the clinical trunk muscle 12. Ismaeil Ebrahimi, Gholam Reza Shah Hosseini,
endurance tests in low back pain’. Clinical Mahyar Salavati, Hosseini Farahini, Massoud
Rehabilitation; 2007,Vol.2, No7, Page 640-647. Arab, ‘Clinical trunk muscle endurance tests in
2. Amir M Arab, Leila Ghamkhar, Mahnaz Emami, subjects with and without low back pain’.
Mohammad R Nourbakhsh ‘Altered muscular Medical Journal of the Islamic Republic of Iran;
activation during prone hip extension in women Aug. 2005, Vol 19, no.3, page 95-101,
with and without low back pain’. Chiropr Man 13. Latikka P,Battie MC, Videman T, Gibbsons LE, ‘
Therap; 2011, Vol 19: No.18. Correlation of isokinetic and psychological back
3. Bayramoglu M, Akman MN, Kilinc S, Cetin N, lift and static back extensor endurance test in
Yavuz N, Ozker R, ‘Isokinetic measurement of men’. Clinical biomech; 1995, 10, page 325-330.
trunk muscle strength in women with chronic low 14. Lee, JH, Hoshino Y, Nakamura K, Kariya Y, Saita
back pain’. American journal of physical K, Ito K, ‘Trunk muscle weakness as a risk factors
medicine and rehabilitation; Sep.2001, 80(9) page for low back pain. A 5 year prospective study.
650-655. Spine 1; Jan. 1999, 24(1) 54-57.

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15. Moffroid MT, Haugh LD, Haig AJ, Henry SM, Trunk Flexors in patients with low back pain’.
Pope MH, ‘Endurance training of trunk extensor The internet journal of allied health sciences and
muscles’. Physical therapy; 1993, 73; page 3-10. practice; April. 2004, Vol.2, No.2.
16. Nourbakhsh MR, Arab AM. ‘Relationship 18. Svensson H, Anderson G, Johansson S,
between mechanical factors and incidence of low Wilhelmson C, Vedin A, ‘ A retrospective study
back pain’. Jour. Orthop. Sports phys. Ther; 2002, of low back pain in 38 to 64 year old women’.
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17. Shari A Rone-Adams, Eric Shamus, Melissa services Spine 13; 1988, page 548-552.
Hileman, ‘Physical therapists Evaluation of the

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 DOI Number: 10.5958/j.0973-5674.7.3.086
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 167

Study of the efficacy of the Mulligan's Movement with

Mobilization and Taping Technique as an Adjunct to the
Conventional Therapy for Lateral Ankle Sprain

Punam Ghadi1, Chhaya Verma2

1
Consulting Physiotherapist, Jaslok Hospital & Research Centre, Mumbai, 2Professor, Seth G. S Medical College & KEM
Hospital, Mumbai

ABSTRACT

Objective: This study was designed to assess the efficacy of the Mulligan's Movement with
mobilization & taping technique in functional recovery of lateral ankle sprain when used as an adjunct
to conventional therapy & thus establish the role of the hypothesis of positional fault in lateral ankle
sprain.

Study Design: Cohort study involving 30 patients diagnosed with grade 1 & 2 lateral ankle sprain
divided randomly in 2 groups of 15, one control group & another experimental group.

Methodology: Control group received conventional therapy which involved RICE or ultrasound &
home exercise program according to the stage of healing, while experimental group received
Mulligan's MWM & taping along with conventional therapy. Duration of the treatment was 6 days or
till VAS on walking reduces to 1.

Results: VAS on walking & tender point palpation showed significantly greater reduction in
experimental group (p<0.01) than control group. Duration of Single Leg Stance improved to
significantly greater extent (p<0.005) in experimental group, while the duration of the treatment was
found to be reduced significantly when Mulligan's technique was used.

Conclusion: When Mulligan's ankle technique & fibular taping is used along with the conventional
therapy, there is a faster functional recovery. This study highlights the importance of positional fault
concept in clinical practice.
Keywords: Lateral Ankle Sprain, Mulligan's Ankle Technique, Mwm, Fibular Taping

INTRODUCTION There are 3 major contributors to the stablity of the

ankle joint10.
Ankle injuries are one of the most common
orthopaedic injuries (over one million each year). 1. Congruity of the articular surfaces when joints are
Approximately 85 % of these injuries are ankle sprains3, loaded.
2
. While incidence of ankle sprain is increasing, the
treatment protocol has been same over the years9 i.e. 2. Static ligamentous restraints
RICE followed by ROM exercises, stretching of
3. Musculotendinous unit which allow for dynamic
musculotendinous tissues, efforts to improve the stabilization of joints
neuromuscular control & strengthening exercises. But
even after this treatment, the reinjury rate after lateral In weight bearing position, when hind-foot is
ankle sprain has been reported to be as high as 80% in pronated, joints of both hind & midfoot are free to make
athletes & previous injury has been identified as a compensatory changes required to maintain contact
strong predictor of reinjury8. of the foot to the ground. But with the supination of

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 168 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

hind foot, forefoot is also locked & there is no chance (ROM exercise + self stretching + strengthening
for compensation1. In normal gait, this facilitates exercise + proprioception exercise + functional
weight transfer during the second half of stance phase. activities)
But when hind foot has been supinated by uneven
terrain, locking of hind & midfoot blocks any • Experimental group- These patients received
compensatory movement in foot causing entire medial Mulligan’s ankle technique (MWM + Taping)
border of the foot to lift & unless the muscles on lateral along with conventional therapy
side of the foot are active, the supination sprain of Duration of the study was 6 days of treatment or
lateral ligament occurs1. VAS on walking less than or equal to one,
When the locked talocalcaneonavicular (TCN) and whichever comes first. Parameters studied where
transverse-tarsal (TT) joints are unable to absorb the VAS on walking, VAS on tender point palpation
rotation superimposed by the weight bearing limb or and duration of the single leg stance (SLS) on the
by uneven ground, the forces are dissipated at the injured leg
ankle and may result in injury to the ankle joint Material used was plinth, dermaplast adhesive
structure. Joint dysfunction found in patients with bandage, micropore tape, ultrasound unit & ether
ankle sprain has been attributed to hypermobility or solvent.
hypomobility.
• Mulligan’s ankle mobilization with movement &
With this pre-existing background, Brian Mulligan taping technique- Patient is in supine position on
in 1995 introduced his ‘Positional Fault’ theory and the plinth with the ankle out of the plinth.
claimed that anterior subluxation of the fibula on tibia Therapist holds the distal end of the fibula with
at distal tibio-fibular joint may be the cause of painfully the base of the thumb & glides it posteriorly &
restricted inversion after lateral ankle sprain and hence superiorly. Holding this position ask the subject
the reason for reinjury4. At the same time he introduced to do inversion & plantarflexion of the ankle
movement with mobilization (MWM) for ankle joint (Fig 1). Ten repetitions of such MWM is given. At
followed by the fibular taping technique to treat lateral the end of the mobilization, fibula is taped in glide
ankle sprain. The technique is claimed to accelarate position. First the part of the leg is cleaned with
the rehabilitation of lateral ankle sprain and gives ether solvent. Distal end of the fibula is glided in
whole new direction to physiotherapeutic approach posterior & superior direction and the position is
towards lateral ankle sprain. maintained by micropore tape. Tape starts anterior
Though the Mulligan’s technique has been to lateral malleolus going posterior & superior in
introduced long back & there have been some spiral direction to end on antero-medial aspect of
experimental studies based on the concept, there are distal tibia. Now reinforcement is done by
few studies done to test the clinical efficacy of the dermaplast tape in the similar manner(Fig 2). Tape
technique. Hence this is a clinical trial done with the should be maintained in position for 24 hours &
aim to study the clinical efficacy of the Mulligan’s removed on next day. Tape should be reapplied
MWM & taping technique as an adjunct to the everyday while mobilzation technique used every
conventional therapy in the functional rehabilitation alternate day.
of the lateral ankle sprain.

MATERIAL AND METHODOLOGY

This was a cohort study done with sample size of

30 subjects. Adult patients diagnosed with lateral ankle
sprain grade 1 & 2 by orthopaedic surgeon were
included in the study irrespective of their age and
sex, while patients having fracture associated with the
ankle sprain &/or grade 3 ankle sprain were excluded
from the study. Consent of all the subjects in this study
was taken. The sample size of the 30 patients was
divided into 2 groups

• Control Group- These patients received

conventional therapy (RICE or ultrasound
according to the phase of healing) + home exercise Fig. 1. Inversion & Plantarflexion of the ankle

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 169

(both legs & then affected leg), stepping, standing on

toes, treadmill, biking, jump rope, jogging & then
running, cutting exercise e.g. running in figure of 8,
crossover walking.

DATA ANALYSIS

30 patients with lateral ankle sprain were studied

by dividing into 2 groups of 15 each & observed over
the specified treatment period. Both the groups were
comparable with respect to basic criteria such as mean
age, male to female ratio & proportion of acute &
chronic cases.

Fig. 2. Reinforcement done by dermaplast tape Parameters analyzed were VAS on walking & on
palpation taken every day & duration of SLS taken on
1st & last day. From the data collected mean & standard
Conventional therapy- Exercise program deviation of the parameters were calculated.
Comparison of the improvement of the VAS scores &
• Phase I
SLS duration pre & post treatment was done between
1. Protection of ankle in splint or crepe bandage the 2 groups using unpaired t-test and p<0.05 was
taken as significant.
2. Rest for approximately 24 hours with only
movements of toes & ankle in pain free range RESULTS
3. Ice application for 20 minutes for every 2 hours Analysis of the data shows that VAS on tender point
for first 48 - 72 hours palpation and on walking was reduced to significantly
greater extent (p<0.01- highly significant) when
4. Compression by crepe bandage
Mulligan’s technique was used as an adjunct.
5. Elevation- Elevate the foot higher than the waist (Fig 3 & 4)
to reduce swelling and pain
Fig 3. Comparison of VAS on tender point palpation

• Phase II: Starts when pain & swelling lessens VAS Mulligan’s & Conventional
Conventional
1. Stretching - Before & after activity, vigorous calf Pre Mean 7.9 8.23
stretches initiated ASAP with moderate pull but SD 1.69 1.47
no pain, ankle movements, toe curls. Post Mean 0.38 3.6
SD 1.02 2.28
2. Strengthening-Begin with isometric exercise &
progress to isotonic exercises in a pain free range Fig 4. Comparison of VAS on Walking
with an elastic band. Start working in all 4
VAS Mulligan’s & Conventional
directions along with heal raise within pain limit Conventional

3. Proprioception- Loss of proprioception causes loss Pre Mean 6.58 6.8

of balance hence start early weight bearing on the SD 1.95 2.22

ankle progressing to standing with eyes closed & Post Mean 0.43 2.92

standing on injured leg with eyes closed. SD 1.12 1.98

Fig 5. Comparison of duration of treatment

• Phase III- Full functional level
VAS Mulligan’s & Conventional
It includes full ROM exercises, 80-90% strength Conventional
exercises, swimming, running in pool, full weight Pre Mean 3.47 5.86
bearing, lunges forward & sideways, pain free hopping SD 1.55 0.35

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 170 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Fig 6. Comparison of SLS duration Lateral ankle sprain does not cause isolated
SLSDuration(sec) Mulligan’s & Conventional ligament injury, but along with the ligaments of the
Conventional ankle joint, joint mechanics of the subtalar joint & tibio-
Pre Mean 4.87 4.67 fibular articulation are also often affected15. According
SD 1.64 1.68 to Mulligan, in case of lateral ankle sprain, there is
Post Mean 15.8 8.47 positional fault at distal tibio fibular joint. There is
SD 3.19 2.64 anterior & inferior subluxation of fibular tip4. This
subluxation prevent normal excursion of fibula &
Fig 5 shows that the treatment duration required
limits posterior translation of talus in relation to the
to reduce pain was significantly shorter in case of
mortise during dorsiflexion12, 13 and thus restricts the
Mulligan’s group (p<0.01)
dorsiflexion at the ankle.
Results also show that the performance of the
If the lateral malleolus is stuck in this displaced
patient on SLS test(Fig 6) improved significantly when
position, the Anterior Tibio-Fibular Ligament (ATFL)
Mulligan’s technique was used along with
may be slacker in its resting position. Thus when the
conventional therapy (p<0.005).
rearfoot begins to supinate, the talus can go through a
greater ROM before ATFL becomes taut and can result
DISCUSSION
in episodes of recurrent instability, leading to repetitive
The present study was conducted to evaluate the ankle sprains.
efficacy of the Mulligan’s MWM technique followed
Unaddressed hypomobility at the injured joint may
by fibular taping for lateral ankle sprain. The concept
result in compromised tissue repair & compensatory
of positional fault & effect of Mulligan’s MWM
motions at other joints. Thus, if the fibula remains
Technique has been studied in the past by various
subluxed anteriorly & inferiorly during healing, the
researchers
inferior tibio-fibular interosseous ligament may be
The Findings of Hethrington B (1996), O’Brien T., stressed during healing, thereby compromising
Vicenzino B. (1998) present preliminary evidence for mortise stability and resulting in chronic instability
‘Positional Fault’ theory, by showing evidence of syndrome15.
restriction of posterior filbular glide after lateral ankle
sprain, suggesting that lateral malleolus may be The inability of the fibula to move may also
subluxated in anterior direction7, 11. Kavanagh (1999) compromise the stable base from which the peroneus
supported this assertion by demonstrating the longus and brevis muscles act to plantarflex the first
difference in mobility at tibio-fibular joint between ray, transfer weight across the metatarsals &
subjects with & without ankle sprains6. dynamically stabilize the ankle15. Hence, in case of
lateral ankle sprain, peronei are shown to have delayed
Schoening S (2004) clinically implemented reaction time18,19,20.
Mulligan’s technique for two chronic ankle sprain
patients to get the improvement consistent with By Mulligan’s technique, we are correcting the
Mulligan’s theory14. Merlin DJ (2005) proved with the positional fault at the distal tibio-fibular joint &
help of MRI scan that subjects with lateral ankle sprain restoring the normal accessory joint motions at the
showed significant displacement of the tip of the fibula distal tibio-fibular joint. At the same time, conventional
& the same was relocated in a superior direction with therapy protects the damaged ligaments from stresses
MWM technique5. that compromise the repair at the anatomical length16,17.
The taping technique that follows the mobilization
Thus this study strongly supports the experimental helps the following mechanisms21
data5, 6, 7 which says that, in lateral ankle sprain there
is positional fault at the distal tibio fibular joint and • Taping aids in the reduction of mechanical ankle
Mulligan’s MWM technique corrects the same, instability
accelerating the clinical recovery. We can see from the
results & analysis that, pain on tender point palpation • It limits the extent of ankle motion, that may occur
& on walking (as taken on VAS scale) has reduced during physical activity
rapidly & to a significant greater extent. This finding
• Taping when applied appropriately can shorten the
has been confirmed objectively by significantly
reaction time of the peronei muscles
increased SLS duration.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 171

• By affecting the proprioceptive function of the 5. Merlin DJ, McEwan I, Thom JM.XIV international
ligament and joint capsule around the ankle joint congress on sports rehabilitation & traumatology,
and the muscles of the lower leg 2005.
6. Kavangh J Is there a positional fault at the inferior
• It also helps by maintaining posterior & superior tibio fibular joint in patients with acute chronic
glide of fibula which normalizes the ankle sprains compared to normals?Man Ther
arthrokinematics of the distal tibiofibular joint. 1999; 4:19-24
• It reduces abnormal proprioceptive inputs to the 7. Hethrington B Case study: lateral ligament strains
CNS & thus normalizing reflex patterns. on the ankle. Do they exist? Man Ther, 1996; 1:274-
275
• It provides cutaneous sensory stimulation affecting 8. Milgrom C, Shlamkovich N, FinestoneA et al.
the joint position sense & hence better ankle Risk factors fpr lateral ankle sprain: a prospective
stability. study among military recruits. Foot Ankle 1991;
12:26-30
From the results of this study one can say that,
9. www.wrongdiagnosis.com/a/amkle_sprain/
Mulligan’s technique provides rapid relief of pain intro.htm
which increases the ability to bear weight on the 10. www.Ankle%20sprain/articlerender.fci8.htm
sprained ankle and hence faster functional recovery.
11. O Brien T, Vicenzino B. A Study of the effects of
Mulligan’s mobilization with movement
CONCLUSION treatment of lateral ankle sprain using a case
Mulligan’s MWM and taping technique is highly study design. Man Ther. 1998; 3:78-84.
efficient in immediate treatment of the lateral ankle 12. Meadows, J TS. McGraw-Hill; New York, NY:
sprain, when used as an adjunct to conventional theory. 1999. Orthopedic differential diagnosis in
It significantly shortens the duration of the treatment Physical Therapy: A Case Study Approach; pp.
resulting in faster functional recovery. Thus the study 114-115.
establishes the importance of Mulligan’s concept of 13. Dananberg S J, Shearstone J, Guillano M.
positional fault in clinical practice. Manipulation method for treatment of Ankle
equinus. J AM Podiatr Med Association, 2000;
ACKNOWLEDGEMENT 90:385-389.
14. Schoeing S, Physical Therapy, Feb 2004.
I am thankful to my family whose valuable support 15. Craig R.Denegar & Sayers J Miller, III. J Athletic
gave me courage & confidence throughout the study. training 2002 Oct -Dec; 37(4):430-435.
16. Hertel J. The role of non steroidal anti
I extend my sincere thanks to Mr Kailash
inflammatory drugs in the treatment of acute soft
Gandewar, PSM Department for helping me in the
tissue injuries. J Athl Train. 1997; 32:352-358.
statistical analysis.
17. Low & Reed, Electrotherapy explained. pg 172-
Last but not the least I would like to thank all the 211
subjects of my study without whom this task would 18. Bullock Saxton J E. Sensory changes associated
not have been possible. with servers ankle sprain. Scand J Rehab Med.
1995; 27:161-167.
REFERENCES 19. Konradson L, Ravn J B.Ankle Instability caused
by prolonged peroneal reaction time Acta Ortho
1. Levangie, P. K.; Norkin, C C. 3rd Edition FA Davis Scand. 1990; 61:388-390.
Co; Philadelphia, PA: 2001. Joint Structure & 20. Lynch S A, Eklund U, Go ttlieb D Renstrom PA,
Function: A Comprehensive Analysis; pp.379-415. Beynnon B. Electromyographic latency changes
2. www.podiatry.curtin.edu.au/encyclopedia/ in the ankle musculature during inversion
ankle2 moments. Am J Sports Med 1996; 24:362-369.
3. w w w. s t e a d m a n - h a w k i n s . c o m / a n k l e / 21. Karlsson J, Sward L & Andresson G 1993. The
overview.asp effect of taping on ankle instability Sports
4. Mulligan, B R 3rd ed Plane view Services Ltd, Medicine, 6(3), pp 210-215
Wellington New Zealand 1995. Manual therapy:
“NAGS”, “SNAGS”, “MWMS”, etc pp 95-101.

33. Poonam Ghadi--167--171.pmd 171 8/1/2013, 8:31 AM

 DOI Number: 10.5958/j.0973-5674.7.3.087
172 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Comparative Study between the efficacy of Muscle Energy

Technique and Static Passive Stretching on Hamstring
Flexibility in Healthy Indian College Athletes

Pratik A Gohil
M.P.T Musculoskeletal and sports physiotherapy, KIMS, Physiotherapy, Bangalore

ABSTRACT

Background: Success in sports depends on athlete's ability to develop and produce a specific set of
coordination and joint range of motion/flexibility. Purpose of the study is to compare efficacy of
muscle energy technique and static passive stretching on hamstring flexibility in healthy Indian college
athletes.

Subjects: The subjects were healthy Indian college athlete from Bangalore metropolitan area.

Method: 30 healthy college athlete subjects with hamstring tightness were randomly allocated to
two study groups. Groups-A (n=15) subjects were treated with Muscle energy technique (Isometric
contraction - using post isometric relaxation, approximately 30% of patient's strength, Duration of
contraction is 20 seconds, muscle is taken to its new restriction barrier and held in this position for at
least 60 seconds, three repetition with 15 second of rest interval) where as other group-B (n=15) were
treated with static passive stretching (No warm up was allowed prior stretching, Subjects received
three stretches of 60 seconds). The treatment was given for 1 day.

Outcome Measure: Subjects were assessed for hamstring flexibility by measuring straight leg raise
angle i.e. active straight leg raising range of motion prior and immediately after intervention.
Measurement was done by standard universal goniometer.

Results: Paired Samples t -Test showed that Muscle Energy Technique and static Passive Stretching
both the treatments are significant (P=0.000). Mann-Whitney Test showed a statistically significant
improvement in the Muscle Energy technique group when compared to static passive stretching.

Conclusion: A muscle energy technique is more effective than static passive stretching for
improvement in hamstring flexibility.
Keywords: Muscle Energy Technique, Static Passive Stretching, Straight Leg Raise Angle, Hamstring
Flexibility

INTRODUCTION menisci injuries, Chondromalacia patella, and poor

posture often come from tight hamstrings also; altered
Most medical professionals, coaches and athletes
flexibility of the hamstring may produce significant
consider aerobic conditioning, strength training and
postural deviations and affect the functionality of the
flexibility as integral components in any conditioning
hip joint and lumbar spine 5. Hamstring muscle injuries
program 1. Flexibility has been defined as the capacity
are seen primarily during high speed or high intensity
to move a joint through its available range of motion
exercises and have a high rate of recurrence 6. Lack of
(R.O.M), without producing excessive myo-tendinous
hamstring flexibility was the single most important
stress 2. Flexibility is a physical fitness attribute and is
characteristics of hamstring injuries in athletes 7.
often evaluated from the joint range of motion (ROM)
3
Muscle energy technique (MET) is a manual technique
, an essential element of normal biomechanical
developed by osteopaths and is now used in many
functioning in sports 4. Soft tissue injuries, knee pain,

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 173

different manual therapy professions 8. It is claimed to c) Previous history of spinal or lower limb fractures.
be effective for a variety of purposes including
lengthening a shortened muscles, as a lymphatic or d) Any lower limb surgery in past one year.
venous pump to aid the drainage of fluid or blood and e) Skin disease on treatment area.
increasing the range of motion 8, 9. Static passive
stretching of 60 second is claimed to be effective 10. PROCEDURE
When soft tissue is stretched, elastic, viscoelastic, or
plastic changes occur. During passive stretch both Thirty healthy collegiate subjects with hamstring
longitudinal and lateral force transduction occurs 11. tightness were randomly allocated to two study
When initial lengthening occurs in the series elastic groups. Subjects were assessed for hamstring flexibility
(connective tissue) component, tension rises sharply. by measuring pelvic femoral angle i.e. passive straight
After a point, there is mechanical disruption leg raising range of motion (Fig.1). Groups-A (n=15)
(influenced by neural and biochemical changes) of the subjects were treated with Muscle energy technique
cross-bridges as the filaments slide apart, leading to where as other group-B (n=15) were treated with static
abrupt lengthening of the sarcomeres, 11, 12, 13 sometimes passive stretching. The subjects were tested prior and
referred to as sarcomere give 12. immediately after intervention for one day. The
outcome was measured in terms of straight leg raise
METHODOLOGY angle i.e., active straight leg raising range.

SOURCES OF DATA: The subjects were healthy Straight Leg Raise Angle / Acive Straight Leg Raising
Indian college athlete from Bangalore metropolitan Range
area, Karnataka, India. A straight leg raise angle is measured by making
the subject lie flat on a plinth with their knee fully
STUDY DESIGN extended position. And then with knee extended
position the hip gradually flexed up to the onset of
Experimental study with a pretest-posttest design
discomfort at back of thigh. While performing test the
was conducted. The study design was approved by
other limb is fixed. Now hip R.O.M measured with
the research and ethical committee of Kempegowda
the standard universal goniometer. Three repetitions
institute of medical science – Physiotherapy
were performed and an average of the three was taken
department.
as the final reading for straight leg raise angle 15.

SUBJECTS Group-A (Muscle Energy Technique) The muscle

energy technique was applied to the group A. Isometric
Thirty healthy Indian college athlete volunteers contraction – using post isometric relaxation,
were selected on the basis of the inclusion and approximately 30% of patient’s strength, Duration of
exclusion criteria. A written informed consent was contraction is 20 seconds, muscle is taken to its new
obtained from all those subjects who fulfilled the restriction barrier and held in this position for at least
inclusion and exclusion criteria. 60 seconds, three repetitions with 15 second of rest
interval 8.
Inclusion Criteria
Group-B (Static Passive stretching) The static
a) Aged between 18- 25 year of age.
passive stretching technique was applied to the group
b) Gender- Both Male and female. B. While stretching, each subject’s knee was
maintained in extension with ankle at neutral position
c) Tight hamstring (the finger-ground distance had without internal or external rotation of the hip, and
to be greater than zero cm means unable to touch the extremity was raised in respect to patient’s
the floor when bending forward and the passive feedback about stretching pain. No warm up was
straight leg raising range was not to exceed 80°). allowed prior stretching; Subjects received three
stretches of 60 seconds 10, 14.
Exclusion Criteria

a) Acute or chronic low back pain with or without DATA ANALYSIS

radiculopathy.
Statistical analysis was done by using SPSS-16
b) Acute or chronic hamstring injury. software.

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 174 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

RESULTS

The result of this study was analyzed in terms of

gain range of motion (straight leg raise angle values)
in and between both group-A and B subjects.

Demographic Profile: Age of all subjects was

recorded. The mean age of Muscle Energy Technique
group was 22.6 years with S.D. ± 1.0; the mean age of
Static Passive Stretching group was 22.0 years with S.D.
± 0.6. There is no significant difference between groups
in terms of demographic variables. Graph: 1 Mean range of motion

Within Group Analysis: In both groups values Table 1 and Table 2 have represented that muscle
(graph 1) of straight leg raise angle (Degrees) shows energy technique and Static Passive Stretching have
that the mean range of motion during posttest is higher shown statistically significant (P<0.05) improvement
than that during pretest. from baseline for hamstring flexibility.

Table 1. Paired Samples Test for Group- A (Muscle Energy Technique)

Paired Differences
Mean Std. Std. Error 95% Confidence t df Sig.
Deviation Mean Interval of the Difference (2-tailed)
Lower Upper
7.93333 1.48645 .38380 8.75650 7.11017 20.671 14 .000

Table. 2. Paired Samples Test for Group- B (Static Passive Stretching)

Paired Differences
Mean Std. Std. Error 95% Confidence t df Sig.
Deviation Mean Interval of the Difference (2-tailed)
Lower Upper
6.26667 1.75119 .45216 5.29689 7.23644 13.860 14 .000

Between Group Analysis of Mean and Standard deviation suggesting that

Muscle energy technique is more effective compared
Mann-Whitney Test shows significant difference to Static Passive stretch for hamstring flexibility.
between Group-A and B with p value is 0.000. So values

Table 3: Between Group Analysis by Mann-Whitney Test

Group N Mean Std. Deviation Std. Error Mean

Difference A 15 7.9333 1.48645 .38380
B 15 6.2667 1.75119 .45216

DISCUSSION hamstring flexibility in healthy Indian college athletes.

For the purpose of this comparison a pre–posttest,
To improve hamstring flexibility muscle energy experimental study was carried out. Hamstring was
technique, passive stretch, and other many more the muscles of choice since it is the muscle that is most
techniques were used by therapist but there is no much prone to injuries during sporting activities, and if the
research literature available which shows which one flexibility of hamstrings is adequate the incidence of
is more efficient way to improve flexibility. Therefore hamstrings strains can be decreased and performance
the current study was undertaken to compare Muscle can be enhanced as well. Also there are well
Energy Technique and Static Passive Stretching on documented, reliable and valid methods of testing

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 175

flexibility of hamstring muscles, such as the straight of maintenance of results. Muscle Energy Technique
leg raise angle 15. Hamstring flexibility was measured is very simple and can be easily used on those who
by straight leg raise angle i.e., Straight leg raising range are experiencing lack of muscle flexibility.
as hip angle could be the parameter for hamstring
flexibility test based on the direct relation of the REFERENCES
hamstring with the pelvis and hip’s functionality So
using this test we can come to know a minimal change 1. Russell T N, William DB. Eccentric training and
in the hamstring flexibility16. A comparison of the pre- static stretching improve hamstring flexibility of
test and the posttest values of the straight leg raise high school males. J Athletic Training. 2004: 39:
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in the both groups following treatment. Whereas 2. RL Carregaro. Comparison between two clinical
comparison between group A and group B has shown tests for the evaluation of posterior thigh muscles
significant improvement in group-A. Thus it may be flexibility. Rev. Bras. Fisioter. 2007: 11(2).
said that Muscle Energy Technique is effective 3. Hopper D, Decan S, Das S, Jain A, Riddell D, Hall
individually in improving flexibility of hamstrings T. Dynamic soft tissue mobilization increases
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with considering the previous research studies that 4. Murphy DF, Connolly DAJ, Beynnon BD. Risk
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5. Taylor DC, Dalton JD, Seaber AV, Garrett WE.
of Static passive Stretching on hamstring muscle length
Viscoelastic properties of muscle-tendon units:
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of motion was observed at the knee (p<0.019) following extensibility: The mechanism of altered flexibility.
a single application of MET to hamstring muscle in J Osteopathic Medicine. 2003: 6: 59-63.
the experimental group. No change was observed in 7. Chaitlow L, Liebenson C (Ed) In: Muscle Energy
the control group 18. K L Lenehan (2003) presented Techniques. 2001: 2nd Edition, Donald R Murphy,
research report on the effect of Muscle Energy London. Pg. 95-106.
Technique on gross trunk range of motion. This study 8. Ballantyne F, Fryer G, Mclaughlin P. The effect of
examined whether a single application of thoracic MET muscle energy technique on hamstring
could significantly increase the range of motion in extensibility: The mechanism of altered flexibility.
asymptomatic volunteers 19. J Osteopathic Medicine. 2003: 6: 59-63.
9. Freyer G. et al. Muscle energy concepts: a need
CONCLUSION for change. J osteopathic medicine. 2000: 3: 54-
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On the basis of present study, it can be concluded
10. Carolyn kisner, Lynn Allen Colby: Therapeutic
that all the subjects belonging to group–A and group
Exercise Foundations and Techniques. 2002: 5th
– B were able to increase the straight leg raise angle
Edition, F. A. Davis Company, US. Pg. 99
i.e. improvement in the hamstring flexibility. However
11. De Deyne. Application of passive stretch and its
on the basis of statistic analysis we can clearly say that
implications for muscle fibers. Phys Ther.
Muscle energy technique is more efficient technique
2001:81(2):819–827.
in improving hamstring muscle flexibility compared
to static passive stretching for Indian athletes. This 12. Flitney, FW, Hirst, DG: Cross bridge detachment
study can further be extended on to varying age group and sarcomere “give” during stretch of active
populations also with follow up to see the time period frog’s muscle. J Physiol 1978: 276:449.

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13. Lieber, RL, Boodine-Fowler, SC: Skeletal muscle 16. Gajdosik RL, Rieck MA, Sullivan DK, Wightman
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Ludwig N.H. Goeken. Sport stretching: Effect on
passive muscle stiffness of short hamstrings.
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 DOI Number: 10.5958/j.0973-5674.7.3.088
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 177

Effect of Maitland Spinal Mobilization Therapy Versus

Conventional Therapy in Lumbar Spondylosis with
Radiculopathy

Priya Igatpurikar
Lecturer - N.D.M.V.P'S college of Physiotherapy, Nashik, Maharashtra

ABSTRACT

Objectives: To compare SMT with conventional therapy in lumbar spondylosis with radiculopathy.

Design : Randomized controlled trial.

Material : Inch tape, pen , goniometer, SWD , lumbar traction unit , Hot packs.

Method: A RCT was done and patients with lumbar spondylosis were allocated in two group.
Gr. I received Maitland's mobilization in P-A , rotational and transverse mobilization with hot
packs and core stabilization. Gr. 2 received lumbar traction, Shortwave diathermy and core
stabilization.

Each group had 20 patients and they were evaluated on day one pre treatment and day 30 post
treatment. Outcome measures used for assessment were pain on VAS scale, spinal ROM by Schober's
test SLR and Oswestry Disability Scale for functional evaluation.

Results: Spinal mobilization and conventional therapy both showed improvement in pain and spinal
ROM but spinal mobilization however mobilization therapy showed significant improvement than
conventional group (t value = 2.149, p < 0.05). SLR & ODI showed improvement within group but
not between the two groups.

Conclusion : Spinal mobilization is better than routine conventional therapy .

Keywords: Lumbar Spondylosis, Maitland spinal Mobilization, PA glide, Transverse glide, Rotational
mobilization, SWD

INTRODUCTION Out of various conditions affecting low back,

degeneration of spine is the most common cause.
The loss of youth is melancholy enough : but to
Spondylosis affects intervertebral disc, facet joints,
enough into through the gate of infirmity, most
bones and ligament. Unfortunately as we age, our
dishearting”16
intervertebral disc lose their flexibility , elasticity and
Horace Walpole, 1765
shock absorbing characteristics. 6,10 The annulus
Although backache with or without sciatica is a fibrosis become brittle & nucleus pulposus begin to
benign, often self-limiting condition, it drains upto $ dessicate. The combination of damage to intervertebral
60 billion dollars per year from American disc, development of bony spurs, and gradual
Government’s health care budget.16,11 thickening of ligaments that support the spine can all

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 178 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

contribute to degenerative arthritis of lumbar spine. Blood coagulation disorders.

This can cause several symptoms including back pain,
leg pain and weakness due to compression of nerve Severe osteoporosis.
roots.11 Sacroiliac diseases.
There are few studies done by Sims Williams et al 1. Method of Collection of Data: Randomized
(1978,79) Rasmussen (1979) , Bergquist – Ullman controlled trial.
(1977), Christman et al (1964) , Doran and Newel
(1975), Coxhiah et al (1981) as well as Farrell and 2. Sample Size: Total patients :- 40
Towmey (1982) documented that SMT is superior than
Group A: 20 patients receiving Maitland
any other conventional therapies. Dr.P.Senthil Kumar,
Dr. Preeth John Cherian, MAHE, has done studies on Mobilization Therapy, hot packs and core
stabilization.
Maitland’s mobilization versus conventional therapy
in treatment of lumbar disc herniation and showed that Group B: 20 Patients receiving conventional
Maitland’s mobilization had significant results as therapy (traction and SWD) and core stabilization.
compared to conventional therapy . Thus this study
was taken to update the effectiveness of Maitland 3. Materials or Equipment Used :
spinal mobilization in degenerative spines in Indian
• Inch tape
populations.
• Traction table
MATERIAL AND METHODOLOGY
• SWD
1. Selection of Cases
• Hot packs
Kamala Nehru Hospital and Sancheti Hospital’s
P.T.O.P.D. 4. Outcome Measures

2. Age Group: 45 to 60 years. • VAS for pain

3. Inclusion Criteria: Patients diagnosed as having • ROM

lumbar spondylosis with radiculopathy.
• SLR
Both sexes included.
• Oswestry Disability Index
VAS 6 to 10
PROCEDURE
4. Exclusion Criteria: spondylolysis and
spondylolisthesis. Patients included in this study were known case
of lumbar spondylosis with radiculopathy. Consent
Spinal tumors. was taken and patients were randomly allocated
for treatment.
Infective spinal condition.
Group 1: Received Maitland spinal mobilization
Severe canal stenosis. (grade 1 to 4) Hot packs and core stabilization.
Ankylosing spondylosis. Group 2: SWD, Intermittent lumbar traction & core
Spinal fractures. stabilization.

• Pain on VAS , number of past and present

Spinal surgeries.
complaints was taken. Spinal ROM was assessed
Pregnancies. by Modified Schober Test and side flexion and
rotations was assessed by tape method . MMT
Severe sensory or motor weakness. was done according to Kendall method for
abdominals , back extensors and lower limb
Disease of spinal cord and cauda equine.
muscles. Sensory evaluation, reflex testing and
Scoliosis. special tests such as neural tissue tension test
and sacroiliac joint test was also done.

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Group A : This consists of experimental group Patient was taken in supine with hip-knee in 90-90
in which subjects were given hot packs for and leg supported on stool with pillows. Angle of pull
relaxation prior to mobilization therapy. was adjusted between 18 to 34 degrees & weight
Maitland’s gr1 to gr.4 central , unilateral , applied was slightly less than 50 % of body weight
transverse ,rotational mobilization was given to Hold and relax time: 15/15 min. duration of treatment:
the affected vertebra and one vertebra above 15 min.
and one vertebra below.
SWD : Patient was taken in supine with hip- knee
1. The amplitude used initially was Gr. I and II for flexed position and coplanar method of application
pain relief & grade III and IV was used to was used.
improve ROM, slow speed, smooth rhythm & 2
to 3 oscillations /sec for 30 sec. 2 to 3 sets for each Statistical Analysis
vertebra. Data Collection: The study was conducted
2. Mobilization was followed by core stabilization between May 2005 to 15 October .2006.
exercises . Statistical Analysis: A paired‘t’ test was done to
3. Patients were treated for 4 weeks and analyze the results within group for pain in VAS, spinal
assessment and outcome measures were taken ROM and SLR.
on 1st and 30th day . Unpaired t test was done to analyse the results
Group B: the other group received intermittent between the two groups for VAS, spinal ROM and
lumbar traction , Short wave diathermy and core SLR. The p level was set to 0.05.
stabilization and flexibility exercises . Oswestry disability index results were analyzed
ILT parameters: As per the study done by Lee and by Mann-Whitney test.
Evans

Table 1. Demographic Data

Patient Characteristics
Sr No Variables Experimental Grouop Control Group
(N = 20) (N = 20)
1 Mean Age 50.75 50.35
2 Male / Female 6 M / 14 F 7 M / 13 F
3 Mean Duration Of Symptoms (Months) 1.45 1.3
4 Number Of Patients With Past Episodes 13 9
5 Occupation Distribution
• Light Work • 12 • 10
• Moderate Work •6 •7
• Heavy Work •2 •3

Table 2. Vas Score

Experimental Control Unpaired

T Test
Pre mean_+ S.d. Post mean _+ S.d. Paired T Test Pre mean_+Sd Post mean_+Sd Paired T Test
7.55_+0.88 1.45_+0.51 24.375* 7.5_+0.688 2.05_+0.68 32.1056* 2.1495*

* Indicates P < 0.05 (Significant Difference)

Table 3. SLR

Experimental Control Unpaired

T Test
Premean_+ S.d. Postmean _+ S.d. T Value Premean_+Sd Postmean_+Sd T Value
51_+ 5.98 94.5_+ 5.1 33.1* 51_+ 5.938 91_+ 5.53 22.6* 1.703

* Indicates P < 0.05 (Significant Difference)

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 180 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Table 4. Spinal Rom

Movement Group Mean Rom S.d. T Unpaired T Test

Flexion Exp 4.55 0.944 21.54*
Cont 3.275 0.525 22.6* 5.276*
Extension Exp 1.75 0.5 15.62*
Cont 1.85 0.609 12.6* 0.567
Rt. Side Flexion Exp 3.75 0.786 21.35*
Cont 3.15 0.75 18.9* 2.171*
Lt. Side Flexion Exp 3.75 1.164 14.36*
Cont 2.65 1.03 11.39* 0.9839
Rt. Rotation Exp. 0.975 0.8 5.44*
Cont. 1.45 0.551 11.58* 2.476*
Lt. Rotation Exp. 1.25 0.769 6.46*
Cont. 1.45 0.483 13.39 3.1513*

* Indicates P < 0.05 (Significant Difference)

Table 5. Oswestry Disability Index

Experimental Control
Grade Pre Post Pre Post
Minimum - 20 - 20
Moderate 6 - 6 -
Severe 11 - 14 -
Crippled 3 - - -
Bed Bound - - - -

Oswestry Disability ( Mean ± Sd) And U Value :-

Experimental Control U Value

Mean 36.2 30.5 145
Sd 10.758 5.226

Critical U Value – 127, Results Higher Than 127 Indicate Insignificant Values.

Fig. 1. Rotational mobilization Fig. 2. Transverse glide

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 181

diminished when there is pain or stiffness in a

lumbar segment. Neurological deficits associated with
radicular pain are thought to arise from mechanical
compromise , ischemia , or inflammation of spinal
and dorsal root ganglia complex (Hause 1993)
possibly associated with intervertebral disc lesion or
osteophytic encroachment.

Pain showed improvement in both the groups i.e

(P<0.05) There was however more improvement in
the experimental group than the control group. This
could be attributed to the stimulation of
mechanoreceptors in the joint capsule , ligament, disc
Fig. 3. Central P-A glide etc there by causing stimulation of large diameter
that block the transmission of nociceptive impulses
(Paris 1979 , Wyke 1985) Thus closing the gate of pain
(Melzack and Wall ) The other mechanism of
relief of pain is by reducing the swelling containing
neurotransmitter such as substance P , histamine
and gentle oscillations may also raise the threshold
of nociceptors (Zusman 1986)

Similarly radicular pain reduction in control group

is attributed to the mechanical effects of ILT and
thermal effects of SWD . Since SWD causes deep
heating , increased circulation and extensibility of
collagen and induces relaxation and reduces muscle
spasm. Traction separation of vertebra thus
increases diameter of vertebral foramen and is
Fig. 4. Unilateral P-A glide
responsible for reduction of pain and normalize
neurological deficits by directing relieving pressure
DISCUSSION (Colachis and Stroem 1969, Twomey 1985) It is also
said to reduce disc protrusion and stimulate
Low back pain is the most common ailment and
mechanoreceptors by intermittent movement. (Martin
every one in life experiences it due to one or the other
Krause 2000)
reason. Out of the various reasons lumbar spondylosis
is the third leading cause of disability in people above Core stabilization also plays important role in
45 years. 12 reducing pain and it was given to both the groups.
Core exercises helps motor control training & patient
The rational for using Spinal manipulative
learns to activate his natural lumbar corset of body
therapy in the hypomobile joint in lumbar spondylosis
and stabilize the spine during various activities. When
is that these joints place excessive stress or strain
deep segmental muscles are activated , there is
on neighboring joint and may if long standing
improved motor control, endurance, and thus less fear
promote hypermobility in neighboring joints similar
of re-injury.
to translational hypermobility.13, 14 ,16
There was statistically significant improvement in
Janda noted that altered joint function affects the
SLR in both the groups. (Exp t- 33.13 and control t-
quality of muscle function across the involved joint
25.29) but no significance was found between the
. Jull and Janda stated that the proprioceptive
two groups.
input required for good motor control may be

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 182 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

When spinal movements are considered , both the 5. Barr KP,Griggs M, 2005 Lumbar Stabilization
groups showed improvement in ROM. (P<0.05) Program to treat low back pain, an overview,
American Journal of Physical Medical
Oswestry Disability Index did not show statistical
Rehabilitation.Jun;84;473-80.
significance ,(U=145) but there was clinical
6. Christena A. NIOSI, Thomas R Degenerative
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mechanics of the lumbar spine. , spine journal 4
after analyzing the results , it can be concluded
(2004) 2025-2085
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7. Ferreira M L ,Ferreira P H et al Does spinal
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8. Geert JMG Vander Heijden ,Amma JHM
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journal of physiotherapy 2003 vol – 49.
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spine sagittal plane model of PA mobilization.
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back pain following a specific exercise chronic low back pain.Australian journal of
intervention.JOSPT;27;Feb 1998. physiotherapy;43;Mar;1997.
21. Ricardson CA,Hides JA.1996. Multifidus muscle 24. VAS reliability –Ong K.S. Seymour R A Pain
recovery is not automatic after resolution of measured in humans 2004: 2 15 -25(7_)
acute,first-episode low back pain.Spine;21;2763- 25. Wordon R E ,Humprey T L therapeutic effect of
69;1996. spinal traction on digit of body .Arch Physical
22. Spinal manipulation therapy for low back pain: Med Rehabil 45, 318-320, 1964
an updated systematic review of RCT. Spine 21,

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 DOI Number: 10.5958/j.0973-5674.7.3.089
184 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Importance of Screening in 0-18 Months Infants by using

INFANIB at Tertiary Hospital

Parmar Sanjay1, Praveen S Bagalkoti2, Netravati Shettar2, Rajlaxmi Kubasadgoudar3

1
Assistant Professor, Department of Physiotherapy, 2Associate Professor, Department of Pediatrics, SDM College of Medical
Sciences and Hospital, Dharwad, 3Consultant Pediatric Physiotherapist, Regional Neuroscience Centre, Hubli, Karnataka

ABSTRACT

Objectives: Child development is a dynamic process and is often hard to measure by its very nature.
The various streams of development, including gross motor, fine motor, language, cognitive, and
adaptive behaviour, are interrelated and complex within themselves. Developmental delay refers to
when a child's development lags behind established normal ranges for his or her age. The prevalence
of developmental delay, deviation, disability or deformity in India is 2.5%. So the objective of this
study was to screen the infants at Tertiary hospital and to categorize them as normal, transiently
abnormal & abnormal neurologic development according to the INFANIB score.

Design: Cross sectional study

Method: 639 subjects were included in this study. According to the INFANIB manual guidelines,
screening test was administered and infants were categorized as normal, transiently abnormal and
abnormal neurologic development. Then, the data was evaluated statistically and results were
obtained.

Results: In Group 1(age of less than 4 months) as per INFANIB score out of 194 samples there were
161(82.99%) normal, 24(12.37%) transiently abnormal and 9(4.64%) abnormal neurologic development
infants. Group 2 (age of 4-8 month) had 162(86.63%) normal, 12(6.42%) transiently abnormal and
13(6.95%) abnormal neurologic development infants out of 187 samples. In Group 3(age of 8 months
or more) out of 258 samples there were 205(79.46%) normal, 18(6.98%) transiently abnormal and
35(13.57%) abnormal neurologic development infants. When all three age groups were considered,
there were 528(82.63%) normal, 54(8.45%) transiently abnormal, 57(8.92%) abnormal neurologic
development infants.

Conclusion: On INFANIB screening, there were 8.45% transiently abnormal and 8.92% abnormal
neurologic development infants at the Tertiary hospital.
Keywords: Screening, INFANIB, 0-18 month's Children

INTRODUCTION more areas of development.1,2 Various pre, peri &

neonatal factors contributed to the developmental
The term “high-risk infant” is used to those infants
delay. To increase survival rate of neonates and
whose perinatal medical course might contribute to
effectiveness of early intervention, the risk factors
motor, cognitive or social deficits. The term high risk
could be considered as a valuable clue. Neuro
infant designates infants who should be under close
developmental screening for neonates and infants for
observation by experienced physicians & nurses. It is
early detection of neuro developmental delays is
well known that the incidence of developmental delay
highly recommended. The prevalence of
in high-risk infants is higher. Developmental delay
developmental delay, deviation, disability or deformity
refers to when a child’s development lags behind
in India is 2.5%.4 Screening is a “brief assessment
established normal ranges for his or her age.1
procedure designed to identify children who should
At least 8% of all children from birth to six years receive more intensive diagnosis or assessment.”
have developmental problems and delayed in one or Developmental screening is aimed at identifying

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 185

children who may need more comprehensive exclusion criteria, infant’s parents were requested to
evaluation.5 There are various developmental participate in the study. Subject’s parents who were
screening test which are used to assess the newborn. willing their child to participate in the study were
Some of them are: briefed about the study and their informed consent
was taken.
1. Denver Developmental Screening Test 2.
Inclusion Criteria
2. Alberta Infant Motor Scale.
0-18 months of children of either gender.
3. Assessment of Movement Activity in Infants.
Exclusion Criteria
4. Movement Assessment of Infants.
No parental consent, unco-operative subjects,
5. Milani Comparetti Motor Developmental infants admitted for unstable medical conditions,
Screening Test. infants under the effect of drugs acting on CNS E.g:
Phenobarbitone.
6. Primitive Reflex Profile.

7. The Brazelton Neonatal Behavioural Assessment PROCEDURE

Scale.
In this study 639 subjects were taken using
8. Infantile Neurological International Battery systematic random sampling method. Their
(INFANIB).6 demographic data was collected and infants were
screened and scored as per INFANIB manual
Infantile neurological international battery guidelines. INFANIB has 20 items that assesses the
(INFANIB) is a developmental screening test used to infant’s motor development in supine, prone, standing,
determine tone and posture of 0-18 months infant. It and suspended positions for reflexes and French angles
is used to evaluate infants who are born prematurely, as well as muscle tone and body posture. Scoring was
treated in neonatal intensive care, affected by sickness based on age groups.
such as meningitis and heart failure or infants whose
development is slow. It is used to distinguish infants Infants with age less than 4 months score of less
with normal neuromotor function from those with the than or equal to 48 was considered abnormal, 49-65 as
abnormal findings and to predict the need for follow transient and e” 66 as normal. Age group of 4-8 month
up treatment. This scale does not require any special less than or equal to 54 was abnormal, 55-71 as
training for the therapist to administer.6 transient and e”72 was normal. Age group 8 month or
more score less than or equal to 68 was abnormal, 69-
METHOD 82 was transient and e”83 was considered as normal.

For this study, ethical clearance was obtained from Statistical Analysis
SDM institutional ethical committee, Dharwad before
Statistical analysis was done by using SPSS 16.0
commencement of the study. All infants age between
0-18 months visiting Department of Physiotherapy & version statistical software. Chi square test was used
Department of Pediatrics Shri Dharmasthala to categorize the infants as normal, transiently
abnormal and abnormal neurologic development. This
Manjunatheshwara College of Medical Sciences &
Hospital (SDMCMS & H) Dharwad were screened. categorization was done according to age groups and
After finding their suitability as per inclusion and gender.

RESULTS
Table1. Distribution of samples according to groups and degree of normality and abnormality.

Group Normal % Transient % Abnormal % Total

Less than 4 months 161 82.99 24 12.37 9 4.64 194
4 to 8 months 162 86.63 12 6.42 13 6.95 187
8 months or more 205 79.46 18 6.98 35 13.57 258
Total 528 82.63 54 8.45 57 8.92 639

Chi-square= 16.8272 df=4 p=0.0020, S

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 186 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Table 1 shows the number and percentage of FUTURE RECOMMENDATIONS:

normal, transiently abnormal and abnormal neurologic
development. In Group 1 as per INFANIB score out of  Causative factor for abnormal neurologic
194 samples, there were 161(82.99%) normal, development in children can be studied in future.
24(12.37%) transiently abnormal and 9(4.64%)  Children who categorized under transient
abnormal neurologic development infants. Group 2 abnormal neurologic development can be followed up
had 162(86.63%) normal, 12(6.42%) transiently after few months to know whether they fall under
abnormal and 13(6.95%) abnormal neurologic normal or abnormal neurologic development category.
development infants out of 187 samples. In Group 3
out of 258 samples there were 205(79.46%) normal,  Children who categorized under transient and
18(6.98%) transiently abnormal and 35(13.57%) abnormal neurologic development, early intervention
abnormal neurologic development infants. When all can be started and reapplication of screening can be
three age groups were considered, there were done.
528(82.63%) normal, 54(8.45%) transiently abnormal,
57(8.92%) abnormal neurologic development infants. CONCLUSION

DISCUSSION On INFANIB screening, there were 8.45%

transiently abnormal and 8.92% abnormal neurologic
The purpose of this study was to screen the infants development infants at the Tertiary hospital. So we
at Tertiary Hospital and to categorize them as normal, recommend regular screening of infants who are
transiently abnormal and abnormal neurologic visiting to health profession and if required
development as per INFANIB scoring. appropriate early intervention to be undertaken.

A study was done to know the neuromotor

REFERENCES
outcome in risk infants using Infant Neurological
International Battery (INFANIB). Correlation between 1. Developmental delay. Encyclopedia of children’s
INFANIB results and neuromotor outcome for 2 years health 2005 Available from URL: http://
in 70 risk infants was also studied. All the infants of w w w. e n o t e s . c o m / c h i l d r e n s - h e a l t h
the abnormal result group (29 cases) on the initial encyclopedia/ developmental-delay.
INFANIB examination grew into either cerebral palsy 2. Tervo R. Identifying Patterns of Developmental
(26 cases) or minor neural dysfunction group (3 cases) Delays Can Help Diagnose Neurodevelopmental
on the follow-up examinations. All the infants of the Disorders. A Paediatric Perspective 2003
normal results group (12 cases) appeared to be in july;12(3):1-6.
normal developmental outcomes on the follow up. 3. Soleimani F, Vameghi R, Hemmati S, Roghani RS.
However, the transient results group (29 cases) showed Perinatal and Neonatal Risk Factors for
variable outcomes, which were 9 cases of cerebral Neurodevelopmental Outcome in Infants in
palsy, 6 cases of minor neural dysfunctions, and 11 Karaj. Arch Iran med 2009 March;12(2):135-139.
cases of normal development. INFANIB test results of 4. MKC Nair, Babu G, Padmamohan J, Sunitha RM,
the infants were highly sensitive and specific. Normal Resmi VR et al. Developmental delay and
disability among under -5 children in a rural ICDs
INFANIB results can be used to reassure parents of
blocks. Indian Paediatrics 2009 Jan;46:75-77.
risk infants and an early intervention programs can
5. Aly Z, Taj F, Ibrahim S. Missed opportunities in
be started to abnormal INFANIB infants. It can be used
surveillance and screening systems to detect
as a reliable screening tool for suspicious
developmental delay: A developing country
neurologically deviant neonates and infants. perspective. J braindev 2010;32:90-97.
With this study we come to know that as per routine 6. Wilhelm IJ. Physical therapy assessment in early
screening on INFANIB scale subjects who visited at infancy. New York: Churchill Livingstone; 1993.
tertiary hospital there are normal, abnormal and p.46-48.
transiently abnormal children. So routine screening of 7. Sung IY, Kang W. Infant Neurological
the children is required and early intervention to be International Battery (INFANIB) as a Predictor
started to improve the score on INFANIB scale.7 of Neuromotor Outcome in Risk Infants. J Korean
Acad Rehabil Med 1997 April;21(2):406-413.
LIMITATIONS OF THE STUDY

Follow up of the subjects was not considered.

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 DOI Number: 10.5958/j.0973-5674.7.3.090
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 187

Effect of Stroke on Mantainence of Balance and Sense of

Equilibrium

Nidhi Kashyap1, SavitaTamaria1

1
Lecturer, Banarsidas Chandiwala Institute of Physiotherapy, Chandiwala Estate, Kalkaji, New Delhi, India

ABSTRACT

Introduction: Perception of the visual vertical (SVV) is affected by cerebral hemispheric lesions.
Knowledge of this disturbance is of interest for the study of its possible relation to balance disturbances
and sense of equilibrium.

Aims and Objective: To see the effect of stroke on balance and vestibular component.

Methodology: Ten subjects were included in the study. Subjects were asked to perform time up and
Go test, MSQ and Dynamic Gait Index.

Results: The mean value of MSQ for 10 subjects was found to be 49.4. Vestibular component is affected
moderately in 7 of 10 patients. The mean value of TUG is 51.86.

Conclusion: On the basis of the present study we concluded that, the orientation of vertical position
and balance is affected in stroke patients.
Keywords: Stroke, Vestibular Component, Hemiplegia

INTRODUCTION Many vestibular reflexes are controlled by process

that exists primarily with in the brainstem. Extensive
Stroke or brain attack is the sudden loss of
connections between the vestibular nuclei and the
neurological function caused by an interruption of the
reticular formation, thalamus and cerebellum,
blood flow to the brain .The term cerebrovascular
connections with vestibular cortex, thalamus and
accident (CVA) is used interchangeably with stroke to
reticular formation enable the vestibular system to
refer to the vascular conditions of the brain.
contribute to the integration of arousal and conscious
Ischemic stroke- Ischemic stroke is the most awareness of the body, as well to discriminate between
common type, affecting about 80 percent of individuals movement of self and environment2.
with stroke, and results when a clot blocks or impairs
Central nervous system (CNS) injuries can affect
blood flow, depriving the brain of essential oxygen and
the vestibular system .Cerebrovascular insults
nutrients.
involving the anterior –inferior cerebellar artery
Hemorrhagic stroke- occurs when blood vessels (AICA),posterior- inferior cerebellar artery (PICA) and
rupture, causing leakage of blood in and around the vertebral artery may cause vertigo ,though other signs
brain.1 associated with these infarcts are present may clarify
the site of pathology. Lesions of the vertebral artery
Vestibular system consists of peripheral and central may affect the cerebellum only and can mimic a
vestibular system. The three primary functions of peripheral vestibular hypo function in its clinical
vestibular system are stabilization of the visual images presentation.3
on the on the fovea of the retina during head movement
to allow clear vision, maintaining postural stability; Perception of the visual vertical (SVV) is affected
especially during movement of the head, providing by cerebral hemispheric lesions. Knowledge of this
information used for spatial orientation.2 disturbance is of interest for the study of its possible
relation to balance disturbances.

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 188 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

METHODOLOGY measure. Score within ten seconds are normal for most
adults; score of 11 to 20 seconds are within normal
Sample size of ten subjects was taken. .The patient
limits for disabled patients; score greater than 20
included had recently experienced their first
seconds are considered abnormal Sample size of ten
And only cerebral hemispheric stroke, resulting at subjects was taken4.
least in initial motor and balance impairment,
MOTION SENSITIVITY QUOTIENT
The time since stroke was no longer than three
months, Subjects to be chosen with either side The motion sensitivity quotient (MSQ) was
involved. .Patients was excluded if they had perturbed developed to provide subjective score of an
vigilance, a history of neurological disturbances, individual’s dizziness. The test involves placing
vertigo or vestibular dysfunction, amblyopia or severe patients into positions incorporating head or entire
aphasia, if they had received pharmacological body motions to determine whether the movement
medication (analgesic, anticonvulsant or sedative), had reproduces dizziness. Each subject was instructed to
deficient from earlier brainstem events, prior to the indicate the onset and offset of any dizziness that
onset of disease, and showed acute multiple lesions of occurred in each position. The duration of dizziness,
the brainstem and or the hemispheres. which was recorded with a stopwatch, was assigned
the following values: 1 point for 5 s to 10 s of dizziness,
INSTRUMENTATION 2 points for 11 s to 30 s of dizziness, and 3 points for
>30 s of dizziness. Once the duration was recorded
Instruments and Tool used for a position, the subject was asked to rate verbally
the intensity (severity) of the dizziness just experienced
1. Arm chair
on a scale of 0 to 5 (0 = no symptoms; 5 = severe
2. Tape measure dizziness). By adding the duration score to the intensity
score, investigators calculated a raw score for each
3. Tape position. The maximum raw score for each of the 16
positions is 8 points (3 points for dizziness lasting >30
4. Stop watch
s and a score of 5 points for severe dizziness); the total
5. Plinth possible MST raw score is 128 (8 points × 16 positions).
The MST quotient was calculated with the use of the
PROCEDURE formula 5.

The purpose of the study was explained to the

subjects and they were encouraged to participate in
the study. Subjects for this study were recruited on the
basis of inclusion and exclusion criteria. Dynamic Gait Index
The study was initiated only after taking an It has 8 items: walking, walking while changing
informed consent from the subject After this, the speed, walking while turning the head horizontally
demographic data was collected which included age and vertically, walking with pivot turn, walking over
(years), weight (kg), height (cm) etc. and around obstacles and stair climbing. The scoring
• Baseline assessment of the subject was done prior of DGI is based on a 4 point scale ranging from 0-36.
to the start of the study.
RESULTS
• Following this, the subjects were asked to perform
TUG test, MSQ test and Dynamic Gait Index. The effect on balance and vestibular component
was assessed on three parameters: Dynamic Gait
Timed Up and Go (TUG) Test Index, Motion Sensitivity quotient and Time up and
Go Test respectively. The mean value of DGI is 8.40
The timed up and go test is a clinical balance test
.The mean value of MSQ for 10 subjects was found to
that examines functional limitation related to balance.
be 49.4. The mean value of Time Up and Go Test is
The individual rises from the chair and walks 30meters
51.86.
and then returns to the chair. It uses time as an outcome

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 189

Table1. Shows mean value and standard deviation of nystagmus , the eyes move slowly to the right (VOR),
DGI, TUG and MSQ in stroke patients. and the resetting eye movement is to the left (fast
VARIABLES MEAN S.D component). Nystagmus due a vestibular lesion is
DYNAMIC GAIT INDEX 8.40 .984 most commonly after an acute unilateral insult,
TIMEUP AND GO TEST 51.86 4.31 spontaneous (at rest) nystagmus12 .
MOTIONSENSTIVITY QUOTIENT 49.4 .987
Patients with acute unilateral thalamic infarctions
that only lesions of the poster lateral region cause
DISCUSSION
transient vestibular signs and symptoms such as
The vestibule -ocular reflex (VOR) is responsible perceptual deficits with ipsi- or contralateral tilts of
for maintaining stability of an image of an image on the subjective visual vertical and corresponding
the fovea of the retina during rapid head movements. deviations of stance and gait. However, they cause no
Then VOR generate rapid compensatory eye ocular motor deficits. These signs and symptoms of
movements in the direction opposite to the head vestibular imbalance are probably identical with the
rotation. The VOR achieves this with connectivity in syndrome called earlier ‘thalamic stasis’, a condition
the central pathways. In the most basic form pathways of irresistible falls without paresis or sensory or
controlling the VOR can be described as a three neuron cerebellar signs.6 Like these earlier findings of a tonic
arc.7 vestibular deficit in patients with posterolateral
infarctions, our patients also presented with ipsi- or
In the case of anterior SCC, primary vestibular contralateral tilts of the SVV and postural imbalance1.
afferents from the anterior SCC synapse in the In addition, seven of eight patients had mild
ipsilateral vestibular nuclei8. Secondary vestibular contralateral hemiparesis and one contralateral
neurons receiving innervations from the ipsilateral hemiataxia, signs of which were due to ischaemic or
labyrinth decussate and synapse in the contralateral oedema of the adjacent internal capsule, which is
occulomtor nucleus. Motorneurons from the regularly seen in combination with the vestibular signs.
occulomotor nucleus then synapse at the Thus, this combination of signs and symptoms was
neuromuscular junction of the ipsilateral superior compatible with a lesion of the vestibular relay station
rectus and the contralateral inferior oblique muscle. within the posterolateral thalamus, the function of
Similar pattern of connectivity exist for the vertical SCC which was described earlier in humans and animals.13
and the eye muscles that receive innervations from Neurophysiological data and tracer studies of the
them for insertions of the ocular muscles.9 posterolateral thalamus in cats and monkeys describe
these subnuclei as a relay station for vestibular cortex
Normally as the head moves in one direction, the
areas, since vestibular stimulation of the animals
eyes move in opposite direction with equal velocity.
elicited corresponding responses in their neurons.
This relation of eye velocity to head velocity is
Most ascending vestibular fibres in the subnuclei such
expressed as the gain (VOR gain) of the vestibular
as VPL were in close contact, intermingled with
system. Since there is a direct relationship between
proprioceptive relay cells, and also responded to opto
vestibular receptors in the inner eye and eye
kinetic stimuli; this finding argues for an integration
movements produced by the VOR, the examination
of vestibular and proprioceptive information at the
of the eye movements can be of primary importance
thalamic level. Electrical stimulation of the
in defining and localizing vestibular pathology10.
posterolateral thalamic subnucleus in humans elicited
Nystagmus is the primary diagnostic indicator a rotation or spinning of the body, head or eyes either
used in identifying most peripheral and central counter clockwise (more often) or clockwise. These
vestibular lesions .An in voluntary eye movement, signs during stimulation of thalamic neurons were in
nystagmus due to peripheral vestibular lesions is agreement with the human ‘vestibular thalamic
composed of both slow and fast component eye deficits’ described earlier in patients with
movements. For individual with a unilateral vestibular posterolateral thalamic infarctions as well as the
lesions , the slow component is due to relative patients in our current stud. However, anatomical
excitation of one side of the vestibular system. The fast differences and divergent nomenclature make it
component is generated from the parapontine reticular difficult to correlate human and animal thalamic
formation in the brainstem repositions the eye to the structures directly. Jones compared monkey and
centre of the orbit, for example, in left beating human data and proposed a carefully revised

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 190 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

nomenclature for the ventral nuclei, according to of visual and vestibular inputs for the determination
which the ‘vestibular’ thalamic nuclei in humans were of visual vertical was unaffected by the lesion.
considered to be the ventral parts of nucleus Consequently, when patients with pusher syndrome
ventrolateralis, pars posterior (VLp), nucleus sit upright, they experience a mismatch between visual
ventroposteriorlateralis, pars posterior (VPLp) and vertical, based on vestibular and visual inputs on the
nucleus ventroposterior inferior (VPI) . The preferably one side, and their perception of tilted body orientation
affected subnuclei in the current study were the VPLp relative to the vertical.11
and dorsal and ventral parts of the VLp12.
Clinical Relevance: The study concluded that there
Multisensory neurons tuned to both vestibular and is effect of stroke on balance and vestibular component.
visual motion (optic flow) signals are found in several So in the rehabilitation protocol of stroke patient must
cortical areas in the dorsal visual stream. HuiMeng and include the rehabilitation of vestibular component.
Dora E. examine whether such convergence occurs
subcortically in the macaque thalamus. They searched CONCLUSION
the ventral posterior nuclei, including the anterior
pulvinar, as well as the ventro-lateral and ventral Based on the results of this study, it can be
posterior lateral nuclei, areas that receive vestibular concluded that the stroke moderately affects the
signals from brain stem and deep cerebellar nuclei. vestibular component. Hemispheric stroke affects
Approximately a quarter of cells responded to three- subjective visual vertical perception, which closely
dimensional (3D) translational and/or rotational related to visuospatial neglect. Hence affects the
motion. More than half of the responsive cells were balance and coordination.
convergent, thus responded during both rotation and Conflict of Interest: Nil
translation. The preferred axes of translation/rotation
were distributed throughout 3D space7. The majority Source of Funding: Nil
of the neurons were excited, but some were inhibited,
during rotation/translation in darkness. Only a couple REFERENCES
of neurons were multisensory being tuned to both
vestibular and optic flow stimuli. They conclude that 1. Alain P. Yelnik, MD; Frederique O. Lebreton, MD,
multisensory vestibular/optic flow neurons, which are Isabelle V. Bonan, MD, Florence M.C. Colle,
commonly found in cortical visual and visuomotor MD, Francesca A. Meurin, MD, Jean Pierre
areas, are rare in the ventral posterior thalamus13. Guichard, MD, Eric Vicaut, MD: Perception of
the vertility after recent cerebral hemispheric
Pusher ’s syndrome- The researchers found an stroke. American Journal of Physical Medicine
altered perception of the body’s orientation in relation and Rehabilitation.2000;75(4):221-224.
to gravity by using a seating device that allowed tilting 2. HuiMeng, Dora E. Angelaki : Responses of
the patient to the right or to the left without ground ventral posterior thalamus neurons to three
contact. After a random tilt to the left or to the right of dimensional vestibular and optic flow
at least 35 degrees, the patients were required to stimulation. Journal of neurophysiology.2009;
indicate when they reached upright body orientation. 817 -826.
On the average, patients with controversies pushing 3. Lee H , Kim HJ, Koo JW : Superior divisional
experienced their body as oriented “upright” when vestibular paresis in anterior inferior cerebellar
actually tilted 18 degrees to the side of the brain lesion. artery infarction. Journal of Neuro Sciences.2009;
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orientation perception of the visual world (visual 4. Hans ottokarnath, Susanne Ferber : The neural
vertical). Thus, in contrast to their disturbed perception representation of postural control in humans.
of upright body posture, patients with pusher Journal of Neuro Sciences.2010; 300-304.
syndrome could align their longitudinal body axis to 5. Kim HA ,Lee SR ,Lee H :Acute peripheral
earth vertical upright when using visual cues from the vestibular syndrome of a vascular cause . Journal
laboratory’s surrounding. In addition, without a visual of neurology Sciences.1999; 99 -101 .
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correctly determine visual vertical when sitting upright cause side specific suppression of vestibular
as well as when tilted in the position that is perceived cortex activations. Journal of neurophysiology.
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7. Lee H, Ahn BH, Baloh RW: Sudden deafness with 11. Baloh RW: vertibrobasilar insufficiency and
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 DOI Number: 10.5958/j.0973-5674.7.3.091
192 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Accessory Inspiratory Muscles Energy Technique effect on

Pulmonary Function in COPD Subjects

Akanksha Anand1, Ravinder Narwal2, Girish Sindhwani3

1
Physiotherapist, Ram Pyari Orthopaedic Hospital, Ranchi, JHA, 2Lecturer, 3Pulmonary Medicine, Head of Department,
HIHT University, Dehradun, UK

ABSTRACT

Aim & Objectives: Chronic Obstructive Pulmonary Disease (COPD) accounts 17 million lives in
India, which will rise to 22 million by 2016 & it kills 250 people every hour. Global initiative for
Obstructive Lung Disease (GOLD) portrayed skeletal muscle dysfunction as a significant contributor
to severity in these patients resulting in reduced exercise capacity and impaired Quality of life. Muscle
Energy technique (MET) had been a well known treatment in musculoskeletal disorders, yet literature
supporting its use in chronic respiratory disorders is limited. So the present research is design to
study the effects of MET on pulmonary function in COPD subjects and describes its impact on
Conventional chest Physiotherapy.

Method: 30 Moderate & Severe staged COPD patients in 40-60 years age group were allocated into
two groups: Conventional Chest Physiotherapy (CPT) and Conventional Chest Physiotherapy with
MET(CPT + MET) group. Chest expansion, Dyspnea, Exercise tolerance, Respiratory rate, Heart rate,
Oxygen saturation and Quality of life were the variables that recorded prior and after the intervention
for three days.

Results: Significant improvement was seen in both groups on all 3 days with greater improvements
in CPT with MET group in form of increased chest expansion, reduced Dyspnea, increased exercise
tolerance, regulation of autonomic dysfunction and improved Quality of life.

Discussion: Study reveals the potential benefits of MET on pulmonary function and its efficacy in
upgrading the Conventional chest Physiotherapy in COPD subjects. It also recognizes the importance
of management of Accessory Inspiratory muscle dysfunction in providing a better Quality of life in
COPD patients.

Conclusion: MET proved to be a highly magnificent technique in improving pulmonary function

and must be thus incorporated as a basic part of pulmonary rehabilitation in COPD subjects.
Keywords: COPD, Chronic Obstructive Pulmonary Disease, MET- Muscle Energy Technique, Accessory
Inspiratory muscle dysfunction, CPT- Conventional Chest Physiotherapy

INTRODUCTION Respiratory compromised conditions like COPD

disrupted the breathing states. Dynamic lung
Chronic Obstructive Pulmonary Disease (COPD)
hyperinflation, as a result of chronic expiratory airflow
is currently estimated to be the fifth leading cause of
limitation in COPD patients, impairs Diaphragm
death worldwide and will rank third by 2030.It
efficiency for inspiration leading to its functional
accounts 17 million lives in India, which will rise to 22
weakness, dysfunction and overuse of Accessory
million by 2016 & it kills 250 people every hour. Global
Inspiratory muscles. Campbell (1955) stated that
initiative for Obstructive Lung Disease (GOLD)
Scalene and Sternocleidomastoid (SCM) were the first
portrayed skeletal muscle dysfunction as a significant
among accessory muscles to be recruited and that
contributor to severity in these patients resulting in
spastic state of these accessory muscles was a
reduced exercise capacity and impaired Quality of life.1

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 193

contributory cause of Dyspnea in chronic respiratory the effects of MET in treating Musculoskeletal
patient. 2 dysfunction associated with COPD.6 So The current
study aims to explore the effects of MET of Accessory
This leads to Thoraco-abdominal dys-synchrony Inspiratory muscles on pulmonary function and their
which further results in biomechanical changes impact on Conventional chest physiotherapy
characterized by chest wall muscles shortening, management in patients with COPD.
weakness and fascia restriction contributing to
increased work of breathing and reduced exercise METHODOLOGY
capacity. As severity of the disease increases, patients
develop Barrel shaped chest leading to elevated, This single-blinded experimental design study was
protracted, rounded shoulders and kyphotic spinal based on population of 120 COPD patients & out of
deformities. These postural deformities places them 30 COPD subjects were taken for study on the
Pectorals and other chest wall muscles in a shortened basis of Inclusion and Exclusion criteria. All the
position increasing the chest wall resistance to subjects were randomly allocated into two groups :
expansion, further increasing the Work of Breathing Conventional Chest Physiotherapy group (CPT) and
and thus reduced exercise capacity. Moreover these Conventional Chest Physiotherapy with MET group
muscles, Scalene, SCM and Pectorals, are also required (CPT with MET). CPT group received Diaphragmatic
for the movement of Upper limb and neck in daily controlled breathing, Pursed lip breathing, Postural
activities.2,3 drainage and Thoracic expansion exercises. CPT with
MET group received MET of Scalene,
These Musculoskeletal complications increase the Sternocleidomastoid and Pectoralis major muscles in
work of breathing and adversely affect patients’ addition to exercises mentioned for CPT group.
Quality of life in the way that they start to associate
Dyspnea on exertion with disease and no longer Inclusion criteria: Male and female subjects
consider it as a normal response to exertion leading to between age 40-70 yrs were taken suffering from
moderate to severe staged COPD.
a vicious cycle of physical inactivity. This results in
deconditioning of respiratory and peripheral muscles Exclusion criteria: Subjects with Musculoskeletal
leading to impaired exercise tolerance and reduced disorders affecting spine and shoulder, all cardiac
Quality of Life.4 conditions, Pulmonary conditions except COPD, any
Systemic pathologies interfering with pulmonary
Recently, GOLD guidelines identified improved
rehabilitation, e.g. unstable Hypertension, Recent post-
Exercise tolerance and Quality of Life as important
operative patients, , Patient underwent pulmonary
clinical goals of treatment for patients with COPD.
rehabilitation programme since 1 month &
Medical management mainly emphasizes on
uncooperative subjects were excluded from the study.
pulmonary function but may not necessarily have an
effect on functional exercise tolerance and quality of Independent Variable: Muscle Energy Technique
life. Pulmonary rehabilitation and chest physiotherapy (MET).
thus becomes an important part of a comprehensive
management and rehabilitation program in COPD Dependent variables :Chest wall expansion
patients.5 (CE),Dyspnea, Oxygen saturation (SpO2), Respiratory
rate (RR),Heart rate (HR),Six Minute Walk Distance
Recommendations for pulmonary rehabilitation for (6MWD), Quality of Life (QoL).
chronic respiratory impairment have limited literature
Instrumentation: Cloth Inch tape, Pulse Oximeter,
studies regarding the Accessory Inspiratory muscle
Stethoscope, Stopwatch, Modified Borg rating scale,
dysfunction. Manipulative therapists developed
Clinical COPD Questionnaire (CCQ), Six minute walk
Muscle Energy technique (MET) as a highly effective
test.
treatment for musculoskeletal dysfunction. Review of
various studies indicated that improvements made to
musculoskeletal mechanics of the thoracic region result DATA COLLECTION
in improvement of pulmonary function.11 Despite of Data was collected pre and post intervention daily
all these facts there is a dearth of literature investigating for 3 days of both groups.

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 194 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Procedure Flowchart

DATA ANALYSIS RESULTS

The Data was analyzed by the statistical package The study sample had an average mean age of 61
of SPSS -13, Graphical Pad software as required and years with 90% males and 10% females & this
significant level was set at pd”0.05 and confidence illustrating the fact that our study was male
interval was 95%. The comparison analyses of dominated.
dependent variables were done by parametric “t-test”
test in consecutive 1 to 3 days in form of pre and post The baseline comparison of both groups by the
intervention. outcome variables in the form of Age (yrs), CE (cm),
Dyspnea (Borg), SpO2 (%), 6MWD (m), HR (beats/
min.), RR (breaths/min.), CCQ score showed no
statistical significant differences

Table1 .Comparision of Both groups at Baseline on the basis of outcome variables.

Variables Mean ± S.D T value P value

CPT group CPT +MET group
Age (yrs) 61.53 ± 7.94 61.20 ± 5.84 0.124 0.903
CE (cm) 1.39 ± 0.39 1.56 ± 0.41 -1.221 0.242
Dyspnea (Borg) 5.40 ± 0.63 5.20 ± 0.67 0.676 0.510
SpO2 (%) 88.00 ± 2.50 88.60 ± 2.26 -0.854 0.407
6MWD (m) 149.06 ± 41.1 167.73 ± 43.64 -1.211 0.246
HR (beats/min.) 98.26 ± 3.51 97.26 ± 4.11 0.697 0.497
RR (breaths/min.) 23.86 ± 1.06 23.46 ± 0.99 0.972 0.348
CCQ score 3.8 ± 0.40 3.49 ± 0.79 1.547 0.144

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 195

Table2. Comparison b/w both groups by following variables after 3Days

Variables Mean ± S.D T value P value

After Day3 Post-intervention CPT group CPT + MET group
Chest Expesion 1.95 + 0.48 2.59 + 0.37 -5.184 0.001
Dyspnoea 3.86 + 0.63 2.40 + 0.63 7.643 0.001
SpO2 97.33 + 2.49 99.60 + 1.12 -3.745 0.002
Functional exercise capacity 240.26 + 65.86 393.73 + 53.67 -10.197 0.001
Respiratory rate 21.46 + 0.99 20.40 + 0.82 3.096 0.008
Heart Rate 81.26 + 2.71 76.00 + 4.78 3.445 0.004
Quality of life 2.25 + 0.72 1.32 + 0.61 3.726 0.002

Fig. 1. Comparison b/w both groups on Chest expansion from

Fig. 6. Comparison b/w both groups on Heart rate from Day1-Day3
Day1- Day3

Fig. 2. Comparison b/w both groups on Dyspnea from Day1-Day3 Fig. 7. Comparison b/w both groups on Quality of Life from
Day 1 - Day 3

DISCUSSION

The results suggested that our study is based on

the sample of elder population and is male dominated.
This can be correlated with findings of GOLD
Fig. 3. Comparison b/w both groups on SpO2 from Day1-Day3
guidelines on COPD which states that the disease is
more prevalent in 45 years and above age group and
with males more commonly affected than females.7

The results have been discussed by taking a no. of

variables in the study: Chest expansion, Dyspnea,
Functional exercise capacity, Respiratory rate (RR),
Fig. 4. Comparison b/w both groups on Functional exercise
Heart rate (HR), Oxygen saturation and Quality of life,
capacity from Day1 – Day3 because of two reasons: firstly, previous studies
conducted so far included either of the variables and
not all. Secondly, all the variables are inter-related with
one another and will provide a better understanding
for a composite view of Respiratory, cardiovascular
and musculoskeletal systems.

The Baseline comparison of both groups on all

Fig. 5. Comparison b/w both groups on Respiratory rate from outcome variables showed no significant differences
Day1-Day3 and so we can say that both the groups were at same

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 196 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

level of CE, Dyspnea, SpO2, 6MWD, RR, HR and QoL there is greatest perfusion. As a result, V/Q matching
prior to the manipulation of interventions. increases resulting in an increase in SpO2. 11

Within the group comparison shows significant 4.Functional exercise capacity: This was determined
improvement in both the groups in all outcome by the distance walked in six minutes by Six minute
variables on all 3 days of our intervention. On walk test. Dyspnea and reduced SpO2 have been
comparing both the groups improvements were much described as major contributing factors to reduced
greater in CPT with MET group on all 3 days. This exercise capacity by Lam Pui. 12 So by relieving
reveals the fact that MET contributes significantly in Dyspnea and increasing arterial Oxygen saturations
improving pulmonary function and increases the by above said mechanisms Conventional chest
efficacy of Conventional chest Physiotherapy in physiotherapy and MET techniques increase
patients with COPD. Functional exercise capacity. In addition to Dyspnea
and reduced SpO2, increased Work of breathing was
1.Chest Expansion: The role of Diaphragmatic also reported to limit exercise capacity. Upper chest
breathing exercises in increasing chest expansion is breathing as a consequence of accessory muscles
well established in the literature. Lenehan, Fryer and overuse expend up to 30% of body’s energy in
McLaughlin8 stated that single sessions of thoracic comparison to Diaphragmatic breathing which
MET effectively increased trunk ROM as a result of requires less than 5% of body’s energy. MET thus by
viscoelastic and plastic changes in myofascial eliminating upper chest breathing and optimizing
connective tissue elements following isometric Diaphragmatic breathing reduces Work of Breathing
contraction by MET. So we can say that MET increased in these patients and thus increases Functional exercise
chest expansion by increasing thoracic ROM.9 capacity more effectively.13
2.Dyspnea: Pursed lip breathing exercises are very 5.RR and HR: One of the important findings of our
effective in relieving Dyspnea by reducing dynamic study was the regulation of autonomic function in our
hyperinflation and thus have always been a part of body in form of reduced RR and HR by Conventional
Conventional physiotherapy management in COPD chest physiotherapy and MET. Breathing cycle reflects
patients. However, results also suggested the role of a balance between Parasympathetic and Sympathetic
MET in reducing Breathlessness. The mechanics divisions of Autonomic Nervous system (ANS).
behind this improvement can be explained by the fact Diaphragmatic breathing and pursed lip breathing
that MET stretching of accessory inspiratory muscles exercises regulate RR via Hering- Breuer reflex.13
relaxes them and decreases the rate of muscle spindle
firing in lengthening phase. This reduces the central Slowing of RR leads to a relative increase in vagal
respiratory motor command required for given tone and further reduction in sympathetic activity,
ventilation and consequently alleviates Dyspnea.9 thereby reducing HR. In addition to the above
mechanism of autonomic regulation Gail Dubinsky 14
3.Oxygen saturation (SpO 2 ): Apart from emphasized the fact that there exists a bi-directional
Diaphragmatic breathing and Pursed lip breathing relationship between breathing pattern and ANS. He
exercises Postural drainage plays a significant role in described that Sympathetic nervous system
increasing arterial Oxygen saturation by clearing stimulation leads to, and is stimulated by, upper chest
secretions from the airways and increasing Ventilation- breathing. Thus, MET by eliminating upper chest
Perfusion matching. Nitz and Burke et al. highlighted breathing and making Diaphragmatic breathing more
the fact that PNF technique increased SpO 2 by effective optimizes breathing pattern of the patient and
improving musculoskeletal mechanics of thoracic accordingly regulates RR and HR more effectively.
region.10
6. Quality of Life: The improvement in Quality of
Since MET and PNF techniques are similar in their Life, as determined by Clinical COPD Questionnaire
principle to stretch and facilitate specific muscles or (CCQ) scoring, depends on three factors: Symptomatic
joints (Voss, Ionta and Meyers,1985) , so we can say relief, improvement in functional state and
that MET can also increase SpO2. On top of it MET improvement in emotional state. In the past era
also corrects Accessory Inspiratory muscle dysfunction Conventional Chest physiotherapy in COPD patients
and respiratory mechanics thus making has successfully improved Quality of life in a long run.
Diaphragmatic breathing more effective. This The present study explains the efficacy of MET in
improves Ventilation especially in lower lobes where providing a better Quality of life by upgrading

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 197

Conventional chest physiotherapy in form of better 5. Dantzker DR, MacIntyre NR, Bakow ED.
symptomatic relief, enhanced functional state and Pathophysiological principles in COPD. In:
improved mental status in these patients. Moreover, Comprehensive respiratory care. Saunders WB
the current study also illustrates the short-term effects 1995; pp: 694.
on Quality of life.15, 16 6. Putt MT, Watson M, Seale H, Paratz JD. Muscle
stretching technique increases vital capacity and
Conflict of Interest Range of motion in patients with COPD. Arch
Thus in the light of the varied results from the Phys Med Rehab. 2008; 89: 1103-7.
current study we suggested that MET is a highly 7. Gosselink R, Troosters T, Decramer M. Exercise
magnificent technique in improving pulmonary testing in COPD patients: the basic questions.
function and in escalating the efficiency of Review. Eur. Respir. J. 1997; 10: 2884-2891.
Conventional chest physiotherapy. Thus it must be 8. Lenehan KL, Fryer G, Mc Laughlin P. The effect
incorporated as a basic part of pulmonary of muscle energy technique on gross trunk Range
rehabilitation programs in COPD patients. of motion. Journal of Osteopathic medicine 2003;
6(1): 13-18.
Conclusion and Future Research 9. Leelarungrabyub D, Pothongsunum P, Yankai A
et al. Acute clinical benefits of chest wall
Thus, from the above discussions we conclude that
stretching exercise on expired tidal volume,
MET of Accessory Inspiratory muscles increases the dyspnea and chest expansion in a patient with
effectiveness of Conventional chest physiotherapy and
COPD: a single case study. J Bodywork Mov Ther
promises better results in context of patient recovery Oct’2009; 13(4): 338-343.
in form of increased chest mobility, reduced 10. Nitz J, Burke B. A study of the facilitation of
breathlessness, increased arterial Oxygen saturation
respiration in Myotonic dystrophy.
levels, improved functional exercise capacity, regulated Physiotherapy Research International 2002; 7(4):
Autonomic functioning and ultimately an improved
228-238.
Quality of life in COPD patients. This also holds a 11. Voss, Ionta and Meyers et al. Effect of a muscle
viewpoint which identifies the role of correction of stretching program using the Global postural Re-
Accessory inspiratory muscle dysfunction associated
education method on respiratory muscle strength
with COPD. The study also describes the short-term and thoraco-abdominal mobility of sedentary
benefits of MET and Conventional chest physiotherapy
young males. J Bras Pneumol 2007; 33(6): 679-686.
on pulmonary function in patients with COPD. 12. Lam Pui LS et al. Exercise testing in COPD
It is recommended in future to conduct studies patients. Hong Kong Resp. medicine updated
with large sample sizes investigating long-term effects August’2010; 23(13).
of MET on pulmonary function. Moreover, effect on 13. Chan D, Chan G, Cheung C et al. Physiotherapy
spirometric variables is recommended for further Practice guidelines for COPD. PTCOC March
studies to provide direct assessment of lung functions. 2000.
14. Gail Dubinsky et al. Effects of respiratory muscle
REFERENCES stretch gymnastics in COPD patients. Showa
Univ J Med Sci. 1996; 8: 63-71.
1. Global initiative for Obstructive Lung Disease 15. Hosking SW. The effect of Osteopathic
(GOLD). Global strategy for the diagnosis, manipulative techniques on diaphragm
prevention and management of COPD. 2010; pp: movement and respiratory function in
225-229. asymptomatic subjects. Unitec Institute of
2. Campbell EJM. The role of Scalene and SCM technology 2009.
muscles in breathing in normal subjects. An EMG 16. Minoguchi H, Shibuya M, Miyagawa T et al.
study. J Anat 1955; 89: 378-386. Cross-over comparison between Respiratory
3. Porth CM. Respiratory function. In: muscle stretch gymnastics and Inspiratory
Pathophysiology: concepts of altered health muscle training. Internal medicine 2002; 41:
states. 6th edition. London: Lippincott Williams 805-812.
& Wilkins, 2002; pp:585-589
4. Gosselink R. Controlled breathing and Dyspnea
in patients with COPD. JRRD 2003. DOI: 10.1682.

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 DOI Number: 10.5958/j.0973-5674.7.3.092
198 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

A Randomized Comparison of effectiveness of Clinical

Exercises and Manual Therapy Procedures Versus Clinical
Exercises alone in the Treatment of Osteoarthritis of Knee

Sapna S Sharma
Lecturer as Physiotherapist, Smt. Kamlaben P. Patel Institute of Physiotherapy and Occupational therapy, APMS, Opp. New
Bus Stand, Anand, Gujrat

ABSTRACT

Aim: This study is designed to compare the effectiveness of clinical exercises and manual therapy
procedures with clinical exercises alone for reducing pain and improving physical function in OA
knee patients. To know particularly the effectiveness of manual therapy procedures for the
management of OA knee patients.

Study design: Experimental study, Randomized Control Trial.

Method: 40 patients of OA knee were recruited into two groups .Experimental Group (n=20) received
Manual Therapy which included passive physiological and accessory movements (Maitland), muscle
stretching and soft tissue mobilization along with clinical exercises as strengthening ,muscle
stretching, range of motion exercises of knee joint and stationary bicycle. Control Group (n=20) received
clinical exercises alone which included strengthening, muscle stretching, range of motion exercises
of knee joint and stationary bicycle with detailed evaluation including WOMAC, ROM and all
parameters of 6-minute walk test were taken as baseline as well as after 4 week of treatment.

Results: Both the groups showed clinically and statistically significant improvement in WOMAC
and 6- minute walk test at 4-weeks .WOMAC scores had improved by 52% in experimental group
and by 41% in control group. Average 6- minute walk had improved about 10% in both the groups.

Conclusion: There was significant improvement in both the groups; however the manual therapy
and clinical exercises group was more effective in reducing pain and improving knee ROM for patients
of Osteoarthritis of knee as compared to clinical exercises group.
Keywords: Knee Osteoarthritis, Manual therapy, Clinical Exercises

INTRODUCTION It was influenced by work involving heavy lifting,

kneeling, climbing stairs or ladders, or kneeling/
Osteoarthritis of the knee joint is a major
squatting combined with heavy lifting.8
musculoskeletal problem in elderly and reported to
be a major health problem worldwide.1, 2 The prevalence of knee OA increases with age
throughout the elderly and obesity 5-7. Females have a
In 2007, Osteoarthritis (OA) was India’s No. 1
higher prevalence and incidence of knee OA. 9 The
ailment3. The overall prevalence of OA in elderly
disability and pain associated with knee OA correlate
population of Union Territory, Chandigarh was 56.6%4
with a loss of quadriceps femoris muscle strength. 10
and in rural areas of Amritsar was 60.6%5.
In 2007, NICE does not advocate the use of electro-
Symptomatic OA is associated with joint
acupuncture , glucosamine and intra-articular
degeneration, chronic pain, muscle atrophy, decreased
hyaluronon injections for treatment of OA.11 Cold packs
mobility, restriction in activities of daily living,
decrease swelling and hot packs are not effective to
decreased quality of life, poor balance and physical
reduce oedema in patients with knee OA. 12
disability.6, 7

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 199

Well-designed studies show that modalities like 2. Any knee deformity such as genu varus, genu
laser and transcutaneous electrical nerve stimulation valgus or fixed flexion at knee.
(TENS) decrease the pain associated with OA.13
3. Subjects could not attend required number of
Benefits have been reported with manual therapy visits.
techniques used in combination with joint mobility and 4. Subjects with knee pain duration more than 1 year.
strengthening exercises 14,15 .Falconer et al found
improvements in motion, pain, and gait speed after 12 Instrument for Data Collection
treatments of stretching, strengthening and mobility
exercises combined with manual therapy procedures 1. WOMAC questionarrie
over 4 to 6 weeks. A comparison group that received 2. Universal Goniometer
the same exercise and manual therapy interventions
plus therapeutic doses of ultrasound demonstrated no 3. Stop watch
additional improvement.15 4. Measure tape
Deyle et al found twice the improvements of 5. Resistant band
physical function and reduction of pain in the clinic 6. Weighing machine
treatment group compared to home exercise group
over 4 week period, the clinic treatment group received 7. Red ink
supervised exercise, manual therapy and home 8. Paper sheet for foot print
exercise program. Subjects in the home exercise group
received the same home exercise program. A After meeting suitable criteria, the written informed
comparison group that received the home exercises consent, baseline parameters had been measured
demonstrated no additional improvement. 16 before allocating them into two groups.

There is no sufficient data available to check

OUTCOME MEASURES
effectiveness of clinical exercises and manual therapy
procedures with clinical exercises alone in the Primary outcome measure
treatment of OA knee. So, there was need to study it
Western Ontario and McMaster Universities
MATERIAL AND METHODOLOGY (WOMAC) Osteoarthritis Index. (includes 24 questions
to measure patient’s pain, stiffness and physical
Universe: OA knee patients coming to department of function)
College of Physiotherapy, Anand.
There are 3 sub division of WOMAC index:
Type of Study: Experimental study
a) Pain consists of 5 questions
Sampling Technique: Simple random sampling b) Stiffness consists of 2 questions
technique.
c) Physical function consists of 17 questions
Sample Size: 40.
Each question was answered and grading done as
20 subjects in each group given below
The experimental procedure was ethically revised 0- none 1-mild 2-moderate 3-extreme 4- severe
and approved by the Research and Ethical committee
of College of Physiotherapy. Secondary outcome measure

Inclusion Criteria 1) 6 minute walk test (to measure functional exercise

capacity).
1. Subjects with age group between 40-70 years were
included. - distance measured in metres
2. Both the genders were included. - walking velocity measured in metres/second

3. Subjects with duration of knee pain more than 1 - cadence

month and less than 1 year. - step length measured in centimeters
Exclusion Criteria - stride length measured in centimeters
1. Subjects with any recent surgery at knee joint, any 2) Range of motion of knee joint measured using
intra –articular injections or medications. goniometer.

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 200 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

METHODOLOGY Grade III: Large amplitude movement performed

into resistance or up to the limit of the range..Grade
Baseline data includes demographics (age in years, IV: Small - amplitude movement performed well into
height in meter, weight in kg, BMI in kg/m2, resistance.
occupation, address), history of present & past problem
,posture, knee ROM, knee muscle power, reflexes, For Tibiofemoral joint
sensations, WOMAC,6 minute walk test were taken. • Subjects with active loss of knee flexion .
i. Knee flexion with abduction
ii. Knee flexion with adduction
iii. Anteroposterior movement
iv. Medial rotation
• Subjects with loss of active knee extension.
a) Knee extension with abduction
b) Knee extension with adduction
c) Knee Extension
d) Posteroanterior movement
Repetition: 2-6 bouts of 30 sec per manual technique

Fig. 1. Flow chart describing the progress of subjects through the

trial.

PROCEDURE

Subjects were randomisly divided into 2 equal

groups:

Group 1: EXPERIMENTAL GROUP received

Manual Therapy 16 which includes passive
physiological and accessory movements (Maitland) 17,
muscle stretching and soft tissue mobilization along
with clinical exercises 16 as strengthening, muscle
stretching and range of motion (mobilization) exercises
of knee joint and stationary bicycle.
Fig. 2: Tibiofemoral flexion
Group 2: CONTROL GROUP received clinical
exercises 16 alone which include strengthening, muscle
stretching, range of motion (mobilization) exercises of
knee joint and stationary bicycle.

On day 1, pre-test measurements were taken for

both the groups which include WOMAC, Range of
Motion and 6-minute walk test. Then exercise regime
was started for both the groups. At the end of the 4th
week, post test measurements were taken for both the
groups as similar to the pre-test measurements.

GROUP 1: Experimental Group

1) Manual Therapy

A) Passive physiological and accessory movements

Fig. 3: Tibiofemoral anteroposterior with abduction
(Maitland) movement, Grade IV.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 201

For Patellar femoral articulation B) Muscle stretching:

• Subjects with loss of patellar glides. - Assessment was done to check muscle tightness
of quadriceps femoris, hamstring, gastrocnemius,
I. Transverse movements medially adductors, iliopsoas, tensor fascia latae and
iliotibial band.
II. Transverse movements laterally
- Method: sustained manual stretch at end length
of muscle
III. Longitudinal movement caudad
- Duration: 12-30 second
IV. Longitudinal movement cephalad
- Repetition: 1-3 times per muscle.
Repetition: 2-6 bouts of 30 sec per manual technique
C) Soft Tissue Mobilization
- Assessment for soft tissue tightness was done in
suprapatellar and peripatellar regions, medial and
lateral joint capsule and popliteal fossa.
- Method: circular fingertip and palm pressure
mobilization at the depth of the capsule or
retinaculum
- Repetition: 1-3 bouts of 30 second per area.
2) Clinical Exercises
It includes
i. Stretching exercises
ii. Range of motion exercises
iii. Strengthening exercises
Fig. 4. Patellar femoral articulation: Longitudinal movement
caudad
iv. Stationary bicycle

Table 1: Stretching Exercises

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 202 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Table 2: Range of Motion Exercises

Table 3: Strengthening Exercises

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 203

GROUP 2: CONTROL GROUP value of experimental group is significantly higher

than control group.
The subjects received the clinical exercises alone as
treatment regime: For knee extension ROM,

Stretching exercises shown above in table 1 Number of subjects having restricted extension
ranges were 13 (32.5%) out of 40.
Range of motion exercises shown above in table 2
Due to less observation, stastical test is not applied
Strengthening exercises shown above in table 3 for knee extension. There is improvement of knee
Stationary bicycle extension ROM in affected subjects involving both
bilateral and unilateral sides .
All exercises were progressed only if the symptoms
Table 6: 6. minute walk test for distance, cadence ,
and signs of OA were decreasing.
walking velocity, step and stride length for bilateral
(right and left) sides and unilateral (affected) side
All above clinical exercises were given as home
between the two groups.
exercise program twice a day in both groups.
Unpaired t-test
DATA ANALYSIS 6-minute walk test ‘t’ calculated value P- value
Step length
To find out homogeneity of two groups for all the bilateral(right side) 2.199 0.041
parameters at baseline and to compare the outcome Bilateral(left side) 2.201 0.041
measurement data between two groups, we have used Unilateral(affected side) 2.280 0.035
unpaired ’ t’ test. Stride length
Bilateral(right side) 2.160 0.044
In present study, P- value is used to test two tailed
Bilateral(left side) 2.226 0.039
hypothesis at 5% level of significance. i.e if P-value is
Unilateral(affected side) 2.203 0.041
less than0.05, the difference is significant otherwise not.
Statistical software SPSS had been used. P < 0.05 .There is significant difference for all
parameters of 6-minute walk test i.e. Mean of all
Table 4: WOMAC scale between both the groups.
parameters value in 6-minute walk test of
Unpaired t-test experimental group is significantly higher than control
WOMAC ‘t’ calculated value P- value group.
Pain subscale 2.161 0.037
Stiffness subscale 2.884 0.006 RESULTS
Physical Function 2.178 0.003
subscale Results obtained from the study after 4-week
Total 3.538 0.001 intervention program showed that :
P < 0.05 .There is significant difference between the There was significant reduction in WOMAC pain,
groups for all subscale and total WOMAC score. i.e stiffness and physical function subscale and total score
Mean WOMAC score of experimental group shows between the groups (experimental and control) , knee
significantly higher reduction than control group. flexion ROM for bilaterally and unilaterally affected
side and also in 6 –minute walk test for distance,
Table 5: Knee flexion ROM for bilateral (right and
cadence , walking velocity, step and stride length of
left) sides and unilateral (affected) side between both
the groups both bilateral and unilateral affected side.

Unpaired t-test However, the experimental group showed

Knee ROM flexion ‘t’ calculated value P-value significantly higher reduction compared with control
Bilateral (right side) 2.458 0.024 group after intervention between the groups.
Bilateral (left side) 2.630 0.017
Unilateral (affected side) 2.370 0.029 CONCLUSION

P < 0.05 .There is significant difference for bilateral Results of the study concluded that there was
(right and left) sides and unilaterally (affected) knee significant improvement in both the groups; however
flexion ROM between the groups. i.e. Mean flexion the manual therapy and clinical exercises group was

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 204 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

more effective in reducing pain and improving knee stairs or ladders, or kneeling/squatting combined
ROM for patients of Osteoarthritis of knee as compared with heavy lifting. Occupational and
to clinical exercises group. Environmental Medicine 2008;65:72-89
9. Lawrence RC,et al.Estimates of the prevalence of
ACKNOWLEDGEMENTS arthritis and selected muscluskeletal disorders in
united states .Arthritis Rheum .1998:41(5):778-99
There are no words to gratitude sufficient enough 10. Fitzgerald GK, et al. Quadriceps activation failure
to thank my honorable Prof. C.G. Padole, Dr.Setu as a moderator of the relationship between
Sharma, Dr.K.Vaittianadane for his help, direction, quadriceps strength and physical function in
supports and encouragement for my work. individuals with knee osteoarthritis. Arthritis
Rheum.2004; 51:40–48.
REFERENCES 11. NICE Clinical Guideline. The care and
1. Corti MC, Rigon C. Epidemiology of management of osteoarthritis in adults.
osteoarthritis: prevalence, risk factors, and Osteoarthritis: Jan 2008
functional impact. Aging Clin Exp Res.2003; 12. Brosseau L, et al. Thermotherapy for treatment
15:359–363. of osteoarthritis. Cochrane Database Syst
2. De Filippis L, et al. Epidemiology and risk factors Rev.2003; (4):
in osteoarthritis: literature review data from 13. Gro Jamtvedt et al. Physical Therapy
“OASIS” study [in Italian]. Reumatismo.2004; Interventions for Patients with Osteoarthritis of
56:169–184. the Knee: An Overview of Systematic Reviews.
3. Times of India newspaper. 6th sept. ,2007 Phys Ther. 2008 :88, 1; 123-136
4. MK Sharma, HM Swami, et al. An 14. Nancy E. Henderson ,et al. Effectiveness of
Epidemiological Study of Correlates of Osteo- manual physical therapy and exercise in
Arthritis in Geriatric Population of UT osteoarthritis of the knee: a randomized,
Chandigarh. Indian Journal of Community controlled trial. Ann Intern Med.2000; 132:
Medicine.2007; 32. 173–181.
5. Padda AS,et al. Health profile of the aged persons 15. Falconer J,et al. Effect of ultrasound on mobility
in urban and rural field practice areas of Medical in osteoarthritis of the knee: a randomized clinical
College, Amritsar. Indian J of Community trial. Arthritis Care Res.1992; 5:29–35.
Medicine 1998; 23:72-76. 16. G D Deyle,et al. Physical Therapy Treatment
6. Nutrition Research Newsletter. Knee Effectiveness for Osteoarthritis of the Knee: A
osteoarthritis; exercise capacity and quality of life Randomized Comparison of Supervised Clinical
in obese individuals.2007 Exercise and Manual Therapy Procedures versus
7. Robert F. Zoeller et al, Physical Activity: Physical a Home Exercise Program. Physical
Activity in the Management of Osteoarthritis of Therapy,2005: 85
the Knee and Hip, American Journal of Lifestyle 17. Maitland GD. Peripheral Manipulation. Boston,
Medicine,2007 ;Vol. 1: 4, 264-266 Mass: Butterworth Heinemann; 1991:1–128,
8. L K Jensen et al. Knee osteoarthritis: influence of 221–289.
work involving heavy lifting, kneeling, climbing

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 DOI Number: 10.5958/j.0973-5674.7.3.093
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 205

Comparing the effects of Manipulation of Wrist and

Ultrasound, Friction Massage and Exercises on Lateral
Epicondylitis: A Randomized Clinical Study

Sharvari Joshi1, Santosh Metgud2, Ebnezer C3

1
Student, Professor, KLE Institute of Physiotherapy, 3HOD, Metas of Seventh Day Adventist College of
2

Physiotherapy, Surat, Gujrat

ABSTRACT

Background and Purpose: Lateral epicondylitis ("tennis elbow") is a common entity. Several
nonoperative interventions, with varying success rates, have been described. The aim of this study
was to compare the effectiveness of 2 protocols for the management of lateral epicondylitis: (1)
manipulation of the wrist and (2) ultrasound, friction massage, and muscle stretching and
strengthening exercises.

Design: A Randomized Clinical Study.

Subjects and Method: Ten subjects with a history and examination results consistent with lateral
epicondylitis participated in the study. The subjects were randomly assigned to either a group that
received manipulation of the wrist (group 1) or a group that received ultrasound, friction massage,
and muscle stretching and strengthening exercises (group 2). Follow-up was at 3 weeks. The primary
outcome measure was a global measure of improvement, as assessed on a 10-point scale. Analysis
was performed using independent t tests, Mann-Whitney U tests, and Fisher exact tests.

Results: Differences were found for 2 outcome measures: success rate and decrease in pain at 3
week. Both findings indicated manipulation was more effective than the other protocol. After 3 weeks
of intervention, the success rate in group 1 was 62%, as compared with 20% in group 2. Also,
improvement in pain as measured on a 10-point numeric scale was 5.2 (+ 2.4) in group 1, as compared
with 3.2 (+ 2.1) in group 2.

Conclusion: Manipulation of the wrist appeared to be more effective than ultrasound, friction massage,
and muscle stretching and strengthening exercises for the management of lateral epicondylitis when
there was a short-term follow-up.
Keywords: Tennis Elbow, Manipulation, Ultrasound, Stretching

INTRODUCTION Manipulation has frequently been used

successfully for management of back and neck
Lateral epicondylitis is characterized as pain on the
complaints (4, 5) and is thought to, (1) free motion
lateral side of the elbow that is aggravated with
segments that have undergone disproportionate
movements of the wrist, by palpation of the lateral side
displacement or are felt to be hypomobile and (2) cause
of the elbow or by contraction of the extensor muscles
muscle relaxation (6, 7). These mechanisms are thought
of the wrist (1).It is a self limiting complaint and the
to be associated with distribution of abnormal stresses
symptoms will resolve within 8-12 months even
within the joint, resulting in pain, restriction of motion,
without intervention (2, 3).
and potential inflammation. Manipulation of the wrist
The basic anatomical cause is sudden and often also has been described previously, however its
repeated use of the forearm extensor muscles, which effectiveness for management of lateral epicondylitis
previously had not been much used. has not been demonstrated. The aim of this study was

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 206 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

to compare the effectiveness of manipulation of the 2. Visual Analogue Scale (VAS) for pain.
wrist with the effectiveness of an intervention
Where
consisting of friction massage, ultrasound and muscle
stretching and strengthening exercises for the 0 - No pain
management of lateral epicondylitis.
5 - Minimum pain with tolerance
Deep transverse friction massage is a specific type
10 - Maximum pain without tolerance
of connective tissue massage developed by Cyriax. It
is applied with the fingers and transverse to the muscle 3. Goniometer (for ROM).
fiber direction. It is vital that transverse massage be
performed only at the site of the lesion. The effect is so Intervention tools
local that unless, the finger is applied to the exact site 1. Dumbells.
and friction given in the right direction, relief cannot
be expected. 2. Elastic resistance bands (therabands).

3. Rubber bands.
Ultrasound increases blood flow and oxygen to the
affected area by raising the temperature of the muscles. 4. Soft ball.
Clinical studies show it has limited effectiveness in
reducing the disability caused by tennis elbow. PROCEDURE
However, when ultrasound is combined with physical
therapy such as massage and strengthening and Group 1: Subjects in this group were treated 2 times
stretching exercises, its effectiveness increases. per week, with a maximum of 5 intervention sessions
over the 3 weeks period of the study. All intervention
METHOD AND MATERIALS sessions were conducted by the same physical
therapist, experienced in this manipulative procedure.
Method As soon as the symptoms resolved the maneuver was
stopped. The manipulative procedure was a thrust
The present study was conducted in a
technique and was done as follows. Each subject rested
physiotherapy department during the time period
the forearm of his/her affected side on a table with
from January 2010 to July 2010 on 10 patients
the palmar side of the hand facing down towards the
diagnosed with lateral epicondylitis by the physician.
floor. The therapist sat at right angle to the subject’s
The study design used for the study was randomized
affected side and gripped the subject’s scaphoid bone
controlled trial and the sampling design used was non
between the thumb and index finger. The therapist then
probability convenient sampling.
placed the thumb and index finger of the other hand
Inclusion Criteria on the top of them. The therapist then extended the
subject’s wrist dorsally and at the same time the
Lateral epicondylitis with complains being present scaphoid was manipulated ventrally. This part of the
for at least 6 weeks and no longer than 6 months. maneuver was repeated approximately 10 times,
alternated by either forced passive extension of the
Exclusion Criteria
wrist or extension against the resistance. The duration
1) No limitation in range of motion. of a treatment session was 15-20 minutes. This
maneuver was done according to maneuver described
2) Bilateral complains. by Lewit (9).
3) A definite decrease in pain for the last 2 weeks as Group 2: Subjects in this group were using a
described by the patient. protocol that was previously used for lateral
epicondylitis (12). During the 3 weeks intervention
- Severe neck or shoulder problems likely to cause
period, the subjects underwent a total of 5 intervention
or maintain the elbow complaints.
sessions. Every session included a 7 minutes pulsed
ultrasound treatment around the lateral humeral
MATERIALS
epicondyl, at an intensity of 2 W/cm2 (10). In addition,
Measurement tools subjects were treated with friction massage for
approximately 10 minutes by the physical therapist.
1. Hand dynamometer

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 207

Position of the patient: Statistical Analysis

- Patient sits with elbow 90 degrees flexed with arm Table 1: Baseline Values
supported on a table Characteristics Group 1 Group 2
No. of subjects 5 5
- Massage across the muscle fibers in a
Pain at the moment 4.0 5.4
Counterclockwise direction. SD 2.7 2.8
MEAN 2-8 2-8
- Do not use any oils, creams or lotions for massage.
Pain during the day 5.5 5.5
- Pain tolerance should be 6 out of 10 for this. SD 1.5 1.4
MEAN 6-8 6-8
- This maneuver can be done everyday for 10 - 20 Inconvenience 6 7.5
minutes. SD 2.4 1.4
MEAN 3-10 3-10
When pain subsided, subjects were instructed in Pain Free Grip Force (PFGF) (Kg) 20.7 14.9
muscle stretching and strengthening exercises by the SD 10.7 11.0
physical therapist and were instructed to perform MEAN 3.6-39 3.5-38.6
those exercises twice daily at home (11). These exercises Maximum Grip Force (MGF) (Kg) 33 29
consisted of movements against resistance, rotational SD 13.7 14.4
exercises and occupational exercises. These exercises MEAN 5.8-53.6 2.0-50.2
were intensified in four steps, with increasing
(The measurements were taken using a 10 point
resistance. Subjects were allowed one step up if all
scale, with 0-10 values on it. SD - Standard Deviation)
exercises could be performed without pain. Subjects
were instructed to use the affected elbow to the pain
threshold. When pain had resolved the intervention
was stopped.

Stretching exercises:

- Elbow is extended and the arm is straight.

- Keeping the arm straight increase the range of

stretch.

- Hold each stretch for 10 seconds and repeat it 2-3

times.
Graph 1: Shows the difference in the outcome measures of pain
and inconvenience after 3 weeks of treatment with the 2
- Stretch only to the point of comfortable motion. interventions.

Strengthening exercises:

- Movements like wrist flexion, extension, ulnar

deviation, radial deviation, forearm supination,
pronation, elbow flexion, elbow extension and
finger extension are performed using dumbells,
elastic resistance bands, rubber bands and other
strengthening devices.

- Gradually increase the amount of work that you

are doing. Begin with a very light weight. Begin
with performing 10 movements in a row. Repeat
this sequence 3 times, do 3 sets of 10 repetitions. Graph 2: Shows the difference in the outcome measures of grip
strength between the 2 groups after 3 weeks of treatment.

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 208 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Table 2: Outcome Measures: (After 3 Weeks Treatment) corticosteroid injections with non-steroidal anti-
Characteristics Group 1 Group 2 inflammatory drugs, the initial advantage of injections
No. of subjects 5 5 subsided at long-term follow-up.
Pain at the moment 1 1.5
Also, the manipulation of the wrist has to be done
Pain during the day 2.5 1.7
by an experienced manual therapist, to have its exact
Inconvenience 3.5 2.3
effects. Thus, this technique should not be performed
PFGF (kg) 5.8 3.7
by a less experienced manual therapist, so that any
MGF (kg) 1.8 0.5
adverse effects of the manipulation can be avoided.
(All values except PFGF and MGF are taken out of
10 on a 0-10 scale) Despite its broad application, the mechanism by
which manipulation may work is poorly understood.
Data were analyzed using SPSS version 10.0. Manual therapy is used quite often for the spine and
Differences in continuous outcome measures were peripheral joints, despite of the inability of clinicians
compared using independent t tests in case of normal to accurately diagnose the pathway at which a
distribution. Distribution was normal in severity of the manipulation is targeted. In people with low back pain
patients’ main complaint (pain during the examination and neck pain, spinal manipulation is thought to free
and pain during the day). In case the distribution was motion segments that have undergone
not normal, the Mann-Whitney U test was applied. disproportionate displacements and to relax muscles
This was the case in inconvenience during daily by sudden stretching.(14-16). Unwanted muscle activity
activities, pain-free grip force, and maximum grip in people with low back pain, in theory, can cause a
force. limited range of motion to protect against sudden
movements. Pain in these individuals often can be
RESULTS elicited by palpation on the insertion of these
The initial baseline measurements were similar paravertebral muscles 17. Thus our study was to find
between the 2 groups. After 3 weeks of intervention, out the effects of similar type of manipulation on pain
our primary outcome measurements differed between in lateral epicondylitis.
2 groups, indicating that manipulation was more
Another drawback of this study is that, there is very
effective than the other intervention used in the study.
less literature supporting the effects of manipulation
Moreover the decrease in Visual Analogue Scale (VAS)
of the wrist as a treatment of lateral epicondylitis. Thus,
scores for the main complaint, pain at the moment,
there is no strong evidence to prove that manipulation
pain during the day and inconvenience also differed
between the 2 groups. of wrist helps treat the symptoms of tennis elbow.
There is an ample of literature showing the effects of
DISCUSSION ultrasound, friction massage and exercises on lateral
epicondylitis.(11, 12).
The study was conducted to compare the effects of
manipulation of the wrist with the most commonly The advantages of the manipulation of the wrist
used interventions like ultrasound, friction massage are the potential effectiveness over the short term and
and stretching and strengthening exercises, for lateral the ability for the patient to maintain his or her daily
epicondylitis. Considering the outcome measures of activities without restrictions. In addition,
pain and inconvenience, differences were noted in the manipulation might be more cost-effective due to a
2 groups. The results showed that, manipulation of reduction in the number of treatments needed.
wrist was more effective than the other interventions. Considering the relatively high prevalence of the
injury, this cost-effectiveness might lead to a major cost
One drawback of the study was that, only short reduction for payers.
term effects were considered. Long term effects were
not considered, because patients did not turn up for LIMITATIONS
follow up and the patients expected a faster recovery,
which was achieved with manipulation of the wrist. 1. Sample size was small.
With ultrasound, friction massage and stretching and
strengthening exercises the recovery time would be 2. No follow up to see long term effects of wrist
prolonged. In a recent study by Hay et al (13) comparing manipulation.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 209

CONCLUSION 8. Triano JJ. Studies on the biomechanical effect of

a spinal adjustment. J Manipulative Physiol Ther.
Manipulation of the wrist is more effective than
1992;15:71–75.
ultrasound, friction massage and stretching and
9. Wilder DG, Pope MH, Frymoyer JW. The
strengthening exercises for lateral epicondylitis, when
biomechanics of lumbar disc herniation and the
short term effects are considered. However, more study
effect of overload and instability. J Spinal Disord.
is required to be done to further prove the effectiveness
1988;1:16–32.
of manipulation of wrist on lateral epicondylitis
10. Lewit K. Manuelle Medizin: Im Rahmen der
symptoms and also the long term effects must be
Medizinischen Rehabilitation. Leipzig, Germany:
considered.
Auflage Johan Ambrosius Barth; 1977.
11. Binder A, Hodge G, Greenwood AM, et al. Is
REFERENCES therapeutic ultrasound effective in treating soft
1. Friedlander HL, Reid RL, Cape RF. Tennis elbow. tissue lesions? BMJ (Clin Res
Clin Orthop. 1967;51:109–116. Ed).1985;290(6467):512–514.
2. Hamilton PG. The prevalence of humeral 12. Pienimaki TT, Tarvainen TK, Siira PT, Vanharanta
epicondylitis: a survey in general practice. J R Coll H. Progressive strengthening and stretching
Gen Pract. 1986;36(291):464–465. exercises and ultrasound for chronic lateral
3. Bailey RA, Brock BH. Hydrocortisone in tennis epicondylitis. Physiotherapy. 1996;82:522–530.
elbow: a controlled series. J R Soc Med. 1957; 13. Hay EM, Paterson SM, Lewis M, et al. Pragmatic
50:389–390. randomized controlled trial of local corticosteroid
4. Cyriax JH. The pathology and treatment of tennis injection and naproxen for treatment of lateral
elbow. J Bone Joint Surg Am. 1936; 4:921–940. epicondylitis of elbow in primary care. BMJ. 1999;
5. Koes BW, Assendelft WJ, van der Heijden GJ, et 319 (7215) : 964–968.
al. Spinal manipulation and mobilisation for back 14. Solveborn SA. Radial epicondylalgia (“tennis
and neck pain: a blinded review. BMJ. 1991; 303 elbow”) – treatment with stretching or forearm
(6813) : 1298–1303. band: a prospective study with long-term follow-
6. Shekelle PG, Adams AH, Chassin MR, et al. up including range-of-motion measurements.
Spinal manipulation for low-back pain. Ann Scand J Med Sci Sports. 1997;7:229–37.
Intern Med. 1992;117:590–598. 15. Koes BW, Bouter LM, van Mameren H, et al.
7. Cooperstein R, Perle SM, Gatterman MI, et al. Randomised clinical trial of manipulative therapy
Chiropractic technique procedures for specific and physiotherapy for persistent back and neck
low back conditions: characterizing the literature. complaints: results of one year follow up. BMJ.
J Manipulative Physiol Ther. 2001;24:407–424. 1992; 304 : 601–605.

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 DOI Number: 10.5958/j.0973-5674.7.3.094
210 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

The effect of Tra Training alone and in Combination with

Pelvic Floor Muscle Training in Women with Stress
Urinary Incontinence

Chandan Kaur Khandpur1, Shipra Bhatia2

1 2
PT, MPT, Assistant Professor, Amity Institute of Physiotherapy, Amity University,
K- Block, Sector-44, Noida

ABSTRACT

Objective: To study the effect of TrA training alone and in combination with PFM training in women
with stress urinary incontinence.

Methodology: 45 female patients with mean age of 39.31±4.6 years, having stress urinary incontinence
were selected and divided into three groups. Group A was given TrA training alone, group B was
given "knack" advice, and group C was given TrA training in combination with PFM exercises for
two consecutive weeks. The outcome measures were VAS score, TrA strength, pad weight and number
of leaks and data was collected on Day 0, 7 and 14 of treatment.

Results: TrA training was found to be more effective than control in treating women with stress
urinary incontinence. There was no statistically significant difference between the effects of TrA training
alone and TrA training in combination with the PFM training. Both the trainings were found to be
better than the control group.

Conclusion: TrA training alone & in combination with PFM training produces significant results in
women with stress urinary incontinence. Therefore, both the exercises can be utilized as a treatment
option in patients with stress urinary incontinence.
Keywords: Stress Urinary Incontinence, Pelvic Floor Muscles, Transversus Abdominis

INTRODUCTION abdominal pressure is increased by contraction of the

abdominal muscles5. The timing of the PFM activity is
The international continence society defines Stress
critical in maintaining continence during straining
Urinary Incontinence (SUI) as the complaint of any
activities. In normal cases with straining activities like
involuntary leakage of urine that occurs with physical
coughing, urethral pressure increases before the
exertion and a rise in abdominal pressure1. Postnatal
increase in bladder pressure by 200 to 250ms5. This
stress urinary incontinence is an important social and
early increase of urethral pressure does not occur in
health problem affecting between 3% and 24% of adult
most women with stress incontinence.
women2. In an Indian study, it was found that only
8.6% women have heard about PFM exercises and 72% It is believed that anticipatory activity of PFM
had UI for more than 1yr3. Still, the consultation rate contraction cannot be a reflex response to afferent input
for UI was low in the north Indian women4. from muscle stretch as a result of increased intra-
abdominal pressure, because it precedes such an
PFM have been suggested in the initial conservative
increase in abdominal pressure. Rather, it is considered
management of SUI because the levator ani muscle
to be pre-programmed by the central nervous system
contributes to continence by providing support to
in preparation for the increase in intra-abdominal
pelvic organs, by increase in urethral closure pressure
pressure to maintain continence. Thus, the timely
and by elevating the bladder neck PFM enhance
contraction of PFM is the key to preventing leakage of
urethral enclosure 1,13 . Activation of the PFMs is
urine in SUI5.
essential in maintaining continence when intra-

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 211

Recently, in 2009, a theoretical model involving METHODOLOGY

training of deep abdominal muscles in particularly
Inclusion Crieteria
TrA, to initiate tonic PFM activity has been introduced6.
This approach was based on the understanding that 1) Females aged 30-45yrs
synergistic activity of the PFM and TrA occurs in
2) Subjects with symptomatic urinary incontinence
normal trunk activity6 and hence, can be utilized to
as diagnosed by a gynaecologist.
activate PFM contraction in patients with SUI.
3) Continuous symptoms of incontinence present at
Sapsford advocates the use of the independent TrA least once per week for 3 months or more9
contraction to gain PFM co-contraction as the
foundation of PFM rehabilitation for urinary 4) Multiparous women
incontinence7. He suggests that, TrA contraction is 5) Pregnancy > 1yr back
supposed to facilitate more tonic PFM activity in
patients with SUI and helps in counteracting gravity 6) Patients showing positive pad test (more than
and intra-abdominal pressure. He found that similar 2gm)6
increase in urethral pressure occurs with instructions Exclusion Crieteria1
to contract either the PFM or TrA separately8. It has
also been proved that contraction of the TrA instead 1) Any prior treatment taken for urinary incontinence
of PFM is useful as many women are not able to (collagen injection, vaginal cones etc.)
contract PFM and, therefore, contraction of TrA is one 2) Pacemaker fixation
way of activating the PFM6.
3) Using intrauterine device
Thompson and O’Sullivan found that during PFM
contraction, all the abdominal muscles were more 4) Having medical history of vaginal cancer
active than the PFM in symptomatic women with 5) Severe endometrium, neurologic or metabolic
mixed incontinence compared to asymptomatic disorders likely to impair bladder function
women, and that the incontinent group increased the
intra-abdominal pressure more than the continent 6) vaginal prolapse
group during PFM contraction9.Also, Smith et al using 7) Any neurological impairments
EMG compared co-contraction activity of the TrA and
PFM contractions in those with and without continence 8) Pelvic inflammatory disease
showed that there was an alteration in the balance
between PFM and TrA contractions in women with PROCEDURE
UI, with severely incontinent women using more TrA 45 Subjects fulfilling the inclusion criteria were
and less PFM actively during a postural task3. Hence, taken from different hospitals in NCR region and
based on these studies which show that a co- Chandigarh. They signed a consent form and were
contraction of PFM occurs with TrA contraction in assessed & randomly allocated using chit method to
healthy women, it is recommended that all females one of the following three groups:
with urinary incontinence be trained with TrA
Group A: TrA training group (TrA)
contraction.
Group B: Control group
There is limited literature available evaluating
whether TrA alone can treat or improve SUI and Group C: Pelvic floor exercises and TrA training group
studying the effect of combining PFM & TrA together
Each subject was given treatment for 2 weeks. A
in patients with SUI. Therefore, the primary aim of
baseline measure was taken before starting the
the study was to find out the effect of TrA training alone
treatment. Patients were asked to maintain a
in patients with SUI & the secondary aim was to study frequency-volume chart for each day and the data was
the effect of combining TrA & PFM training in patients collected on Day 0, Day 7 and Day 14.
with stress urinary incontinence.

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 212 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

1) Group A: TrA strengthening exercises other end ‘always wet’18.

Patient was made to lie supine on couch and a 4) TrA strength: was measured using the
sphygmomanometer pressure cuff was placed under sphygmomanometer cuff reading.
their lumbar spine and mercury was raised to 40mm
Hg and patient was asked to maintain this pressure RESULTS
by giving her the command “tuck your tummy in”
and patient was made to see the mercury level all the One way repeated measures ANOVA was used to
time throughout the exercise protocol. While doing statistically analyse the data for between group
exercises the initial range of mercury was maintained differences and significant improvement was seen in
as per patient’s strength and the patient was asked to VAS score, Pad test, TrA strength & no. of leaks on
maintain the same level throughout10. Day 14 at p<0.05. Also, paired t-test showed significant
improvement within groups A & C in all the outcome
Three types of TrA strengthening exercises were measures, however, no difference was found in group
given for a period of 2 weeks with 10 repetitions each B. No statistically significant difference was found
in one set. The command was given to “tuck your between group A & C.
tummy in” while performing the exercises:
TABLE 1: Baseline Characteristics
11
a) Leg lift in supine Groups Age (In years)Mean+S.D. Number of
PregnanciesMean±S.D.
12,14
b) Leg lift in prone
Group A: TrA 38.93±5.09 2.33±1.11
c) Curl ups from supine 15
Group B: control group 40.47±5.58 2.6±1.35
2) Group B: Control group Group C: TrA+PFM 38.53±2.72 2.13±0.51

Subjects in this group were given only “knack” TABLE 2: Effect on VAS score:
advice to contract her pelvis before any of the events Groups VAS Day 0Mean±S.D. VAS Day 7Mean±S.D.
e.g. Coughing, sneezing, laughing, nose blowing, VAS Day 14Mean±S.D. Intra Group P-Value
lifting, running or jumping or a strong desire to void.
Group A TrA 4.33±1.63 2.80±1.26 1.40±0.82 0.00*
3) Group C: Pelvic floor plus TrA training group Group B control 4.07±1.16 4.00±1.25 3.93±1.16 0.164

TrA strengthening exercises along with PFM Group C: TrA+PFM 4.60±1.40 2.93±1.33 1.33±0.97
0.00*
exercises. Subjects while lying supine on bed were told
to contract their PFMs by giving the command “try to Inter Group P-Value F-ratio=111.13 P<0.05*
stop passing urine”. The subjects were asked to hold
A significant improvement was seen in VAS score on Day 14 at
each contraction for 6-8 seconds and to complete 3or 4 p<0.05. Also, paired t-test showed significant improvement within
additional quick contractions at the end of 6-8seconds. groups A & C.
The subjects performed 3 sets of 10 contractions twice
daily for two weeks 17.
TABLE 3: Effect on pad weight (in grams)

OUTCOME MEASURES Groups Day 0 Mean±S.D. Day 7 Mean±S.D. Day 14

Mean±S.D. Intra Group P-Value
1) Pad test: Patient was provided with pre-weighed
Group A TrA 12.93±1.03 11.60±0.83
pads and were asked to wear continuously for 10.47±0.51 0.00*
24hrs and were put in plastic bag and returned on
respective days to be weighed18. Group B control 12.67±1.49 12.67±1.49
12.67±1.49 No change found
2) Number of leaks: Patient was given a frequency- GroupC:TrA+PFM 13.87±1.24 12.47±0.99
volume chart and was asked to record the number 10.60±0.63 0.00*
of leaks in last 24 hours on it 18. Inter Group P-Value F-ratio =102.52 p<0.05*

3) Visual analogue scale: The patient was asked to The results showed significant decrease in Pad
put appropriate score at the point on a 10cm line, weight on Day 14 at p<0.05. Also, significant
starting marked with “no problem’, and at the improvement was found within groups A & C,

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 213

however, no difference was found in group B. No outcome measures than the control group. This could
statistically significant difference was found between be attributed to a theoretical model involving training
group A & C. of deep abdominal muscles in particularly TrA, to
initiate tonic PFM activity16. There is an automatic
response of PFM to a TrA manoeuvre as indicated by
cranio-ventral displacement of the ano-rectal angle19.
In another study done by Madill SJ et al, it was found
that during voluntary maximal PFM contractions, TrA
was activated to 224.30%20.

According to Sapsford, with SUI it appears that a

TrA contraction is supposed to facilitate more tonic
PFM activity to counteract gravity and intra-
abdominal pressure. Another reason is that if
maximum or close to maximum PFM contraction is
only possible with abdominal co-contraction19, such
co-contraction must be allowed during training, as
close to maximum contraction is important in building
Fig. 1. Comparison of TrA strength (in mm Hg) between the groups muscle volume and strength. It has also been proposed
that contraction of the TrA instead of PFM is useful as
A significant improvement was seen in TrA strength many women are not able to contract the PFM and,
on Day 14 at p<0.05. However, no statistically therefore, contraction of TrA is one way of activating
significant difference was found between group PFM6.
A & C.
Another important factor in the continence
mechanism is that the PFM should contract
automatically with correct timing and with sufficient
strength to counteract the downward impact on the
pelvic floor from the abdominal muscle contraction.
Hence, a co-contraction of the PFM during abdominal
contraction in continent women is expected and
normal. While there is also some evidence that PFM
contraction occurs during TrA contraction in continent
women, data suggests that this co-contraction is lost
or altered in some women with SUI. Thus, by training
both PFM & TrA together, motor learning occurs,
leading to better timing of the PFM contraction and
TrA contraction and increased perception of
contraction. This corrects the timing of PFM
contraction in patients with SUI. Hence, the co-
contraction of PFM occurs during TrA contraction as
an anticipatory activity & prevents leakage of urine in
Fig. 2. Comparison of Number of Leaks (NOL) between the groups
patients with SUI following pelvic floor rehabilitation
programmes.
A significant improvement was seen in no. of leaks
Study done by Sapsford et al proved that a
on Day 14 at p<0.05. However, no difference was found
in group B. maximum PFM contraction does not seem to be
possible without a co-contraction of the abdominal
DISCUSSION muscles especially the TrA19. Hence, by training both
PFM and TrA better closure of sphincter can be
The results demonstrate that TrA training group achieved in patients with SUI.
showed significantly better improvement on all

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 214 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

The significant improvement seen with both the 5. Ruth R. Sapsford, DipPthy, Paul W. Hodges, PhD.
training programmes in our study are not consistent Contraction of the PFMs during abdominal
with the findings of Dumoulin et al, whose primary maneuvers. APMR; August 2001. Volume: 82;
objective was to assess the effectiveness of PFM in issue 8:1081-1088.
postnatal SUI. Their results have shown no additional 6. Kari Bo, Siv Morkved, Helena Frawley and
benefit of adding abdominal training to PFM training2. Margaret Sherburn. Evidence for Benefit of TrA
However, the present study shows statistically Training Alone or in Combination With PFM
significant results with TrA training. Training to Treat Female Urinary Incontinence:
A Systematic Review. Neurol Urodynam. 2009.
LIMITATIONS & FUTURE SCOPE 7. Bo K, Sherburn M, Allen T. Tranabdominal
ultrasound measurement of PFM activity when
• PFM strength was not taken. activated directly or via a TrA muscle contraction.
• Short-term follow-ups & small sample size. New Zealand J of Physiotherapy. 2004 November.
8. Sapsford RR, Hodges PW, Richardson CA. Co-
• EMG study measuring the activation of PFM and activation of the abdominal and pelvic floor
TrA simultaneously. mucles during voluntary exercises. Neurology
and Urodynamics.2001, 20(1):31-42.
CONCLUSION 9. Thompson J, O Sullivan P. Levator plate
movement during voluntary PFM contraction in
TrA training is more effective than control in
subjects with incontinence and prolapse: A cross-
treating women with urinary incontinence. There was
sectional study and review. Int Urogynecol J
no statistically significant difference between the
Pelvic floor Dysfunct 2003; 14:84-8.
effects of TrA training alone and TrA training in
10. Cheri L. Drysdale, Jennifer E. Earl, and Jay Hertel.
combination with the PFM training, however, both the
Surface Electromyographic Activty of the
exercises were found to be better than the control
Abdominal Muscles during Pelvic-Tilt and
group. Therefore, both the exercises can be utilized as
Abdominal Hollowing.J Athi Train. 2004 Jan-
a treatment option in patients with stress urinary
Mar;39(1):32-36
incontinence.
11. Kaul Rohini, Thakral Gaurav, Sandhu Jaspal
Singh. Omparison of eefects of Specific
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3. Diane F Borello-France, Halina M Zycynski, Extension exercises in Management of Chronic
Patricia A Downey. Effect of PFM Exercise Disc prolapse. IJPOT. 2007; Vol.1: No.3 (07-09).
Position on Continence and Quality-of Life 12. Fontana FE, Bressel E. Effort of surface stability
Outcomes in Women with Stress Urinary on core muscle activity for dynamic resistance
Incontinence.Phys Ther. 2006; 86:974-986. exercises. Int J Sport Physiol Perform. 2009
2. Chantale Dumoulin, Phd, Pt.Physiotherapy for Mar;4(1):97-109.
Persistant Postnatal Stress Urinary Incontinence: 13. Di Benedetto P, Coidessa A, Floris S. Rationale of
A Randomised Control Trial.American College PFMs training in women with urinary
of Obstetricians and Gyneacologists.Vol.104, incontinence. Minerva Ginecol. 2008 Dec;
NO.3, SEPTEMBER 2004. 60(6):529-41.
3. Smith MD, Coppieters MW, Hodges PW. Postural 14. Fabio Renovato Franca, Thomas Nogueira Burke.
response of the pelvic floor and abdominal Segmental stabilization and muscular
muscles in women with and without strengthning in chronic low back pain – a
incontinence. Neurourol Urodyn 2007; 26:377-84. comparative study. Clinics. 2010; 65(10):1013-1017
4. Santosh Kumari, AJ Singh, Vanita Jain. Treatment 15. Willardson JM, Fontana FE, Bressel E. Effort of
seeking behaviour for urinary incontinence surface stability on core muscle activity for
among north Indian women. Indian J of Medical dynamic resistance exercises. Int J Sport Physiol
Sciences.2008: Volume 62; issue: 9; 352-356. Perform. 2009 Mar; 4(1):97-109.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 215

16. Manoj K Poonia, Ginpreet Kaur, Meena 18. Margaret Polden and Jill Mantle. Physiotherapy
Chintamaneni. New insights into molecular in Obstetrics and Gynaecology. P.B. No. 7153.
targets for urinary incontinence. Ind J of 354-358.
Pharmacology. Year 2010; volume: 42, isuue 5: 19. K Bo, Pt, PhD, M Sherburn, PT, M.Evaluation of
261-266. female pelvic-floor muscle function and strength.
17. Kimberley Fisher, Lisa Riolo. Clinical question: Physical therapy Journal. 2005 March
What is the evidence regarding specific methods 20. Madill SJ, McLean L. Relationship between
of pelvic floor exercise for a patient with urinary abdominal and pelvif floor muscle activation and
incontinence and mild anterior vaginal prolapse? intravaginal pressure during PFM contractions
Case Study. Physical therapy.2004 in healthy continent women. Neurourol Urodyn.
August.Volume 84. Number 8. 2006;25(7):722-30.

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 DOI Number: 10.5958/j.0973-5674.7.3.095
216 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Comparison of Two Sit and Reach Tests for Measurement

of Hamstring Flexibility in Female University
Physiotherapy Students

Nidhi Kathuria1, Sumit Kalra2

1 2
Student, Masters of Physiotherapy, Assistant Professor, Banarsidas Chandiwala Institute of Physiotherapy, Kalkaji,
New Delhi, India

ABSTRACT

Background: Sit and reach test is commonly used for measuring the flexibility for hamstrings muscle.
Objective: To compare two sit and reach test for measurement of hamstrings flexibility in 60 females
physiotherapy students.

Method: Sit and Reach test, Back Saver Sit and Reach test and Straight leg measurements were taken
that was administrated after 5 minutes warm-up and stretching on the same day with rest period of
20 minutes in between the tests.

Results: The value of correlation between hamstring flexibility and BSSR Test of Right leg (r) is 0.51
and value of correlation between hamstring flexibility and BSSR Test of Left leg is (r) is 0.57 whereas
the value of correlation between hamstring flexibility of Right leg and SR Test (r) is 0.24 and value of
correlation between hamstring flexibility of Left leg and SR Test is (r) is 0.56.

Conclusion: The results indicated that back saver sit and reach test produces reasonably accurate
and stable measures of hamstring flexibility. Moreover, it appeared that this test was safe and acceptable
alternative to the sit and reach test as a measure of hamstring flexibility in young females.
Keywords: Sit and Reach Test, Hamstrings, Flexibility, Students

INTRODUCTION The test is designed to measure the extensibility of the

hamstrings muscles and the lower back articulations
Flexibility is a key component for injury prevention
by evaluating the maximal reach an individual can
and rehabilitation. 1, 2According to the American
make in a seated position.8 The purpose of the study is
Alliance for Health, Physical Education, Recreation,
to compare two different sit and reach test as a
and Dance , the flexibility test is important because
measurement of hamstring Flexibility in female
decreased flexibility, particularly in the hamstring
physiotherapy students.
muscles and the back, is thought to contribute to the
development of low back pain 3 and it is a predisposing Russell T. Nelson and William D. Bandy9 et al
factor to hamstring strains.4,5,6 The Sit-and-Reach Test concluded that flexibility gains achieved in range of
(SRT), proposed initially by Wells and Dillon on the motion of knee extension with eccentric training of 6
50s, is commonly used for measuring the flexibility of weeks in high school males were equal to those made
the lumbar spine and hamstring muscles. The interest by statically stretching the hamstrings muscles. Barlow
in researching the hamstring muscles and the 10
et al concluded that a single massage of the hamstring
measurement of its length is due to the possible muscle group was not associated with any significant
dysfunctions and lesions caused by alteration in its increase in sit and reach performance immediately
flexibility. Not only are there injuries caused by the after treatment in physically active young men(n=5).
muscle itself, there are also biomechanical alterations
that may lead to femoro-patellar dysfunction, pubic Cornbleet SL, Woolsey NB11 et al did a study to
and lumbar pain, tendonitis and postural deviations.7 describe hamstring muscle length as reflected by use

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 217

of the SRT and the hip joint angle (HJA) in children, to Subjects with low backache, having apparent and
examine the correlation between SRT and HJA true length shortening that would limit performance
measurements, and to examine gender differences for in these tests, athletes and subjects with any of the
both measures. Each child performed the SRT. In the contraindications of stretching were excluded in the
final position, the SRT score was obtained and the HJA study.13, 18, 19
was measured using an inclinometer placed over the
sacrum. A mean SRT value of 24 cm and a mean HJA Instruments and tools used
value of 81 degrees were obtained for all subjects. There
was a difference between boys and girls for both Sit and reach box- box approximately 12 inches high
measures. and measuring scale; universal goniometer; stop
watch.
Bandy WD, Irion JM, Briggler M 12indicated that
the change in flexibility appeared to be dependent on
PROCEDURE
the duration and frequency of stretching and It was
suggested that a 30-second duration was an effective Subjects fulfilling inclusion criteria were taken into
amount of time to sustain a hamstring muscle stretch consideration. The procedure was explained to the
in order to increase Range of motion. Also it was found subjects and a written consent was taken after
that no increase in flexibility occurred when the explaining the benefits and clearing the doubts of the
duration of stretching was increased from 30 to 60
subject regarding study. Goniometric measurement, Sit
seconds or when the frequency of stretching was
and Reach Test16 and Back Saver Sit and Reach Test16,
increased from one to three times per day.
were performed and scores were recorded. After that,
Bandy Wd, Irion Jm13 et al suggested that duration subjects were asked to perform a 5-minute warm up
of 30 seconds was an effective time of stretching for and static stretch routine in which subject had to go
enhancing the flexibility of the hamstring muscles and for 2 minutes of jogging followed by rest period for
also it was found that no significant difference existed one minute and again subjects were asked to go for
between stretching for 30 seconds and for 1 minute. next 2 minutes, emphasizing lower body. Immediately
Scott G. Spernoga14 et al concluded that a sequence of after which, the flexibility tests were performed on the
5 modified hold-relax stretches produced significantly same day with rest period of 20 minutes in between
increased hamstring flexibility that lasted 6 minutes
tests and scores were recorded. After demonstration,
after the stretching protocol ended.
one practice trial and three tests were performed for
James W. Youdas 15 et al did a study did a study in each of measures. Average of three test trials was used
which it was concluded that there was a statistically for all tests.
significant correlation between performance on the sit-
and-reach test as measured by hip joint angle and the Goniometric Measurement16 is done during passive
supine passive straight-leg raise, but the sit-and-reach straight leg raise. The axis is aligned with axis of hip
test only accounted for 35% of the variability in the joint. Stationary arm is in line with the trunk and
supine passive straight-leg raise. moveable arm is in line with the femur. With knees
held straight, her leg was moved passively into hip
METHODOLOGY flexion until tightness was felt. In both test, static
position was held for 2 seconds while the
60 healthy females were taken.
physiotherapist recorded the reached score using a
The study was conducted at Banarsidas measuring scale positioned parallel to the lower leg.
Chandiwala Institute of Physiotherapy, New Delhi.
DATA ANALYSIS
Asymptomatic healthy females with age between
20-24 years with no history of low backache in last 3 • Pearson correlation coefficient is used to analyze
months, no musculoskeletal disorders, no neurological the data.
disorder and also with no psychiatric and
psychological disorder were included in the • Excel 2000 is used for calculating Correlation.
study.10, 16, 17

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 218 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Table 1: Mean and Standard Deviation values of Sit Table 2: Mean and Standard deviation values of Sit
and Reach, Back Saver Sit and Reach Tests and and Reach, Back Saver Sit and Reach Tests and
Goniometer measured flexibility at Pre Intervention. goniometer measured flexibility at Post
Intervention.
Pre Intervention Mean Standard
Deviation Pre Intervention Mean Standard
ROMR 58.99 12.39 Deviation
ROML 59.89 13.88 SRT 7.85 3.35
SRT 6.83 3.20 BSSRR 8.08 2.83
BSSRR 7.017 2.75 BSSRL 8.08 2.88
BSSRL 8.79 18.32 ROMR 67.81 13.35
ROML 67.67 12.40
KEYWORDS: ROMR: Range of Motion of Right leg, ROML: Range
of Motion of Left. SRT: Sit and Reach test. BSSRR: Back Saver Sit
and Reach Test for Right leg. BSSRL: Back Saver Sit and Reach Test
for Left Leg

Table 3: Intercorrelations of sit and reach, and back saver sit and reach tests with goniometer measured flexibility
in all participants (n=60)

ROMR ROML SRT BSSRR BSSRL SRT BSSRR BSSRL ROMR ROML
ROMR - .71 .48 .42 .20 .24 .51 .42 82 .56
ROML .71 - .46 .59 .35 .56 .59 .57 .77 .84
SRT .48 .55 - .83 .28 .97 .80 .83 .62 .62
BSSRR .42 .59 .83 - .34 .84 .97 .97 .60 .64
BSSRL .24 .35 .28 .34 - .30 .36 .38 .29 .33

PRE POST

RESULTS

The value of correlation between Hamstring

flexibility and BSSR Test of Right leg (r) is 0.51 and
value of correlation between Hamstring flexibility and
BSSR Test of Left leg is (r) is 0.57 whereas the value of
correlation between Hamstring flexibility of Right leg
Graph 1: Comparison of Mean between SLR ROM values at pre
and post intervention.
and SR Test (r) is 0.24 and value of correlation between
Hamstring flexibility of Left leg and SR Test is (r)
is 0.56.

DISCUSSION

SR and BSSR tests are the most commonly used

field measures of hamstring flexibility in current fitness
test batteries. The purpose of this study was to
Graph 2: Comparison of Mean between Sit and reach test (SRT)
values at pre intervention and post intervention.
determine the relations between the two SR tests and
hamstring flexibility because the test is used as a
measure of hamstring flexibility in young females.

This study indicates that both the traditional SR and

BSSR tests are related to hamstring flexibility. The value
of correlation between Hamstring flexibility and BSSR
Test of Right leg (r) is 0.51 and value of correlation
between Hamstring flexibility and BSSR Test of Left
Graph 3: Comparison of Mean between Back Saver Sit and Reach leg is (r) is 0.57 whereas the value of correlation
Test (BSSR) at pre intervention and post intervention. between Hamstring flexibility of Right leg and SR Test

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 219

(r) is 0.24 and value of correlation between Hamstring REFERENCES

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1. Corbin, CB, Noble, L. Flexibility: a major
These results support the findings of Jackson and component of physical fitness. J Phys Educ
Baker and Chung and Yuen. However, they concluded Recreat Dance. 1980; 51:57–60).
that hamstring flexibility can only be measured by the 2. Jacklyn K. Miller, Ashley M. Rockey. Foam Rollers
traditional SR test, but we have provided evidence that Show No Increase in the Flexibility of the
the BSSR test can be used instead of the traditional SR Hamstring Muscle Group. Journal of
test in young females. Although the SR tests do not Undergraduate Research IX (2006).
satisfactorily measure lower back flexibility and are 3. Carolyn Kisner. Therapeutic exercise foundation
only moderately valid measures of hamstring and techniques, Fourth Edition, Chapter 5,
flexibility, they are still the only field tests that are Page 171
practical and easy to administer. Moreover, Jackson et 4. Glen M. DePino, William G. Webright, Brent L.
al reported that the SR test was not related to reported Arnold. Duration of Maintained Hamstring
lower back pain in either a cross sectional or Flexibility after Cessation of an Acute Static
prospective sample of adults. Evidence of the relation Stretching Protocol. Journal of Athletic Training
between hamstring flexibility or lower back flexibility 2000; 35(1):56-59.
and lower back health is not documented. Future 5. B Dadebo, J White, K P George. A survey of
studies are needed to explore the influence of flexibility training protocols and hamstring
hamstring flexibility on lower back health.12 strains in professional football clubs in England.
Br J Sports Med 2004; 38:388–394.
Studies have shown that the classical sit-and-reach 6. Gary Suttont. Hamstrung by Hamstring Strains:
(CSR) test, the modified sit-and-reach (MSR), and the A Review of literature. The Journal of
newly developed back-saver sit-and-reach (BS) test Orthopaedic and Sports Physical Therapy. Feb
have poor criterion-related validity in estimating low- 1984.
back flexibility but yielded moderate criterion-related 7. S.Lakshami Narayanan. Textbook of therapeutic
validity in hamstring flexibility. The V sit-and-reach exercises. Page 40.
(VSR) test was found to be practical but the validity 8. Brad Appleton. Stretching and flexibility.
has not been established so still the choice of test to 9. Russell T. Nelson and William D. Bandy. Eccentric
check hamstring flexibility is sit-and-reach test and Training and Static Stretching Improve
back saver sit and reach test. But as shown by the Hamstring Flexibility of High School Males.
present study we can rely more on Back saver sit and Journal of Athletic Training. 2004 Jul–Sep; 39(3):
reach test. 254–258.
10. A Barlow, R Clarke, N Johnson, B Seabourne, D
CONCLUSION Thomas, J Gal. Effect of massage of the hamstring
muscle group on performance of the sit and reach
The results indicate that this back saver sit and reach
test. Br J Sports Med; 2004; 38:349–351.
test produce reasonably accurate and stable measures
11. Cornbleet SL, Woolsey Nancy B. Assessment of
of hamstring flexibility. Moreover, it appeared that this
hamstring muscle length in school-aged children
test is safe and acceptable alternative to the sit and
using the sit-and-reach test and the inclinometer
reach test as a measure of hamstring flexibility in
measure of hip joint angle. Phys Ther. 1996 Aug;
young females.
76(8):850-5.
Therefore, results have proved the experimental 12. Jean M Irion, Michelle Briggler, William D Bandy.
hypothesis as positive. The Effect of Time and Frequency of Static
Stretching on Flexibility of the Hamstring
ACKNOWLEDGEMENT Muscles. Physical Therapy. 1998 Mar; 78 (3):
321-322.
It is my pleasure and privilege to record my deep 13. William D Bandy, Jean M Irion. The effect of time
sense of gratitude to all those who helped me during on static stretch on flexibility of hamstring
this dissertation. It is my pleasant duty to acknowledge muscles. Physical Therapy 1994 Sep; 74(9):
all the subjects participated in my study that allowed 845-852.
me to learn.

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14. Scott G. Spernoga, Timothy L. Uhl, Brent L. Course of 24 Hours. Journal of Orthopaedic &
Arnold, Bruce M.Gansneder. Duration of Sports Physical Therapy.
maintained hamstring flexibility after a one time, 18. J Brent Feland, J William Myrer, Shane, S
hold relax stretching protocol. Athletic Training Schulthies, Gill W Fellingham, Gary W Measom.
2001 Jan–Mar; 36(1): 44–48. The Effect of Duration of Stretching of the
15. Youdas JW, Krause DA, Hollman JH. Validity of Hamstring Muscle Group for Increasing Range
hamstring muscle length assessment during the of Motion in People Aged 65 Years or Older.
sit-and-reach test using an inclinometer to Physical Therapy 2001 May; 81(5): 1110-7.
measure hip joint angle, Research journal of 19. David O. Draper, Jennifer L. Castro, Brent Feland,
NSCA,ISSN 1064-8011,Pages 303-309. Shane Schulthies, Dennis Eggett. Shortwave
16. G. Baltaci, N Un, V Tunay, A Besler, S Gerceker. Diathermy and Prolonged Stretching Increase
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Shamus. The Effect of Static Stretch and Warm-
up Exercise on Hamstring Length over the

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 DOI Number: 10.5958/j.0973-5674.7.3.096
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 221

Home Based Exercise Program for Frozen Shoulder-

Follow-up of 36 Idiopathic Frozen Shoulder Patients

Shishir S M1, Manoj Abraham M2, Kanagasabai R3, Syed Najimudeen4, James J Gnanadoss5
1
Assistant Professor, Department of Orthopaedics, 2Tutor, Department of Physical Medicine & Rehabilitation, 3Professor,
Department of Orthopaedics, 4Professor and Head of Department, Department of Orthopaedics, 5Professor, Department
of Orthopaedics, Pondicherry Institute of Medical Sciences, Pondicherry

ABSTRACT

Introduction: Adhesive capsulitis or frozen shoulder is a condition characterized by generalized

pain and stiffness with progressive global restricted motion of the shoulder1. There are many variations
of physical therapy protocol .Most of the protocols are extensive and do not suite the Indian scenario
as most of the patients are not involved in active sports or high end activities. Furthermore, the
compliance of the patient is not good and cost of physiotherapy is high.

Hence, we decided to develop and validate a Shoulder Accelerated Rehabilitation Protocol (SHARP)
for patients with frozen shoulder in our Indian scenario.

Method and Material: Thirty six consecutive idiopathic frozen shoulder patients with a painful
shoulder of more than 4 weeks and less than 6 months duration and with limitation of active and
passive range of movement greater than 25% in abduction and external rotation compared with the
other shoulder were selected and subjected to the SHARP protocol.

RESULTS: The mean constant shoulder score at the start of protocol was 26.69 (SD- 8.522), which
improved to 98.58 (SD-2.892) at 15 months. Maximum patients reached a constant shoulder score of
100 at 15 months (22 patients).

The mean VAS score for pain at the start of the protocol was 7.14 (SD-1.222) which improved to 0 at
18 months.

Conclusion: SHARP is a non-invasive, easy to follow and reproduce, home based exercise program
effective in early improvement of pain and disability in patients with frozen shoulder
Keywords: Adhesive Capsulitis, Frozen Shoulder, Shoulder Accelerated Rehabilitation Protocol (SHARP)

INTRODUCTION It is most commonly observed in patients in their fifth

and sixth decades of life1. The incidence is 2-5% in
Adhesive capsulitis or frozen shoulder is a
general population with a much higher frequency in
condition characterized by generalized pain and
women (as high as 70% in some reports).3 There is
stiffness with progressive global restricted motion of
recent literature to support a relationship between
the shoulder1. This entity is unique to shoulder joint.2
hormonal changes in women during menopause and
frozen shoulder4. There is a much higher incidence in
Corresponding author: patients with diabetes mellitus (10-35%) and an
Shishir. S M increased incidence in people with Parkinson’s disease,
Assistant Professor, previous injury to the shoulder, immobilization of the
Department of Orthopaedics arm and closed head trauma4. There is some evidence
Pondicherry Institute of Medical Sciences, Pondicherry of increased frequency in those with thyroid disease,
[email protected] cardiopulmonary disease, cervical spine degenerative
Telephone No. : +91 8870135734

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 222 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

disc disease, and personality disorders although no Furthermore, the compliance of the patient is not good
specific causal relationship has been clearly and cost of physiotherapy is high.
established5-12.
Hence, we decided to develop and validate a
1
Natural History and Phases of Adhesive Capsulitis Shoulder Accelerated Rehabilitation Protocol (SHARP)
for patients with frozen shoulder in our Indian
The natural history of adhesive capsulitis is scenario.
uncertain. Some believe it is a self-limiting disorder
lasting as little as 6 months2, whilst others suggest it is METHOD AND MATERIALS
a more chronic disorder leading to longer term
disability 3. Data were reported as means ± the standard
deviation of the mean (SD) and were analyzed using
In general there are three phases of frozen shoulder SPSS software. Repeated-measures ANOVAs were
depending on the presenting symptoms and used to analyze the constant score measured at
examination findings. different time point. Results were considered
The Inflammatory Phase or Freezing Phase significant at an α level of 0.05. The study was
conducted between November 2010 and March 2013
The patient has a spontaneous and gradual onset in Pondicherry Institute of Medical Sciences.
of aching pain at rest which progresses to pain with
use. As the pain worsens, there is night pain which Inclusion Criteria
interferes with the patient’s ability to sleep 1. Patient with a painful shoulder of more than 4
comfortably. It is common for patients to associate the weeks and less than 6 months duration with
development of symptoms with a trivial trauma; limitation of active and passive range of movement
however, there is usually no causal relationship. greater than 25% in abduction and external rotation
During this phase the patient has significant pain and compared with the other shoulder were selected.
a gradual increase in stiffness. This phase typically lasts Patients were excluded if their pain was less than
between 3 and 9 months and is characterized by an 4 weeks duration as such patients may have had
acute synovitis of the glenohumeral joint. spontaneous recovery in the early stages.
The Frozen Phase or Transitional Stage 2. The presence of restriction of active and passive
The patient has a slow improvement in rest pain range of movement in both external rotation and
but little change in the range of motion and stiffness glenohumeral abduction was taken to indicate a
or the pain at the extremes of motion. This phase diagnosis of capsulitis as opposed to rotator cuff
characteristically lasts 4-12 months. tendinopathy.

The Thawing Phase 3. Patients with normal shoulder radiographs, with

exception of evidence of Osteopenia.
Lasts anywhere from 12 to 42 months and is defined
by a gradual return of shoulder mobility. The patients 4. Patient with minimum follow-up of two years.
with uncontrolled diabetes mellitus take a longer time Exclusion criteria
to recover4.
1. Patients who received previous intra-articular
Initial treatment of adhesive capsulitis is usually injection or prior physiotherapy before the start of
conservative involving physical therapy, anti- the protocol were also excluded as it could
inflammatory medication, and corticosteroid influence the outcome of the study.
injections. Intra-articular steroid injections are used to
help with pain relief by limiting the inflammatory 2. Patients with limitation of movement in one plane
process that occurs with frozen shoulder13. only.

There are many variations of physical therapy 3. Lack of tenderness on palpation of

protocol .Most of the protocols are extensive and do acromioclavicular joint excluded the pain
not suite the Indian scenario as most of the patients originating from this joint. Cross chest adduction
are not involved in active sports or high end activities. test was done to rule out AC joint arthritis.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 223

4. Patients presenting with frozen shoulder rest 15 on the left side. Range of movements at shoulder
secondary to some other disease or having co joint was recorded; especially active and passive
morbidity, e.g. Diabetes mellitus, Parkinson’s forward flexion, abduction, internal and external
disease, hyper or hypothyroidism. rotation. The shoulder movements were checked while
patients were standing and were measured using a
5. Those with bilateral adhesive capsulitis.
goniometer. All the patients were followed up for a
6. Patients with evidence of glenohumeral period of 24 months with 3 month interval. Data of
osteoarthritis on plain X-ray, clinical evidence of a each patient was recorded at every visit by an observer
complete rotator cuff tear (i.e. positive empty can who was not connected to this study to avoid bias.
test, full can test and drop-off sign), clinical Patients were asked to follow the SHARP protocol.
evidence of significant cervical spine disease,
history of significant trauma to the shoulder or a We demonstrated the exercises to the patients in
history of inflammatory joint disease or of a the out-patient department and a hand out were given
cerebrovascular accident affecting the study. to them. They were advised to do the entire set of
exercises, each 15 minutes per session. This protocol
Thirty six patients with idiopathic unilateral frozen was advised for a minimum of 5 sessions per day with
shoulder, 23 male and 13 female were included in the a gap of minimum 1 hour between each session.
study. The age range was 33 to 73 years (mean age of
49.69 years). All the patients were in phase 1 of frozen The SHARP protocol which we devised and used
shoulder. Out of the 36 cases, 21 were right side and for the study has been described in table1.

Table 1: SHARP–Shoulder Accelerated Rehabilitation Protocol

TREATMENT GOAL
Phase – I Month 0-3 • Shoulder range of motion, mobilization exercise at
physiological end range
• Codman's pendulum exercises
• Arm slides
• Shoulder abductors and rotation stretch To achieve 60% to full Range of Motion
• Finger ladder exercise
• Towel exercise
• Wand Exercise
• Active assisted Range of motion
• Exercise hot water bag, moist heat may be used.
Phase - II Month 4-6 • Continue Phase I
• Shoulder range of motion, mobilization exercise at To achieve 80% to full Range of Motion
physiological end range.
• Shoulder abductors and rotation stretch exercises AROM, PROM & G-H jt. mobility
• Shoulder shrugs and scapular retraction
• Passive range of motion exercise & shoulder Normal scapulo-humeral meaning
joint mobility No compensations seen with
• Active assisted Range of motion raising arm overhead
• Isometrics and scapular strengthening exercises using
therabands.
Phase - III • Progress strengthening program to isotonics. Should have more than 90% or
• Work specific rehabilitation if functional with ADL's, full range of motion and be
Month 7 onwards • Progress to strengthening exercises functional with ADL's

RESULTS 8.03) at 9 months, 93.81 (SD- 5.98) at 12 months, 98.58

(SD-2.89) at 15 months, 99.72 (SD-1.66) at 18 months
Repeated-measures ANOVA found that there were
and 99.78 (SD-1.33) at 21 and 24 months (Figure 2).
no significant changes between gender on constant
score F(1, 34) = 0.026, p=0.872.All the patients were The mean VAS score for pain at the start of the
subjected to SHARP protocol. NSAID’s and Opiods protocol was 7.14 (SD-1.22) which improved to 4.17
were given for pain relief on SOS basis. The mean (SD-0.81) at the end of 6 months, 0.89 (SD- 0.74) at 1
constant shoulder score14 at the start of protocol was year, 0.19 (SD-0.40) at 15 months and 0 at 18 months.
26.69 (SD- 8.52), which improved to 55.14 (SD-14.08) No additional changes were seen at the end of 24
at 3 months, 75.83 (SD-11.99) at 6 months, 87.39 (SD- months (Table 4).

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 224 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Maximum patients reached a constant shoulder Table 2: Sex Distribution of Patients

score of 100 at 15 months (22 patients). At the end of SEX FREQUENCY PERCENT
18 months 35 patients reached a score of 100 (Figure Female 13 36.1
1). One patient reached a maximum score of 92 at the Male 23 63.9
end of 24 months of follow up. Total 36 100.0

Table 3: Mean distribution of forward elevation, abduction and external rotation at different duration of
follow –up

Duration Forward elevation Total (n=36) Abduction Total (n=36) External rotation Total (n=36)
Mean (±SD) score Mean (±SD) score Mean (±SD) score
0 month 59.44 (±15.34) 64.44 (±15.98) 8.89 (±10.01)
3 months 96.67 (±23.84) 103.89 (±25.72) 20.00 (±10.76)
6 months 132.36 (±29.46) 133.75 (±25.92) 31.25 (±13.80)
9 months 159.44 (±21.31) 158.33 (±20.74) 41.11 (±15.26)
12 months 173.47 (±9.32) 173.33 (±12.76) 53.75 (±15.96)
15 months 179.03 (±2.62) 177.22(±6.15) 71.39 (±11.06)
18 months 179.58 (±1.84) 178.47 (±3.74) 77.22 (±9.89)
21 months 179.58 (±1.84) 178.61 (±3.70) 81.25 (±8.34)
24 months 179.72 (±1.67) 178.61 (±3.70) 82.36 (±8.74)

Fig. 1. Number of Patients Attaining Constant Score of 100 by the

Time Period

Fig. 3. Constant Score Attained by the Time Period by Gender

Fig. 2. Constant Score attained by the Time Period (Overall)

Table 4: Showing the Descriptive Statistics of VAS Score at Various Intervals

Duration Sex Mean Std. Deviation

0 month Female 7.54 0.77
Male 6.91 1.37
Total 7.14 1.22
3months Female 5.77 1.23
Male 5.13 1.18
Total 5.36 1.22

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 225

Table 4: Showing the Descriptive Statistics of VAS Score at Various Intervals (Contd.)

Duration Sex Mean Std. Deviation

6months Female 4.31 0.63
Male 4.09 0.90
Total 4.17 0.81
9 months Female 2.23 0.92
Male 2.43 0.84
Total 2.36 0.86
12months Female 0.62 0.65
Male 1.04 0.76
Total 0.89 0.74
15months Female 0.15 0.37
Male 0.22 0.42
Total 0.19 0.40
18months Female 0.00 0.00
Male 0.00 0.00
Total 0.00 0.00
21 months Female 0.00 0.00
Male 0.00 0.00
Total 0.00 0.00
24 months Female 0.00 0.00
Male 0.00 0.00
Total 0.00 0.00

DISCUSSION Widiastuti-Samekto and Sianturi claimed that

intraarticular steroid injection gave rapid relief when
Frozen shoulder has an insidious onset and follows
compared to oral route.19 Dudkiewicz I et. al (2004), in
a protracted course. The pathogenesis is unclear, but
their study of 54 patients, with mean follow up 9.2
it is thought to be a progression of inflammation and
years , claimed that conservative primary treatment
fibrosis1. It has many similar features to Dupuytren’s
for frozen shoulder i.e., physiotherapy and intra-
disease, including the presence of adhesions.2, 3.
articular steroid injection was an effective long term
There are many methods of treating frozen shoulder treatment method.20
and variable success has been claimed. Symptoms of
Farrell CM et al, reported that, in patients with
frozen shoulder show much improvement when
persistent severe stiffness, manipulation of shoulder
treated with deep heating and stretching exercise
under general anaesthesia improves range of
combined.13, 14 Superficial heating alone has proven less
movement at shoulder joint for a mean period of 15
effective.15 Traditionally, stretching exercises have been
years after treatment21. Some authors have claimed that
used to stretch the shoulder capsule. Continuous
this does not add to the benefit of exercise program.
passive motion has shown more promising results as
compared to this traditional practice.15 Combining oral In our study, patients who followed the home
steroids, non steroid anti-inflammatory drugs and exercise programme properly were early to recover
physiotherapy, is said to provide good pain relief, that and had good results even at the end of 2 years of
usually does not extend beyond six weeks. 16 follow up. All the patients improve with physical
Manipulation under anaesthesia and surgical therapy (SHARP) alone. Home based heat therapy was
(arthroscopic or open) release can often restore motion advised as per the patient tolerance to pain especially
and obtain pain relief for patients with refractory after a session of exercises. Patients who presented to
cases.17 Although patients who initially present with us in phase 2 or 3 of frozen shoulder were subjected to
frozen shoulder should always be treated non- multi-modality approach of treatment using a
operatively while allowing a chance for recovery combination of physical therapy, anti-inflammatory
without surgical intervention.18 medications, intra-articular corticosteroid injections,

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 226 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

manipulation under anaesthesia or arthroscopic 8. Riley D, Lang A, Blair R, Birnbaum A, Reid B.

release of the tight capsule. Frozen shoulder and other shoulder disturbances
in Parkinson’s disease. J Neurol Neurosurg.
CONCLUSION 1989;52:63–6
9. Boyle-Walker K, Gabard GL, Bietsch E, Masek-
SHARP is a non-invasive, easy to follow and Van Arsdale DM, Robinson DL. A profile of
reproduce, home based exercise program effective in patients with adhesive capsulitis. J Hand Ther.
early improvement of pain and disability in patients 1997;10:222–228
with frozen shoulder. It helps the patient to get back 10. Tuten HR, Young DC, Douoguih WA, Lenhardt
to the pre-disease status as early as possible. KM, Wilkerson JP, Adelaar RS, et al. Adhesive
capsulitis of the shoulder in male cardiac surgery
ACKNOWLEDGEMENT patients. Orthopedics. 2000; 23:693–696
We sincelry thank MR. RAVICHANDRAN, 11. Jayson M. Frozen shoulder: Adhesive capsulitis.
Lecturer, Department of biostatistics, Pondicherry Br Med J.1981;283:1005–1006
Institute of Medical Sciences for having analysed the 12. Reeves B. The natural history of the frozen
data statistically. shoulder syndrome.Scand J Rheumatol
1975;4:193-196
CONSENT 13. Wadsworth C. Frozen shoulder. Phys Ther.
1986;66:1878–83
Informed consent has been taken from all the 14. Constant CR, Murley AG. A clinical method of
patients for this publication. ”The author(s) declare functional assessment of the shoulder. Clin
that they have no competing interests’’. No funding Orthop Relat Res 1987; 214: 160–164.
received from any source for this study. 15. Ogilvie-Harris DJ, Biggs DJ, Fitsialos DP, MacKay
M. The resistant frozen shoulder. Manipulation
Ethical clearance from the ethical committee has versus arthroscopic release. Clin Orthop
been obtained for the above study. 1995;319:238-248.
16. Steinbrocker O, Argyros TG. Frozen shoulder:
REFERENCES treatment by local injections of depot
1. Reeves B. The natural history of the frozen corticosteroids. Arch Phys Med Rehabil
shoulder syndrome. Scand J Rheumatol 1975; 1974;55:209-213.
4:193–6 17. Thomas D, Williams RA, Smith DS. The frozen
2. Grubbs N. Frozen shoulder syndrome: a review shoulder: a review of manipulative treatment.
of literature. J Orthop Sports Phys Ther 1993;18: Rheumatol Rehabilitation 1980; 19:173-179
479–87 18. Rizk TE, Gavant ML, Pinals RS. Treatment of
3. Binder AI, Bulgen DY, Hazleman BL, Roberts S. adhesive capsulitis (frozen shoulder) with
Frozen shoulder: a long-term prospective study. arthrographic capsular distension and
Ann Rheum Dis 1984;43:361–4 rupture.Arch Phys Med Rehabil 1994;75:803-807
4. Bridgman JF. Periarthritis of the shoulder and 19. M M Widiastuti-Samekto, GP Sianturi. Frozen
diabetes mellitus. Ann Rheum Dis. 1972;31: shoulder syndrome: comparison of oral route
69–71. corticosteroids and intra-articular corticosteroid
5. Wohlgethan J. Frozen shoulder in infection. Med J Malaysia 59(3);312-6 (2004),
hyperthyroidism. Arthritis Rheum. 1987;30: PMID.
936–939 20. Dudkiewicz I,Oran A, Salai M, Palti R, Pritsch
6. Bowman C, Jeffcoate WJ, Pattrick M, Doherty M. M. Idiopathic adhesive capsulitis : long term
Bilateral adhesive capsulitis, oligoarthritis and results of conservative treatment. Isr Med Assoc
proximal hypothyroidism.Br J Rheum. J. 2004; 6:524-6.
1988;27:62–4 21. Farrell CM, Sperling JW, Cofield RH.
7. Choy E, Corkill M, Gibson T, Hicks B. Isolated Manipulation for frozen shoulder: long-term
ACTH deficiency presenting with bilateral frozen results. J Shoulder Elbow Surg 2005; 14:480-4
shoulder. Br J Rheum. 1991;30:226–227

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 DOI Number: 10.5958/j.0973-5674.7.3.097
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 227

Effect of Vibration on Skin Blood Flow in Type 2 Diabetes

Mellitus

Everett B Lohman1, Kanikkai Steni Balan Sackiriyas2, Gurinder S Bains3, Kulbhushan H Dhamane2,
Kinjal J Solani2, Chandip K Raju2, Howard W Sulzle4
1
Professor, 2Student, 3Primary Research Coordinator, 4Assistant Professor, Department of Physical Therapy, Loma Linda
University, Loma Linda-92350, California, USA

ABSTRACT

Background: Recent researches support the use of passive vibration (PV) to increase circulation
without the risk of burns. The aim of this study is to determine the effect of short duration vibration
on skin blood flow (SBF) in Type 2 diabetics.

Materials and Method: 18 subjects with Type 2 diabetes mellitus between 47-74 years of age, and 18
age matched controls between 50-75 years of age received PV on the anterior aspect of forearm and
on plantar aspect of first three metatarsal heads. SBF was measured before, after and 10 minutes post
vibration.

Results: There was a significant difference in the foot and forearm SBF across time for both groups.
However, there was no significant difference in foot and forearm SBF across time between the groups.
Greatest percent increase was seen in the diabetic foot SBF (118.53%) from baseline to end of vibration
vs. non diabetic foot (37.62 %). Also, looking 10 minutes post, there was a less change in diabetic foot
SBF (-15.25%) vs. non diabetic foot (-27.64%). There was only a slight increase from the start to the
end of the vibration in diabetic subjects (129.78%) vs. non diabetic subjects (127.97%). There was no
significant change on the foot SBF vs. the forearm at the baseline, at the end of vibration and at 10
minutes post between the groups (F=.679, P=.476).

Conclusion: The diabetes mellitus group with fair to good glucose control responded similarly to PV
as compared to non-diabetes mellitus group although there was no significant difference in foot and
forearm SBF across time between the groups.
Keywords: Vibration, Blood Flow, Aging, Diabetes Mellitus, Nitric Oxide

INTRODUCTION circulating levels of endogenous insulin are present in

the body and in some cases elevated (1), (2) (Type 2),
Diabetes Mellitus (DM) is a group of metabolic
leading to high blood glucose levels. Type 2 diabetes
diseases in which the beta cells of the pancreas do not
(T2D) is the most common (90% to 95%) in the
produce insulin (Type 1) or insulin resistance where
USA(2),(1), (3).
target cells fail to use insulin properly even though
It is a major health care problem in America
affecting millions each year (4). It is the leading cause
Corresponding author:
of stroke and heart disease and is the 7th leading cause
Everett B LohmanIII
Professor of death (1). Medical expenses and risk of death in
Department of Physical Therapy, Loma Linda diabetics is two times higher than people of similar
University, Loma Linda, CA 92350 age without diabetes (1). Prevalence of diabetes in the
Telephone: 001-(909) 558-1000 United States is 8.3% of the total population (25.8
Fax: 001-(909) 558-0459 million) and 26.9% of people e” 65 years (10.9
Email: [email protected] million)(1).

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 228 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

CIRCULATION Vibration

Blood circulation plays a significant role in tissue Mechanical oscillations applied randomly or
healing (5). Aging and diabetes adversely affect periodically are known as vibration. Vibration can be
autonomic and endothelial function (6), (5), (7) which leads divided into active (AV) and passive vibration (PV).
to impaired healing and ulcerations(8). Vibration is delivered vertically to the body part and
requires active participation in AV(29).
Damage to the autonomic nervous system occurs
before clinical symptoms of diabetes are evident (9), (10). PV does not require the patient to weight bear and
Damage to endothelial cells in DM reduces their ability mechanical oscillations are delivered horizontally with
to produce Nitric oxide (NO) and decreases their the subjects relaxed (29). Studies conducted on vibration
sensitivity to NO leading to decreased SBF (11), (12), (9) reported changes associated with vibration such as
and increases the risk of ulcerations (13). Coagulation increase in SBF(6), (30). Physical therapists may use
defects and impaired fibrinolysis in diabetes mellitus vibration to improve SBF without significantly
lead to increased blood viscosity and platelet adhesion increasing the risk of burns in health individuals.
(14), (15)
. Increased blood flow is associated with
improved wound healing and increased soft tissue Lohman et al., (2007) demonstrated that PV at a
repair (16), (17). frequency of 30 Hz (high) and high amplitude (5-6mm)
for a short duration (3 minutes) applied to the posterior
SBF calf muscles improved SBF significantly in healthy
subjects (6). A follow up study performed on the
The glabrous skin (palms, soles) is mainly
forearm muscles demonstrated that 50 Hz was more
innervated by sympathetic vasoconstrictor nerves (18),
(19).
effective than 30 Hz (31). These studies suggest that PV
It has numerous thick walled atriovenous
significantly increases SBF in extremities on hairy skin;
anastomoses (AVA) with low resistance and high blood
however, these studies were performed on non-
flow. The nonglabrous skin (dorsal area of hand) has
diabetics.
fewer AVA and is controlled by both the sympathetic
vasoconstrictor and vasodilator nerves (20), (21). The
PURPOSE
superficial skin has more nutritive (NUTR) perfusion
and is influenced by small capillaries. Numerous larger The purpose of this study was to find how PV
diameter arterioles and venules are found in areas such affects SBF in T2D. The hypothesis was that Type 2
as the face and the toes (18), (22), (23) allows for low diabetics will exhibit vibration induced increase in
resistance, high blood flow directly from the arterioles upper and lower extremity SBF; however less than age
to venules (18), (24). Opening and closing of AVA has and gender matched controls following the short -
substantial changes in SBF (19). The SBF rate is different duration, high frequency, and high amplitude PV.
between AVA and NUTR sites in response to posture
induced pressure, heat, and diseases. Posture induced A secondary hypothesis was that vibration will
pressure change is larger in large upstream arteries increase SBF more significantly in hairy than non-hairy
and is greater in AVA sites than NUTR sites (25), (26). Heat skin in both diabetics and non-diabetics.
induced blood flow rate is greater in AVA sites than
NUTR sites. Decreased SBF due to aging and diabetes MATERIAL AND METHOD
are not very common in the AVA but NUTR sites(18), (27).
Study population
Since all of the organs in the body need blood to
18 subjects (10 females and 8 males) with T2D aged
function effectively, measuring their resting blood flow
between 18 to 75 years and 18 age matched NDM
provide the health status of these organs(28).
controls (8 females and 10 males) between 18 to 75

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 229

years were recruited (Table 1). Research subjects were Diabetes Treatment Center at Loma Linda University
identified from the Diabetes support group and in the (LLU) Medical Centre (LLUMC).

Table 1: Demographic data between DM versus NDM groups.

Groups Average age Average Average Average body Average

(years) height (cm) weight (kg) mass index hemoglobin
(BMI) A1c (%)
DM 64.1 ± 7.3 168.4 ± 9.5 85.6 ± 19.1 30.3 ± 7.2 6.8 ± 0.9
NDM 64.4 ± 6.6 166.2 ± 9 73.6 ± 14.9 26.6 ± 4.9 —

Subjects with overt neurological, orthopedic

conditions (e.g., recent fractures, inability to sit for 5
minutes), documented cardiovascular diseases,
bleeding disorders and history of deep vein
thrombophlebitis, Hemoglobin A1C (Hb A1C) level
of e” 9% (Estimated Average Glucose (eAG) = 212),
documented history of diabetic neuropathy (DN) with
or without treatment, failed to sense vibration and
monofilament testing, leg ulcer, chronically exposed
to vibration stimulus and pregnant females were
excluded. Fig. 1. SBF measurement of foot.

The subjects were assigned into two groups:

Group 1 = T2D and Group 2 = Control. Subjects The MLDI uses a red laser beam to capture the
received PV on their foot and on forearm of opposite reflected energy of blood flow. The instrument has
extremity on same day. The institutional review board captured SBF and produced pictures at the rate of 4ms/
at LLU approved all procedures and subjects signed pixels. The flow was measured in “flux” unit.
statement of informed consent.
Cutaneous sensation of the foot was assessed non-
Instrumentation invasively using Semmes-Weinstein Monofilament
(SWM) Touch-Test® Sensory Evaluators produced by
Physio Plate ® was used to deliver mechanical
North Coast Medical, Inc (North Coast, Morgan Hill,
vibration. It is a vibration platform (Physio Plate®,
CA, USA). SWM is simple, inexpensive, valid, and a
Domino S.R.L, San Vendemiano, Italy) with frequency
reliable clinical tool to assess sensation (32), (33).
settings ranging from 15-70 Hz. In this study, vibration
frequency of 50 Hz at high amplitude (5-6 mm
PROCEDURE
displacement) with peak acceleration of 7g was
delivered. MV was applied for bouts of 60 seconds Screening
working time with a rest period of 2 seconds for a total
number of 5 cycles for forearm and 10 cycles for foot. The room was pre-warmed and maintained at
22°-24°C for approximately 30 minutes. Procedures
Prior to subjects entering the laboratory, MOOR were explained and all subjects signed the informed
Laser Doppler Imager (MLDI) warmed up for 30 consent form. The subject’s age, weight and height
minutes. Skin blood flow was measured by MLDI were recorded. A subjective examination was carried
produced by MOOR Instruments, Inc. (MOOR FLPI out for exclusion. Although relatively rare, annual
V 2.1, Oxford, England). The MLDI scanner was placed incidence of deep vein thrombosis in diabetic and non-
perpendicular to the forearm and foot (Figure 1). The diabetic individuals is 0.4% and 0.08% respectively (14),
machine can provide blood perfusion images at the subjects were screened for possible deep vein
rate of as high as 25 images per second. thrombophlebitis (DVT) prior to receiving vibration.

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 230 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Calf pain, swelling, erythema, warmth and for ten minutes (Figure 5). Subjects immediately
difference in calf diameter were examined. A Well’s returned to the plinth for post vibration SBF
criteria score was calculated for each potential measurement. A third measurement was taken 10
subject(34). A score of d” 0 was considered as low risk minutes following vibration. Next the subjects were
(3% probability of DVT), 1 to 2 as moderate risk (17% positioned in long sitting with their forearm pronated
and resting on the vibration platform for five minutes
probability of DVT), and e” 3 as high risk (75%
(Figure 5). Similar SBF measurements were repeated.
probability of DVT) for individuals with signs and
symptoms of DVT and scores of e” 2 were excluded.

Cutaneous sensation of the foot was then

performed by using SWM in a quiet room with subjects
being asked to look away. The areas of the foot were
randomly tested by pressing the monofilament at a
90° angle against the skin. The monofilament was
placed in each area for 1.5 seconds. The stimulus was
checked with the six different evaluator sizes: 2.83
(0.07g), 3.61 (0.4g), 4.31 (2g), 4.56 (4g), 5.07 (10g), and
6.65 (75g). The stimulus was checked three times in
the same location for the filament sizes of 2.83 to 3.61
and one time for 2g to 75g. Sensory responses, color
on the handle, notation were noted on the sensory foot
mapping form (Appendix 1).

Vibratory sensation assessment (128 MHz tuning

fork)

Vibration sense is first affected in peripheral

Fig. 5. Foot PV
neuropathy(35). A strong vibration stimulus was applied
to the hallux and compared with examiner’s wrist
dorsally (36). A score of 0 (normal) was given if both the
subject and examiner simultaneously noted the
sensation had stopped. A score of 1 (reduced) if the
examiner can feel when subject reports it as ceased.
Absent sensation or a score of 2 was given when the
subject does not feel the vibration stimulus. The 128
Hz TF is a valid and reliable clinical tool to assess
DP(37), (38).

Testing

Subjects were positioned in supine on the plinth. A

square shaped scan area of 3cm×3cm was marked on
the anterior aspect of the forearm 2.54 cm distal to the
midpoint of the cubital crease. Four points on the
corners of the square were marked and was scanned
to measure SBF. The same procedure was applied on Fig. 6. Forearm PV
the plantar aspect of first three (1-3) metatarsal heads
for measuring the blood. The baseline SBF recordings RESULTS
were measured and then the subjects received
vibration. Mixed factorial ANOVA was used to compare the
effect of vibration. Bonferroni test was used to further
Subjects were asked to sit erect with their hip and identify the significance of group, time and site of
knee at 90° and foot placed on the vibration platform application.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 231

Tables 2 and 3 show a significant difference in foot between the groups (P=.102). Table 4 shows the mean
SBF across time for both DS and NDS (P<.001). There forearm SBF across time for both the groups. There
was no significant difference across time between was only a slight percentage change increase from the
groups (P=.102). Table 4 shows the percent change in start to the end of vibration in the DS (129.78%) vs. the
mean foot SBF across time for both groups. The greatest NDS (127.97%).
percent was seen in the diabetic foot (118.53%) from
baseline to end of vibration vs. non diabetic foot (37.62 Comparison Between Time, Location and Diabetes
%). When looking from the end of the vibration Status.
intervention to 10 minutes post, there was a less of Table 2 shows the BF comparisons between location
percentage change in the blood flow in the diabetic of vibration vs. Diabetes status at baseline, vibration
foot (-15.25%) vs. the non diabetic foot (-27.64%). end and 10 minutes post. There was no significant
Table 2 shows a significant difference in the forearm change in BF on the foot vs. the forearm at baseline,
SBF across time for both groups (P=.000). There was vibration end and 10 minutes post vibration between
no significant difference in forearm SBF across time groups (F=.679, P=.476).

Table 2. Comparison of significance of BF between time, location and diabetes status

Source F Sig.
Site Sphericity Assumed 1.376 .249
Site *Group Greenhouse-Geisser .740 .396
Time Greenhouse-Geisser 29.960 .000
Time *Group Greenhouse-Geisser 2.515 .102
Site *Time Greenhouse-Geisser .574 .525
Site * Time * Group Greenhouse-Geisser .679 .476

* Mixed-factorial ANOVA

Table 3. Bonferroni test for between subject effects

Source F Sig.
Group .000 .996

Table 4. Percent change in mean SBF (Flux) ± (SD) across time for each location.

Location Start (S) End (E) 10 min post (P) % change (S-E) % change (S-P) %change (E-P)
Foot DM 72.3 (8.1) 158.0 (17.0) 133.9 (13.8) 118.53 85.20 -15.25
NDM 117.5 (11.7) 161.7 (13.7) 117.0 (17.2) 37.62 -0.43 -27.64
Forearm DM 67.5 (14.8) 155.1 (7.6) 112.4 (7.9) 129.78 66.52 -27.53
NDM 61.5 (9.4) 140.2 (9.4) 88.1 (7.4) 127.97 43.25 -37.16

DISCUSSION (230%) vs. NDS (228%). No significant difference post

intervention suggesting that both groups had similar
Any small improvement in microcirculation
capacities to respond to PV. At 10 minutes post PV,
without stressing the thermoregulatory and
forearm SBF in both groups remained elevated but was
cardiovascular system will be beneficial to diabetes
beginning to decrease. The diabetics had a 27.5%
subjects. PV increases SBF without significantly
reduction while non diabetics had a 37.2% reduction
increasing skin temperature (ST) and blood pressure
in forearm SBF from the end of intervention as
(BP) in healthy adults (6), (30). There was no study
compared to 10-minutes post. In other words, forearm
performed on the effect of PV in diabetics. This study
SBF was maintained for longer time in diabetics than
focused on the effect of vibration on SBF in hairy vs.
non diabetics 10 minutes post vibration. However,
non hairy skin in T2D subjects.
there was no significant difference in the forearm SBF
There was no significant difference at baseline in between the groups.
SBF for the forearm (hairy) between the groups. The
On contrary to hairy skin, there was a decrease in
percentage change in forearm SBF more than doubled
non hairy (foot) SBF in the DS (72.3 ± 8.1 Flux) vs. the
from the start to the end of the vibration in both DS

44. Steni Balan--227--233.pmd 231 8/1/2013, 8:31 AM

 232 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

NDS (117.5 ± 11.7 Flux) at the baseline. The diabetics 2. Sumpio BE. Foot ulcers. N Engl J Med. 2000 Sep
had a significantly lower baseline SBF on the plantar 14;343(11):787-93.
surface of the foot. This is the most common site for 3. Webmed. diabetes. 2011 [cited 2011 July 13];
skin ulcers in this population. The greatest percent Available from: http://diabetes.webmd.com/
increase of SBF was seen in the diabetic foot from guide/type-2-diabetes.
baseline to end of vibration (218.53%) vs. non diabetic 4. Ziegler D. Diabetic cardiovascular autonomic
foot (137.62 %). In other words the non-diabetic foot neuropathy: prognosis, diagnosis and treatment.
only increased by approximately one-third in response Diabetes Metab Rev. 1994 Dec;10(4):339-83.
to PV while the diabetics foot’s SBF more than doubled. 5. Petrofsky J, Lee S. The effects of type 2 diabetes
At the end of 10 minutes post, the non-hairy foot blood and aging on vascular endothelial and autonomic
flow in diabetics (- 15.25%) was maintained for longer function. Med Sci Monit. 2005 Jun;11(6):CR
time than the non diabetics (- 27.64%). In other words, 247-54.
foot skin blood flow was maintained for a shorter 6. Lohman EB, 3rd, Petrofsky JS, Maloney-Hinds C,
period of time in the NDS than the DS 10 minutes post Betts-Schwab H, Thorpe D. The effect of whole
vibration. However, there was no significant difference body vibration on lower extremity skin blood
in foot SBF between DS and NDS. flow in normal subjects. Med Sci Monit. 2007
Feb;13(2):CR71-6.
Although there was a significant difference in foot 7. Ray CA, Monahan KD. Aging attenuates the
and forearm SBF across time within the groups, there vestibulosympathetic reflex in humans.
was no significant difference in foot and forearm SBF Circulation. 2002 Feb 26;105(8):956-61.
at baseline, vibration end and 10 minutes post between 8. Watkins PJ. The diabetic foot. BMJ. 2003 May
the groups. 3;326(7396):977-9.
Recommendations 9. Accurso V, Shamsuzzaman AS, Somers VK.
Rhythms, rhymes, and reasons—spectral
Future studies can focus on the activity level and oscillations in neural cardiovascular control.
body fat percent with vibration and can compare Auton Neurosci. 2001 Jul 20;90(1-2):41-6.
10. Sagliocco L, Sartucci F, Giampietro O, Murri L.
1. good control (A1c <7.5%) versus poor control (A1c
Amplitude loss of electrically and magnetically
>9%) diabetics(39) evoked sympathetic skin responses in early
2. moderately active (3 to 6 METs) vs. vigorously stages of type 1 (insulin-dependent) diabetes
active (> 6 METs) T2D subjects mellitus without signs of dysautonomia. Clin
Auton Res. 1999 Feb;9(1):5-10.
CONCLUSION 11. Hogikyan RV, Galecki AT, Pitt B, Halter JB, Greene
DA, Supiano MA. Specific impairment of
There is no difference in SBF in the forearm and endothelium-dependent vasodilation in subjects
foot at the baseline, vibration end and 10 minutes post with type 2 diabetes independent of obesity. J Clin
vibration between DS (fair to good control) and NDS. Endocrinol Metab. 1998 Jun;83(6):1946-52.
However, diabetics in fair to good control responded 12. Caballero AE, Arora S, Saouaf R, Lim SC,
similarly to PV as compared to non-diabetics. Smakowski P, Park JY, et al. Microvascular and
macrovascular reactivity is reduced in subjects
Acknowledgement: Nil
at risk for type 2 diabetes. Diabetes. 1999
Conflict of Interest: Nil Sep;48(9):1856-62.
13. Colberg SR, Parson HK, Holton DR, Nunnold T,
Source of funding: Nil Vinik AI. Cutaneous blood flow in type 2 diabetic
individuals after an acute bout of maximal
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14. Petrauskiene V, Falk M, Waernbaum I, Norberg
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M, Eriksson JW. The risk of venous
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thromboembolism is markedly elevated in
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http://diabetes.niddk.nih.gov/dm/pubs/
15. Jones EW, Mitchell JRA. Venous Thrombosis in
statistics/.

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Diabetes-Mellitus. Thromb Haemostasis. 29. Lohman EB, Bains G, Lohman T, Deleon M,

1983;50(1):237-. Perrofsky JS. A comparison of the effect of a
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17. Bracciano A. Physical agent modalities: theory MT81.
and application for the occupational therapist. 2 30. Lohman EB, Sackiriyas KSB, Bains GS, Calendra
ed. Thorafare, NJ: SLACK; 2008. G, Lobo C, Nakhro D, et al. A comparison of the
18. Rendell MS, Milliken BK, Finnegan MF, Finney whole body vibration and moist heat on lower
DA, Healy JC. The skin blood flow response in extremity skin temperature and skin blood flow
wound healing. Microvasc Res. 1997 in healthy older individuals. Med Sci Monit.
May;53(3):222-34. 2012;18(7):CR 415-24.
19. Lossius K, Eriksen M, Walloe L. Fluctuations in 31. Maloney-Hinds C, Petrofsky JS, Zimmerman G.
blood flow to acral skin in humans: connection The effect of 30 Hz vs. 50 Hz passive vibration
with heart rate and blood pressure variability. J and duration of vibration on skin blood flow in
Physiol. 1993 Jan;460:641-55. the arm. Med Sci Monitor. 2008 Mar;14(3):Cr112-
20. Johnson JM, Proppe DW. Cardiovascular Cr6.
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neuropathy. Asian J Surg. 2010 Oct;33(4):193-8.
21. Johnson JM, Brengelmann GL, Hales JR,
33. Lee S, Kim H, Choi S, Park Y, Kim Y, Cho B.
Vanhoutte PM, Wenger CB. Regulation of the
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22. Hales JR, Jessen C, Fawcett AA, King RB. Skin
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AVA and capillary dilatation and constriction
34. Wells PS, Owen C, Doucette S, Fergusson D, Tran
induced by local skin heating. Pflugers Arch. 1985 H. Does this patient have deep vein thrombosis?
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 DOI Number: 10.5958/j.0973-5674.7.3.098
234 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Immediate Effect of Jacobson's Progressive Muscular

Relaxation in Hypertension

Nisha Shinde1, Shinde KJ2, Khatri SM3, Deepali Hande4

1
Associate Professor, College of Physiotherapy, 2Professor & HOD, Dept. of ENT, 3Professor & Principal, College of
Physiotherapy, 4Lecture, College of Physiotherapy, Pravara Institute of Medical Sciences, Loni, Ahmednagar, District,
Maharashtra State, India

ABSTRACT

Objective: To study the effectiveness of Jacobson's relaxation techniques as an adjunct therapy in

control of hypertension.

Design: A Experimental study.

Setting: Constituent colleges of Pravara Institute of Medical Sciences (Deemed University) and the
colleges of Pravara Rural Education Society in the vicinity. Cardio-respiratory Physiotherapy
Department, College of Physiotherapy & Pravara Rural Hospital (Tertiary Hospital), Loni, Tal-
Rahata, Dist- Ahmednagar , Maharashtra State, India- 413 736.

Participants: A total of 250 college teachers were screened for hypertension. Out of which 105 subjects
were found suitable and willing for participation in the study.

Interventions: Jacobson's progressive muscle relaxation lying in supine position for 30 minutes.

Main outcome measures: Blood pressure and Heart rate.

Results: Significant difference was noted in systolic & diastolic blood pressure and heart rate
immediately after 30 minutes of Jacobson's progressive muscular relaxation technique.

Conclusions: Jacobson's progressive muscular relaxation may be used as an adjuvant therapy for
immediate control of hypertension.

Clinical Trial Registration Number: (PMT/PIMS/RC/ 2012/06)

Keywords: Hypertension, Relaxation, Blood pressure and Heart rate

INTRODUCTION cerebral and renal disease. 2 Hypertension experts still

debate the level of blood pressure considered
Hypertension is ranked as fourth top most disease
abnormal. A great deal of effort has been devoted to
on the basis of its prevalence1. Since most of the
search for a dividing line between normal tension and
individuals who suffer from hypertension do not have
hypertension. Systolic blood pressure above 140 mm
specific symptoms related to their elevated blood
Hg and or diastolic blood pressure above 90 mmHg
pressure, it is often called as the silent killer disease.2
probably, hypertension is a major health problem and are the currently accepted dividing line based on
biggest of the challenges of the 21st century. It affects epidemiological and interventional studies. From 1983
approximately one billion individuals worldwide. 3 In onwards, World Health Organization recommended
India, the prevalence of hypertension in adult the use of non-pharmacological approaches in the
population varies from 3 to 10% and the average figure treatment of hypertension 5 . Various Non-
is 4.8%. The population at risk above the age of 20 years pharmacological measures for hypertension includes;
is 330 million as per 1981 population figures.4 High life style modification, weight reduction, regular
blood pressure is major risk factor for causing cardiac, physical exercises, cessation of smoking, tobacco use

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 235

cessation, increase in intake of fruits & vegetable, SUBJECTS

reduction in alcohol, sodium intake and potassium
A total of one hundred and five subjects with
supplementation. Beneficial effects of Jacobson’s
primary hypertension without any known associated
progressive relaxation technique has been reported by
major health problem and who were working as
various authors 6,7. However, there is hardly any study
teachers in various colleges in the vicinity of the place
that has investigated the immediate effectiveness of
of study during September 2011 to December 2011.
this technique since it is believed that the information
Subjects who were not regular in taking medications
about immediate effectiveness may increase the
and who reported about aggravation of any symptom
hypertensive individuals’ adherence to this technique
due to exercise were excluded from the study.
and may serve as a non-pharmacological option for
immediate control of hypertension. Outcome measures
Relaxation can be highly beneficial if practiced The outcome measures used in the study were
routinely in one’s everyday life. Techniques involving systolic blood pressure, diastolic blood pressure
relaxation are widely used by people to reduce anxiety measured and heart rate.
and cope with stress-related problems. There are
countless methods used to achieve relaxation, but the PROCEDURE
procedures that are most commonly practiced in the
clinical setting are Jacobson’s (1938) Progressive The study received approval from Ethical
Muscular Relaxation, Schultz and Luthe’s (1969) Committee of Pravara Institute of Medical Sciences,
Autogenic Training, and Benson’s (1975) Relaxation Loni. Participants were screened based on the inclusion
Response (Weiten & Lloyd, 1998). In the last few and exclusion criteria and those willing to participate
decades, a substantial amount of data has been were briefed about the nature of the study and
collected on many factors relating to relaxation such intervention in the language best understood by them
as: specific effects of different methods of relaxation; and written informed consent was obtained. They were
individual differences in response to treatment; encouraged to clarify questions regarding the study,
variables that increase adherence to treatment and if any. Each subject underwent a standardized history
relaxation therapy effects on specific health problems.10 and physical examination. As well as the data was
“Silent water, It is said that they are deep and collected for the baseline blood pressure measurement
dangerous”, “A volcano is also quiet till interrupts with and heart rate. Systematic technique developed by Dr.
devastating results”. High blood pressure is somewhat Edmund Jacobson (1938), used for achieving a deep
such a situation and if left undetected and untreated it state of relaxation. All subjects received supervised
results in brain attack (stroke), heart attack, heart Jacobson’s relaxation ( JPMR). For Jacobson’s
enlargement, heart failure and kidney failure. Unlike Progressive muscular relaxation, the investigator
volcano, which cannot be predicted, high blood demonstrated technique to contract and relax various
pressure can be detected in the silent phase and if groups of muscles, to coordinate contractions and
treated adequately the hypertension volcano can be relaxations with deep breaths and to perform the entire
procedure with eyes closed in supine lying down
prevented from eruption.
position. After the trial session every subject performed
The goal in treating high blood pressure is to reduce this supervised Jacobson,s progressive muscular
the risk of serious complications, including heart relaxation for 30 min. After 30 min of training,
disease and stroke, by getting blood pressure under Outcome measures were reassessed immediately after
control, ideally which means reducing blood pressure the JPMR that is Blood Pressure and Heart Rate. The
upto 120/80 mm Hg. However, even a partial lowering data, thus obtained were considered for statistical
of blood pressure may bring major benefits. There is a analysis.
need of medication prescriptions to treat hypertension,
but changes in lifestyle including diet, exercise, and RESULTS
relaxation are also needed. 12 . for control of
Statistical analysis was done by using Statistical
hypertension.
Package of Social Sciences (SPSS) 13.0 using various
statistical measures such a mean, standard deviation
METHOD
(SD) and tests of significance such as unpaired ‘t’ test.
The study was designed as an experimental study. The results were concluded to be statistically

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 236 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

significant with p <0.05 and highly significant with p blood pressure. There was statistically significant
< 0.01. Unpaired ‘t’ test was used to compare difference in the mean and SD of diastolic blood
differences between the Pre and post session of pressure.
relaxation. (Table 1) The score showed statistically
significant difference in pre and post measurement in Table 3 shows statistically significant difference in
systolic blood pressure. There was statistically pre and post measurement in heart rate There was
significant difference in the mean and SD of systolic
statistically significant difference in the mean and SD
blood pressure. Table 2 shows statistically significant
of the heart rate.
difference in pre and post measurement in diastolic

TABLE 1. Mean deviation and standard deviation of systolic BP.

Pre Treatment Post Treatment ‘P’value ‘T’value Result

mean± Sd mean± Sd
147 ± 1.721 142 ± 2.231 <0.01 2.883 Highly significant

TABLE 2. Mean deviation and standard deviation of Diastolic BP.

Pre Treatment Post Treatment ‘P’value ‘T’value Result

mean± Sd mean± Sd
96 ± 1.291 94 ± 1.412 < 0.05 0.1187 Highly Significant

TABLE 3. Mean deviation and standard deviation of HR

Pre Treatment Post Treatment ‘P’value ‘T’value Result

mean± Sd mean± Sd
98 ± 1.157 94 ± 1.412 < 0.05 2.742 Highly Significant

DISCUSSION between the findings on anxiety and those on sustained

attention. Previous work has also observed
This study shows that Jacobson,s progressive
improvements in sustained attention as a result in
musculer relaxation techniques helps in better control
anxiety reduction, resulting in decreased distraction.
of blood pressure in hypertensive patients, regardless
Significant anxiety reduction was great and anxiety
of their initial level of hypertension. New research
reduction is responsible for some of the improvement
shows that the simple act of becoming relaxed can have
on the attention. The results of the three measures
surprising health benefits. In addition to the obvious
reported in present study show that anxiety reduction
psychological effects of relieving stress and mental
may have an effect on blood pressure.16.
tension, the new findings indicate that the deep
relaxation, if practiced regularly, can strengthen the The main idea of initiating the relaxation response
immune system and produce a host of other medically in this way is to take control of the voluntary muscles
valuable physiological changes.5 through creation of tension in them, followed by
forcing them into a state of relaxation. When the body
The greatest reduction was found in blood pressure.
is aware of the presence of the tension, it will respond
Blanchard et. al. (1988). The present findings are
by triggering the muscles to relax, where the rest of
consistent with the cross cultural studies conducted
the other components of the relaxation response will
on USA & USSR populations. There are several types
naturally follow 15. In addition to the findings, this
of relaxation therapies such as stretch release relaxation
study demonstrates a number of possibilities for the
(SRR),Jacobson,s progressive muscle relaxation
implementation of complementary therapies in an
(JPMR), cognitive imagery relaxation (COG), and some
evidence-based medicine environment. The existing
types of meditations. Here, the JPMR technique is used
evidence can be validated in practice in the form of
because of its better reported results, its simplicity in
small-scale studies in the context of implementation.
performance and easy independent practice at home.
The research process can be used as a structured form
The deep relaxation technique produces an immediate
of monitoring the effects of complementary practice.
reduction in state of anxiety 6 .The possible relationship

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 237

These observations encourage the belief that such Community health Science. DASH Collaborative
small-scale studies can be replicated or maintained on Research Group. NEJM ;336:1117-24.
a long-term basis as a part of everyday practice.19 The 9. NC VI- (1997) The sixth Report of the Joint
data thus obtained are amenable to meta-analysis at a National Committee on prevention,. Detection,
later date, and as such make it more likely that Evaluation and Treatment of High Blood
complementary therapies are included in the Pressure. Arch Intern Med.; 15fl4 13-46.
systematic reviews. 10. George M. Manesh,(2000) Bombardier C. et at
Clinical Approach to Hypertension. Harvard
CONCLUSION publication. 43:1520-1528.
11. Pescatello, Linda S, Franklin, Barry A. (March
Jacobson’s progressive muscle relaxation may be 2004) Exercise and Hypertension. Medicine &
used as an adjunct to conventional physiotherapy in Science in Sports & Exercise. 36(3):533-553.
hypertension. 12. Lesniak, Karen T.; Dubbert, (November 2001)
Exercise and hypertension Patricia Current
ACKNOWLEDGEMENTS Opinion in Cardiology. 16(6):356-359.
Ethical approval: Ethical Committee of Pravara 13. Stephen Archer, MD; Stuart Rich, MD (2000)
Institute of Medical Sciences, Loni, Maharashtra state, Primary Pulmonary Hypertension. A Vascular
India. (PMT/PIMS/RC/2012/06) Biology and Translational Research “Work in
Progress”. Clinical Cardiology: New Frontiers;
Funding: No funding was gained for the study. Circulation; 102:2781-2791.
14. Gupta R. (1999) Hypertension in India–definition,
Conflict of interest: None declared. prevalence and evaluation. Journal of Indian
Medical Association ; 97(3): 74-80.
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 DOI Number: 10.5958/j.0973-5674.7.3.099
238 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Chronic Abdominal Wall Pain in Children may be

Improved By Physiotherapy

Siba Prosad Paul1, Gina Farmer2, Krishna Soondrum3, David CA Candy4

1
ST4 in Paediatrics, 2Paediatric Physiotherapist, 3Specialist Registrar in Paediatrics, 4Professor, Consultant Paediatric
Gastroenterologist, St Richard's Hospital, Chichester, PO19, 6SE, United Kingdom

ABSTRACT

Functional abdominal pain is common in children and a proportion of these children suffer from
chronic abdominal wall pain (CAWP). CAWP is suggested when a positive Carnett's sign is elicited
in a child where the pain gets worsened by movement. Analgesics are generally not helpful in children
with CAWP. We describe a novel approach with physiotherapy (by core stability programme) for
managing children with this condition. The therapy was delivered by a paediatric therapist after
other organic causes of abdominal pain were ruled out. Forty two out of 49 children (85%) showed
improvement with this therapy. As the improvement was noticed during the therapy and sustained
thereafter we suggest that this therapy is helpful in children in CAWP.
Keywords: Chronic abdominal wall pain, Carnett's sign, Straight leg raising test, Physiotherapy, Children

INTRODUCTION to posture such as lying, sitting, standing, and

exercise3,4,5. A localised tenderness may be identified,
A significant proportion of children experiences
however, the pain often radiates over the periphery of
chronic abdominal pain. The child’s quality of life and
the abdomen where abdominal muscles join the
often school attendance are adversely affected 1,2.
skeleton.
Managing these patients can be challenging and can
lead to unnecessary invasive investigations and Abdominal wall pain is suggested by a positive
tertiary paediatric gastroenterology clinic referrals2,3. Carnett’s sign when the abdominal pain increases
when the abdominal muscles are flexed3,4 by straight
Abdominal pain-related functional gastrointestinal
leg raising (SLR) or lifting head and shoulders while
disorders (FGIDs) include functional dyspepsia,
the child lies supine. Abdominal wall pain could result
irritable bowel syndrome, and abdominal migraine.
from referred pain from the spine or myofascial pain.
Children whose non-organic abdominal pain does not
The pain can also result from structural conditions,
have the clinical features of these syndromes are said
such as localised endometriosis or rectus sheath
to have functional abdominal pain (FAP). FAP is
hematoma, or from incisional or other abdominal wall
characterised by episodic or continuous abdominal
hernias which need to be excluded3,4.
pain with insufficient criteria for other FGIDs and
which does not have evidence of an inflammatory,
METHOD
anatomic, metabolic, or neoplastic process to explain
the child’s symptoms. These criteria should be fulfilled We describe the use of paediatric physiotherapy as
at least once per week for at least 2 months before a a novel approach for treating CAWP in children on
diagnosis is made1. We suggest that, in a proportion the basis that the pain is of musculoskeletal or neural
of children, FAP is due to chronic abdominal wall pain tension in origin and is made worse by poor posture.
(CAWP).
The study group
CAWP is suggested by a chronic and unremitting
abdominal pain, with minimal or no relationship to The single centre cohort consisted of 60 children
food intake or defecation but can have a relationship out of which there were 46 girls (76%).

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 239

The children were aged between 6 to 16 years and

were referred to the paediatric gastroenterology clinic.
CAWP was suspected after the organic causes of
abdominal pain were ruled out and these children were
then referred to the physiotherapy clinic.

Forty nine children were adjudged to have a CAWP

after a physiotherapy assessment.

These children had abdominal pain made worse

by movement without gastrointestinal symptoms and
were started on the therapy and are included in the Fig. 1. Response to physiotherapy on CAWP
analysis; 46 children completed the full course of
physiotherapy. DISCUSSION

Physiotherapy assessment and treatment This case series suggests that CAWP might be a
cause of FAP in the paediatric population and is
The rationale for the use of physiotherapy and the amenable to treatment in the majority of affected
expected benefits were discussed by a paediatric children with physiotherapy. The finding that the
physiotherapist with the family before commencing symptoms did not improve while the children were
the therapy, which was continued for 8 weeks. waiting for treatment and that the improvement was
Treatment comprised of a core stability programme sustained during follow up suggests that the
spread over six sessions of physiotherapy, home interventions were therapeutic, rather than the CAWP
exercise programme and a telephone follow-up 4 improved spontaneously.
weeks after the last clinic session. Being mindful of the placebo effect of interventions
in CAWP, a randomised controlled trial of
The exercise programme in the clinic consisted of
physiotherapy versus an alternative treatment such as
correcting the eccentric use of abdominal muscles
relaxation therapy is required.
(lordotic posture and protruding abdomen “like
holding cup from the inside” or trying to support the
REFERENCES
spine by bracing outwards) and retraining the
abdominal muscles (work concentrically providing 1. Rasquin A, Di Lorenzo C, Forbes D, Guiraldes E,
better support with less effort). The home exercise Hyams JS, Staiano A, et al (2006). Childhood
programme involved maintaining a neutral spine: functional gastrointestinal disorders: child/
practicing standing, sitting, walking and good posture adolescent. Gastroenterology, 2006; 130(5):1527-37.
being integrated into everyday situations with a 2. Lindley KJ, Glaser D, Milla PJ. Consumerism in
muscular effort of 30% maximum. healthcare can be detrimental to child health:
lessons from children with functional abdominal
pain. Arch Dis Child, 2005; 90:335–7.
RESULTS 3. Fishman MB, Aronson MD, Chacko MR (2010).
At initial assessment all children had poor posture Evaluation of the child and adolescent with
chronic abdominal pain. Available at
and a limited SLR. Three out of 49 children did not
h t t p : / / w w w. u p t o d a t e . c o m / c o n t e n t s /
tolerate the therapy and complained of back pain;
evaluation-of-the-child-and-adolescent-with-
hence, the therapy was discontinued early. Forty two chronic-abdominal-pain accessed on 3rd Feb, 2012
children (85%) with CAWP responded to the 4. Suleiman S, Johnston DE. The abdominal wall:
physiotherapy program of treatment and the results an overlooked source of pain. Am Fam Physician,
are shown in figure 1. The group of children, who 2001; 64(3):431-8.
responded well to the physiotherapy programme, also 5. Srinivasan R, Greenbaum DS. Chronic abdominal
had improved SLR at discharge. wall pain: a frequently overlooked problem.
Practical approach to diagnosis and management.
Am J Gastroenterol. 2002; 97(4):824-30.

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 DOI Number: 10.5958/j.0973-5674.7.3.100
240 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Functional Status and Disability in Stroke Survivors of

North India

AGK Sinha1, Divya Dhamija2, Supreet Bindra3

1
Head & Reader, MPT Student, 3PhD Scholar, Department of Physiotherapy, Punjabi University, Patiala
2

ABSTRACT

Stroke is one of the leading causes of morbidity and mortality. It is necessary to not only focus on the
medical aspect of the disease but to also cater the disabilities associated with it. The study investigated
the complexity of factors that influence the functional status and disability following stroke using
qualitative interviews. It was found that majority of stroke patient's fall in the age group of 60-75
years. Occurrence of stroke was found to be more among high income group; those living in joint
families and urban dwelling, but the post of disabilities were more severe in rural dwellers. The
percentage of motor disability was highest followed by cognitive and social. A majority of stroke
patients were leading a poor quality of life with male sufferer's leading a comparatively better life.
Disability increased with the increase in level of spasticity and decrease in balance status Majority of
subjects who received physiotherapy were mildly dependent for their daily activity and on the other
hand those who did not receive were moderate to very severely dependent, depicting that
physiotherapy is essential during rehabilitative phase of stroke management.

INTRODUCTION Inclusion criteria

Stroke is currently the third leading cause of death 1. Patients who were diagnosed with stroke at least
in the Western world, ranking after heart disease and 1 year before.
cancer and is responsible for a large proportion of 2. Patient’s with either hemorrhagic or ischemic
disability and reduced quality of life, becoming more stroke.
frequent with increasing age¹. There is limited data
3. Patient’s aged between 30-90 years.
available on stroke mortality in India, however it is
estimated that stroke represented 1.2% of the total Exclusion criteria
deaths in the country, when all ages were included². 1. Patients with recurrent stroke
The incidence of stroke increases exponentially from
30 years of age, and etiology varies by age³. 2. Patient’s with any significant past medical history
of cardiac disease, malignancy, head injury, severe
Complications following stroke have been shown road traffic accident, and any other neurological
to impede rehabilitation, leading to poor functional problem which may hamper patient’s functional
outcome, and increased cost of care4. It is observed that status.
less work has been done on chronic stroke patients to
Tools of data collection
assess their functional status and disability in
developing countries. Considering the paucity of 1. Interview Schedule Technique
literature on stroke in India, present study would 2. Clinical Evaluation form.
supplement the existing knowledge of stroke.
3. Patient’s Medical Records.
Study Design and Methodology 4. Modified Ashworth Scale (MAS)
The study was conducted on a random sample of 5. Berg Balance Scale (BBS)
50 post stroke subjects from various multi specialty
6. Modified Barthel Index (MBI)
hospitals, private clinics and organizations in North
India (Yamunanagar district of Haryana, Jagadhari 7. Functional Assessment Measure (FAM)
(Haryana) and Patiala district of Punjab). 8. Disability Assessment Schedule II (WHO DAS 2.0)

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 241

Protocol 32% of the subjects took ayurvedic, 14%

homeopathic, 24% traditional form and 30% did not
Each subject was interviewed and clinically take any kind of treatment, besides taking the
examined individually using tools for data collection; allopathic one. Out of total subjects 72% received
however no award or incentive was given to any physiotherapy whereas 28% did not (Table 2).
subject. Those found afflicted with severe disability
were referred to nearby physiotherapy clinics or Table 2: Distribution of subjects on the basis of treatment
hospitals. Also some of the therapeutic exercises, Treatment Total Male Female
ergonomic advice and other measures to be taken were (%) (%) (%)
told to the majority of the subjects by the investigator. Ayurvedic 32 12 20
Homeopathic 14 6 8
The data so collected was then organized in a Traditional 24 8 16
tabular form, for all the variables studied. The Nil 30 22 8
Arithmetic mean and Percentages were used for Physiotherapy Treatment
summarizing the data and drawing inferences. Received 72 34 19
Not Received 28 14 7
RESULTS
56% of the subjects were found to have mild and
The minimum age of the study subjects was 30 4% maximal spasticity on assessment using MAS. 28%
years and maximum 85 years. Minimum duration of of the subjects were found to have good balance and
stroke was 1 year and maximum 6 years. 16% of the 20% had poor balance when assessed on BBS. Majority
subjects were illiterate, 38% of the subjects belonged of the subjects (90%) required minimal to moderate
to high income and 32% to low income group. 56% of assistance following stroke when measured using
subjects belonged to nuclear families and 64% subjects FAM. 48% of the subjects were mildly dependent and
resided in urban areas (Table 1). 22% were moderately dependent when level of
Table 1: Distribution of subjects on the basis of dependence was measured on MBI. 69.28% subjects
had motor, 44.33% cognitive and 22.12% had social
Demographic Features
disability following stroke. 20% of the subjects were
Parameter Total Male Female
(%) (%) (%)
mildly disabled, 34% moderately (male (22%) and
Age Group female (12%) Table 4) and 34% severely disabled
30-45 12 6 6 following stroke when measured using WHO DAS 2.0
46-60 28 10 18 (Table 3).
61-75 48 26 22
Table 3: Distribution of subjects on the basis of
76-90 12 6 6 Assessment Scales
Premorbid Education level*
Parameter Subjects (%)
Illiterate 16 2 14
Level of Spasticity (MAS)
Literate 46 2 24
Nil 20
Educated 38 24 14
Mild 56
Socioeconomic status**
Moderate 20
HIG 38 20 18
Maximal 4
MIG 30 12 18 Balance (BBS)
LIG 32 16 16 Good 28
Family Type Acceptable 52
Joint 56 26 30 Poor 20
Nuclear 44 22 22 Level of Assistance (FAM)
Place of Dwelling Minimal 62
Urban 64 32 32 Moderate 28
Rural 36 16 20 Maximal 6
Level of Dependence (MBI)
*Illiterate: never studied; Literate: passed 10th standard; Educated:
passed 12th or more Minimal 14
Mild 46
**HIG high income group: above 1 lac; MIG medium income
group: 50000-1lac; Moderate 22
Severe 4
LIG low income group: below 50000

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 242 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Table 3: Distribution of subjects on the basis of Table 7: Distribution of subjects in various levels of
Assessment Scales (Contd.) disability according to Socioeconomic status

Type of Disability Disability HIG (%) MIG (%) LIG (%)

Motor 69.28 No 2 0 0
Cognitive 44.33 Mild 12 6 2
Social 22.12 Moderate 12 16 6
Level of Disability Severe 10 6 18
No 2 Very Severe 2 2 6
Mild 20 Total 38 30 32
Moderate 34
Table 8: Distribution of subjects in various levels of
Severe 34 disability according to Premorbid Education level
Table 4: Distribution of subjects according to Level of Disability Illiterate Literate Educated
Disability measured on WHO DAS 2.0 (%) (%) (%)

Disability Male (%) Female (%) No 0 2 0

No 2 0 Mild 0 4 16

Mild 12 8 Moderate 4 14 16

Moderate 22 12 Severe 10 20 4

Severe 10 24 Very Severe 2 6 2

Very Severe 2 8 Total 16 36 38

Total 48 52 In subjects with mild disability, 12% had mild and

Among the subjects who resided in urban areas 16% 8% had no spasticity. In subjects with severe disability,
were mildly and 12% were severely disabled while 22% had mild and 8% had moderate spasticity (Table
those in rural areas 4% were mildly and 22% were 9). In subjects with mild disability 12% had poor
severely disabled (Table 5). Among those who lived in balance and 8% had acceptable balance. In subjects
nuclear families 14% were mildly and 12% were with severe disability 22% had acceptable and 10% had
severely disabled and those living in joint family 6% poor balance (Table 10).
were mildly and 22% severely disabled (Table 6). 10% Table 9: Distribution of subjects in various levels of
were severely disabled in high income group, 6% in disability according to Level of Spasticity using MAS
medium and 18% in low income group (Table 7). 10%
Disability Nil Mild Moderate Maximal
were severely disabled among illiterate subjects, 20% (%) (%) (%) (%)
among literate and 4% among educated subjects No 2 0 0 0
(Table 8). Mild 8 12 0 0
Moderate 6 20 8 0
Table 5: Distribution of subjects in various levels of
Severe 2 22 8 2
disability according to Dwelling place
Very Severe 2 2 4 2
Disability Urban (%) Rural (%) Total 20 56 20 4
No 2 0
Mild 16 4 Table 10: Distribution of subjects in various levels of
disability according to Balance status using BBS
Moderate 30 4
Severe 12 22 Disability Good Acceptable Poor
Very Severe 4 6 (%) (%) (%)

Total 64 36 No 2 0 0
Mild 12 8 0
Table 6: Distribution of subjects in various levels of Moderate 12 20 2
disability according to Type of Family
Severe 2 22 10
Disability Nuclear (%) Joint (%) Very Severe 0 2 8
No 2 0 Total 28 52 20
Mild 14 6
Moderate 14 20 In subjects with mild disability 20% required
Severe 12 22 minimal assistance. Subjects with very severe disability
Very Severe 2 8 required maximal to total assistance (Table 11). 8%
Total 44 56 subjects with mild disability were found to be

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 243

minimally dependent and 12% were mildly DISCUSSION

dependent. 12% subjects with severe disability were
While analyzing the data grossly it was found that
moderately dependent and 10% were severely
majority of stroke patient’s fall in the age group of 60-
dependent (Table 12).
75 years. Similar results have been given by Ellekjaer
Table 11: Distribution of subjects in various levels of et al. (1997)³. It was found that the premorbid level of
disability according to Level of Assistance required education posed no threat on the prevalence of stroke
measured by FAM
whereas socioeconomic status proved to be a
Disability Minimal Moderate Maximal Total significant factor with occurrence of stroke to be more
(%) (%) (%) (%)
among high income group. Engstram etal. (2002)5 also
No 2 0 0 0
gave the same statement that majority of people with
Mild 20 0 0 0
good income suffers with diabetes, hypertension and
Moderate 28 6 0 0
habit of smoking thus contributing factors of stroke. It
Severe 12 20 2 0
is also observed that more number of stroke sufferers
Very Severe 0 2 4 4
belonged to joint families and resided in urban areas.
Total 62 28 6 4

Table 12: Distribution of subjects in various levels of While examining the physical status of the subjects
disability according to Level of Dependence required on the ground of spasticity and balance, it was found
measured by MBI that 80% were suffering from mild to maximum level
Disability Minimal Mild Moderate Severe Total
of spasticity. Salem (2010)6 in his study determined 68%
(%) (%) (%) (%) (%) of subjects as spastic. In present study it was
No 2 0 0 0 0 established that 28% subjects had good and 20% had
Mild 8 12 0 0 0 poor balance. The results are similar with the finding
Moderate 0 26 8 0 0 of Tyson (2006)7 who in his study concluded that 25%
Severe 4 8 12 10 0 of the subjects had good balance and 75% had
Very Severe 0 2 2 4 2 considerable balance deficit following stroke. While
Total 14 48 22 14 2 examining the level of assistance it was found that 62%
of subjects required minimal assistance and 38%
12% were severely disabled following Ayurvedic
required moderate to maximal assistance even 1 year
and 6% following Homeopathic and traditional
after stroke. Also while examining the level of
treatment (Table 13). Among those who took
dependency it was found that 48% of the subjects were
physiotherapy, 22% were severely disabled and those
mildly dependent and 22% were moderately
who did not 10% were moderately, 12% severely and
dependent for the completion of their ADL’s.
6% were very severely disabled (Table 14).

Table 13: Distribution of subjects in various levels of It was found that motor disability owns the highest
disability according to treatment value which is similar to the results of Mercier et al. in
20018. Majority of women in the study suffered with
Disability Ayurvedic Homeopathic Traditional Nil
(%) (%) (%) (%) severe and very severe form of disability and majority
No 0 0 0 2 of men suffered with mild and moderate form of
Mild 6 2 4 8 disability. Jonathan et al. (2004)9 following his study
Moderate 10 4 12 8 stated that women were more prone to greater
Severe 12 6 6 10 disability owing to delay in seeking medical and
Very Severe 4 2 2 2 rehabilitative treatment and ignorance for self care
Total 32 14 24 30 activities. It is also observed that more severe form of
disability occurs among those dwelling in rural areas
Table 14: Distribution of subjects in various levels of
disability according to Physiotherapy received or not than those in urban areas with finding being consistent
with that of Sethi et al. in 200710. The results revealed
Disability Received (%) Not received (%)
that low and medium income group was more
No 2 0
disabled. Kapral et al. (2002) 11 studied that
Mild 20 0
socioeconomic status affects mortality and access to
Moderate 24 10
Severe 22 12 some health services after stroke leading to marked
Very Severe 4 6 residual disability.
Total 72 28

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 244 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Majority of subjects belonging to nuclear families REFERENCES

had mild to moderate form of disability while those
1. Davidson. Principles and Practice of Medicine.
from joint families had moderate to very severe form
18 ed. New York: Churchill Livingstone. 1999;
of disability and thus higher dependency on other
974-977.
family members. It was found that more severe form 2. Anand K, Chowdhury D, Singh KB, Pandav CS
of disability exists among illiterate subjects, less severe and Kapoor SK. Estimation of mortality and
among literate ones. morbidity due to strokes in India. J.
Neuroepidemiology 2001; 20(3): 208-11.
In establishing the physical factors affecting the
3. Ellekjaer H, Holmen J, Indredavik B and Terent
level of post stroke disability, it was found that
A. Epidemiology of stroke in Innherred, Norway,
disability increased with the level of spasticity and this 1994 to 1996: Incidence and 30-Day Case Fatality
finding has been supported by Watkins (2002)12. The Rate. J. Stroke 1997; 8(11): 2180-2184.
balance status also generated similar results. 4. Sackley CM, Baguley BI, Gent S and Hodgson P.
Acceptable and poor balance was associated with The use of a balance performance monitors in the
moderate to very severe form of disability. Tyson treatment of weight bearing and weight
(2006)7 in his study also produced similar results. The transference problems after stroke. J.Stroke 1992;
present study also determined that the assistance 78:907-913.
required by the subject (FAM) and the level of 5. Engstram G, Berglund G, Hedblad B, Janson L,
dependency (MBI) are directly proportional to the level Jerntop I and Rasmussen H. Geographic
of disability (WHO DAS). distribution of stroke incidence within an urban
population: relations to socioeconomic
The majority of the subjects who did not receive circumstances and prevalence of cardiovascular
physiotherapy were suffering from moderate to very risk factors. J. Stroke 2001; 32(5): 1098-103.
severe form of disability and those who received had 6. Salem NC Pioneering stroke spasticity expert
no or mild form of disability and thus were living a Welcomes FDA approval of botox to treat upper
nearly independent life. Pound et al. (1994)13 also gave limb spasticity following stroke. Wake Forest
similar results and stated that the impact of University, Baptist Medical Centre, Medical
Centre, Boulevard 2010.
physiotherapy is not confined to reducing physical
7. Tyson SF, Tallis RC, Chillala J, Hanley M. and
disability but may also affect well being. The study
Selley A. Balance disability after stroke. J. Phys
focused on the fact that total 78% of subjects received
Ther 2006; 86(1): 30-8.
ayurvedic, homeopathic and other traditional forms 8. Mercier L, Rochette A, Audet T, Dubios MF and
of treatment plus physiotherapy and 24% took only Hacbert R. Impact of motor, cognitive, and
ayurvedic, homeopathic and other traditional forms perceptual disorders on ability to perform
of treatment and out of those 23% had moderate to activities of daily living after stroke. J.Stroke 2001;
very severe form of disability (Table 13). This shows 32(11):2602-8.
that other forms of treatment did not bless any extra 9. Jonathan W, Amanda K, Geoffrey A, Dewey P,
visible or affective benefit to the victims and efficient Donnan MD, Helen M, Richard A, Sturm PD,
results of physiotherapeutic intervention as far as level Macdonnel MD, and Velandi S. Quality of life
of disability is concerned. after stroke. J. Stroke 2004; 35:2340.
10. Sethi N, Anand I, Ranjan R., Sethi P, and
CONCLUSION Torgovnickn J. Stroke: The neglected epidemic,
an Indian perspective. The Internet Journal of
The results of the study conclude that among Neurology 2007; 8(1).
demographic factors except premorbid level of 11. Kapral MK, Mamdani M and Wang H. Effect of
education, all other factors affect the incidence of socioeconomic status on treatment and mortality
stroke. The prevalence of stroke was more among after stroke. J. Stroke 2002; 33(1):274-5.
12. Watkins CL, Gregson JM, Leathley MJ, Moore AP,
urban population but the post of disabilities were more
Sharma AK and Smith TL. Prevalence of
severe in rural dwellers. Male sufferers were living a
spasticity post stroke. J. Clin Rehabil 2002;
comparatively better life than females. The percentage
6(5):515-22.13. Pound P, Ebrahim S, Bury M and
of motor disability was highest followed by social and Gompertz P. Views of survivors of stroke on
cognitive. Disability increased with the increase in level benefits of physiotherapy. J. Quality Health Care
of spasticity and decrease in balance status. 1994; 3(2):69-74.
Physiotherapy proved to be a boon for patients as far
as level of disability is concerned.

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 DOI Number: 10.5958/j.0973-5674.7.3.101
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 245

Kinetic Chain Exercise for Patello Femoral Pain

Syndrome - A Randomised Control Study

Suresh Kumar T1, Leo Rathinaraj A S2, Jeganathan A3, Vignesh Waran Vellaichamy4
1
Assistant Professor, Maharashtra Institute of Physiotherapy, Latur, 2Lecturer, Department of Physical Therapy, COAMS,
University of Hail, Saudi Arabia, 3Professor, MAEER's Physiotherapy College, Talegaon, Pune, 4Lecturer, Santosh College of
Physiotherapy, Ghaziabad

ABSTRACT

Objective: The objective was to compare the effect of open kinetic chain exercise and closed kinetic
chain exercise in quadriceps strength and pain in patients with patella femoral pain syndrome.

Introduction: Patello femoral pain syndrome [PFPS] can be defined as retropatellar pain or peri
patellar pain resulting from physical and biochemical change in patella femoral joint. The patients
with patello femoral pain syndrome have anterior knee pain, which typically occurs during activity
and often worsens with descending stairs and also triggered by prolonged sitting. Patello femoral
pain syndrome is due to the degeneration in the articular cartilage of the knee cap. PFPS is the most
prevalent disorder involving the knee and can be misdiagnosed sometime as bursitis, meniscus, and
ligament instability. Osteoarthritis, chondromalacia patella produce more stress on the patella femoral
mechanism.

Materials & Methodology: After getting the ethical clearance for this study 30 patients with PFPS
were selected and randomized into 2 groups after due consideration of the inclusive and exclusion
criteria. The patients consent for this study was taken and documented. Procedure: Group A and
Group B subjects were given with open kinetic chain [OKC] and closed kinetic chain [CKC] exercises
respectively. The dosimetry of these exercises was 30 minutes duration every alternate day for 4
weeks. Data collected for statistical analysis included Maximal Isometric Voluntary Contraction
[MVIC] using surface EMG on Vastus Medialis [quadriceps muscle] and Pain by visual analog scale
[VAS] before and after exercise.

Result: Data collected were statistically analyzed using the SPSS 11 version for t-test. The paired t-
test value for both CKC and OKC shows that there is a significant improvement in the quadriceps
strength and pain reduction in both the groups. The unpaired t-test between the groups for quadriceps
interference [3.45] and pain score in VAS scale [2.89] with p value at 0.01 shows that closed kinetic
chain [CKC] exercise is better than the open kinetic chain [OKC] exercise in improving the strength
and reducing the pain among PFPS patients.

Conclusion: To conclude, though both OKC and CKC exercises are beneficial in PFPS patients, CKC
proved to be better than the OKC in improving the quadriceps muscle strength and reducing the
pain. This study proves this statement statistically with significance.
Keywords: Patello Femoral Pain Syndrome [PFPS], Open Kinetic Chain Exercise, Closed Kinetic Chain
Exercise, Kinetic Exercises

INTRODUCTION typically occurs with activity and often worsens with

descending stairs and is triggered by prolonged sitting.
Patello femoral pain syndrome [PFPS], a
PFPS is one of the most prevalent disorders involving
retro-patellar pain or peri-patellar pain resulting from
physical and biochemical change in patella femoral the knee1. Patella, the largest sesamoid bone articulates
joint. PFPS patient complains anterior knee pain which with femoral grove to form the patella-femoral joint.

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 246 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Normal function of patellofemoral joint depends upon Kinetic chain is sequential activation of the
passive stabilizer; the chief one is vastus medialis segments of the limb, allowing it to generate force,
muscle which realign the patella medially. stabilization of the limb and transfer force to the distal
Insufficiency of this muscle leads to patella mal- end of the chain10. Open kinetic chain exercise [OKC]
alignment, causing articular cartilage breakdown and is an activity in which the distal part of the end is not
leading to patella femoral pain syndrome. The fixed, but free 11, providing a motion segment in
symptoms of PFPS are caused by structural orbio- isolation and usually considered as an exercise with
mechanical changes of the joint, exacerbated by no weight bearing. Closed kinetic chain [CKC]
activities such as going up and down stairs, sitting for exercises involving multi-joint movements performed
a prolonged period, squatting or kneeling, resulting with fixed distal extremity, often associated with
in increased compressive forces in the patella-femoral weight bearing 12. CKC exercises generate muscle co-
joint. PFPS are also associated with patellar crepitus, contraction of agonists and antagonists, in order to
swelling, and joint blockage2. provide greater articular surface13,14, producing still
lower shear load of the tibia, the compression force
PFPS may be caused by patellar malalignment,
increasing and decreasing the tibia-femoral
increased Q angle, high or low patella, excessive
compressive forces near patella-femoral the
subtalar pronation, lateral rotation of the tibia, femoral
extension15.
anteversion, knee valgus or varus, shortening of the
lateral retinaculum, muscle hamstrings and iliotibial Proprioception is also an influential factor in the
tract3. The inappropriate behavior of the patella can choice of these exercises, since it is believed that the
cause pain in the anterior knee 4. Previous study feedback is more efficient due to the compressive forces
showed that the combination of factors, such as of the body and the foot contact with the ground, and
abnormal lower limb biomechanics, soft tissue tension, reproduce functional movements commonly
muscle weakness and excessive exercise may result in performed activities of daily living16.
increased stress on the cartilage and subchondral bone
leads to the patellar misalignment and resulted in the In addition several methods have reported patella
development of pathology of PFPS5. femoral pain syndrome, it is generally agrees that
patella femoral pain syndrome should be managed
Quadriceps muscle is the main structure
initially by conservative rather than operative means.
responsible for activating the forces exerted on the
The basis of conservative treatment is strengthening
patella, which controls the position of the patella on
of quadriceps and soft tissue stretching of quads
the femoral groove, medially by the oblique fibers of
musculature. The most successful rehabilitation
vastus medialis [VM] and laterally by vastus lateralis
program should emphasize progression to without
[VL]6. Vastus Medialis muscle is divided into two
increasing symptoms keeping exercise intensity and
portions, a proximal one called the vastus medialis
patella femoral stress low and repetition relatively high
longus (VML) whereas the distal portion is the vastus
will help to reduce pain in patella femoral pain
medialis oblique (VMO). Both these parts differs
syndrome.
anatomically, functionally, histochemically and also in
the pattern of innervation7. VMO originates mainly
NEED FOR STUDY
from tendon of adductor magnus muscle and inserted
at an angle of 50-55 degrees in the longitudinal axis of Exercise to strengthening the quadriceps is
the femur8 and it is considered as the primary dynamic considered the best option for the treatment of PFPS.
medial stabilizer of the patella-femoral joint9. Both CKC and OKC exercises are used to strengthen
Primary goal in treating a patient with PFPS is to the quadriceps muscle fibre and choosing this is still
reduce the pain, improve the function and thereby confusing. Thus the current study is done to find a
enhance their quality of life. Though management of solution and to identify the superiority among these
PFPS involves multidisciplinary approach like exercise programs.
pharmacological intervention, use of physical
modalities [cryotherapy, diathermy, TENS, cold MATERIALS AND METHODOLOGY
LASER], therapeutic exercises [strengthening,
After obtaining the ethical approval for this study,
stretching, mobilization] and behavioural treatment,
30 patients with PFPS attended the outpatient
exercise to retrain the quadriceps muscle plays an vital
physiotherapy department of YCRH, Latur were
role in the management of PFPS.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 247

divided into 2 groups with 15 patients in each by Intervention: Group A given with Open kinetic
simple random sampling method, after due chain exercise of 30 minutes for 4 weeks with warm
consideration to the inclusive and exclusion criteria. up and cool down exercise. Patient advised to do High
Inclusion criteria were both sexes are included, age sitting quadriceps exercise [90 to 0 degree knee
between 18 to 35 years, VMO insufficiency, Patello
extension], standing Hamstring curl, Straight leg
femoral pain syndrome patients. Exclusion criteria
raising with holding for 5 seconds.
were patients with fixed deformities, peri-patellar
subluxation and dislocation, fracture of patella, any Group B given with Closed kinetic chain exercise
recent knee surgery, knee ligament injury, any intra for 30 minutes for 4 weeks with warm up and cool
articular pathology, disorders of patella like bipartite
down exercise. Patient advised to do mini squats,
patella. The pathology, exercise program and its effects
forward lunge, lateral step ups, standing wall slides.
were explained to these patients and their informed
consent for the study was taken and documented. Data & Statistical analysis: The VAS values were
Evaluation: Before the evaluation, the subjects measured in the first [before] and last [after] sessions,
signed an informed consent form. In the first and last obtaining values between zero and 10 cm. The EMG
sessions, the following elements were evaluated: signal was processed by means of the software and
electromyographic activity - Maximal Isometric the maximum EMG activity – MVIC was selected with
Voluntary Contraction [MVIC] and pain. The lower the MUAP of the rectified signal calculated in the
limb showing the greater clinical complaint was chosen selected period. The mean of the three attempts was
for evaluation. Pain was measured using a visual analyzed. The collected data were then statistically
analogue scale [VAS] with values between zero and analyzed using the SPSS version 11 for ‘t’ test with the
10cm. EMG muscular activity was detected using an level of significance set at á<0.01.
8-channel EMG equipment interfaced with a computer
and data collection software – Neuro Perfect plus with
RESULTS
sweep -10ms, sensitivity 100 micro volts, low cut
100Hz, high cut 5 KHz, pulse / sec - 1, pulse width - The application of the paired t-test for the outcome
0.02ms. The surface electrodes [SEMG] were placed exhibited a highly significant reduction in the pain and
on the muscle motor point, located by electrical
improvement of MVIC in both OKC [group A] and
stimulation, to allow the reproduction of this study
CKC [group B]. The Analysis of the post intervention
after treatment. Surface electrodes were positioned on
parameters between OKC and CKC group exhibited a
the muscle belly, 2 cm apart, and fixed with adhesive
tape. The EMG activity of the VM muscles was highly significant [á < 0.01] reduction in the pain and
measured during three repetitions of isometric knee improvement of MVIC in CKC [group B] as compared
extension and documented [MVIC]. to the OKC [group A] (Tab.1).

Table 1: Comparison of the outcome measures between group A and group B.

Evaluation Parameters Group Mean Value ± SD Result [Un-paired ‘ t’ value]

Pre-test Post-test
Maximal Voluntary Isometric Group A 26.8 ±4.64 32.3 ±4.05 3.45 [Highly significant with
Contraction [MVIC] p < 0.01]
Group B 26.7 ±4.30 37.3 ±3.75
Pain Group A 6.05 ± 0.69 2.95 ± 0.16 2.89 [Highly significant with
p < 0.01]
Group B 5.90 ± 0.81 2.1 ± 0.70

DISCUSSION to 0° extension. Up to 30º, the angle between the forces

is too small to generate high compressive stress
In open kinetic chain exercise, the quadriceps between the patella and the condyles and the contact
muscle works in isolation, increasing the area of articulating surface decreases from 90° to 0°.
patellofemoral compressive forces 17. In this type of With a larger force and a smaller contact area, there is
exercise, the center of gravity is in front of the knees, increased stress in the articulating surface that can
so that the strength in flexion is greater than 90 degrees delay the recovery.

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 248 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

According to Pattyn E the last degrees of knee syndrome may tolerate closed kinetic chain exercises
extension exercise in open kinetic chain, provide lower better and consequently may exhibit better functional
articular contact and therefore less instability. There is results after such a rehabilitation program21. The reason
also higher patellofemoral stress, since the contact for reduction of pain close kinetic chain exercise may
angle is less and therefore the compressive forces be the increases in circulation to local area which clears
although smaller, are distributed over a smaller contact metabolites away from that area and causes
area, increasing the stress18. stimulation of endorphins there by reducing pain.

In CKC type of exercise there is greater amplitude

CONCLUSION
of the signal of the VMO compared with the open
kinetic chain exercises. However, the signal VMO is Based on the statistical analysis the results of these
lower than that of VL, both in open and closed kinetic study shows that there was a significant improvement
chain19. To selectively strengthen the VMO muscle, in both the groups between pre and post exercise
which seeks not only the range of motion that shows session. Further between groups analysis shows that
more activity, but also offers greater stability, higher the subject who participated in CKC [group B] has
compressive strength and greater activation in relation shown more reduction of pain than OKC [group A].
to the lateral components. So this study concluded that closed kinetic chain
exercise were beneficial for improving quadriceps
Selfe J et al. (2006) recorded improvement in muscle strength and pain reduction.
passive proprioceptive test evaluated during 40° knee
flexion and 50° knee extension in patients with PFPS Conflict of Interest: There is no conflict of interest
at the end of the isokinetic treatment of 6 weeks20 . In between the authors
this study, improvement was observed in concentric
phase proprioceptive senses of patients in both groups Source of Funding: Nil
at the end of the active proprioception evaluation at 0- Ethical Clearance
45° knee flexion angle. The improvement in
proprioceptive senses provided by CKC exercise This research study is given clearance under Ethical
programs may be associated with the increase in committee headed by Prof Dr. Koti Reddy, Principal,
muscle strength and the decrease in patellofemoral Maharashtra Institute of Physiotherapy, Latur.
joint reaction strengths.
ACKNOWLEDGEMENTS
Based on literature review & statistical analysis
results of our study shows that the subjects who The authors are thankful to Prof Dr.Koti Reddy
participated in Group B shown good improvement in M.P.T, Principal Maharashtra Institute of
quadriceps strengthening and reduce pain than Physiotherapy for kindly providing laboratory
Group A. facilities to carry out these works. A special thanks to
my senior Dr.Lenin, for being the source of inspiration.
The reason for improving quadriceps strength in
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controlled co-contraction synergist and antagonistic G.B .Functional and EMG responses to a physical
muscle which increases sensory motor co-contraction. treatment in patellofemoral syndrome patients.
CKC exercises contains more eccentric muscle work Journal of Electromyography and
and because it is known that eccentric exercise develop Kinesiology.2006;16: 167-74.
more tension in the muscle and there by obtain greater 2. Tunay, V.B.,et al. Treatment of patellar tracking
effect. and pain in patellofemoral malalignment:
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4. Doucette SA, Goble EM. The effect of exercise on 13. Boucher, J.P., King, M.A., Lefebvre, R., and Pépin,
patellar tracking in lateral patellar compression A. Quadriceps femoris muscle activity in
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Rehabil. 2006; 85 [3]: 234 – 243. contact mechanics associated with patellofemoral
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Hip strength in females with and without prospective randomized study. The American
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Dysfunction: an Updated Revision. Clinical 18. Pattyn E, et al. Vastus medialis obliquus atrophy:
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 DOI Number: 10.5958/j.0973-5674.7.3.102
250 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Effect of Mechanical Low Back Pain on Postural Balance

and Fall Risk

Ibrahim M M1, Shousha T M2, Alayat MS3

1
Associate Professor, Faculty of Physical Therapy, Physical Therapy Department for Musculoskeletal Disorders, Cairo
University, Department of Physical Therapy, Faculty of Applied Medical Sciences, Umm al QURA UNIVERSITY
2
Associate Lecturer, Physical Therapy Department for Musculoskeletal Disorders, Faculty of Physical Therapy,
3
Lecturer, Physical Therapy Department for Basic Sciences, Faculty of Physical Therapy, Cairo University

ABSTRACT

Objective: To evaluate the effect of mechanical low back pain on postural balance and fall risk.

Materials and Method: This study was conducted on 20 mechanical low back pain (MLBP) subjects
compared with 20 norms using the Biodex Balance System to evaluate balance as the dependent
variable including postural stability, fall risk and limits of stability.

Result: There were significantly differences between both groups in the postural stability test
(p=0.0008), fall risk test (p=0.0093) and limits of stability test (p= 0.0001) revealing the increase in fall
risk with MLBP.

Conclusion: It could be concluded that balance exercises are essential and should be considered
during rehabilitation of LBP patients.
Keywords: Low Back Pain, Fall Risk, Balance, Biodex

INTRODUCTION of displacement under physiologic loads so there is

no initial or additional neurologic deficit, no major
Low back pain (LBP) is a common medical problem.
deformity, and no incapacitating pain.(8) Several studies
There is a 50–70% chance of an individual having LBP
show that LBP patients have poorer postural stability
pain during his or her lifespan. (1) With a prevalence of
than healthy subjects.(9,10) The maintenance and control
about 18% in the industrialized societies. (2) The Exact
of balance, in static or dynamic situations, is an
causes for most LBP conditions are not known.
important requirement for physical and daily
Although negative social interaction (for example,
activities.(11) So well-functioning postural balance is
dissatisfaction at work) has been found to relate to
essential to maintain normal daily life (12).
chronic LBP, a significant portion of the problem is of
mechanical origin. It is often referred to as clinical Postural stability is a subdivision of postural
spinal instability. (3) However several patients with low balance defined by the ability to maintain a specific
back pain are referred to physical therapy, which starts posture and repeatedly described by changes in center
with a thorough evaluation involving observation of pressure (COP).(13) In contrast to the previous,
and/or measurement of range of motion, strength, Kathleen et al, showed that no difference was found
overall function, posture, and body mechanics. (4,5) So between unilateral low back pain patient and control
it is not easy to rule out the source of LBP because it is group in limits of stability test (14).
often complicated by psychological, social and
economic factors. However good balance is needed for carrying out
normal activities of daily living, it is important for
The symptoms of mechanical low back pain physical therapists to evaluate balance in patients with
(MLBP) are normally aggravated by Physical activity, potential impairments to keep balance during normal
specially bending, extending, twisting and lifting. (6, 7) activities, a persistent relation is required between
Clinical spinal instability is not well understood. White central and peripheral components of the nervous
and Panjabi defined clinical instability of the spine as system that controls the center of gravity within the
the loss of the spine’s ability to maintain its patterns base of support (15,16), therefore, the purpose of the

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 251

present study was to evaluate the effect of mechanical poor balance and increased fall risk. The BSS provides
low back pain on postural balance and fall risk in an visual feedback that allows individuals to relate to and
attempt to avoid the falling complications which are reproduce specified motion patterns
dangerous including fractures and head trauma.
Testing Procedures
MATERIALS AND METHOD The platform balance task required the subject to
Twenty MLBP subjects were compared with twenty stand barefooted in a comfortable upright position. The
matched norms using The Biodex Balance System to participants instructed to adjust feet positions until
evaluate balance as the dependent variable including they found a position at which they were able to
postural stability, fall risk, limit of stability. During the maintain a moving point in the center or near the center
test each subject was instructed to keep a cursor on of the cir-cles, with the difficulty level of 6 resulting in
the screen of the Biodex system, directly in the middle a moderately unstable platform. Then the platform was
while balancing on the platform, after adoption of a locked and the feet placement was recorded and saved
proper position on the platform and accordingly results for assessing trials in all testing sessions. Foot position
were conducted. coordinates were constant throughout the test sessions.
During Postural stability and fall risk tests the subject
Collection of Sample: was instructed to keep the cursor directly in the middle
of the screen while balancing on the platform. During
Forty subjects aged from 20 to 30 years participated the test, the subjects tried to maintain their balance by
in this study. The mechanical low back pain patients themselves looking at a target on a screen and keeping
(MLBP) group consisted of twenty patients (mean age a dot marker at the center of the target. Three 20-second
21.85 ± 0.93 years) while the control group consisted practice trials were performed and a 10-second rest
of twenty subjects (mean age 21.8 ± 0.83 years). The period was allowed between trials. The Biodex limit
Biodex Balance System was used to evaluate balance of stability (LOS) test prompts participants to move a
as the dependent variable including postural stability, cursor, by leaning toward a target while standing on
fall risk, limit of stability. During the test each subject the fully unstable platform (level 6). Participants were
was instructed to keep a cursor on the screen directly instructed to “complete the test as accurately as
in the middle while balancing on the platform, after possible. The LOS test measures the time and accuracy
adoption of a proper position on the platform. with which participants transfer their estimated COG,
The Biodex Balance System (BBS) moving the cursor to intercept each of 8 successive
targets on the display screen. The participant reaches
The Biodex Balance System (BBS) (Biodex Medical the target by leaning and returning to the center
Systems, Inc., Shirley, New York) (fig1) was used to position before the next target is selected and displayed
evaluate balance indicators as the dependent variables. on the screen. The test is complete when all 8 targets
The platform of BSS allowed movements in a 360 have been reached.
degrees range and up to 20 degrees of tilt at any point
in the range. The BBS uses a circular platform that is OBSERVATION & RESULTS
free to move about the anterior-posterior (AP) and
Table 1: Comparison between groups in postural
medial-lateral (ML) axes simultaneously.
stability test.
This BBS measures the degree of tilt about each axis Postural stability
during dynamic conditions. The BBS level indicates Mean±SD T sig
the stiffness or stability of the foot platform, with level Normal 1.07±0.4 3.6 0.0008
12 being the most stable and level 1 the most unstable. Patients 1.8±0.8
The stability settings of 12 through 1 allow the foot
platform a full 20 degrees of deflection from level in Table 2: Comparison between groups in Fall Risk test
any direction. The platform is interfaced with
Fall Risk
computer software, which enables the device to serve
as an objective assessment of balance. Mean±SD T sig
Normal 1.9±0.6 2.7 0.0093
The fall risk test result includes over all stability Patients 3.3±2.2
index (OSI) score. The high score in the index indicates

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 252 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Table 3: Comparison between groups in Limit of As no reference values exist, we have no firm
Stability test. knowledge on this point.
Limit of Stability
In that study of concurrent and predictive validity
Mean±SD T sig
of postural balance in LBP patients, no association was
Normal 37.8±12.1 4.5 0.0001
found between Center of pressure measures and pain,
Patients 22.8±8.1
fear of pain, and physical function. Correlations were
not clinically relevant, and most were even non-
DISCUSSION
significant. Furthermore, no differences were found
The etiology of LBP in most patients is not known, in Center of pressure measures at baseline when
as mentioned earlier. It may be hypothesized that a comparing patients with clinically relevant
certain percentage of these patients may have improvements and patients with no change in back-
suboptimal neuromuscular control, especially under specific function and pain. (18)
dynamic conditions. The results of this study suggest
It is certain that LBP subjects present deficits in the
there are differences in balance reactions for those who
sense of position for of the hip region, and then they
suffer from mechanical low back pain compared to
evoke an ankle strategy to keep the standing posture.
those with no history of low back pain. At the time of
The influence of muscle fatigue due to change in trunk
the study, all of the subjects with low back pain
position combined to pain would may lead to
subjectively had relatively low levels of pain; their
increased instability in low back subjects, even for
balance reactions were different from their pain-free
those subjects with chronic pain.(19)
counterparts. A few studies have specifically looked
at this aspect of LBP. An increase in body sway of low Considering LBP as the only factor related to
back pain patients has been previously reported by changes in postural control, this change in normal
Byl and Sinnott, (12) who demonstrated that subjects standing posture leads to increase muscle activation
with low back pain tended to keep their center of force of back muscles, which will result in an increased
posterior compared with healthy subjects. They fatigue rate. These changes in the pattern of back
suggested that this posterior shift causes a relaxation muscle activation have been suggested as a strategy
of the subject’s trunk muscles, an increase in lumbar to limit spine movements regardless of the pain
lordosis, and greater compressive forces to the intensity.(20) Harding et al,(21) designed a 30-sec 1-leg
vertebrae and neural foramina (12). stance test for low back pain patients in which the
number of times the non-weight bearing foot touched
It is unknown whether this shift is a cause or a result
the ground and the elapse time to the first touch was
of the impaired balance, but this postural
recorded. Their test showed poor test-retest reliability.
compensation may cause greater mechanical stress and
These findings are in line with previous work showing
muscle imbalance, thus continuing the progression of
the largest differences between CLBP patients and
low back pain. Further studies mentioned that, subjects
healthy subjects. It is important to rule out that pain
with low back pain had an outwardly low level of
itself is not directly responsible for the observed
dysfunction, yet they subjectively felt that chronic low
modification of the control of balance.
back pain was adversely affecting the quality of their
lives (17). The absence of acute pain in our patients during
testing conditions does not necessarily rule out the
They suggested that patients who have a higher
possibility of some activity arising from nociceptive
level of pain and/or a lower level of function would
afferents,(22) Muscle pain can cause marked decrease
have more severely impaired static balance, resulting
in position sense, (23) possibly through increased
in greater postural sway and a continuing cycle of
presynaptic inhibition of muscle afferents at spinal
muscular imbalances, chronic pain, and dysfunction.
level or by a down-regulation of cortical proprioceptive
,they also suggest that subjects with low back pain
processing.
would most likely show deficits in dynamic balance
reactions compared with normal subjects as well.(17) Granat et al, suggest that direction of systems
Another study revealed that it is possible that impaired involved in sway angle may be an important indicator
balance is present in just a subgroup rather than in all of instability, especially in patients with pathology (24).
LBP patients, meaning that some patients should not It has been claimed that balance dysfunction in patients
be expected to experience any change in balance.(18). with CLBP may be due to altered proprioceptive

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 253

feedback from the lumbar spine. (25, 26) This suggestion 2. Nagi S.Z, Riley L.E, Newby L.G. A social
has been made on the basis of trunk exact CLBP epidemiology of back pain in a general
assessment rather than measures of whole body population, J Chron Dis., 1973; 26: 769–779.
performance.(27) 3. Nachemson A.L. Advances in low-back pain, Clin
Orthop, 1985; 200: 266–278.
Sensory dysfunction may increase the threshold to 4. Ambrosius F.M, Kremer A.M, Herkner P.B,
movement detection at the level of the ankle joint. DeKraker M, Bartz S. Outcome comparison of
Ankle muscle input and, possibly, cutaneous input workers’ compensation and noncompensation
from the foot sole contributes to the control of human low back pain in a highly structured functional
erect posture. (28) It seems then reasonable to suggest restoration program, Orthop Sports Phys Ther,
that when the proprioceptive system is stressed small 1995; 21(1):7-12.
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group, compared to the healthy group, may become Wheeler K.J. Managing low back pain: Attitudes
important for sway control. and treatment preferences of physical therapists,
Finally it should be pointed out that care must be Phys Ther 1994; 2: 219-226.
taken when evaluating individual CLBP patients since 6. Sypert G.W, Joy A.S. Evaluation and Management
a wide range of balance responses exists between of the failed back syndrome, in Youmans:
individuals and balance exercise is essential and Neurological Surgery, ed 5. Philadelphia: WB
should be considered during rehabilitation of LBP Saunders, 2003; 4: 4327-4345.
patient. 7. Rensick D.K, Choudhri T.F, Dailey A.T, Groff
M.W, Khoo L,Matz P.G, et al. Guidelines for the
Conflict of Interest performance of fusion procedures for
degenerative disease of the lumbar spine .Part
There are no financial and personal relationships 8:lumbar fusion for disc herniation and
with other people or organizations that could
radiculopathy. J Neurosurg: spine. 2005; 2:
inappropriately influence this work. 673-678.
8. White, A.A. Panjabi,M.M: Clinical biomechanics
FUNDING of the spine, 1990; 2nd ed, JB Lippincott,
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sectors. Changes in coordination of postural control
during dynamic stance in chronic low back pain
Ethical Clearance patients. Gait Posture. 2005; 24(3): 349–355
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This research work was approved by the physical
excursion as a measure of balance performance
therapy department council, faculty of applied medical
in patients with non-specific low back pain
sciences, Umm Al-Qurra University.
compared to healthy controls: a systematic review
of the literature.2011; 3: 358-68
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The authors would like to express their deepest are posture and movement coordinated? Prog
appreciations to all participants for their sincere Brain Res 2004;143:13–27.12
cooperation. 12. Byl N.N, Sinnott P.L. Variations in balance and
body sway in middle-aged adults. Subjects with
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17. Maribo T, Schiøttz C.B, Jensen L.D, Andersen N.T, Andrews B. Technique for calculating the
Stengaard P.K. Postural balance in low back pain direction of postural sway. Med Biol Eng Comput
patients: criterion-related validity of centre of 1991; 29:599-601.
pressure assessed on a portable force platform 25. Mok N.W, Brauer S.G, Hodges P.W. Hip strategy
2012; 21(3):425-31. for balance control in quiet standing is reduced
18. Gill, K.P, Callaghan M.J. The measurement of in people with low back pain. Spine 2004;
lumbar proprioception in individuals with and 29:E107–12.
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19. Brumagne S, Cordo P, Verschueren S. Swinnen S. The role of paraspinal muscle spindles
Proprioceptive weighting changes in persons in lumbosacral position sense in individuals with
with low back pain and elderly persons during and without low back pain. Spine 2000; 25: 989–
upright standing. Neurosci Lett. 2004; 366(1): 994.
63–66. 27. Mientjes M.I, Frank J.S. Balance in chronic low
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 DOI Number: 10.5958/j.0973-5674.7.3.103
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 255

Alteration in Pelvic Inclination & its Correlation with

Lumbar Lordosis in Pregnant Women

Madhura M Inamdar1, Unnati Pandit2, Bharati V Bellare3

1
Lecturer, Dept of Physiotherapy, MAEER'S Physiotherapy College, Talegaon (D), Pune, 2Associate Prof , Dept. of
Physiotherapy, Padmashree Dr. D.Y. Patil University, Nerul, Navi Mumbai, 3Retd Professor & HOD, Dept of
Physiotherapy, L. T. M. Medical College, Sion, Mumbai

ABSTRACT

Background: A cross sectional comparative study to explore whether pelvic inclination angle [PIA]
alters during third trimester & correlates with associated alteration if any in lumbar lordosis angle
[LLA] in primigravid women

Method: PIA & LLA were measured with pelvic inclinometer & Flexirular respectively in a convenient
sample of 100 Primigravid healthy women carrying single foetus in third trimester of pregnancy
within age group of 21.61 + 2.29 years & 100 healthy age matched [22.07 + 2.41years] nulliparous
controls . SPSS 16 soft ware was used to calculate unpaired t value with 95% confidence interval for
comparing PIA & LLA respectively between two groups and Intra-group Correlation coefficient [r
value ] between PIA & LLA in both groups .

Result : PIA in study & Control groups was found to be 3.340 2.57 & 5.140 2.82 respectively where
as LLA was 37.750 12.87 & 44.880 12.36 respectively. Comparison of PIA & LLA between groups
showed highly significant decrease [p < 0.0000 & p < 0.0001respectively ] in both variables in study
group suggesting posterior tilt associated with lumbar flattening. In both groups Intra-group
correlation showed moderate correlation between PIA & LLA [ r=0.66 in study group & 0.6 in
controls]

Conclusion: Study showed significant decrease in PIA & LLA in Pregnant women. The LLA &
PIA correlated moderately in both the groups.
Keywords: Lumbar Lordosis Angle, Flexirular, Pregnancy, Pelvic Inclination, Pelvic Inclinometer

INTRODUCTION are the alterations in the body mass and the consequent
changes in the centre of gravity, retention of fluid, and
There are wide ranges of postural and physiological
laxity in supporting structures. Apart from the growth
adaptations to the endocrine, musculoskeletal,
of the foetus, the woman’s body mass increases
circulatory and metabolic changes experienced by
because of growth uterus, placenta and membranes
women during pregnancy. The changes of pregnancy
and the increased volume of amniotic fluid and
are chiefly the direct result of the interaction between
circulating blood. 2
hormonally mediated changes in collagen and
involuntary muscles due to action of relaxin, Postural adaptations to these physiological changes
progesterone, estrogen and cortisol; the growth of the usually entail in alteration in the loading and alignment
foetus resulting in consequent enlargement and of, and muscle forces along the vertebral column and
displacement of the uterus; the increase in body and in the weight bearing joints. 3
adaptive changes in the centre of gravity and posture.1
Conflicting findings are documented in the
Postural adaptations appear to be a natural literature about alterations in the lumbar lordosis.
consequence of pregnancy. The most obvious physical Some studies report about the aggravated LLA 4, 5, 6, 7,
features in pregnancy influencing the woman’s posture where as some report about the flattening of

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 256 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

LLA8,9,13,14, Colliton10 stated that lumbar lordosis remains measures was 0.92-0.96. Measures by the inclinometer
the same or increases only slightly. Standerson 11 had a high degree of reliability compared with the
reported increase in lumbar lordosis during pregnancy, criterion roentgenographic measure, ICC = 0.93.
but this is a misconception. Gilleard12 reported that no Martha L Walker 18 measured of pelvic tilt with an
significant effect of pregnancy on the upper-body inclinometer as used in their study had a high degree
posture, although there was a tendency in some subjects of reliability when repeated measurements with one-
for a flatter thoracolumbar spinal curve in sitting as minute rest intervals were taken by the same examiner.
pregnancy progressed.
A Lumbar flexible ruler (flexi-rular) was used to
It was hypothesized that alterations in the LLA measure the lumbar lordosis
are associated with the alteration in the PIA. Levin &
Whittle 16 investigated whether the manoeuvre of Reliability & validity of flexirular is also widely
altering the PIA while standing is effective in changing documented. Hart et al 19 found high reliability of
the LLA. Their findings showed an average PIA of 11.4 flexirular, with ICC 0.97 which is well supported in
degrees increased by an average of 10.8 degrees the literature. 20, 21 , 22
[p<0.001]with anterior pelvic tilt & decreased by an The assessment of LLA & PIA was conducted in a
average of 9.0 degrees with posterior pelvic tilt . relaxed standing posture in a room which provided
Since our earlier findings15 supported the good privacy . After exposing the area to be tested ,
literature evidence of flattening of lumbar spine during each subject was instructed to assume natural standing
advance pregnancy, the research question was whether posture with weight distributed evenly & feet parallel
the Lumbar flattening is also associated with the to each other and slightly apart. Each foot was
compensatory posterior pelvic tilt –i.e decrease in PIA. approximately in line with the respective acetabulum.
The secondary research question was to verify The upper limbs were maintained in the normal
whether the PIA correlates with the LLA. position, hanging relaxed and by the side of the body.
The subject was asked to look straight ahead.
MATERIAL & METHOD For measuring pelvic inclination, Right Anterior &
It was a cross sectional comparative exploratory posterior superior iliac spines were palpated and
study. 1000 pregnant women in the third trimester marked. Pelvic tilt (pelvic inclination) was measured
registered for delivery & attending Out patient by placing one arm of inclinometer over Anterior
department of the Obstetrics & Gynaecology unit of superior iliac spine[ASIS] and other arm was placed
the LTMG hospital, Sion ,Mumbai were screened over Posterior superior iliac spine[PSIS] and the
within a period of 15days . A convenient sample of reading over the dial was noted 17
100 healthy primi-gravid women carrying single foetus For the determination of the LLA, the spinous
with age group of 18 to 25 [21.61 + 2.29 ] years was processes of L1 & S 2 were marked as upper & lower
selected as a study group . An equal number of age bony land marks respectively as reference points based
matched healthy controls [22.07+2.41 years] were on study done by Link et al 22. The subject was asked
selected from the working women‘s hostel ,Matunga to expose Lumbar area & was made to assume bare
[w] & known college going students. After the footed relaxed standing position with her back facing
approval of the ethical committee, of the LTMM the investigator. The spinous processes of the spine
College, the informed consent was obtained from all were palpated. First the lower point S2 was marked
the subjects included as samples. with a marker pen at the intersecting line joining both
A mechanical pelvic inclinometer was used for the PSIS. Then palpating six segments proximally, L1 was
assessment of pelvic tilt. Reliability & validity of the marked. The flexible ruler was placed against the
pelvic inclinometer is well documented. Crowell RD17 subject’s bare back, spanning the length between L1
studied the intra-tester and inter-tester reliability and and S2. The curve of the ruler, representing the lumbar
validity of measures taken with a pelvic inclinometer. curve, then was traced onto paper for further analysis,
The intra-class correlation coefficient (ICC) for repeated noting where the two reference points for L1 and S2
measures of the pelvic inclinometer fixed to a were located. The method for determining the degree
mechanical model was 0.99. In measures of 20 male of lumbar curvature (theta)was measured as done by
subjects by three testers, the ICC for intertester Hart and Rose 19. Two points on the curve, representing
reliability was 0.95 and the range of ICCs for intratester L1 and S2 were connected by a line (l) a perpendicular

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 257

line (h) representing the height of the lumbar curve,

bisected line l. Length of each line was determined in
millimetres (mm) and the values were inserted into
the formula:

Ø= 4 X arctan (2h/l) 22

SPSS -16 soft ware was used for statistical

calculation to compare PIA & LLA respectively Graph 1. Moderate correlation between PIA & LLA in control
group [r=0.6 ]
between two groups by using unpaired t test at 95%
confidence interval & for correlating[ r value] intra-
group LLA with PIA for both the groups.

FINDINGS

The mean age of the Control & Study groups

matched well [ t =1.3837, p=0.1680 ,standard error of
difference = 0.332]
Graph 2 : Moderate correlation between PIA & LLA in study
Table 1. presents the details of statistical analysis group[r=6.66]
of the PIA & LLA in both the groups

Table 1. Comparison of Pelvic tilt & Lumbar lordosis

During pregnancy the corpus luteum releases the
between Control & Study groups
hormone Relaxin that softens the ligaments by
Groups Pelvic Lumbar Lordosis altering the ground substance and by digesting the
Tiltn=100 angle n=100
collagen fibres. Effects of relaxin account for the
Study group 3.34 ± 2.57 37.75 ± 12.87
postural changes associated with pregnancy 8, 23.
Control 5.14 ± 2.82 44.88 ± 12.36
Pregnant women may gain as much as quarter of their
t value 4.7177 3.9958
body weight. Their center of gravity (COG) shifts,
p Value * 0.0000 *0.0001
requiring changes in posture to maintain balance.
Standard Errorof 0.382 1.784
difference
These changes are not same in all women.24

* Highly significant The postural behaviours adapted by pregnant

women during quiet standing must maintain
The PIA in the study & Control groups was found equilibrium about the vertebral and hip joints.8 In non-
to be 3.34 ± 2.57 & 5.14 ± 2.82 respectively .The pregnant individuals this involves balancing the flexor
comparison showed highly significant decrease of PIA moments generated by both super-incumbent weight
[ t = 4.7177 ; p = 0.0000] in the study group. Where as and the activity of the iliopsoas muscle with the
the LLA in study group was found to be 37.75 ± 12.87 extensor moments generated by the activity of the
were as the same in Controls was 44.88 ± 12.36 trunk and hip extensor musculature. During pregnant
.Comparison of LLA showed highly significant status, based on the anatomical arrangement of the
decrease [ t =3.9958;P= 0.0001] in the study group. lumbodorsal fascia, a relaxation of this tissue would
Thus the findings suggested that the postural tend to straighten out the lumbar spine. Similarly, since
adjustment was done by the concomitant flattening the vertebral ligaments preload the intervertebral disc,
of lumbar spine & associated posterior pelvic tilt by their relaxation may also lead to straightening of the
primigravid women in advance pregnancy lumbar spine.8

Graph 1 & 2 show graphical presentation of Colliton[1996] 10 suggested that during pregnancy,
firstly, pregnant women can, in fact compensate at least
correlation between PIA & LLA between Controls &
in part for the additional flexion moment by counter-
Study group respectively. The Intra-group Pearson
balancing it through extension of the upper trunk, head
Correlation Coefficient between PIA & LLA showed
and neck. Apparently pregnant women compensate
moderately positive correlation in both the groups
for the flexion moment by hip extension rather than
(Study group r = 0.66 & Controls r = 0.6).
lumbar spine extension.

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 258 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Hinman[2003-04] 21 reported that the Pelvis is in ACKNOWLEDGEMENT

posterior tilt and sways forwards in relation to the
We are very much thankful to the dept of
stationary feet causing the hip joint to extend. The effect
Obstetrics & gynaecology ,LTMG hospital for referring
is equivalent to extending the leg backwards with the
their patients for our study .We also thank the
pelvis stationary. With posterior pelvic tilt, the lumbar
spine flattens. Also there is backward deviation of the volunteers who participated in our study as a control
upper trunk.. This observation is also supported by group. .
Britnell et al[2005] 3 ,. Hinman 21 further reported that Conflicts of Interest: Nil
due to this the long curve in the thoraco-lumbar region
is mistakenly referred to as lordosis. (The term sway Source of Funding: Nil
back posture is appropriate label and requires that the
word ‘sway back’ is not used synonymously used with REFERENCES
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 DOI Number: 10.5958/j.0973-5674.7.3.104
260 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Barriers Associated with Community Access by Stroke

Patients in Indian Population

Mohammad Usman Akhtar1, Shubha Arora2, Man Mohan Mehndiratta3

1
Tutor (OT), Deptt of Rehab, HIMSR, Jamia Hamdard, 2Assistant Professor, Deptt of Rehab, HIMSR, Jamia Hamdard,
3
Director, Janakpuri Super-specialty Hospital, New Delhi

ABSTRACT

A study was done to perform a survey on unilateral stroke survivors to determine their perceived
barriers to exercise participation and community access. 91 subjects with unilateral stroke of mean
age 52.87 were selected through convenient sampling from different government and non government
hospitals in New Delhi. Outcome measures used for assessments were 1) Barriers to physical activity
and disability survey, 2) Folstein Mini Mental Status Examination. Major barriers reported by our
participants were lack of transportation followed by lack of accessible facility and least reported
barriers were lack of interest and too old to exercise. Data was analyzed and P-value interpreted was
0.05 which indicates that our study was significant.
Keywords: Barriers, Community Access, Unilateral Stroke, Assistive Devices

INTRODUCTION with a physical disability. 4 Physical activity

participation among people with stroke and other
Stroke is a leading cause of disability that results
disabling conditions is substantially lower than in the
not only in persistent neurological deficits, but also
general population. Inadequate amounts of exercise
profound physical deconditioning that propagates
can accelerate a person’s functional decline and limit
disability.1
his or her ability to work, recreate, and engage in
Exercise is normal human function that can be community events. 5, 6 Studies of leisure activities
undertaken with a high level of safety by most of the persuaded by stroke patients have found transport to
people, including stroke survivors. Many stroke be one of the factors hindering participation in
patients will not have equipments or facilities in their activities outside the home.7 Options for exercise and
homes to sustain interest in an exercise program in the recreation are often limited by numerous personal (e.g.,
long term they will need to seek assistance, equipments motivation, self efficacy) and environmental or facility
and facilities in the community. To enhance exercise barriers (e.g., inaccessible programs, equipments, and
compliance the issue of social isolation will need to be services offered in community recreation facilities). A
actively addressed and resolved.3 systematic examination of the personal and
environmental /facility mediators of physical activity
Tasks such as transferring from a wheelchair to an in persons with stroke requires a better understanding
automobile, ascending a ramp or walking with braces of the contextual factors associated with this
can be become major obstacles for individuals aging population’s participation in physical activity.
Recommendations developed for the general
Corresponding author: population are likely to be effective for individuals
Mohammad Usman Akhtar with stroke since reduced mobility, health conditions
Tutor (OT)
associated with stroke, and existing barriers to
Deptt of Rehabilitation Sciences
community access often limit these individual
Hamdard Institute of Medical Sciences and Research,
Jamia Hamdard, New Delhi-110062 opportunities to engage in physical activity.5 this study
Office Phone: 011-26059681 examined the multidimensional nature of barriers to
Mobile: 9891810989, 8860069786 physical activity reported by people with stroke.
E-mail: [email protected]

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 261

RATIONALE Exclusion criteria

This study will help to know why number of stroke • Score of 23 or less on the mini mental state
survivors is less in rehabilitation department. examination.

Secondly limited work has been done in India about • Subjects should not have primary disability (other
the barriers that are faced by unilateral stroke survivors major medical, psychiatric, psychological disorder)
to participate in exercise programs or community unrelated to stroke.
events.
• Subjects having speech related deficits/disorders.
This study will also help rehab professionals to
build a structured community based exercise program Outcome Measures
that will incorporate more number of stroke survivors 1. Barriers to Physical Activity and Disability Survey
and will focus in their long term adherence to the
program. The barriers to physical activity and disability
survey (B-PADS) were used to collect data on the
The Aim of this study was to perform a survey on types of barriers (personal or environmental/
unilateral stroke survivors so as to determine perceived
facility) that individuals with disabilities
barriers with exercise and community access experience related to exercise participation.

METHODOLOGY The B-PADS consists of 34 items, 31 of which have

two response choices: yes or no. The remaining 3
Research design: Survey items are open-ended, and 2 of these are follow-
Sample design: up questions that ask participants to explain a
previous “yes” response.
Sampling type: Convenient Sampling
2. Folstein Mini mental state examination.
Sample size: 91 subjects
PROCEDURE
Source: various community and government hospitals
Consent regarding the use of B-PADS was taken
Site of study: G.B. Pant Hospital, New Delhi
from the Author
L.N.J.P Hospital, New Delhi
HAHC Hospital, New Delhi Subjects (n=91) of unilateral (Rt or Lt) stroke were
AIIMS, New Delhi selected using convenient sampling from various
community and government hospitals to determine
Time period of data collection: 5-6 months
their perceived barriers associated with community
Age Group: 30-70 years access and exercise in India.

Inclusion Criteria Before participating in a study, written consents

were taken from subjects or caregivers.
• Subjects not below 30 years of age and not more
than 70 years of age. At first all the participants were screened according
to FMMSE, subjects scoring 24 or more on FMMSE
• Subjects should be able to walk at least 50 feet were selected.
without assistance.
They were assessed on the basis of age, gender,
• Subjects should be post stroke at least 3-6 months. marital status, assistive devices used, side affected and
annual house hold income.
• Subjects using or not using an assistive aid such
as cane, walker, brace, and/or wheelchair were These subjects were asked series of questions
also included. related to BPADS n=91 were divided into two groups
based on annual household income. Barriers to
• Score of 24 or more on the mini mental state
physical activity participation were than tabulated and
examination.
compared between lower and higher income groups.

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 262 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Data collected was than analyzed on the basis of subjects followed by “health concerns prevents me
SPSS17 statistical software. from exercising” (33%), “pain that prevents me from
exercise” (31.9%) and “lack of energy” (24.2%). Barriers
RESULTS least reported were patients elderliness i.e., subjects
reported “I am too old” to exercise 12.1% and “Lack of
Data were summarized with the descriptive interest” 7.7%.
statistics of mean, percentage and cumulative
frequency values for each item and analyzed with the
graphical methods of bar-graphs and pi-charts.

Table 1. illustrates/depicts demographic

parameters.

Total of 91 stroke subjects were selected (mean age

52.87 yr; SD ± 11.5) out of which 80(87.9%) were
married, 1(1.1%) unmarried, 9(9.9%) widowed and
1(1.1%) divorced. Many of them used assistive devices
such as cane 20(22%), walker 7(6.6%), wheelchair
1(1.1%) and 63 (70.3%) did not reported any use of Our findings represented that out of 91 subjects
assistive devices. Out of 91 subjects, 45(49.5%) were 58(63.7%) showed willingness to participate in an
Right side affected and 46(50.5%) were Left side exercise program. Whereas 83(91.2%) of all subjects
affected. When analyzing socio economic status annual felt that an exercise program would help them in
household income were divided into lower and higher treatment (recovery). 63(69.2%) out of 91 were
income groups which included 65(71%) and 26(29%) encouraged for post stroke rehabilitation exercises, and
participants respectively. about 29(31.9%) of the subjects were aware of the
fitness facility in the community and about same
Table 1 illustrates/depicts demographic parameters. number of subjects were afraid to leave there homes
Characteristics No of subjects Percentage
after stroke disability.
Marital Status By applying the Pearson chi square test, the P-value
Married 80 87.9 was evaluated to be 0.057. Which is statistically nearest
Unmarried 1 1.1 to the threshold expectance level i.e., 0.05. Therefore
Widowed 9 9.9 the data can be considered clinically significant.
Divorced 1 1.1
Assistive Devices Used DISCUSSION
Cane 20 22
Walker 7 6.6 Findings in our study revealed that a group of
Wheelchair 1 1.1 predominantly males (78%) and females (22%) with
None 63 70.3 stroke who resided in and near to the national capital
Side Affected territory of Delhi reported multiple barriers to
Right 45 49.5 participate in an exercise program or to community
Left 46 50.5 events.
Annual Household Income
The few major barriers reported were lack of
Lower Income <100000 65 71
transportation to a fitness facility, lack of accessible
Higher Income >100000 26 29
facility, not knowing where and how to exercise and
Histogram below describes barrier of physical cost associated with exercise program which was
activity reported by participants which represents why supported by Rimmer.et.al, they found that cost
patients might not involve in exercise program. The associated with joining a fitness facility and
most common barriers reported in decreasing transportation to a fitness facility were major barriers
hierarchy were –”lack of transportation” (71.4%), “lack reported by the participants.5 lack of time, was also
of accessible facility” (68.1), “don’t know how to one of the major barrier in our study, however the most
exercise” (61.5%), and “don’t know where to exercise” of the participants were either not employed or retired,
(57.1%). “Lack of time” and “lack of attendant” were time constrain as a major barrier to exercise was also
another major barriers reported by about 40.7% of the reported in two other studies (Rimmer.et.al 2000,

51. Usman Akhtar--260--264.pmd 262 8/1/2013, 8:31 AM

 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 263

Mackeen.et.al 1983)21, 26 , these findings reveal the for helping individuals with stroke and their caregivers
perception of those who were self employed and still overcome these barriers and rehabilitation
manage to work post-stroke. professionals to make a customized post-stroke
community-based rehabilitation program.
Our findings were, in general consistent with
previous researches (creveston.et.al 2000) that involved First, healthcare professionals must systematically
a predominantly African-American group of women identify barriers to exercise when referring patients
with physical disabilities, including stroke. In their with stroke from rehabilitation to community based
study, the common barriers were transportation exercises. Second, while our participants expressed in
(60.5%), and not knowing where to exercise (57.9%).21 participating in an exercise program (63.7%) they were
unable to participate because of the structured exercise
Large no of our participants also reported that they programs, the preponderance of research on the fitness
are unaware of the appropriate fitness facilities in the levels of people with stroke indicates that they are
neighborhood (68.1%). One of the most significant unlikely to be participating in a structured physical
barriers faced by many individuals aging with a activity program and as a group, are considered
physical disability is the lack of information about severely deconditioned 1,3,11.
programs that are available in their community (Riley
& Wang).14 Finally customizing physical activity programs for
persons with stroke is clearly needed to remove as
An environmental barrier reported by nearly 32% many personal and environmental/facility barriers as
of our participants was similar to what Lee found in a possible. Barrier identification and removal should be
population of older Australian women, where 34% based on the various impairments and/or activity
were reluctant to go out alone.21 other barriers reported limitations associated with stroke severity.
by our subjects were health concerns stopping from Environmental assessment tools that measure barriers
exercise (33%). O’ Neil and Reid reported barrier data in the built environment (e.g., home neighborhood,
on a older population of Canadians (55-90 yrs), 28 they community fitness center) are available to help
found 40% of their sample mentioning illness or professionals identify barriers before initiating an
handicap as a barrier to exercise participation, exercise program for this population 5, 29.
Rimmer.et.al also found the same percentage in their
sample when they evaluated health concerns as a The combined identification and removal of
barrier for exercises.21 personal and environmental/facility barriers may
effectively tailor the program to the individual and his
12% of subjects in our study reported too old to or her environment and enhance the likelihood that
exercise, increasing age may be associated with he or she will successfully participate in a structured
decreased outcome and may become a barrier to exercise program. Programs needs to be tailored to suit
physical activity. Rimmer also reported Lack of energy Indian communities especially poor’s.2 significant
as a major barrier, however in our study we have 24.2 improvements in the fitness were obtained by Nicola
of them felt it as a barrier. in 2000 when significant barriers to participation were
The B-PADS is a relatively short instrument that eliminated (i.e., free transportation, no cost off the
can help professionals identify these key barriers to program) 20.
exercise participation. Identifying these barriers will
help the professionals formulate a home or RECOMMENDATIONS
community- based exercise plan founded on the The aging of the population and the resulting
participant’s response pattern. B-PADS was used by expected increase in stroke survivors accentuates the
James Rimmer in 2008 on 83 adults to determine need for further research to define strategies to
perceived barriers to participation in physical activity eliminate barriers to exercise to improve health, fitness
and it was validated in 2001 by Riley & Rimmer and and functions.
had reliability of 0.62.19
Further study to evaluate the correlation between
The perception of these barriers that our age, gender, and disability status and income groups
participants with stroke reported to their exercise with perceived barriers to exercises by participants can
participation helped us to make several suggestions be done.

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 264 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Grouping of the age can also be done to yield better 7. PA Logan, JRF Gladman and KA Radford. The
results. Use of Transport by stroke Patients. Br JOT 2001;
64 (5): 261-64.
Other precise standardized tools can yield much 8. Ariane B, Sascha R, Anita B, Martien L, Frans V.
better results. How predictive is the MMSE for cognitive
performance after stroke? J Neurol 2010; 257:
ACKNOWLEDGEMENT 630-637.
9. Sarah Mc Adam. Stroke survivors in rural areas
The authors are thankful to Mr. James H Rimmer seek better local service. Commission for Rural
for his tremendous support in providing the B-PADS Communities, News Release 2010.
and the Dean, Dr. (Prof) Jain, Deptt of Rehabilitation, 10. Annie MC and Sandy M. Delivering evidence
HIMSR, Jamia Hamdard for providing necessary based outdoor journey intervention to people
with stroke: Barriers and enablers experienced by
permission and facilities to carry out this work. We
community rehabilitation teams. BMC Health
would also like to thank Dr. Ona P Desai, Head, Deptt
Services Research. 2010, 10:18.
of Rehabilitation, HIMSR, Jamia Hamdard for her 11. Shaughnessy M, Resnick BM, Macko RF. Testing
continuous support and guidance throughout the a model of post-stroke exercise behavior. Rehabil
study. Nurs. 2006; 31(1): 15-21.
12. Rimmer JH. Use of the ICF in identifying factors
Conflict of Interest: I have shown the article to my
that impact participation in physical activity/
both other guides before submitting it to you, and it is
rehabilitation among people with disabilities.
after their permission that I am sending it for the
Disabil Rehabil. 2006; 28(17):1087-95.
publication therefore it does not have conflict of any 13. Hammel J, Jones R, Gossett A, Morgan E.
means between the Authors. Examining barriers and supports to community
living and participation after a stroke from a
Source of Funding: This study was part of the
participatory action research approach. Stroke
curriculum for the award of Degree of M.O.T and
Rehabil 2006.
therefore it was self funded.
14. Rimmer JH, Riley B, Wang E, Rauworth A,
Ethical Clearance: this is a survey it does not have Jurkowski J. Physical activity participation
a treatment protocol that is followed on human subjects among persons with disabilities: barriers and
facilitators. Am J Prev Med. 2004; 26(5):419-25.
and was only a observational study, therefore ethical
15. Chu KS, Eng JJ, Dawson AS, Harris JE, Ozkaplan
clearance was not needed.
A, Glyfadottir S. Water-Based exercise for
cardiovascular fitness in people with chronic
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1. Ivey FM, Hafer-Macko CE, Macko RF, Exercise Med Rehabil. 2004; 85(6):870-74.
rehabilitation after stroke. NeuroRX 2006; 3 16. Rimmer JH, Riley B. Validation of the Barriers to
(4):439-50 Physical Activity and Disability Survey for older
2. Jeraraj D. Pandian, Velandai Srikanth, Stephen J individuals with disabilities. 2001; Oct(5).
Read. Stroke. 2007; 38: 3063-69. 17. Rimmer JH, Riley B, Creviston T and Nicola T.
3. Gordan NF, Gulanick M, Costa F, Fletcher G, Exercise training in a predominantly African-
Franklin BA, Roth EJ, Shephard T; Physical American group of stroke survivors. Med Sci
activity and exercise recommendations for stroke Sports Exerc. 2000; 32(12):1990-96.
survivors. Circulation. 2004; 109 (16): 2031-41. 18. Rimmer JH, Rubin SS, Braddock D. Barriers to
4. Rimmer JH, Exercise and physical activity in exercise in African American women with
persons aging with a physical disability. Phys disabilities. Arch Phys Med Rehabil. 2000: 81(2);
Med Rehabil Clin’ N Am. 2005; 16 (1): 41-56. 182-88.
5. Rimmer JH, Wang E, Smith D. Barriers associated 19. O’Neil KO, Reid G. Barriers to physical activity
with exercise and community access for by older adults. Can J Public Health 1991; 82:
individuals with stroke. JRRD 2008; 45(2): 392-396.
315-322. 20. Rimmer JH, Riley B, Wang E, Rauworth A.
6. Kelly Jo, Kilbreath SL, Davis GM, Zeman B, Development and Validation of AIMFREE:
Raymond J. Cardio respiratory fitness and Accessibilty Instruments Measuring Fitness and
walking ability in sub acute stroke patients. Arch Recreation Environments. Disabil Rehabil. 2004;
Phys Med Rehabil 2003; 84 (12): 1780-85. 26(18):1087-95.

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 DOI Number: 10.5958/j.0973-5674.7.3.105
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 265

Immediate effects of Taping of Upper Back on Peak

Expiratory Flow Rate (PEFR) in Stable Chronic
Obstructive Pulmonary Disease (COPD) Subjects

S Kimothi1, V K Nambiar2, B Yadav3

1
Master in Clinical Physiotherapy, International School of Physiotherapy. GEF-CU Collaborative Programme,
MSR Nagar, Bangalore, 2Associate Professor, Dept. of Physiotherapy, M.S.R.M.T.H, Bangalore, 3Lecturer, International
School of Physiotherapy, GEF-CU Collaborative Programme, MSR Nagar, Bangalore

ABSTRACT
Background: The activation of respiratory muscles is influenced by a change in gravitational force
and length-tension variations. Many studies have shown the influence of posture on respiratory
muscles in normal adults. The proprioceptive facilitation of musculoskeletal system has shown
improvement in pulmonary functions of normal adults. The lack of evidence on the effect of posture
in COPD subjects suggested a need to see the immediate effects of proprioceptive facilitation of
upper back on peak expiratory flow rate (PEFR) through taping on stable COPD subjects.
Objectives of the study: To determine the PEFR values pre and post-taping in experimental group, to
determine the PEFR values pre and post-taping in control group, to compare the PEFR values pre and
post-taping within the groups and to compare the PEFR values pre and post-taping between the groups.
Methodology: 34 stable COPD subjects were recruited through convenience sampling. All the subjects
were randomly allocated to experimental group (17) and control group (17). The PEFR was measured
by peak flow meter as baseline data for both the groups. The experimental group was given
proprioceptive facilitation through taping of upper back by instructing the subjects to erect their
spine and retract their shoulders whereas control group was given sham taping. The PEFR for both
the groups was measured pre and post taping.
Results: Paired t test was done to compare the PEFR values within the groups and independent t test
was used for comparison between the groups.
Interpretation: On analyzing the test, significant results were seen in the experimental and control
group. The experimental group showed significant improvement in PEFR value(p<0.024) when mean
difference of the two groups were compared.
Conclusion: The results suggest that proprioceptive facilitation of upper back through taping in
COPD subjects improves pulmonary function.
Keywords: PEFR, posture, respiratory muscle activity in COPD

INTRODUCTION recent study showed an increase in prevalence of

COPD in Tamil Nadu by 2.44% and the prevalence was
Chronic obstructive pulmonary disease (COPD) is
seen higher in biomass fuel users and 2 times higher
ranked 13th in leading cause of burden of disease
in women who spend more than 2 hours in kitchen1.
worldwide and it is expected to become 5th by 20201. A
The disease is known for early mortality rate and high
death rates over the worldwide. The prevalence of
Corresponding author: COPD depends on geographical area, age and sex2.
Bhagwathi Yadav
According to GOLD classification, COPD can be
Lecturer
International School of Physiotherapy defined as ‘a disease characterized by the airflow
GEF-CU Collaborative Programme limitation that is not fully reversible’. The airflow
MSR Nagar, MSRIT Post, Bangalore-54 limitation is progressive and associated with abnormal
[email protected] inflammatory response of the lungs to noxious

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 266 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

particles or gases3 and is often associated with co during activity in COPD patients. The recruitment of
morbidities. abdominal muscles occurs in COPD patients because
it prevents the distortion of the ribs and helps in
According to Trevor4 cigarette smoking is one of unloading of diaphragm. The abdominal muscles also
the major risk factor in COPD, but a variety of other play an important role in movement of the chest wall
factors like exposure to bio mass fuel plays during breathing by reducing the end expiratory
contributing factor for the risk in developing COPD volume13. Macklem13 suggested a thesis in a point:
.In COPD there is an increased inflammatory response, counterpoint study which reported that the dynamic
which is associated with the increase production of hyperinflation and reduced oxidative capacity are
mucus, cycles of resolution, fibrosis and proteolysis. secondary factors resulting from the increase in energy
The pathology of COPD involves large central airways demand combined with a decrease in supply caused
known as chronic bronchitis and lung parenchyma by the excessive recruitment of expiratory muscles. In
known as emphysema. The diaphragmatic (costal) COPD patients, there is a reduction in strength and
fibers transmit the abdominal pressure to pleural space endurance of abdominal muscles, which suggests that
and expand the abdominal rib cage to adjust the they have a poor control on their posture. Thus there
increased lung volume during inspiration. The is a workload on the accessory muscles of respiration,
dynamics of chest wall in normal adults is well which leads to the change in their
coordinated between respiratory muscles (i.e. posture10.Kera15suggested that the gravitational force
diaphragm, abdominal muscles and rib cage muscles). and the length-tension of the respiratory muscles
In subjects with COPD, thoracic cage is placed in hyper change with the variation in the posture. Kera15also
inflated position, caused by the loss of elastic recoiling concluded that in standing position, the activity of
of the lungs5. There is an increase in the anterior- internal oblique muscle increases in both inspiration
posterior diameter of the chest wall. The positioning and expiration and expiratory reserve volume is
of the ribs changes from an oblique to a more reduced as compared to other positions. John 16
horizontal position 6. Thus hyperinflation causes suggested that erecting the spine through
change in chest wall geometry by making it more barrel proprioceptive facilitation enhances respiratory
shaped. There is also a reduction in zone of apposition muscular function and improves PEFR in normal
and operating length7, which alters the diaphragm adults. Barrett17 reported that abdominal muscles
function and causes an increase in mechanical load and activity was more in standing position than in supine
work of breathing8. Schroeder 8 also reported that and also concluded that the lowest load required to
alteration in diaphragm function leads to use of activate the abdominal muscles is in 90-degree head-
accessory muscles to increase their lung volume. The up position, which means the threshold for activation
accessory muscles used by COPD patients are mainly of abdominal muscles is low. This shows that by
- latissimus dorsi9, levator scapulae10, upper trapezius erecting the upper back there is increase in respiratory
and stenocleidomastoid11. muscle activity of abdominal muscles, which improves
Dias5 suggested that use of accessory muscles leads the pulmonary function.
to alteration in the posture, bringing about an increase Thus the use of accessory muscles and weakness
in thoracic kyphosis , increase in the elevation of of respiratory muscles leads to poor control and
scapula and protraction of head and there have been alteration in the posture of COPD patients. It can be
high prevalence of pain located majorly to chest, also said that forward bending of the trunk is the most
shoulders, neck and thorax in COPD patients. preferable position for COPD patients as it enhances
Sharp12suggested sitting with forward bending of the the expansion of upper thoracic cage, but this position
trunk as one of the major change in posture of COPD causes an overload on the body and initiates a vicious
patients, which can be closely related to the features cycle of increased fatigue and dyspnea 10 .
mentioned in above reference. Proprioceptive facilitation of posture effects the activity
There are structural changes occurring in of respiratory muscles and the minimum load required
diaphragmatic fibers due to mechanical workload, to activate the abdominal muscle is 90degrees head
leading to the alteration in the ratio of type 1 and type up position. This suggests that the standing with erect
2 fibers in the muscles and increases the type 1 fibers spine posture increases the activity of abdominal
that makes it highly resistance to the fatigue13. The muscles and improve the pulmonary functions of
expiratory muscles are recruited both at rest14 and abdominal muscles in normal subjects. However, the

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 267

evidences for the effect of posture on pulmonary the spine of both scapulae, diagonally to T12 spinous
functions in COPD patients are very rare. Therefore process. The taping for the control group was sham
the need of the study was to find the effect of taping in which subjects were asked to erect their spine
proprioceptive facilitation of upper back on PEFR in and no movement was performed at scapula. The
COPD patients. taping procedure was same as the experimental group.
The subjects were asked to stand in their normal
MATERIALS AND METHOD posture during the pre taping measurement of the
PEFR in both the groups. The procedure for
Materials Used: Peak flow meter was used to performing the test for the measurement of the PEFR
measure the PEFR. Rigid leucoplast tape was used for was explained to the samples prior to the data
taping of upper back. collection in which they were instructed to inspire the
34 clinically stable COPD subjects were recruited air from their nose and then they were instructed to
through convenience sampling from MS Ramaiah exhale the air out as forcefully and maximally with
Memorial Hospital and the hospital nearby it. The maximum effort by holding the mouth piece of the
subjects were recruited based on Inclusion criteria: - peak flow meter in the mouth as tight as possible to
Male individuals of 30 years or above diagnosed as avoid any leakage of air. No instructions were given
stable COPD with no history of lower respiratory tract during the procedure of the test and the best of the
infection or pneumonia in the last 3 months. All the three trials was recorded.
subjects were asked to perform the pulmonary Statistical analysis: Student paired t-test was used
function test to obtain their FEV1/FVC value or the to compare the PEFR values within the group.
previous test value, which the patient had undergone, Independent sample t test was used to compare the
was taken in the study. The subjects recruited for the homogeneity for demographic data (age, height and
study were in mild to moderate stage of COPD based weight) and baseline data (i.e. PEFR and FEV1/FVC)
on GOLD classification of stages of COPD. Individuals between the groups. The difference in PEFR value, pre
with allergy to taping, other types of lung diseases or and post-taping in both the groups were compared by
neurological disorders and clinical history of scoliosis, student unpaired t test. The confidence interval was
any spinal or cardio-thoracic surgery, ankylosing 95% in both the groups. p<0.05 was considered as
spondylitis and fixed spinal deformity were excluded statistically significant.
from the study.

Procedure of data collection: An ethical clearance FINDINGS

was obtained from the ethical committee of M.S. The two groups were matched for age, height, and
Ramaiah Medical College. Male COPD patients weight as shown in Table 1. The comparison of baseline
satisfying the inclusion and criteria were selected for data i.e. FEV1/FVC and PEFR value in Table 2 of both
the study. The purpose of the study was explained and the groups shows the p>0.05 which suggest that the
an informed consent was obtained from the subjects. baseline data were matched in both the groups.
The clinically stable COPD patients were recruited in comparison within the group showed significant
the study through convenience sampling. An increase (p<0.05) in PEFR value after taping in
assessment chart was performed on each sample prior experimental group and the paired t test done for the
to the allocation to the groups. The digit number on comparison of data within the control group showed
the assessment sheet randomly allocated the subjects significant decrease in the PEFR value after taping as
to two different groups. The sheets with odd numbers shown in Table 3.
were considered as experimental group and even
numbered sheets as control group. 17 samples were Table 1: Comparison of demographic data (age, height,
recruited in each group. PEFR was measured for the and weight) between the two groups
samples in each group, pre and post-taping of upper Experimental Control P value
back. The samples of experimental group actively group group
erected their spine and retracted their scapula in a Age in years 58.88±6.42 57.53±5.08 0.501
standing position following the demonstration of the Height in cm 164.29±3.85 162.71±3.60 0.223
movement by a physiotherapist. The tape was pre - Weight in kg 70.41±18.37 63.41±13.24 0.212
tensioned and applied bilaterally from T1 spinous The above table shows p>0.05 for (age, height, and weight) which
process to T12 spinous process and from the center of suggests that the two groups were matched for demographic data.

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 268 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Table 2: Comparison of baseline data (FEV1/FVC and CONCLUSION

PEFR) between the two groups.
The results of the present study concludes that the
Experimental Control P value
group group proprioceptive facilitation of upper back by taping can
FEV1/FVC (%) 59.16±2.57 58.57±2.25 0.487
enhance the posture in individuals with COPD subjects
Pre-taping 281.76±59.50 247.65±57.83 0.100
and can improve the peak expiratory flow rate.
PEFR(l/min)
ACKNOWLEDGEMENT
The above table shows p<0.05 which suggests that the baseline
data was matched for both the groups.
I owe my sincere thanks to Prof Savita Ravindra,
Table 3: Comparison of PEFR value within and Course Director for the support and encouragement.
between the groups (pre and post-taping) and the My gratitude to Dr. Uma Maheshwari (Department of
comparison of the difference in both the groups.
Chest Medicine), M.S. Ramaiah Medical College for
PEFR(l/min) Experimental Control P value referring the patients for the study. I wish to express
group group my sincere thanks to Dr. Suresh K P (Statistician), for
Pre-taping 281.76±59.50 247.65±57.83 0.100 providing technical assistance and statistical guidance
Post taping 290.59±63.88 240.00±60.83 0.024* for the study. .I would like to express my gratefulness
Difference 8.823 -7.647 <0.001** to all the Patients who contributed their valuable time
95%CI 4.80 to12.84 -11.06 to-4.23 - towards the study.
P value <0.001** <0.001** -

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 DOI Number: 10.5958/j.0973-5674.7.3.106
270 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Functional Status in Post-CABG Patients Following

Physiotherapy- A Retrospective Analysis

Vinod K Ravaliya
MPT, K. M. Patel Institute of Physiotherapy, Karamsad, Anand, Gujarat, India

ABSTRACT
Background of objectives: Following CABG, various pulmonary complications may result with
significant affection of functional recovery of the patients. This adds into the cost of treatment,
prolonged length of stay in the hospital, increased morbidity and mortality . Therefore present study
was undertaken to determine the efficacy of physiotherapy treatment in functional recovery of the
patients following Coronary artery bypass grafting surgery.
Materials & Method: This was a retrospective study, total 65 participants' data were considered for
the analysis, which was retrieved from the medical record department of Shree Krishna hospital. The
demographic status, physiotherapy treatment program, functional recovery, average walking distance
and length of stay in the hospital were analyzed.
Results: In the present study, the medical record of 65 subjects (84% male and 16% female) were
analyzed and average of walking distance, flight of stairs and length of stay was recorded. All the
subjects were given preoperative physiotherapy which included chest physiotherapy in the form of
deep breathing exercise, thoracic mobility exercise, forced expiratory technique and incentive
spirometry as well as post operative physiotherapy regimen taught. Out of 65 subjects, 90% (n=58)
had no post operative complications and 10% (n=7) had eventful CABG with associated complications
like cardiac arrhythmias in 3 patients, uncontrolled diabetes in 1 patients, long term ionotropic support
in 2 patients and pleural effusion in 1 patient etc. The average length of stay of the subjects in hospital
following uncomplicated CABG was 6 PODs and 90% of the subjects were discharged by 6th POD.
Conclusion: It had been concluded that all the subjects with uneventful CABG (80%) following
physiotherapy became functionally independent on 6th POD, whereas subjects with eventful CABG
(10%) on 11th POD.
Keywords: CABG, Functional Status, Post-operative Day, Length of Stay

INTRODUCTION Several complications are associated with CABG

surgery, commonly pulmonary complications like
When the heart is at ease, the body is healthy.
atelectasis, pneumonia and pleural effusion along with
Cardiovascular disorders are the leading cause of
circulatory complications like deep vein thrombosis
morbidity and mortality accounting for almost 50% of
and postural hypotension. There are certain negative
all deaths annually.1 Coronary heart disease is the most
physiologic consequences associated with bed rest
common type of the cardiovascular disease in India
like; decreased plasma and ventricular volume, resting
with the prevalence range from 1.3 to 4.6 million, with
and maximum stroke volume, maximum cardiac
an annual incidence of 0.5 to1.8 million. It is caused
output, maximal oxygen uptake along with increased
by risk factors like sedentary life style, male gender,
heart rate at rest and submaximal levels of activity,
excessive alcohol consumption, chronic smoking, long
venous compliance, and loss of muscle mass, strength
term stress and a positive family history of heart
and endurance.12
attack at an early age.2
Postoperative exercise program is the mean of
CABG is the preferred treatment for CAD involving
optimizing the surgical results and exercise capacity,
left anterior descending artery(LAD), left circumflex
return to work and quality of life in patients who have
artery(LCX), right coronary artery(RCA), to relieve
undergone bypass surgery.12 Immediate post operative
angina and reduce the risk of death from coronary
phase is also called phase 1 cardiac rehabilitation,
artery disease.4

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 271

which is beneficial in certain aspects like The study proposal was submitted and approved
reconditioning the patient sufficiently enough to allow by Human Research Ethics Committee.
him or her to resume customary activities, decreasing
the risk of sudden cardiac arrest or reinfarction, After an official permission taken from the Medical
limiting the physiologic effects of heart disease, Record department of Madhuben and Bhanubhai
enhancing psychological status of the patients which cardiac center, Karamsad a retrospective analysis of
in turn helps to improve overall quality of life. 1 the medical records of the patients who underwent
Therefore to reduce the morbidity resulting from the CABG was carried out. From the medical records
surgical intervention, physiotherapy is found to be various variables were noted down including
very effective in its prevention in immediate post demographic status, diagnosis, risk factors, pre
operative phase. operative PT, post-operative physiotherapy, length of
stay in the hospital and functional status at the time of
This program begins while patients are still in the discharge.
hospital. It includes a visit by a member of the cardiac
rehabilitation team, education regarding the disease DATA ANALYSIS
and the recovery process, personal encouragement,
and inclusion of family members in classroom group The variables such as age, gender, body mass
meetings. In the coronary care unit, assisted range-of- index(BMI), hypertension, diabetes mellitus, obesity,
motion exercises can be initiated within the first 24-48 diagnosis, preoperative physiotherapy, post-operative
hours. Low-risk patients should be encouraged to sit physiotherapy program, functional status of the
in a bedside chair and to begin performing self-care patient at discharge and average length of stay in
activities (eg, shaving, oral hygiene, sponge bathing). hospital were analyzed.
On transfer to the step-down unit, patients should, at Descriptive statistical analysis and mean are used.
the beginning, try to sit up, stand, and walk in their
room.1 RESULTS
Subsequently, they should start to walk in the In the present study, out of 75 subjects who
hallway at least twice daily either for certain specific underwent CABG 10 subjects expired during their
distances or as tolerated. Standing heart rate and blood hospital stay. Hence the medical records of remaining
pressure should be obtained. Walking, often with 65 subjects were analyzed and average of walking
assistance, is resumed, with a target heart rate of less distance, flight of stairs and length of stay was
than 20 beats above the resting heart rate and an RPE recorded.
of less than 14. Starting with 5-10 minutes of walking
each day, exercise time gradually can be increased to Table 1. showing baseline characteristics of the
up to 30 minutes daily.1 subjects with CABG surgery

Average Age (years) 58

In Anand Kheda district, Madhuben and
Gender (n=65)
Bhanubhai Cardiac Center cater its services to the
Male 84% (n=54)
patients suffering from cardiac diseases. In the last 2
Female 16% (n=11)
years, about 75 patients has undergone CABG and
Diagnosis
treated with physiotherapy till the discharge from the
SVD 7% (n=4)
hospital. Therefore, the present study aims to find out
DVD 23% (n=15)
the functional status of CABG patients achieved till
TVD 70% (n=46)
the discharge following physiotherapy.
Risk factors
HTN 80% (n=52)
METHODOLOGY
DM 54% (n=35)
Place of study: Karamsad. Obesity 48% (n=30)

Study design: Retrospective study. All the subjects were given preoperative
physiotherapy which included chest physiotherapy in
Sampling size: Medical record of all patients who the form of deep breathing exercise (DBE), thoracic
underwent CABG. mobility exercise (TME), forced expiratory technique
(FET) and incentive spirometry along with teaching

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 272 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

of post operative regimen. Out of 65 subjects, 90% hospital19. Following CABG surgery, 87% of subjects
(n=58) had no post operative complications and 10% were treated with physiotherapy on 1st POD shortly
(n=7) had eventful CABG with associated after extubation and 3% of subjects received chest
complications like cardiac arrhythmias in 3 patients, physiotherapy under emergency circumstances on 0th
uncontrolled diabetes in 1 patients, long term inotropic POD. The remaining subjects (10%) were not treated
support in 2 patients and pleural effusion in 1 patient from 1st postoperative day due to severe hemodynamic
etc. instability. As soon as subjects became stable on 2nd
postoperative day, 100% of population underwent
The average length of stay of the subjects in hospital physiotherapy.
following uncomplicated CABG was 6 PODs and 90%
of the subjects were discharged by 6th POD. On the 1st POD, all the subjects were treated with
DBE, TME,FET with splinting over median sternotomy
It has been analyzed that no subjects developed site using small cushion(cardiac pillow), Incentive
deep vein thrombosis following CABG surgery till Spirometry (IC 900cc EC 900cc), DVT prophylaxis,
discharge from the hospital. sitting with support, eating and drinking
70% of the subjects were given home advice like independently.
explanation regarding level of physical activity, target On the 2nd POD, the external aids like chest drains,
heart rate and RPE scale, avoidance of personal habits arterial lines, and femoral lines were removed.
and regular follow up. Therefore, all of them could achieve the following
functional status upto sitting edge of bed (EOB)
DISCUSSION independently, standing with minimal assistance and
Madhuben and Bhanubhai Cardiac Center is a well walking indoor with minimal assistance along with
equiped specialized center in Anand district. On an the same protocol followed on the 1st POD.
average 32 patients with coronary artery disease(CAD) On the 3rd POD subjects could achieve functional
underwent CABG over a year. Postoperative status up to walking independently approximately
physiotherapy helps to optimize the surgical results, 75meters along with same protocol followed on 1st and
enhance exercise capacity, return to work, quality of 2nd POD with IS 1200cc and ES 900cc
life in patients who have undergone bypass surgery.10
Therefore the functional status of the patients with Up to 3 rd POD, the emphasis was on chest
CABG following physiotherapy was retrospectively physiotherapy maximally with the frequency of
analyzed and hence records of these subjects were treatment five times/day because chest pain at the
analyzed. incision site inhibit the patient breathing therefore
patient breathe at low tidal volume which result into
Amongst the 65 subjects, 84% of population was derecruitment of the alveoli and thereby
male and 16% was female. It has been widely studied microatelectasis may occur. Therefore, to prevent post
that the males are more prone to develop CAD than operative respiratory complications, intensive chest
females due to personal habits like smoking, excessive physiotherapy for initial 3 days is crucial for prevention
alcohol consumption and increased stress level7, 25. of post-operative pulmonary complications. 20
The age group of the population was between 41 However, from 4th POD onwards, the need of chest
to 85 years. It has been found that the common age physiotherapy emphasized only for prophylactic
group is 45-54 years 24, 25 . The co-morbid factors purpose up to 6th POD and gradual increase in walking
associated with CAD were hypertension (80%), progressed from moderate assistance to independent
diabetes mellitus(54%) and obesity(48%) are the very level.
common risk factors responsible for CAD.2 With regards to early mobilization, it was started
In present study, all the subjects were given 1 from 3rd POD with free active exercises involving upper
session of preoperative physiotherapy. Out of them, and lower body exercise and walking. The walking
90% were discharged on 6th POD. It had been studied was gradually increased over a period of time day by
by Erik H et.al. that preoperative physiotherapy day up to 6th POD with further increase in intensity of
reduces the incidence of post operative pulmonary activity to staircase climbing and descending. The early
complications and the average length of stay in the mobilization helps to rectify the deleterious
hemodynamic effects of bed rest, including decreased

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 273

exercise capacity, are due to loss of upright exposure update for CABG : a report of ACC/AHA.
to gravity rather than inactivity. The reasons 4. Gary J. balady et al., Core components of cardiac
supporting the concept that much of these alterations rehabilitation/secondary prevention programs,
are caused by the: a) Supine exercise does not prevent AHA/AACVPR Scientific statement(May 2000).
deconditioning effects of being in the bed. b) There is 5. Randal J. Thomas et al., Performance Measures
greater decrease in maximal oxygen uptake after a on Cardiac Rehabilitation for Referral to and
period of bed rest measured during upright versus Delivery of Cardiac Rehabilitation/secondary
supine exercise. To limit the decrease in functional prevention services, AACVPR/ACC/AHA
capacity after the surgery have emphasized low level Performance Measure.
activities but studies suggest that simple exposure to 6. Randal J. Thomas et al., Performance Measures
gravitational stress substantially accomplishes this29. on Cardiac Rehabilitation for Referral to and
Delivery of Cardiac Rehabilitation/secondary
The average length of stay extended up to 6th POD prevention services, AACVPR/ACC/AHA
and 90% of the subjects with uneventful CABG surgery Performance Measure.
were discharged on that day with mean walking 7. Indians at Risk, Nivh Chennai.2010
distance 171 meter and 2 flight of stairs independently. 8. Definition of functional status .http://
However 10% of subjects with CABG had certain jech.bmj.com/content/55/7/452.full.
complications like cardiac arrhythmias, uncontrolled 9. Inge D. van der Peijl et al., exercise therapy after
diabetes, long term inotropic support, pleural effusion CABG, October 28, 2003.
and were given physiotherapy treatment as per their 10. Barry L. zaret M.D, cardiac rehabilitation, chapter
specific problems. They had gradual improvement in 28, pg no. 351.
their functional status and became functionally 11. Best practice evidence based guideline, cardiac
independent by the 11th POD. rehabilitation, august 2002, chapter 2, pg no. 5.
12. Victor F. Froelicher, Exercise and Heart, 5th edition,
CONCLUSION pg no. 464.
It has been concluded that the 80% subjects with 13. Moholdt T T et al., department of circulation and
uneventful CABG following physiotherapy became medical imaging, Trondheim, Norway, aerobic
functionally independent i.e. sit, stand, walk, climb up interval training versus continuous moderate
stairs on 6th POD, whereas 10% with eventful CABG exercise after CABG: a randomized study of
could achieve on 11th POD. cardiovascular effects and quality of life, a m heart
journal 2009 december:158(6):1031-7.
The emphasis on chest physiotherapy was given 14. Hansen D. et al., rehabilitation and health care,
shortly after extubation and five times in a day up to Belgium, reduction of cardiovascular event rate:
3rd POD followed by extended prophylactic chest care different effects of cardiac rehabilitation in CABG
twice in a day up to 6th POD. and PCI patients, Acta cardial 2009 October; 64(5):
639-44.
Conflict of Interest: Nil 15. Urell c et al., department of physiotherapy,
Uppsala, Sweden, deep breathing exercises with
ACKNOWLEDGEMENT positive expiratory pressure at a higher rate
The author thanks the faculty members of improve oxygenation in the early period after
Madhuben and Bhanubhai Cardiac Center, Shree cardiac surgery- a randomized controlled trail,
Krishna Hospital, Karamsad for their valuable help. Eur J cardiothorac surg. 2010 december
16. Elisabeth Westerdahl et al., department of
REFERENCES physiotherapy and thoracic surgery, Uppsala,
Sweden, chest physiotherapy after CABG- a
1. Vibhuti N Singh et al., Cardiac Rehabilitation, comparision of three different deep breathing
American College Of Cardiology, September techniques, J Rehab Med 2001; 33:79-84.
19, 200. 17. Tzani P et al., cardiopulmonary department,
2. Huffman MD, Prabhakaran D., Heart Failure: Italy,patient assessment and prevention of
Epidemiology and Prevention in India. pulmonary side effects in surgery,Carropin
3. Eagle, KA, Guyton RA, Davidoff R et al Anaesthesiol,2011 Feb;24(1):2-7.
(October 5, 2004), “ ACC/AHA 2004 guideline 18. Craven JL, Evan GA, Davenport PJ,Williams

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 274 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

RHP.The evaluation of the incentive spirometer 23. William L. Haskell et al.,physical activity and
in the management of post operative public health:updated recommendation for
complications,Br J Surg. 1974;61:793-797. adults from American college of sports medicine
19. Erik H. J. Hulzebos et al.,Americal medical and American heart association. Med.sci.sports
association, Netherland,evaluation of the Exerc.,vol.39,No.8,pp.1423-1434,2007.
prophylactic efficacy of preoperative inspiratory 24. Serruys P.W. et al., PCI versus CABG for severe
muscle training on the incidence of post operative CAD, N Engl J Med 360(10): 961-72, march 2009.
pulmonary complications in high risk patients 25. Heart attack and cardiac arrest in men, men’s
scheduled for elective CABG surgery, JAMA 2011. health, april 2011.
20. Elisabeth Westerdahl et al., department of 26. Women and coronary artery disease, heart
physiotherapy, Sweden, deep breathing exercises disease health center, may 2009.
reduce atelectasis and improve pulmonary 27. Sansone GR.et al., newyork, analysis of FIM
function after CABG, june 2005, vol. 128 no. 5 instrument scores for patients admitted to an
3482-3488. inpatient cardiac rehabilitation program. Arch,
21. Mehta Y et al., department of anesthesia and phys Med Rehabil 2002, apr,83(4): 506-12.
critical care, physiotherapy and cardiac surgery, 28. KongKH et al., department of physical medicine
New delhi, incidence and management of and rehabilitation, usa, functional outcome of
diaphragmatic palsy in patients after cardiac patients on a rehabilitation unit after open heart
surgery; Indian J crit care Med. 2008 july: surgery, J Cardiopulm Rehabil. 1996, nov-dec;
12(3) 91-5. 16(6): 413-8.
22. Proposal and validation of a new functional 29. Convertino VA: effect of orthostatic stress on
ambulation classification scale for clinical use II exercise performance after bed rest: relation to
mediterranean congress of physical medicine and in- hospital rehabilitation: J cardiopulm rehabil
rehabilitation,May 2000,spain. 1983;3:660-663.

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 DOI Number: 10.5958/j.0973-5674.7.3.107
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 275

Effect of Cross Training Techniques in Novice Runners

Vishesh Garg1, M Neethi2, S K Joshi3, Jagmohan Singh4

1
Student MPT (Sports), Associate Professor, 3Athletics Coach, Sports Department Chandigarh, India, 4Professor &
2

Principal, Gian Sagar College of Physiotherapy, Ram Nagar, Rajpura (Punjab), India

ABSTRACT
Background and Objectives: Running is the most common sports event worldwide. Sprints are
short running events in athletics and track and field. Races over short distances are amongst the
oldest running competitions. Runners are trained with different training protocols to perform at
their best. One of the training protocols is known as "cross training techniques" in which athletes are
trained with a variety of exercises which are not specific to their sport. The present study was aimed
to evaluate the effect of cross training exercises in runners. The objectives of the study were to find
the effects of cross training on muscle strength, muscle power and running speed of the runners.
Materials and Method: 60 novice runners were randomly selected and divided in two groups, one
experimental and one control group. Control group was trained only with sports specific exercises
while in experimental group a non sports specific exercise was added. Athletes were trained for 8
weeks. After 8 weeks effects of cross training were observed on the speed of the runners.
Results: The mean values of muscle strength, muscle power and speed for control group are 4.5±4.01,
0.016±0.029 and 0.73±0.069 respectively. The mean values of muscle strength, muscle power and
speed for experimental group are 8.83±5.031, 0.038±0.053 and 0.205±0.0156 respectively.
Unpaired T-test was used to compare results of control group and experimental group. The results of
unpaired t-test were as follows:
Muscle strength: 3.62 (≤0.05)≤
Muscle power: 1.948 (≤0.05)
Speed: 4.13 (≤0.05)
Conclusion & Clinical Significance: It has been concluded on the basis of outcome measures and
statistical results that cross training exercises will help runners to improve their muscle strength,
muscle power and speed.
Keywords: Running, Cross Training, Cycling, Elliptical Training, Muscle Strength, Muscle Power, Running
Speed

INTRODUCTION end of the stadium to the other. There are three

sprinting events which are currently held at the
Biewener1 described the term running in athletics Summer Olympics and outdoor World
as “a gait in which at regular points during the running Championships: the 100 meters, 200 meters, and 400
cycle both feet are off the ground”. This is in contrast meters.
to walking, where one foot is always in contact with
the ground, the legs are kept mostly straight and the Hay2 described at the professional level, sprinters
center of gravity vaults over the legs in an inverted begin the race by assuming a crouching position in
pendulum fashion. the starting blocks before leaning forward and
gradually moving into an upright position as the race
Sprints are short running events in athletics and progresses and momentum is gained. The set position
track and field. Races over short distances are among differs depending on the start. Body alignment is of
the oldest running competitions. The first 13 editions key importance in producing the optimal amount of
of the Ancient Olympic Games featured only one force. Ideally the athlete should begin in a 4-point
event—the stadion race, which was a race from one stance and push off of both legs for the most force

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 276 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

production. There are three main types of crouch start- Exclusion criteria
the bunch or bullet, medium and elongated. In bunch
start the toes of the back foot are placed approximately Subject with any musculoskeletal injury or any
with the heel of the front foot. The toe to toe distance surgery in lower limb within 1 year, subject with any
is therefore of the order of 25-30 cm. in medium start neurological impairment, subject with any history of
the knee of the back leg is placed so that it is opposite tumor And subject declared unfit by his/her physician.
a point in front half of the front foot when the athlete
is in “on your marks” position. such placement yields PROCEDURE
a toe to toe distance of between 40-55 cm. in elongated
start the knee of the back leg is placed level with or Runners were divided in two groups. Group A
slightly behind the heel of the front foot in the “on (control group) and group B (experimental group).
your mark” position. The resulting toe to toe distance Group A was trained using basic training techniques
is of the order of 60-70 cm (1 mile running, plyometrics and squats).

Conventional wisdom says all training is specific- In group B along with basic training cross training
you improve the skills you practice. Runners, then, techniques were also included.
improve endurance with regular long, slow runs, and
improve speed with periodic spells of faster running. Cycling and elliptical training are used as cross
Yet most dedicated runners who train for an occasional training.
triathlon don’t seem to hurt their running. What’s Elliptical Training: 10 min session. Alternate
more, some trainers and coaches recommend cross between 2 min forward and 2 min backward
training for runners. They feel one-sport runners often
maintaining 90 strides/min. 3 days a week for 8 weeks.
are in poor skeletal shape above the waist, and could
use additional workouts for better overall fitness. Cycling: 20 to 30 min. session. (Cadence maintained
Secondly, they believe that running less and spending at 90/min). 3 days a week for 8 weeks.
the time saved on other sports reduces the risk of the
impact injuries associated with running. Outcome measures

But then there are the other trainers and coaches 1) Lower limb Speed test: 30 meter dash Test, This
who stick to the old “training is specific” concept; test requires the athlete to sprint as fast as possible
runners should run, and cross training won’t improve over 30 meters.
their running 2) Lower limb muscle power test: Triple Hop
3 distance Test: Subjects will perform a single leg
According to Morgan and McGlynn Cross-training
in sports and fitness refers to the combining of exercises triple hop for distance with each lower extremity.
to work various parts of the body. Often one particular 3) Lower limb strength test: Squats test: This test
activity works certain muscle groups, but not others; requires the athlete to complete as many squats as
cross-training aims to eliminate this. Both beginners possible with no rest.
and experienced runners can benefit from cross-
training. Measurement tools: Chair, measuring tape, stop watch
and cones
Best cross training activities for runners are:
cycling, swimming, elliptical training All these parameters were measured one day prior
to the training period and one day after the training
MATERIALS AND METHOD period is over.

Type of Study: The study was experimental and All the results were analyzed using standard
comparative in nature. statistical tools (Paired and unpaired T-tests.)

Sample Size- 60 runners were selected randomly RESULTS

by their coach.
The mean values of muscle strength, muscle power
Duration of study: 6 months and speed for control group are 4.5±4.01, 0.016±0.029
Inclusion Criteria and 0.73±0.069 respectively. The mean values of muscle
strength, muscle power and speed for experimental
Both males and females novice runners between group are 8.83±5.031, 0.038±0.053 and 0.205±0.0156
age group 18 to 28 years were included in the study. respectively.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 277

Unpaired T-test was used to compare results of DISCUSSION

control group and experimental group. The results of
unpaired t-test were as follows: According to Whytesides4, Running is a physically
demanding sport. Researchers have estimated that 37
Muscle strength: 3.62 (pd”0.05) to 56% of regularly training runners sustain an injury
Muscle power: 1.948 (pd”0.05) each year. Many athletes find that alternating other
forms of aerobic exercise into their routine allows them
Speed: 4.13 (pd”0.05) to train at greater volumes or intensities without
getting injured. Once an injury has occurred cross
training allows the athlete to maintain or even improve
their performance during recovery.

Tanaka5 describes it as the conveyance of training

effects from one limb to the contralateral or ipsilateral
limb. Irrespective of the definition the primary goal of
cross-training is performance enhancement or
maintenance. Anecdotally performance enhancement
from cross-training may be obtained through a number
of mechanisms: (i) direct improvement in performance
from an alternative mode of exercise; (ii) improved
training compliance associated with a more
Fig. 1. Comparison of muscle strength interesting/diverse training programme; (iii) reduced
incidence of overuse injury; (iv) maintained training
stimulus during rehabilitation from injury.

In present study effects of cross training are thought

to be result of improved training compliance associated
with more diverse training programme and direct
improvement in running speed from alternative mode
of exercise.

Alexander 6 justified the relationship between

muscle strength and sprint kinematics in elite sprinters.
Significant relationships were noted between sprinting
times for the 100 m and peak torque scores (N.m/kg)
for males for fast concentric knee extension and slow
eccentric dorsiflexion.

Fig. 2. Comparison of muscle power Fitzgerald7 said Cross training by participating in

nonimpact forms of cardiovascular exercise such as
cycling or swimming can not only speed your recovery
but also help you prevent injuries in the first place.

Burke8 advocated the benefits of cross training are

numerous. A sensible cross training programme
enables one to develop the five major components of
fitness: cardiorespiratory capacity, muscular
endurance, muscular strength, flexibility and fitness.
The emphasis is on comprehensive conditioning of
whole body.

Millet9 said the endurance athlete will use cross-

Fig. 3. Comparison of speed training mainly to break the boredom of usual routine

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 278 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

regime as a preventive method to minimize the injuries 3. Morgan, G and McGlynn, G 1997, Cross-Training
due to a weight-bearing activity to maintain a general for Sports: Programs for 26 sports, USA
fitness while the athlete has been forced to stop training 4. Bryan whytesides (2010) The runners guide to
in his primary activity because of injury or even to cross training. www.betterrunner.com
limit overtraining during high-volume periods. 5. Tanaka H, 1994 Effects of cross-training. Transfer
However, the cross-training method requires of training effects on VO2max between cycling,
redefining the overall training program, while addition running and swimming. Sports medicine
of new exercises increases the risks of injuries and 18(5):330-9
overtraining 6. Alexander MJ, 1989 The relationship between
muscle strength and sprint kinematics in elite
CONCLUSION sprinters. Canadian journal of sports medicine;
14(3):148-57
It is concluded statistically from the research 7. Fitzgerald M, 2004 Runner’s World Guide to
performed that cross training technique when applied Cross-Training Rodale inc, USA
in conjunction with specific training for runners 8. Burke E, 1994 The wisdom of cross training.
improve muscle strength, muscle power and speed. Strength and conditioning, 58-60
Conflict of Interest: There is no conflict of interest 9. Millet GP, Candau RB, Barbier B. Busso T,
amongst authors to prepare this manuscript. Rouillon JD, Chatard JC, 2001 Modeling the
transfer effects of training on performance of elite
REFERENCES triathletes. International journal of sports
medicine; 23: 55–63
1. Biewener, A A, 2003, Animal Locomotion, Oxford
University Press, USA
2. Hay, J G, 1973, The biomechanics of sports
techniques, Prentice Hall, Eaglewood Cliffs New
Jersey.

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 DOI Number: 10.5958/j.0973-5674.7.3.108
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 279

A Study on efficacy of different Therapeutic Modalities to

Alleviate Pain due to Knee Osteoarthritis

Bibek Adhya1, Anu Gupta2, Mandeep Singh Dhillon3, Upendra Goswami4, Vijay Kumar5
1
Senior Physiotherapist, Deptt. of PRM (Physiotherapy), PGIMER, Chandigarh & Research scholar ,Singhania University,
Pacheri Bari, Jhunjhunu, Rajasthan, 2Intern,Physiotherapy, Deptt. of PRM (Physiotherapy) 3Prof. & Head, Deptt. of
PRM(Physiotherapy) & Orthopedics, 4Physiotherapist, Deptt.of PRM(Physiotherapy) 5Research Associate, Deptt. of PRM
(Physiotherapy), PGIMER, Chandigarh

ABSTRACT
Introduction: Physiotherapy is one of the recommended non pharmacological management options
in patients with osteoarthritis.Ultrasound & Pulsed electromagnetic energy(PEME) & Exercises are
widely used in to treat pain due to osteoarthritis.
Aims& Objectives: The purpose of the study was an effort to find out the role of different modalities
(Therapeutic ultrasound, PEME , Exercises) to control the pain in osteoarthritis of knee.
Study design & Methodology: The study was experimental, pre & post design. 60 female
osteoarthritis patients including those suffering from bilateral osteoarthritis between age group 40-
65 years from the Department of Physiotherapy and Department of Orthopedics, PGIMER,
Chandigarh were chosen for the study & randomly distributed in 3 groups. Electrotherapy modalities
were administered for Group A (PEME) and Group B (Ultrasound) three times weekly for 6 weeks.
The exercises & hot water fomentation were carried daily for all the three groups (Group A, Group B
& Group C). The severity of knee pain was evaluated by Visual Analog Scale (VAS) in a weight
bearing position (walking or standing) in parallel bars. Western Ontario McMaster universities
(WOMAC) index of osteoarthritis was used to assess pain, stiffness, and physical function. SPSS-
Version17 was used for statistical analysis.
Conclusion: It is concluded that all the therapies administered (pulsed electromagnetic energy,
therapeutic ultrasound, exercises) help to reduce pain in knee osteoarthritis but none of the modality
proved more effective than others.
Keywords: Knee, Osteoarthritis, Pain, Pulsed Electromagnetic Energy, Ultrasound, Exercise

INTRODUCTION this condition, there is also remodeling of subchondral

bone occurs along with the varying degree of
Knee osteoarthritis marked by pain, degeneration,
degenerative changes occurs in the joint capsule,
muscle atrophy, inflammation, stiffness, deformity, and
ligaments, muscle and tendon. Due to the neural
progressive loss of independence.1,2
adaptations in the central nervous system and
Although the precise cause of pain accompanying peripheral nervous system in the presence of
this destructive process is not clear, possible causes unremitting pain, one can also expect behavioral
may include bone loss and exposure of bone nerves changes such as anxiety and depression to contribute
due to loss of protective cover of articular cartilage. In to the osteoarthritis pain production and its
detrimental effects on function. Although there is no
successful cure for knee osteoarthritis, the therapeutic
Corresponding author:
Bibek Adhya approach is mainly directed at symptoms and many
Sr. Physiotherapist treatment options including non pharmacological and
Department of PRM (Physiotherapy), P.G.I.M.E.R., pharmacological measures are recommended in the
Chandigarh, India. management of osteoarthritis. Non steroidal anti
Email: [email protected] inflammatory drugs (NSAIDS) and other drug
Ph. +919876044966 therapies involve potential hazards including

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 280 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

gastrointestinal side-effects, particularly in the elderly. Pulsed EME, Hot packs) to control the pain in
Physiotherapy (including PEME, Ultrasound, Hot osteoarthritis particularly in females in Indian scenario.
packs, Exercise etc.) is one of the recommended non
Aims and objectives
pharmacological management options in patients with
osteoarthritis. 3,4,5,6 The aims & objectives were to evaluate the
effectiveness of pulsed electromagnetic energy
Physical agents are devices using physical
(PEME), to evaluate the effectiveness of ultrasound,
modalities to produce beneficial therapeutic effects (e.g
to evaluate the effectiveness of exercises & to compare
therapeutic ultrasound, pulsed electromagnetic
the effect of pulsed electromagnetic energy(PEME)
energy, hot packs etc.). Heat therapy is applied to
,therapeutic ultrasound & exercise in osteoarthritis
obtain analgesia, decrease muscle spasm, increase
knee pain & function.
collagen extensibility and accelerate the metabolic
processes.
STUDY DESIGN & METHODOLOGY
Therapeutic ultrasound is constituted by high
Sampling
frequency sound waves of 0.75 MHz,1MHz and
3MHz. Ultrasound has been widely used for many 60 female osteoarthritis patients including those
years in the treatment of osteoarthritis. Ultrasound suffering with bilateral osteoarthritis between age
converts electrical energy into an acoustic waveform group 40-65 years were chosen for the study.
which is then converted into heat as it passes through
tissues of varying resistance .Ultrasound, reduces Inclusion criteria
muscle spasm through thermal effect, it also causes Radiological changes in the knee reported as
cavitation, microstreaming and acoustic streaming. degenerative or osteoarthritic. Pain emanating from
Cavitational effects result from the vibration of the the joint.
tissue causing microscopic air bubbles to form, which
transmit the vibrations in a way that directly stimulates Exclusion criteria
cell membranes. This physical stimulation appears to
History of previous Surgery of the effected joint.
enhance the cell-repair effects of the inflammatory
response including pain.7 Apparatus
Pulsed electromagnetic energy is a popular variant Curapuls 670, Enraf Nonius, The Netherlands.
of short wave diathermy. This consists of bursts of the
same alternating high frequency current, interspersed Gymna Pulson 200, Belgium.
with a cut off phase, during which heat can be
dissipated in the tissues. It is used for the treatment of STUDY DESIGN
soft tissue injuries and also for more chronic conditions
Experimental, a pre and post study design.
including osteoarthritis pain. In addition, the use of
low frequency pulsed electromagnetic field may Patients were randomly divided into 3 equal
produce a potentiated anti-inflammatory effect and groups of 20 patients each.
reduces pain without the unfavorable effects of the
excessive heat production. Pulsed EME uses electrical Group A: Exercises, Postural and ergonomic care,
energy to direct a series of magnetic pulses through Knee cap, Precautions, Hot water fomentation &
injured tissues whereby each magnetic pulse induces Pulsed electromagnetic energy. Dosage: Treatment
a tiny electrical signal that stimulates cellular dosage was as suggested by previous research 11m
waves at 27.12MHz and 150watts for 15 minutes with
repair.8,9,10,11.
condenser electrode. Treatment was admininistered
Exercises in case of osteoarthritis should be focused for 3 days for 6 weeks.
on pain, muscle weakness and loss of motion in and
Group B: Exercises, Postural and ergonomic care,
around the involved joint, strengthening helps to
Knee cap, Precautions, Hot water fomentation &
overcome pain.3
Therapeutic ultrasonic therapy. Locations of ultrasonic
Here an effort is executed to find out the role of treatment: The regions for application of therapeutic
different electro modalities (Therapeutic ultrasound, ultrasonic therapy are selected according to locations

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 281

of tender points noted on orthopedic clinical All patients were advised to wear knee caps while
examination. Dosage: Therapeutic Ultrasound therapy in weight bearing positions such as standing and
set at a frequency of 1.1MHz,duty cycle 100%, ERA walking.
4.0cm2, intensity 1.00 w/cm2 , treatment time 7.30
minutes, applied to each treatment (the default Patients were advised to avoid crossed leg sitting,
program for Arthrosis with Gymna, Pulson squatting, restrictions in use of steps as the postural &
200,Belgium). Sonication was performed for 3 days for ergonomic care (Precautions).
6 weeks. Measures
Group C: Exercises, Postural and ergonomic care, The severity of knee pain was evaluated by Visual
Knee cap, Precautions, Hot water fomentation. Analog Scale (VAS) after patients had remained in a
The exercises were carried daily for all the three weight bearing position (walking or standing) in
groups. parallel bars. The VAS instrument consisted of
horizontal line which is 10 cm long with anchor points
Exercise protocol of 0(no pain) and 10(maximum pain).

Isometric exercises for quadriceps and hamstrings Western Ontario McMaster universities(WOMAC)
with 10 seconds hold,20 repetitions(=1set), 3 sets each. index of osteoarthritis used to assess pain, stiffness,
Hip abductor dynamic strengthening exercises : 3 and physical function.
sets(1 set=20 repetitions) for each leg with 1 kg weight.
Dynamic strengthening exercises for the knee joint : Statistical analysis
20 repetitions , 3 times a day. SPSS-Version 17 was used for statistical analysis.
Hot water fomentation once per day for 15 minutes.

RESULTS
Table 1: Shows the comparison of the means of the VAS score before-after the treatment and WOMAC score before
& after the treatment in Group-A.

Paired Differences t Df Sig.

(2-tailed)
95% Confidence
Interval of the
Difference
Mean Std. Std. Error Lower Upper
Deviation Mean
Pair -1 VAS Pre Post 1.250 .786 .176 .882 1.618 7.109 19 .000
Pair-2 WOMAC Pre Post 3.250 2.447 .547 2.105 4.395 5.940 19 .000

p-value <0.05, significant

Table 2: Shows the comparison of the means of the VAS score before-after the treatment and WOMAC score
before-after the treatment in Group-B.

Paired Differences t Df Sig.

(2-tailed)
95% Confidence
Interval of the
Difference
Mean Std. Std. Error Lower Upper
Deviation Mean
Pair 1 VAS Pre Post 1.450 .945 .211 1.008 1.892 6.866 19 .000
Pair 2 WOMAC Pre Post 4.850 3.543 .792 3.192 6.508 6.121 19 .000

p-value <0.05, significant.

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Table 3: Shows the comparison of the means of the VAS score before-after the treatment and WOMAC score before-
after the treatment in Group-C.

Paired Differences t Df Sig.

(2-tailed)
95% Confidence
Interval of the
Difference
Mean Std. Std. Error Lower Upper
Deviation Mean
Pair 1 VAS Pre Post 1.350 .671 .150 1.036 1.664 9.000 19 .000
Pair 2 WOMAC Pre Post 4.450 2.874 .643 3.105 5.795 6.924 19 .000

p-value <0.05, significant

Table 4: Shows the VAS pre-post scores and WOMAC pre-post scores.

Sum of Df Mean F Sig.

Squares Square
VAS Score_pre Between Groups 7.3 2 3.65 1.301
(GroupA, GroupB & Within Groups 159.95 57 2.806
Group C) Total 167.25 59
VAS Score_Post Between Groups 9.1 2 4.55 1.188
(GroupA, Group B & Within Groups 218.3 57 3.83
Group C)) Total 227.4 59
WOMAC Score_Pre Between Groups 18.433 2 9.217 0.294
(GroupA, GroupB & Within Groups 1786.15 57 31.336
Group C)) Total 1804.583 59
WOMAC Score_Post Between Groups 90.433 2 45.217 1.038
(GroupA, GroupB & Within Groups 2483.3 57 43.567
Group C)) Total 2573.733 59

p>0.05,non significant

DISCUSSION P-value < 0.05 with therapeutic ultrasound treatment.

Ultrasound sends sound waves into the desired tissue
The analysis of comparison of VAS scores and causing vibration of the tissues. This vibration of
WOMAC scores in the group A shows (Table 1) tissues has numerous effects in improving healing. As
significant results as the P-value <0.05.Hence it is clear the tissue cells vibrate, heat is created. This heat is deep
that pulsed electromagnetic energy is effective to in the tissue and much more advantageous as
reduce pain in patients suffering with knee compared to superficial heat on the skin. This heat
osteoarthritis along with other interventions. Pulsed loosens muscle or ligamentous tissue to increase joint
electromagnetic energy is a popular variant of short range of motion, decreases muscle spasm, increases
wave diathermy. This consists of bursts of the same blood circulation to bring new healing cells to the area,
alternating high frequency current, interspersed with increases cell membrane permeability to allow each
a cut off phase, during which heat can be dissipated cell to take in the appropriate fluids and nutrients and
in the tissues. It increases oxygenation of tissues and rid the area of excess swelling, and stimulates the
accelerating the elimination of debris in the affected release of encephalins, the body’s natural painkillers.
area. It accelerates the regeneration of nerve tissue and Cavitational effects result from the vibration of the
eliminates excessive scar formation. It suppresses tissue causing microscopic air bubbles to form, which
inflammatory responses at the cell membrane level to transmit the vibrations in a way that directly stimulates
alleviate pain. Also exercises focus on pain, muscle cell membranes. This physical stimulation appears to
weakness and loss of motion in and around the enhance the cell-repair effects of the inflammatory
involved joint. 9 Documented study on pulsed response. Thus decreases pain in osteoarthritis patients
electromagnetic field too suggests that this therapy along with other interventions. Exercises on a regular
may be useful to reduce pain associated with knee basis helps to reduce osteoarthritis symptoms, improve
osteoarthritis.11 range of motion in the affected joint, improve joint
The comparison of VAS scores and WOMAC scores function.7
in the group B show significant results (Table 2) as the

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 283

The study conducted by A. Loyala Sanchez, et al. variance (anova) with repeated measures over time
(2010) supports the effectiveness of therapeutic was used to compare the mean scores of each of the
ultrasound. It suggests that 10-24 sessions of three groups such as active, placebo and control group
ultrasound may improve physical function in patients of pulsed electromagnetic energy at pre-treatment and
suffering from osteoarthritis knee.13 post-treatment at 1month and 3months follow up and
stated that there were not any significant differences
The analysis of comparison of VAS and WOMAC
found on the baseline data17.
scores in group C shows significant results as the P-
value is < 0.05(Table3). Exercises help in the muscle
CONCLUSION
strengthening as appropriate strengthened muscles
help to minimize the adverse effects of weight bearing This study shows a mixed result in reduction of
on the joints by reducing the amount of force that is pain in the patients suffering from knee osteoarthritis
transmitted across the affected joints. Some studies as there is significant results found in paired t-test in
have shown that when these patients strengthen their all the three groups when their pre treatment and post
quadriceps muscles significant improvements in pain treatment VAS and WOMAC scale scores were
and function are seen when compared with those who compared but when one way ANOVA was applied
did not strengthen these muscles. Exercise program within and between the groups no significant result
also helps in increasing flexibility and range of motion was found. Findings show that when individual
of the affected joints. Heat such as hot packs helps to patient was considered there was significant
reduce pain by improving circulation and relaxing improvement. Finally it is concluded that all the
muscles. Hot fomentation is the method of choice for therapies such as pulsed electromagnetic energy,
heating superficial tissues such as with the application
therapeutic ultrasound, exercises, hot packs and
of heat in the form of moist hot packs. Ergonomic &
precautions help to reduce pain in knee osteoarthritis
postural care also help by preventing the further
but none of the modality proved more effective than
damage of the joint. Studies performed over the
others.
exercise protocol shows that the patients assigned to
exercise groups had greater pain reduction and
ACKNOWLEDGEMENTS
improved function12,14,15
The authors are thankful to Dr. Sharad Prabhakar,
The analysis of comparison of VAS pre treatment-
Asst. Prof., Deptt. Orthopedics, PGIMER, Chandigarh,
scores, VAS post treatment-scores, WOMAC pre
Dr.Devender Chouhan, Asst. Prof., Deptt. of
treatment-scores and WOMAC post treatment-scores
Orthopedics, PGIMER, Chandigarh & Dr. Sarvdeep
for all the 60 patients and found that there is no
significant result in one way anova (Table 4). Thus it Dhatt, Asst. Prof., Deptt. of Orthopedics, PGIMER,
is clear that there is not much difference in result in all Chandigarh for their support by referring patients for
the three types of treatment. It has been found that the study.
improvement is noticed in every individual patient but Conflict of Interest
no significant value found on comparison of different
groups. Definitely there is scope for study with large Authors declare that there was no financial and
number of samples. personal relationships (employment, consultancies,
stock ownership, honoraria, paid expert testimony,
Study conducted by Y Laufer ,et al.(2005) shows patent applications/registrations, and grants or other
that ,a difference across time was observed for the pain
funding) with other people or organizations that could
and stiffness categories of the WOMAC Osteoarthritis
inappropriately influence (bias) the work.
Index (p < 0.033 and p < 0.008, respectively), with no
differences between groups as treatment is effective Funding Source: None
for individual patient. No other significant differences
across time or between groups were observed in any Ethical clearance
of the other measures16.
The study has been approved by ethical committee
Another study was performed by J.A.Klaber constituted for Physiotherapy research by PGIMER,
Moffett,et al.(1996) in support that when analysis of Chandigarh.

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 284 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

REFERENCES M (Eds). Pain Therapy. Elsevier Biomedical

Press.1983; p. 229-238.
1. Davis M A . Epidermiology of osteoarthritis.
11. Nadasdi M. Inhibition of experimental arthritis
Clinics in Geriatric Medicine.1988;4:241-255.
by athermic pulsating shortwaves in rats.
2. Threlkeld AJ, Currier.DP. Osteoarthritis.Effect on
Orthopedics.1960; 2:105-107.
synovial joint tissues. Physical therapy. 1988;68:
12. Kovar PA, Allegrante JP, Mackenzie CR, Peterson
364-370.
MG, Gutin B, Charison ME. Supervised fitness
3. Hochberg MC: Osteoarthritis: pathophysiology,
walking in patients with osteoarthritis of the
clinical features, management. Hosp Prac1984;
knee-a randomized control trial. Ann Intern
19(12):41-53,.
Med.1992;116:529-534.
4. Marks R. Peripheral mechanisms of pain
13. Loyola-Sanchez A, Richardson J, MacIntyre NJ.
production in osteoarthritis. Australian journal
Effectiveness of therapeutic ultrasound in knee
of Physiotherapy.1992;38:289-298.
osteoarthritis. A systematic review and meta-
5. Altman.RD. Osteoarthritis:Aggravating factors
analysis. Osteoarthritis and Cartilage.
and therapeutic measures. Postgraduate
2010;18:1117-1126.
medicine.1986;80:150-163
14. Chamberlain MA, Care G, Harfield B.
6. Hough AJ. Pathology of
Physiotherapy in osteoarthrosis of the knees. Int
osteoarthritis.In:Koopnian WJ.edition.Arthritis
Rehablitation Medicine.1982;4:101-106.
and allied conditions.13th ed. Baltimore.Williams
15. Marks R, Cantin D. Symptomatic OA of The
and Wilkins.1997; p.1945-1968.
Knee. Physiotherapy 1997 June ; 83 ( 6). 61.
7. American College of Rheumatology
16. Laufer Y , Zilberman R, PoratR , Nahir AM
Subcommittee on Osteoarthritis Guidelines.
.Effect of pulsed short-wave diathermy on pain
Arthritis & Rheumatism.2000;43(9):1905-15.
and function of subjects with osteoarthritis of the
8. George E, Creamer P, Dieppe PA.Clinical Susets
knee:a placebo-controlled double-blind clinical
of osteoarthritis of the hip joint.
trial. Clinical Rehabilitation.2005.19; 3:255-263.
Physiotherapy.1994;77:737-740.
17. Klaber Moffett JA, Richardson PH, Frost H,
9. Fabbri F,Lucchese V .Non thermal effects of
Osborn A. A placebo controlled double blind trial
pulsed magnetic fields.An experimental study of
to evaluate the effectiveness of pulsed shortwave
22 laboratory parameters. Minerva
therapy for osteoarthritic hip and knee
Orthopedica.1980; 31: 251-256.
pain.Pain.1996;67:121-127.
10. Warnke U.The possible role of pulsating magnetic
fields in the reduction of pain. In: Rizzi R, Visentin

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 DOI Number: 10.5958/j.0973-5674.7.3.109
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 285

A Comparative Study of effectiveness of Balance Training

with and without Visual Cues on Activities of Daily
Living in Stroke Patients

Dhoriyani Narendra B1, Patel Fagun B2, Smitha D3, Kagathra Shailesh4, Bhatt Kaushal5
1
Tutor Cum Physiotherapist, Government Physiotherapy College, Jamangar, 2Lecturer, Ahmedabad Institute of Medical
Sciences, Ahmedabad, 3Assistant Professor, Shree Devi College of Physiotherapy, Mangalore, 4Physiotherapist & Director,
Prayas Multispeciality Physiotherapy Center, Rajkot, 5Physiotherapist & CEO, KIDS Paediatric Physiotherapy Clinic,
Bhavnagar

ABSTRACT
Background: In stroke balance can be affected by deficits of strength, range of motion, proprioception,
vision, vestibular function. Patients are trained to rely more on visual input to maintain balance but
rarely are trained for the vestibular and other sensory system. Balance is also a predictor of functional
rehabilitation. Hence aim of this study is to find out the difference between training somatosensory,
vestibular and tactile system with and without visual cues, with emphasis on balance and its effect
on ADL and mobility in stroke patients.
Materials and Method: Thirty post stroke subjects with balance problem were assigned into two
groups: GroupA (Control) and GroupB (Experimental). Both the groups received similar balance
training program for six weeks. Subjects of group A were allowed to use free vision and group B
were deprived of visual cues during balance training. After six weeks both groups were re-evaluated
for balance, ADL and mobility.
Results: There was significant improvement in balance(p<0.001), ADL(p<0.001) and mobility(p<0.001)
in both the groups but between the groups there was significant improvement in balance(p<0.01) but
not in ADL(p>0.05)and mobility(p>0.05).
Discussion and Conclusion: Balance is the basic need for doing all ADL activities but training for
balance will not necessarily improve quality of ADL. This study suggests that patients improved
their integration of somatosensory and vestibular input and enables them to use the pertinent input
to become less reliant on visual input. From this result it was concluded that balance training without
vision is more effective in balance recovery in stroke patients.
Keywords: Balance, Activities of Daily Living, Vision, Stroke

INTRODUCTION from stroke and nearly 400,000 survive with some level
of neurological impairment and disability.2 The WHO
After coronary heart disease (CHD) and cancer of
defined stroke as ‘ rapidly developed clinical signs of
all types, stroke is the third leading cause of death
focal disturbance of cerebral function; lasting more
worldwide. However, Asians have a lower rate of
than 24 hours or leading to death, with no apparent
coronary heart disease and higher prevalence of
cause other than vascular origin.3 In India during
stroke.1 Each year approximately 600,000 people suffer
ninety’s the prevalence rate of stroke was between
250-350/100,000.4
Corresponding author:
Dhoriyani Naredra B In stroke the physical impairments includes motor,
Tutor Cum Physiotherapist sensory, balance, perceptual problems etc. Balance
Mahendranagar, Ta: Morbi , Di: Rajkot, Gujarat, India
impairment is the most common in any type of stroke
Ph: +91-987-971-8851
E-mail: Narendra41067@yahoo,com because balance can be affected by more than one

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 286 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

component. Balance has been defined as the ability to Subjects were excluded if having orthopedic disorders
maintain an upright posture.5,6 Traditionally balance in one or both lower limbs, any neurological diseases
has been divided into either static or dynamic as if such as vertigo, vestibular dysfunction, subjects with
they have separate physiological mechanisms. 7 peripheral neuropathy or cognitive/perceptual
Balance is a very complex task that involves sensory disorders, peripheral or central visual problem, stroke
input, and the execution of the appropriate due to PCA syndrome and not older than 65 years.
neuromuscular response.5 Pre-intervention outcome measures were evaluated
and recorded for the 30 subjects. Berg Balance Scale
In stroke, one’s ability to balance may be impaired for balance impairments, Stroke Specific-Quality of
because of deficits of strength, range of motion, Life Scale (Family Roles, Mobility, Self Care, Upper
proprioception, vision, vestibular function or Extremity Functions and Work/Productivity) for ADL,
endurance.5,11 In this condition balance impairment Rivermead Mobility Index for mobility function.
may be much more complex because of impaired use
of individual sensory system along with impaired The subjects were randomly allocated to either
central processing of the sensory organization control group (Group A) or experimental group (Group
mechanisms.12,13Studies shows the disorders of the B) by using sealed envelopes. The subjects of group B
sensory information organization underlie distorted were blindfolded during balance training sessions with
representation of the body in space due to vestibular a soft and dark colored cloth material, taking adequate
or somatosensory system insufficiency. They are more care to ensure a safe environment. Subjects of group A
dependent on visual system while maintaining balance were allowed to use free vision during balance
and doing ADL. Again balance control will be more training. A set of training exercises as described below
difficult in patients with visuo-vestibular conflict.14, were given to the both the groups for a period of six
weeks. Five sessions of exercises per week was given
Balance is also an important predictor of functional and each session lasted for 45 to 60 minutes. Post-
rehabilitation in post-stroke patients. Functional intervention outcome measures were reassessed at the
improvement may be due to the true physiological end of six weeks exercise protocol. Pre to post
recovery derived from normal balance responses. comparison of each outcome measure was done by
During rehabilitation stroke patients are knowingly or students paired‘t’ test. Comparison between the two
unknowingly trained to rely more on visual input but groups i.e. group A and group B was done using
are rarely trained for the vestibular and other sensory students unpaired‘t’ test. Mean and standard deviation
system. Generally the patient is trained in such a way were calculated and data were subjected to statistical
that the patient always uses vision as compensation analysis using SPSS software. One-way analysis of
to loss of other sensory system to repair themselves to variance was done to determine any significant
their fullest extent. differences between the experimental and control
groups before and after intervention.
Whether there is a statistically significant difference
between training somatosensory, vestibular and tactile Exercise protocol is described below
system with and without vision on balance and
therefore on Activities of Daily Living and mobility in Exercises in supine lying
stroke patients? In supine position with both the knees flexed to 900
and asked to do pelvic bridging. Knees were stabilized.
MATERIALS AND METHODOLOGY Progressed to single leg bridging, therapist supports
A randomized control double blinded study was extremity at knee joint and perturbation was added.
conducted at Yenepoya Hospital, Govt. Wenlock Exercises in prone lying
hospital and Shree Devi College of physiotherapy,
mangalore with sample size of 30 patients in 2008. In forearm support prone lying, with the therapist
Subjects were included based on criteria that patients stabilizing the shoulder and trunk on the affected side.
is having hemiplegia by stroke, could assume Progressed in prone kneeling, with the therapist on
independent standing for minimum of 10 seconds and the affected side stabilizing elbow and shoulder to
have balance problem with minimum 20 scores on BBS. prevent buckling of elbow.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 287

Therapist stood behind. Progressed to without upper

limb support. Then progressively decreasing BOS from
lower limb. Then standing on foam surface without
external support to alter somatosensory input.
Marching on foam surface. Then standing balance on
wobble board. Then walking forward and side to side.

Role of funding source: The study was partly

sponsored by Shree Devi College, however it does not
had any role in study design, in collection, analysis or
interpretation of the data; or in writing the manuscript
Fig. 1. Indicates patients is in prone kneeling position and or the decision to publish the results.
therapist stabilizes elbow and the perturbation is given.

RESULTS
Exercises in sitting
From the below Table 1.1, it is understood that a
In long sitting position on low plinth with both the very highly significant increase is found in the scores
upper limb placed behind trunk on plinth. Care was of Berg Balance Scale (P<0.001) in both groups. When
taken to prevent fall then progressed to cross-leg sitting measured with SS-QOL , the mobility, self care, upper
and then to high sitting with same position of upper extremity functions shows a very highly significant
limbs. In high sitting progressed with decreasing BOS improvement after the treatment in both the groups.
of upper limbs. Then buttocks lifting and moving in Therefore a very highly significant increase in total SS-
side to side and front back. QOL scores. However, no significant increase is found
in family roles(P<0.001) in either groups. It is also
Exercises in standing
understood that a very highly significant increase is
Standing in a parallel bar with wide base of support, found in scores of Rivermead Mobility Index (P<0.001)
upper limbs were supported on horizontal bar. in both the groups.

Table 1.1: Comparison of pre & post measures (Mean & SD) with paired students‘t’ test within Group
and within Group B.

Group Paired Differences t p

Mean Std. Deviation
EXERCISES WITH VISION – A BBS 3.9333 1.53375 9.932 0.001 vhs
Family Roles 0.2000 0.41404 1.871 0.082 ns
Mobility 2.2000 1.01419 8.401 0.001 vhs
Self Care 1.5333 0.83381 7.122 0.001 vhs
UEF 1.3333 0.72375 7.135 0.001 vhs
Total SS-QOL 5.4667 1.72654 12.26 0.001 vhs
RMI 1.7333 0.79881 8.404 0.001 vhs
EXERCISES WITHOUT VISION – B BBS 6.4000 2.61315 9.486 0.001 vhs
Family Roles 0.2000 0.41404 1.871 0.082 ns
Mobility 2.9333 1.33452 8.513 0.001 vhs
Self Care 2.2000 1.32017 6.454 0.001 vhs
UEF 1.6667 0.72375 8.919 0.001 vhs
Total SS-QOL 7.0667 2.78944 9.812 0.001 vhs
RMI 1.9333 0.96115 7.79 0.001 vhs

(p<0.05 significant, p<0.01 highly significant, p<0.001 very highly significant

From the below Table 1.2 it is understood that a vision) compared to group A(with vision). When
highly significant improvement is found in scores of changes in components of SS-QOL like family roles,
Berg Balance Scale (P<0.001) of group B(without mobility, self care and upper extremity functions are

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 288 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

compared between the groups, there is no significant scores of Rivermead Mobility Index (p>0.005) when
difference therefore no significant difference in SS- the two groups are compared.
QOL. It is understood that no significant change in

Table 1.2 Comparison of measures (Mean & SD) with unpaired students ‘t’ test between Group A and Group B.

Exercises Exercises t p
Withvision- A Withoutvisionb-b
Mean Std. Deviation Mean Std. Deviation
BBS 3.9333 1.53375 6.4000 2.61315 3.079 0.004 hs
Family Roles 0.2000 0.41404 0.2000 0.41404 3.00E-07 1 ns
Mobility 2.2000 1.01419 2.9333 1.33452 1.6884 0.102 ns
Self Care 1.5333 0.83381 2.2000 1.32017 1.6418 0.111 ns
Upper Extri. Fun 1.3333 0.72375 1.6667 0.72375 1.2603 0.217 ns
Total SSQOL 5.4667 1.72654 7.0667 2.78944 1.8716 0.074 ns
RMI 1.7333 0.79881 1.9333 0.96115 0.6193 0.540 ns

(p<0.05 significant, p<0.01 highly significant, p<0.001 very highly significant)

DISCUSSION AND CONCLUSION caused by visual cues and not by the balance training
program. In this study balance training was more
The purpose of this study was to assess the
precisely concentrated with longer duration & sessions
effectiveness of balance training with and without
and with more repetition of exercises which could be
vision on activities of daily living and mobility in stroke
the possible reason of this study’s findings.
patients. At the start of study the groups were uniform
in their characteristics. At the end of study the results The findings of this study suggest that the patients
of balance training program were compared between improved their integration of somatosensory and
the subjects with and without vision. Balance, ADL vestibular inputs and that the program enabled them
and mobility improved significantly in both groups to use the pertinent input and to become less reliant
but the visually deprived group had significantly better on visual inputs.
balance scores but not ADL and mobility
improvement. While comparing the individual The predominant influence of visual input
components of SSQOL like family roles, mobility, self constitutes a natural compensatory strategy for coping
care, upper extremity functions between groups, there with initial imbalance and that traditional
was no significant improvement was noticed. rehabilitation reinforces this excessive visual reliance
by focusing on visual compensation rather than
Thus, from the results we can infer that balance will restoring the normal use of all sensory inputs. It is
improve significantly better with visual cue suggested that excessive reliance on vision is an
deprivation but not ADL & mobility. Balance is the attempt to compensate for defective balance is
basic need for doing all ADL activities but training only supported by result of this study that this reliance is
for balance will not necessarily improve the quality of reversible after a vision-deprived balance
ADL activities. ADL can be improved by giving rehabilitation program.
exercises similar to the ADL activities combined with
balance training program. Similarly mobility can be The subjects were treated for balance with vision
improved by training for mobility combined with and without vision for six weeks. Five sessions of
balance training program. exercises per week and each lasted for 45 to 60 minutes.
The subjects in experimental group, who received
Subjects were homogenous for age and level of balance training without vision showed better
recovery: all could assume independent standing for improvement in balance than control group, who
10 seconds without any assistance and screened for received similar balance training with free vision. In
positive balance problem. The same balance training conclusion the balance training without vision is more
program was given to both groups. The only difference effective in balance recovery in stroke patients.
being the visual cues. This ensured that any differences
between the group differences in the results were The limitations of study were as it was done on
smaller sample size and treatment protocol was of

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 289

smaller duration. There may be different result if with 12. Shumway-cookA, McCollumG. Assessment and
longer duration of neuro-rehabilitation protocol. This treatment of balance disorders. In: PC
study can be further extended with modifying sensory Montgomery, BH Connolly,editor:Motor control
input and sensory conflict with very precise and physical therapy. Hixson. TN: Chattanooga
instruments such as Smart Balance Master, forceplate GroupInc; 1993: 123-138.
etc. 13. DiFabioRP, BadkeMB. Relationship of sensory
organization to balance function in patients with
ACKNOWLEDGEMENTS hemiplegia. PhysTher1990 Sep;70(9):542-548.
14. BonanIV, ColleFF, Reliance on visual information
The authors are thankful to Mr.S.Jayasrikanth for after stroke part- 1 Balance on dynamic
guiding throughout the study and thankful to posturography. ArchPhysMedRehab 2004; 85(2):
Principal, Shree Devi College for providing laboratory 268-273.
facility and funding for study. The study was approved 15. BonanIV, Yelnik AP et.al. Reliance on visual
by Research and Development and Ethical committee information after stroke. Part-2effectiveness of
of Shree Devi college of Physiotherapy. balance rehabilitation program with visual cue
deprivation after stroke: A randomised controlled
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 DOI Number: 10.5958/j.0973-5674.7.3.110
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 291

Correlation among Cervical Pain, Neck Disability Index

and Health Related Quality of Life for Subjects Suffering
from Cervical Pain of Age Group 20 to 75 Years

Shubha Arora1, Taruna Mathur2

1
Assistant Professor (Occupational Therapy), Department of Rehabilitation sciences, Jamia Hamdard Delhi, Formerly H.O.D
(Department of Occupational Therapy) of D.I.R.D, Under Guru Gobind Singh I.P. University, 2Occupational Therapist,
G.B. Pant Hospital, Delhi, India

ABSTRACT
Objectives:
1. To evaluate neck pain, neck disability and quality of life of patients with cervical pain
2. To find correlation between pain, disability and quality of life
Outcome measures:
1. Visual analogue scale (VAS) for pain
2. Neck disability index for evaluating disability
3. Rand shortform-36 for health related Quality of life
Methodology:
Approx. 50 patients of age group 20-75 years with cervical pain were included in the study. This
study is based on observation. Data was collected from G.B..Pant Hospital , Delhi, various clinics
and from general population on the basis of inclusion criteria. After rapport building, subjects were
evaluated for pain, disability and quality of life for functional outcomes.
After data collection, correlation between the three scales was established and data was analyzed
statistically by using correlation Regression.
Results:
1. Increase in cervical pain will lead to decrease in quality of life in all different domains
2. Disability is directly correlated to quality of life
Keywords: Disability, Quality of life

INTRODUCTION substantial effect on daily life that results in extensive

use of health care resources.(2,3,4). Neck-pain is frequent
Neck pain is the most chronic pain problems with source of disability causing human suffering and
reported 90% of men older than 50 years and 90% of affecting the well-being of an individual. The outcome
women older than 60 years have evidence of measures ought to be multidimensional and include
degenerative changes in the cervical spine. (1) the subjective experience of the patient. This can be
Mechanism of disability caused by neck pain has yet achieved by measuring the health related qualities of
been elucidated, but it is usually accomplished by life (5).

Corresponding author: Neck-pain has been shown to be associated with

Ms Shubha Arora decrease in health related quality of life in several
Assistant Professor studies (6,7-12). While no gold standards exist for
120-B, Deep Enclave, Pocket –D, Phase-3, assessing health related quality of life among patients
Ashok Vihar, Delhi-110052 with neck-pain. Several different measurement tools
Mob No: 9810195029 have been used such as Rand short form–36 health
Email: [email protected] related survey (13).

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 292 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

To improve functional status and quality of life outcomes.

measuring neck pain is an important component of
clinical practice, and required validated instruments All measurements were performed blind by the
in order to gather information about impact of disease, same occupational therapist.All patients completed the
which is not offered by clinical data. assessment in all 3 scales with in 1-3 days interval.

In recent decades, several questionnaires have been In administration of scales, the following clinical
designed and developed for the purpose, viz, Neck parameters were used to assess neck pain, neck-
disability Index (NDI); Visual analogue scale (VAS); disability and quality of life by the same therapist. :
Rand SF36.(14-17) • Neck- Pain on Visual Analogue Scale.
These three scales were applied to the patient • The Therapist global Assessment
population and compared with regard to their
• Muscle Spasm
psychometric properties and usefulness in order to
determine how pain is correlated with neck disability • Neck - sensitivity
index and neck disability index to Medical outcome
• Active range of motion (ROM) of the cervical spine.
study, Rand SF-36 used for Quality of life (QOL). The
rationale behind this study is keeping in mind the In addition, baseline socio-cultural characteristics
correlation between neck pain and Quality of life; we including age, gender, education level, occupation,
can set better goals for individual subjects suffering disease duration in months and morning stiffness were
from neck pain. assessed

MATERIAL AND METHOD Outcome measures

Fifty patients of age group “20-75 years” with 1. Visual analogue scale (VAS) for Neck- pain
cervical pain were included in the study. This study
2. Neck disability index for evaluating disability
was mainly based on observations. Sample Data was
collected from G.B..Pant Hospital, Delhi ; various 3. The Medical Outcome study Rand Short Form-36
clinics and from general population on the basis of was used to examine health related quality of life
inclusion criteria. (QOL)
Inclusion criteria VAS was presented as 100-mm vertical line
containing word anchors at extreme with no pain on
- Male or female of age group 20-75 years, having
the bottom and worse possible pain on the top with
constant or frequent neck pain for more than 6
ten markings.(19)
months.
Neck disability index is a functional pain
- Mostly office employed.
assessment scale, used as functional outcome tool for
- Motivated to continue working. cervical related disabilities. NDI have been shown to
be valid and reliable tool in evaluation of patients with
- Motivated to continue rehabilitation programme. neck pain. NDI manifested adequate test/retest
reliability (ICC=0.68).(14,20). This scale has 10 sections
Exclusion Criteria each having 5 questions, having equal scores. Good
Several disorders of cervical spine such as disc scores was given highest marks and poor was marked
prolapse, spinal stenosis, post operative conditions in lowest scores, so neck pain score was registered
the neck and shoulder area, history of severe trauma, through a scale of 0-50.
instability, spasmodic torticollis, frequent migraine, Whereas, Medical outcome study “Rand short form
fibromyalgia, shoulder diseases (tendonitis, bursitis, –36”is a likert scale used to assess quality of life and
capsulitis), inflammatory Rheumatic diseases.(18) has 8 health concepts i.e. physical functioning, bodily
pain, role limitations due to physical health problems,
PROCEDURE role functioning due to personal and emotional
problems, emotional well-being, social functioning,
All the participants provided written informed
energy/fatigue-ness and general health perception.
Consents before entry in the study. After rapport
For each concepts, summery score ranges from 0 to
building, each subject was evaluated for neck pain,
100.(21)
neck- disability and quality of life for functional

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 293

From the data collected, correlation between the subjects (Table-2).Their means and standard deviations
three scales was established through data analyzed are also calculated as given in Table- 3.
statistically by using correlation Regression technique.
Table2: Categories of Neck Disability Index with
Statistical Analysis frequency of subjects in each category.

Neck disability index Frequency

Data collected from 50 subjects was tabulated.
Mild Disability 12
Mean and standard deviation was calculated for all
Moderate Disability 21
the 10 variables (e.g..VAS scores, Neck disability index
Severe Disability 17
and eight variables of Rand SF- 36) as given below in
Table-1 Data Sample was subjected to” One way analysis
to variance (Anova) for unrelated subject design test”
Table-1: Mean and Standard Deviation of all ten
variables for finding out “f” value and “t” test for finding
regression coefficient to establish the significance of
Variable Observations Mean Standard the Results
Deviation
Neck pain 50 6.7 1.5 Table3: Mean and standard deviation of different
Neck disability index 50 20.1 9.1 categories of neck disability Index
Physical function 50 62.9 19.3
Categories Frequency Mean Standard
Physical Health 50 37.2 24.0 of Neck Disability Deviation
Emotional problem 50 68.1 33.1 Index
Energy/Fatigue-ness 50 49 20.9 Mild 12 71.6 13.7
Emotional Well-being 50 77.1 19.4 Moderate 21 65.86 19.2
Social Functioning 50 65.8 22.7 Severe 17 52.9 19.45

Bodily pain 50 57.7 24.0 Total/Combined 50 62.86 19.32

General health 50 66.2 18.5 On the basis of Anova test, coefficient “f” was
Correlation coefficient was found between neck calculated among the neck disability variable and all
eight variables of Rand SF-36.one by one to establish
pain and neck disability by conducting Pearson co-
significance of the results. Calculation was performed
rrelation test(22) on the data and was calculated as 0.71
by calculating the variance from mean and standard
(Graph-I). It reflects the positive relationship i.e. if deviation parameters of each group to establish the
neck-pain increases neck disability also enhances. coefficient “f” and probability was read from the table
against the calculated ‘f”. Results of the tests are given
Correlation between two variables is minimum if
in Table-4.
correlation coefficient is equal to zero and is maximum
if it is +1, i.e. closer the co-rrelation coefficient is to Table 4: Variables along with F value and P value
zero, weaker the relationship between the variables.
Variable F Value P Value
Taking the neck disability as principal variable, Physical function 4.23 0.0204
correlation between eight variables as per SF-36, was Physical Health 2.37 0.0104
established one by one (Graph II) Emotional problem 10.07 0.0002
Energy/Fatigue-ness 9.07 0.005
In order to check the chance/Random error, Emotional Well-being 9.01 0.005
subjects were divided into three categories for neck Social Functioning 7.60 .0014
disability index as per severity of neck disability: Bodily pain 5.58 0.0067
General health 4.83 0.0124
1. Mild disability: includes no or mild disability
Data was also subjected to regression analysis to
2. Moderate disability: includes moderate disability
find out regression coefficient “t” for neck disability
3. Severe disability: includes “severely or completely and Rand SF-36 variables one by one through variance
disability” and standard error parameters.This was done to be
doubly sure about test results and correlation among
It was found that for first category of disability there various variables. Result of the test are given below
are 12 subjects, for second 21 subjects and for third 17 (Table5).

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 294 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Table 5: Rand SF36 Variables along with regression

coefficient and T value and p value.

RandSF36 Regression
Variables coefficient. T value P value
Physical function -0.56 -1.75 0.045
Physical Health -0.24 -0.62 0.268
Emotional problem -1.31 -2.68 0.015
Energy/Fatigue-ness -0.82 -2.85 .006
Emotional Well-being -0.54 -1.83 .035
Social Functioning -0.83 -2.44 .009
Bodily pain -0.76 -2.09 0.022
General health -0.53 -1.85 0.035

RESULTS
4. All Rand SF-36 variables, reduces as the neck
1. Correlation between Neck- pain and Neck disability increases. This is being denoted by “t”
disability was found to be in the ratio of 1:0.71. As negative value for all variables. As neck disability
it is positive relation, which shows that if neck pain increases, physical functioning, bodily pain, role
increases, neck disability also increases ( Graph I ) limitations due to physical health problems, role
functioning due to personal and emotional
problems, emotional well-being, social
functioning, energy/fatigue-ness and general
health perception. Same is also reflected in Graph-
II.as all correlation coefficients are negative, with
respect to Neck disability.

DISCUSSION AND CONCLUSION

Fifty subjects suffering from neck pain were

analyzed on the basis of pain (VAS), neck disability
index and quality of life (Rand SF36)

Graph-I: Neck-Pain scores Vs Neck disability First of all pain was correlated with neck disability
Index in relation to Pearson correlation coefficient index on the basis of Pearson Correlation Coefficient.It
was found to having a ratio of 1:0.71 which signifies
2. It is clear from Graph-II that there is Negative that it has a positive correlation. It shows that if pain
correlation of Rand –36 variables with neck increases neck disability also increases. It was
disability index, which in turn is positively co- supported by KoseG (22).who compared the four
related to neck pain. Correlation is maximum in disability scales on Turkish patients with neck pain.
energy/ fatigue-ness variable, followed by
emotional problems, social functioning, body pain, Secondly correlation between neck disability index
emotional well-being, general health, and is and eight variables of QOL (Rand SF-36) was done
minimum for physical health variable. which showed that Pearson correlation is more in
energy/fatigue-ness and least in physical health.
GRAPH-II: Ray diagram showing Pearson corr.
between neck disability and eight variables of All Rand SF-36 variables reduce as the neck
Rand SF36 disability increases. This is being denoted by negative
values of correlation coefficients between neck
3. From Table5 it is clear from the results that but for disability and Rand SF-36 all variables and was
the physical health variable correlation with neck supported by Wanch in 2005(23),Lingin2003(24)and Li Nx
disability, all other results are significant because in 2001(25) who analyzed that SF36 dimensions were
p<5%or 0.05.For Physical health relation, random remarkably impaired in chronic diseases. People with
error or chance error has spoiled the results Chronic diseases had worse quality of life that those
showing high rate of error probability. without.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 295

Ignoring the Physical health analysis (which is one 4. Sintonen H: The 15D instrument of health related
of the variables of Rand SF- 36). Probability error due quality of life properties and applications. Ann
to chance is minimum for emotional functioning and Med 2001, 33(5); 328-336.
maximum for physical functioning so our results are 5. Cote P. Cassidy JD : The factors associated with
significant because “p” value is <5% neck pain and its related disability in
Saskatchewan Population.Spine2000 25(9):
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probability. selected measured of impairment, functional
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10. Lobbezoo F : Impaired health status, sleep
ACKNOWLEMENT disorders and pain in carniomandubular and
cervical spine regions. Eur J Pain 2004,8(1):
I would like to give a vote of thanks to Dr 23-30.
R.N.Pandey, a Biostatician at AIIMS, Delhi who helped 11. Saarni si, Harkanen T,Sintonen H, Suisaari j,
me in analyzing the sample.. koskinen s, Aromaa A, Lonnqurist J: The impact
Conflict of Interest: Nil of 29 chronic condts on health related quality of
life” a general population survey in Finland using
Source of Funding: Self 15D and EQ-5D. Qual life res 2006 15(8):
1403-1414.
Ethical Clearance: As it is observational study, ethical
12. Ware JE Jr, Sherboune CD: the MOS 36- item short
clearance not required.
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 DOI Number: 10.5958/j.0973-5674.7.3.111
Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 297

Profile of Older Adults in Memory Outpatients' Clinic

Setting and effectiveness of Novel Occupational Therapy
Intervention in Patients with Mild to Moderate Dementia

Prakash Kumar1, SC Tiwari2, V Sreenivas3, Nand Kumar4, R K Tripathi5, Dey AB6

1
PhD Scholar, KGMU Lucknow, SRF (ICMR), Occupational Therapist, AIIMS, New Delhi, 2Professor and Head,
Department of Geriatric Mental Health, KGMU, Lucknow, 3Associate Professor, Department of Biostatistics,
AIIMS, New Delhi, 4Associate Professor, Department of Psychiatry, AIIMS, New Delhi, 5Assistant Professor, Department of
Geriatric Mental Health, KGMU, Lucknow, 6Professor and Head, Department of Geriatric Medicine, AIIMS, New Delhi

ABSTRACT
Background: Researchers and clinicians are working hard for prevention and management of dementia
and its complications, no definite remedy is available now. Our aim is to investigate effects of
occupational therapy in maintaining quality of life of patients having mild to moderate dementia.
Methodology: 263 older subjects (new-182, old-81) were included between November 2010 and April
2013. After screening of all patients by a geriatrician, 192 were excluded having [Cognitive impairment
with no dementia (CIND)]. Rest 71 patients were included after satisfying DSM IV criteria and were
randomly assigned to experimental and control groups. Experimental group received newly developed
occupational therapy intervention along with the drug, and control group received only drug for a
period of 5 weeks. Both groups were evaluated using the six outcome measures a) Folstein Mini
Mental status examination, b) Geriatric Depression scale Hindi Version c)Bristol Activity of daily
Living, d) Modified Physical Performance test, e) BEHAV-AD, f)WHO QOL [Hindi Version] obtained
baseline and reassessment after 5 weeks.
Result: Included subjects with mean age 69.39 having 33.80% of primary education, 32.39 % up to
class 12, 47.88% of living with spouse, 47.88% of living with spouse and family, 78.87% married,
16.9% widowed, 22.53% unemployed, 43.66% retired. After application of novel occupational therapy
on experimental group there is statistically improvement in the domain of Depression, ADL, Physical
performance, and quality of life, out of all six domains.
Conclusion: The study reveals that the newly developed occupational therapy program can improve
behavioral status, functionality, physical performance, mood and quality of life in elderly dementia
patient at short term. A follow up study is required to ascertain the long term effect of treatment.
Keywords: Novel Occupational Therapy Intervention Programme and Dementia

INTRODUCTION Dementia can impact daily living as initiating and

completing tasks becomes increasingly difficult with
Dementia is a condition that affects one in eight
declines in cognition.5, 6 There usually comes a time
people over the age of 65 and one in three over the age
when losses in abilities necessitate a caregiver to help
of 85; it is one of the three major diseases with regard
complete first instrumental activities of daily living
to health care consumption1, 2 and is a major cause of
(IADLs; such as grocery shopping and paying bills)
disability and care burden in the elderly. Dementia can
followed by basic activities of daily living (BADLs;
be caused by one or more pathologies, such as
such as bathing, toileting and dressing.7, 8
Alzheimer’s disease, stroke, vascular dementia and
Parkinson’s disease and comprises of a collection of The American Geriatric Society 9 recognizes four
symptoms, including a decline in memory, impaired stages in the progression of AD. These stages are
judgment and reasoning, difficulty in learning, as well identified through the use of standardized screening
as changes in behavior, mood and ability to tools such as the Mini Mental Status Exam (MMSE),
communicate and a gradual loss of skills needed to The initial, or preclinical, stage is classified as MCI with
carry out daily activities.3, 4 MMSE scores between 26 and 30, with complaints of

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 298 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

memory loss, no functional impairment. Progression Lucknow, who met the inclusion criteria, were
to the early stage of AD is classified as Mild recruited in the study which one is diagnosed by
Impairment with MMSE score between 21 and 25. geriatrician/clinician after satisfying DSM IV criteria.
Moderate Impairment is characterized by further Severity of dementia was determined with the use of
decline in screening scores from 11 to 20 and it is MMSE and written consent was obtained from each
marked by the onset of aphasia, deterioration in ADLs, subject /subject’s caregiver. Subjects randomly
IADLs, and the onset or increase in neuropsychiatric assigned into control and experimental group.
symptoms. Late stage AD is accompanied by severe Inclusion criteria were as follows: older adults aged
impairments in memory, cognition, speech, and motor 60 years and above , Mini Mental State Examination
function. Patients are usually incontinent, unable to MMSE ranging from 11 to 23, educational level of
care for themselves, and may exhibit motor or verbal subject is at least 5th standard, who can read and
agitation. understand simple sentences. Exclusion criteria were
as follow: severe Dementia patients, depression
It has been projected that two out of every three (Patients having GDS Score is more than 24), subjects
patients with dementia will soon be in developing having severe behavioral or psychological symptoms
countries and the urgent need to prepare to face it10 in dementia, subjects require nursing care due to severe
and there is a need for developing comprehensive medical illness.
management strategy. In such a strategy, concepts and
interventions of occupational therapy need to be A pilot study was conducted on 13 subjects at
included as a complement to standard drug therapy.11 Memory Clinic, AIIMS in 2011, to find out the
Occupation is the purposeful activity which is feasibility of the study, gather information for framing
performed in daily life, require a balance between a suitable sampling design, and develop a novel
self-care, productivity and leisure and assists people occupational therapy programme. This data suggests
in developing the “skills for the job of living”.12 that the newly developed occupational therapy
intervention programme can possibly improve some
Occupational therapy applicable in old age adults of the parameters include physical performance,
with Dementia mood, and functionality and quality of life. Paper
Principles of occupational therapy includes based on pilot study was awarded as a NIMS best
preventive, accommodative and restorative paper award (3rd prize) IAG congress Vellore, 2011.20
approachs. 13 and for maximizing the remaining
capabilities, use compensatory strategies.14 Therapists INTERVENTION
use client centered methods to determine their own
The study intervention was developed in a
needs and goals.15 The method of assessment is based
consensus process, during pilot study and in delivering
on two patient centric models: the model of human
treatment according to this client-centered
occupation 16 and the Canadian model of occupational
occupational therapy guideline for patients with
performance, 17 whereas for interventions use
dementia.21 Detailed development and content of novel
biomechanical18 and cognitive disability framework of
occupational therapy intervention programme was
reference.19
published in Journal of Indian academy of Geriatrics22,
which include 10 session with duration of one hour
METHODOLOGY ten minutes completed within 5 weeks. Each session
The aim of the research is to see the effect of a novel consist of a. Relaxation for 10 minutes23, b. Physical
occupational therapy intervention programme on Exercises for 10 minutes24, c. Personal activities for 15
cognition, activity of daily living, physical minutes, d. Cognitive exercise for 20 minutes25, and e.
performance, depression, psychological and Recreational activity for 15 minutes26.
behavioral symptom and quality of life of patients with Outcome Assessment
mild to moderate dementia. Experimental Pre and
Posttest control group design was chosen for the study. Each group was assessed at baseline before
Subjects coming at memory clinic, department of intervention by using the general Occupational
Geriatric Medicine, AIIMS, New Delhi, and Therapy assessment Performa performa and further
department of Geriatric Mental Health, KGMU, evaluation were done using 6 standardized scale.

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 299

standardized scale. MMSE 27 , Hindi Geriatric PROCEDURE

Depression Scale 28 (GDS), Modified Physical
263 older subjects (new-182, old-81) were included
performance test29, Bristol ADL Scale30 BEHAV-AD31
between November 2010-April 2013. After screening,
for and Hindi version of WHOQOL-BREF32.MMSE, 192 were excluded and rest 71 patients were included.
MPPT and WHO-QOL have higher scores have better The experimental group received newly developed
performance, whereas BADL, BEHAV-AD and GSD occupational therapy programme along with the drug,
have lower scores have better performance. and control group were only received drug for a period
of 5 weeks.

RESULT

Statistics were performed using STATA 11 software.

Level of significance taken was < 0.05.Two sample t-
test was using for analysis between groups and paired
t-test for within groups. The mean age of control group
is 69.85 years and 68.93 years in experimental group.
Sample size is male dominant with right handedness.
Details of demographic data are shown in table 1.

Table 1. The descriptive statistics of subjects

Control Experimental p-Value

group (%) group (%)
Gender Male 32(78.0) 27 (90.0) 0.218
Female 9 (21.9) 3 (10.0)
Handedness Right 35 (85.4) 27 (90.0) 0.724
Left 6(14.6) 3(10.0)
Occupation Unemployed 12(29.2) 4(13.3) 0.113
Employed 1(2.4) 4(13.3)
Retired 18(43.9) 13(43.3)
Business 7(17.0) 3(10.0)
Farming 3(7.3) 6(20.0)
Education Primary 15(36.5) 9(30.0) 0.455
Class 12 11(26.8) 12(40.0)
Graduate 10(24.3) 8(26.7)
Postgraduate 5(12.2) 1(3.3)
Marital Single 2(4.9) 1(3.3) 0.456
status
Married 34(82.9) 22(73.3)
Widow/ 5(12.2) 7(23.3)
widower
Living Living 2(4.9) 1(3.3) 0.542
arrangement alone
With spouse 22(53.7) 12(40.0)
family with 17(41.5) 17(56.7)
spouse
Dementia Mild 32(78.0) 18(60.0) 0.100
Moderate 9(21.9) 12(40.0)

Graph 1. Showing means value of MMSE, GDS, BADL, PPT,

BEHA-AD, and WHO-QOL pre-post.

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 300 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3

Table -2 Comparison of MMSE, GDS-Hindi, BADL, PPT, BEHAV-AD, and HWHO-QOL-Hindi, within the group,
and between groups.

Variables Group PreMean ±SD PostMean ±SD p-value

MMSE Control 21.12±2.62 20.95±2.52 0.164
Experimental 20.6±2.54 20.76±2.50 0.057
p-value 0.404 0.761
GDS (H) Control 14.31±3.22 15.58±3.94 0.000**
Experimental 15.36±4.26 13.06±3.91 0.000**
*
p-value 0.241 0.009
BADL Control 21.95±5.89 23.56±6.32 0.000**
Experimental 23.1±6.47 15.7±2.93 0.000**
p-value 0.439 0.000*
MPPT Control 17.19±2.56 16.80±2.54 0.040
Experimental 17.06±3.25 20.6±3.72 0.000**
p-value 0.853 0.000*
BEHAV-AD Control 15.60±5.93 15.36±5.80 0.375
Experimental 18.23±8.13 17.2±7.09 0.010**
p-value 0.120 0.235
WHO-QOL (H) Control 68.14±3.26 67.65±3.49 0.010**
Experimental 66.46±3.58 71.33±4.70 0.000**
* *
p-value 0.043 0.003

*p-value between group **p-value between group

DISCUSSION The physical performance (MPPT) of the subject in

control group is decreased (17.19-16.80; p=0.040),
The cognition (MMSE) in the control group has
which is statistically significant, means that without
decreased (21.2-20.95) and increased in experimental
novel programme the physical performance of subject
post intervention, as in shown by their means, (20.6-
is decreased. Whereas in experimental group it is
20.76) though the change in the experimental group
increased significantly (17.06-20.6; p=0.000).
was slightly higher than in the control group. Further
analysis on the scores revealed that these changes are Behavior and psychological issue (BEHAV-AD), of
statistically not significant both in the control (p=0.164) the subject in control group has no changes seen post
and the experimental group (p=0.057). Though it has intervention, whereas in the experimental group a
not reached up to the level of statistical significant, but slight improvement is noted which is significantly
there is visible improvement in experimental group. improved. (18.23-17.20; p=0.010).
Moreover we can conclude better once our study will
be completed with sample size of 100. The quality of life of subject in control groups is
decline significantly (68.46-71.33; p=0.010), and after
The depression score in the control group has application of novel occupational therapy in subject
increased significant (14.31-15.58; p=0.000), whereas in experimental groups, there quality of life were
it has decreased in experimental group (15.36-13.06; increased which is statistically significant. (66.46-71.33;
p=0.000) suggest that occupational therapy has define p=0.000). Though authors accept that there is
role in prevention of progression of depression. significant difference between the two study groups
during index visit, so concluding improvement in
The activity of daily living (BADL) in the control
WHO-QOL is difficult at this juncture may be we will
group has increased (21.95-23.56; p=0.000) means that
be in better position once all sample size will be taken
subjects in this group have increased their dependency
into consideration.
in their activity of daily living in the absence of
occupational therapy intervention. In experimental When all six variables are compared between the
group their independency is increased significantly groups then we found that GDS, BADL, MPPT, and
(23.1-15.7; p=0.000). WHO-QOL is statistically significant results in post
intervention (15.58-13.06; p=0.009), (23.56-15.7;

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 Indian Journal of Physiotherapy & Occupational Therapy. July-September 2013, Vol. 7, No. 3 301

p=0.000), (16.80-20.6; p=0.000), (67.65-71.33; p=0.003) Washington, D.C.: American Psychiatric

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