Effectivness of PNF Stretching and Self Stretching in Patients With Adhesive Capsulitis - A Comparative Study Pag 53

Volume 7
Number 1
January-March 2013
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Indian Journal of Physiotherapy and Occupational Therapy

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Contents
Volume 07 Number 01 January - March 2013
1.
3 Weeks Continuous Passive Motion Vs Joint Mobilization and their Combination in ..................................................... 01 Knee Stiffnes - A Comperative Study Anil kumar, Santosh Metgud Comparison of Blood Pressure and Heart Rate between Young Males and Females ......................................................... 06 During Dominant and Non-Dominant Single-Leg Stance Ankita Samuel, Manish Rajput, Chhavi Gupta, Sumit Kalra Effectiveness of Transcutaneous Electrical Nerve Stimulator (TENS) in Reducing ........................................................ 11 Neuropathic Pain in Patients with Diabetic Neuropathy Apeksha O. Yadav, G. J. Ramteke Evaluation of effects of Nebulization and Breathing Control in Asthmatic Patients .......................................................... 14 Kesharia, Amita Mehta Effect of Neuromuscular Electrical Stimulation Combined with Cryotherapy on ............................................................. 21 Spasticity and Hand Function in Patients with Spastic Cerebral Palsy Chandan Kumar, Vinti Phonophoresis in Continuous Mode Ultrasound has Significant effect in the Reliving .................................................... 26 Pain in Upper Trapezius Tender Point Chhavi Gupta, Manish Rajput, Ankita Samuel, Sumit Kalra Prediction of Relationship of Visual Attention Deficits to Balance and Functional ............................................................ 31 Outcome in Persons with Subacute Stroke Chintan Shah, Hasmukh Patel, Komal Soni, Dhaval Desai, Harshit Soni The effects of Therapeutic Application of Heat or Cold Followed by .................................................................................. 37 Static Stretch on Hamstring Flexibility Post Burn Contracture Emad T. Ahmed, Safa S. Abdelkarim Pulsed Electromagnetic Therapy Improves Functional Recovery in Children with Erb's Palsy ...................................... 42 Reda Sarhan, Enas Elsayed, Eman Samir Fayez
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10. Effectiveness of PNF Stretching and Self Stretching in Patients with Adhesive .................................................................. 47 Capsulitis - A Comparative Study Harshit Mehta, Paras Joshi, Hardik Trambadia 11. Effect of Modified Hold-Relax and Active Warm-Up on Hamstring Flexibility ................................................................. 52 Swapnil U Ramteke, Hashim Ahmed, Virenderpal Singh, Piyush Singh 12. A Comparative Study of effectiveness between Superficial Heat and Deep Heat along with .......................................... 58 Static Stretching to Improve the Plantar Flexors Flexibility in Females Wearing High Heel Foot Wears Hasmukh Patel, Dhaval Desai, Harshit Soni, Komal Soni, Chintan Shah
II 13. Influence of different Types of Hand Splints on Flexor Spasticity in Stroke Patients ......................................................... 65 Eman Samir Fayez, Hayam Mahmoud Sayed 14. Interferential Current Therapy versus Narrow Band Ultraviolet B Radiation in the Treatment ...................................... 70 of Post Herpetic Neuralgia Intsar Salim. Waked 15. Effect of the Duration of Play on Pain Threshold and Pain Tolerance in Soccer Players ................................................... 76 Shahid Raza, C.S. Ram, Jamal Ali Moiz 16. Neuromuscular Electrical Stimulation Versus Intermittent Pneumatic Compression on .................................................. 81 Hand Edema in Stroke Patients Eman S.M.Fayez, Hala Ezz Eldeen 17. A Combination Approach using Manual Therapy and Exercise in the Treatment .............................................................. 87 of Shoulder Impingement Syndrome Annamma Mathew, Abedi Afsaneh 18. Musculoskeletal Pain among Computer Users .......................................................................................................................... 90 Shweta Keswani, Lavina Loungni, Tiana Alexander, Hebah Hassan, Shatha Al Sharbatti, Rizwana B Shaikh, Elsheba Mathew 19. A Report of Body weight Supported Overground Training in Acute Traumatic Central Cord Syndrome .................... 96 Asir John Samuel, John Solomon, Senthilkumaran, Nicole D'souza 20. Effects of Ischemic Compression on the Trigger Points in the Upper Trapezius Muscle ................................................... 99 Bhavesh H. Jagad, Karishma B. Jagad 21. Prevalence of Upper Limb Dysfunction in Subjects with Chronic non Specific ................................................................ 105 Neck Pain in Bangalore City, Karnataka Kinchuk DB, Soumya G, Payal D 22. Randomized Controlled trial of Group Versus Individual Physiotherapy Sessions for .................................................. 110 Genuine Stress Incontinence in Women Komal Soni, Harshit Soni, Dhaval Desai, Chintan Shah, Hasmukh Patel 23. A Study of Electromyographic Changes in Muscle Post Exercise Induced Muscle Soreness ........................................ 116 Manish Rajput, Ankita Samuel, Chhavi Gupta, Sumit Kalra 24. Effect of Pelvic Floor Muscle Strengthening Exercises in Chronic Low Back Pain ........................................................... 121 Manisha Rathi 25. Comparing Hold Relax - Proprioceptive Neuromuscular Facilitation and Static Stretching .......................................... 126 Techniques in Management of Hamstring Tightness Ali Ghanbari, Maryam Ebrahimian, Marzieh Mohamadi, Alireza Najjar-Hasanpour 26. Reliability and Feasibility of Community Balance and Mobility Scale (CB&MS) in Elderly Population ..................... 131 NagaRaju, Arun Maiya, Manikandan 27. Core Stability Training with Conventional Balance Training Improves Dynamic Balance in ......................................... 136 Progressive Degenerative Cerebellar Ataxia Khan Neha Tabbassum, Nayeem-U-Zia, Harpreet Singh Sachdev, Suman K 28. Restoration of Normal Length of Upper Trapezius and Levator Scapulae in .................................................................... 141 Subjects with Adhesive Capsulitis Pandit Niranjan Hemant, Mhatre Bhavana Suhas, Mehta Amita Anil 29. Comparison of Vmo/Vl Ratio in Patello-Femoral Pain Syndrome (Pfps) Patients: A Surface Emg Study .................. 148 Nishant H Nar
III 30. A Study to Check Added effects of Electrical Stimulation with Task Oriented Training in ............................................ 154 Hand Rehabilitation among Stroke Patients Paras Joshi 31. Relationship of Cognition, Mobility and Functional Performance to Fall .......................................................................... 160 Incidence in Recovering Stroke Patients Paras Joshi, Hardik Trambadi 32. Reliability of Modified Modified Ashworth Scale in Spastic Cerebral Palsy ..................................................................... 165 Divya Gupta, Pooja Sharma 33. Evaluation of Pulmonary Function Tests in Patients Undergoing Laparotomy ................................................................ 170 Nahar P S, Shah S H, Vaidya S M, Kowale A N 34. Evaluation of Standardized Backpack weight and its Effect on Shoulder & Neck Posture ............................................. 176 Pardeep Pahwa 35. Effect of Abductor Muscle Strengthening in Osteoarthritis Patients: A Randomized Control Trial .............................. 185 Nishant H Nar 36. Effects of Scapular Stabilization Exercises and Taping in Improving Shoulder Pain & ................................................. 191 Disability Index in Patients with Subacromial Impingement Syndrome Due to Scapular Dyskinesis Bhavesh Patel, Praful Bamrotia, Vishal Kharod, Jagruti Trambadia 37. Effects of Osteopathic Manipulative Treatment in Patients with ......................................................................................... 196 Chronic Obstructive Pulmonary Disease Praniti P. Bhilpawar, Rachna Arora 38. Comparison of Stretch Glides on External Rotation Range of Motion in ........................................................................... 202 Patients with Primary Adhesive Capsulitis Paras Joshi, Bhavesh Jagad 39. A Study of Electromyographic Activity of Masseter Muscle After Gum Chewing in Young Adults ............................ 208 Preeti Baghel, Nidhi Kalra, Sumit Kalra 40. A Study to Evaluate the effect of Fatigue on Knee Joint Proprioception ............................................................................. 213 and Balance in Healthy Individuals Purvi K. Changela, K. Selvamani, Ramaprabhu 41. Effect of Core Stabilization and Balance-Training Program on Dynamic Balance ............................................................ 218 Rabindra Basnet, Nalina Gupta 42. A Retrospective Analysis of Disability-Related Data on Disabled ....................................................................................... 223 Children and their Families in Turkey Rasmi Muammer 43. Effect of Postural Brace for Correcting Forward Shoulder Posture and Kyphosis in ....................................................... 228 Patients with Chronic Obstructive Pulmonary Disease: A Pilot Study Ravi Savadatti, Gajanan. S. Gaude, Prashant Mukkannava 44. Effect of Neck Extensor Muscles Fatigue on Postural Control Using Balance Master ..................................................... 234 Reshma S.Gurav, Rajashree V.Naik 45. Aerobic Capacity in Regular Physical Exercise Group and Indian Classical Dancers: .................................................... 238 A Comparative Study Rupali B. Gaikwad, Vijay Kumar R. waghmare, D.N. Shenvi
IV 46. Comparative Study to Determine the Hand Grip Strength in Type-II Diabetes ................................................................ 243 Versus Non-Diabetic Individuals - A Cross Sectional Study Jayaraj C. Sindhur, Parmar Sanjay 47. Study of Correlation between Hypermobility and Body Mass Index in Children aged 6-12 Years ............................... 247 Parmar Sanjay, Praveen. S. Bagalkoti, Rajlaxmi Kubasadgoudar 48. Comparison of Reaction Time in Older Versus Middle-aged ................................................................................................ 250 Type II Diabetic Patients - An observational Study Shruti Bhat, Sanjiv Kumar 49. Effect of Rehearsal Digit-Span Working Memory Intervention on Sensory Processing ................................................... 254 Disorder in children with Autism: A Pilot Study Smily Jesu Priya V, Jayachandran V, Noratiqah S, Vikram M, Mohamad Ghazali M, Ganapathy Sankar U 50. Evaluation of Inter-Rater Reliability to Measure Hand and Arm Function in ................................................................... 259 Reaching Performance Scale for Stroke Patients SureshKumar T., Leo Rathinaraj A.S., Jeganathan A., Vignesh waran Vellaichamy 51. Effect of Incentive Spirometry on Cardiac Autonomic Functions in Normal Healthy Subjects ..................................... 264 Trupti Ajudia, Pravin Aaron, Subin Solomen 52. Concurrent Validity of Clinical Chronic Obstructive Pulmonary Disease (COPD) ......................................................... 270 Questionnaire (CCQ) in South Indian Population C.M. Herbert, V.K. Nambiar, M. Rao, S. Ravindra 53. To Study the effect of Mental Practice on one Leg Standing Balance in Elderly Population ........................................... 274 Vidya V Acharya, Saraswati Iyer 54. Effect of Midprone Decubitus on Pulmonary Function Test Values in ................................................................................ 280 Young Adults with Undesirable Body Mass Indices (BMI) Junaid Ahmed Fazili, Ajith S, A.M.Mirajkar, Mohamed Faisal C K, Ivor Peter D'Sa 55. Comparison of Quality of Life in off-pump Versus on-pump Coronary ............................................................................ 285 Artery bypass Graft (CABG) Patients before and after Phase II Cardiac Rehabilitation Nikhil Vishwanath, Ajith S, Ivor Peter D'Sa, M.Gopalakrishnan, Mohamed Faisal C K
3 Weeks Continuous Passive Motion Vs Joint Mobilization and their Combination in Knee Stiffnes - A Comperative Study
Anil kumar1, Santosh Metgud2 Post Graduate, Asst Prof, KLE University Institute of Physiotherapy
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ABSTRACT Study design: Randomized clinical trial. Objectives : To determine the effect of continuous passive motion in treatment of knee joint stiffness. To determine the effect of joint mobilization in the treatment of knee joint stiffness. To determine the combined effectiveness of continuous passive motion and joint mobilization in the treatment of knee joint stiffness. Methods : The present randomized clinical trial was conducted among 45 participants which included both male and female symptomatic individuals between the age of 18 to 50 years with knee joint stiffness. Pre-interventional and post-interventional outcome measurements were taken in the form of Range Of Motion, KOSADLS. Results : In the present study, intra - group analysis showed that improved range of motion and functional outcome was statistically significant in all the three groups (p=0.0001) whereas considering the reliability and validity of Knee Outcome Survey Of Activity Daily Living Scale, the between group analysis revealed that Group C was significant as compared to Group A and Group B in knee range of motion and in functional outcome Group B was significant compared to Group A and C . Conclusion : In conclusion, the present randomized clinical trial provided evidence to support the physical therapy regimen in the form of continuous passive motion with joint mobilization in improving range of motion, improving functional performance in subjects with post operative knee joint stiffness. Keywords: Knee Joint Stiffness; Joint Mobilization; Continuous Passive Motion; Exercise
INTRODUCTION The knee is a complex, compound, condyloid variety of a synovial joint. It actually comprises three functional compartments: the femuro-patellar articulation consists of the patella, and the patellar groove on the front of the femur through which it slides; and the medial and lateral femuro-tibial articulations linking the femur, or thigh bone, with the tibia, the main bone of the lower leg.1 Knee injuries from trauma or overuse can cause pain, swelling and sometimes disability, short or long-term depending on how bad the injury is. Injuries can occur to the bones, the ligaments, the cartilage or the tendons.2 Incidence of fractures was 100 per 10,000 population for males and 81 per 10,000 population for females.
Below the age of 55 years of all fractures showed a higher incidence amongst males but amongst the over 55, there was consistent fall in male:female incidence ratio with some sites showing a striking female preponderance.3 Continuous passive motion (CPM) refers to passive motion performed by a mechanical device that moves a joint slowly and continuously through a controlled range of motion. CPM is effective in lessening the negative effects of joint immobilization and also improves the recovery rate and ROM after a variety of surgical procedures. It also prevents development of adhesions and contractures and thus prevents joint Stiffness. It also provides a stimulating effect on the healing of tendons and ligaments and enhances healing of incisions over the moving joint. 4 CPM is used
2 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1
following various types of reconstructive joint surgery such as knee replacement and ACL reconstruction.5 Joint mobilization stimulates biological activity by moving synovial fluid, which brings nutrients to the avascular articular cartilage of the joint surfaces and intra-articular fibrocartilage of the menisci6. Atrophy of the articular cartilage begins soon after immobilization is imposed on joints7,8,9. Maitland techniques involve the application of passive and oscillatory movements to spinal, vertebral and peripheral joints to treat pain and stiffness of a mechanical nature. The techniques aim to restore motions of spin, glide and roll between joint surfaces and are graded according to their amplitude10. METHOD Study design is randomized clinical trial. Data was collected from KLES Dr. Prabhakar Kore Hospital , Belgaum. Study period of one year (Feb 2011 to Jan 2012). Sample size Forty five (45) participants Inclusion Criteria Both male and female participants with knee joint stiffness of duration more than 2 months. Post fracture stiffness of knee joint Ligament injuries of grade 1 and 2 Age group between 18-50 years.
day 01 and on day 21 in the study groups. Once all measurements obtained subjects was randomly allocated into 3 Groups viz. group A, Group B, and Group C. Final scores on the scale and range of motion was measured after 3 weeks of treatment and was then subjected to statistical analysis Participants of all the 3 Groups i.e. Group A - Hot moist pack with Continuous passive motion and exercise for affected knee joint stiffness. Group B - Hot moist pack with Joint Mobilization and Exercise for affected knee joint stiffness. Group C Hot Moist pack, Continuous Passive Motion, Joint Mobilization and Exercise for affected knee joint stiffness. Moist heat therapy was given as conventional treatment for a period of 15 minutes, 2 sessions/day for 3 weeks prior to the CPM and Joint mobilization. The patient was asked to rest supine on the treatment table with affected leg on CPM machine. The speed was kept constant, so that a full cycle lasts for 45 to 60 seconds. The treatment was given for 40 minutes daily in split sessions i.e 20 minutes in the morning and 20 minutes in the afternoon, supervised by physiotherapist. The range was adjusted individually and increased gradually by 10 degrees daily within participants limits of pain. CPM was given for 3weeks during which various parameters was monitored. Anterior-posterior glide The physiotherapist performed an anterior tibiofemoral glide on participants operative limb, the physiotherapist grasps the dorsal aspect of the participants proximal lower leg with one hand and holds it firmly against his body while placing his other hand over the dorsal lateral aspect of the tibia just distal to the knee joint. He passively moves the knee joint to the maximum available knee-extension ROM. He then glides the participants tibia in an anterior direction parallel to the surface of the femoral condoyle to the point where the resistance provided by the knee limited further movements. The mobilization was given for 10 repetitions for 5 times. Total duration lasted for 20 mins. Posterior- Anterior glide The physiotherapist performed an posterior tibiofemoral glide on participants operative limb, the
Exclusion Criteria Total Knee Replacement. Osteoarthritis of knee joint. Knee joint effusion. Bone tumours around knee joint Osteoporotic patients Knee joint malignancy Any local or systemic infection. PROCEDURE Once the patient was included in the study, the demographic data was collected range of motion (ROM) was measured and scores on the scale was noted on
Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 3
physiotherapist grasps the dorsal aspect of the participants proximal lower leg with one hand and holds it firmly against his body while placing his other hand over the dorsal lateral aspect of the tibia just distal to the knee joint. He passively moves the knee joint to the maximum available knee-flexion ROM. He then glides the participants tibia in an posterior direction parallel to the surface of the femoral condoyle to the point where the resistance provided by the knee limited further movements. The mobilization was given for 10 repetitions for 5 times. Total duration lasted for 20 mins. Exercise like open kinetic chain exercise and closed kinetic exercise was given to the patients. Open kinetic chain exercise is typically non weight bearing exercises such as knee extension performed when sitting on a leg extension machine. Closed chain exercise includes a squat or step-up.the exercises were done twice a day and it comprise of 3 sets of 15 repetitions with equal hold and contract time.
OUTCOMES Range of motion was measured with a Universal Goniometer and Physical function outcome measured by Knee outcome survey activities of daily living scale, a well validated, self-report, self-complete questionnaire was used. Statistical Analysis Statistical analysis for the present study was done manually as well as using the statistics software SPSS 13 version so as to verify the results obtained. For this purpose the data was entered into an excel spread sheet, tabulated and subjected to statistical analysis. Various statistical measures such as mean, standard deviation (SD) and test of significance such as paired sample test for within group analysis and between group analysis was done with Multiple Scheffe Test, ANOVA was used for age and demographic distribution.
RESULTS
Table 1. Age distribution & Anthropometric variables
Groups Group A Group B Group C F-Value P-Value Mean Age (Years) 36.8010.23 34.86 7.94 32.80 7.84 0.785 0.463 Mean Height Mean Weight (mts) (Kgs) 1.67 0.05 1.650.052 1.670.08 0.512 0.603 67.8 10.15 65.8 8.82 65.6 9.06 0.253 0.778 Mean BMI (Kg/mt 2) 24.2 3.86 23.92 2.31 23.37 2.01 0.513 0.603
Table 2. Intra group mean difference

Group A pre KOSADLS ROM- FLEX ROM EXT 49.28.47 41.313.1 40.513.4 Post 75.612.83 91.022.25 91.920.0 0.00 0.00 0.00 p Pre 52.56.9 45.713.9 45.613.9 Group B Post 88.26.37 10519.7 10519.7 0.00 0.00 0.00 P pre 56.39.90 40.410.8 42.99.91 Group C post 85.68.5 10917.7 109.316.35 0.00 0.00 0.00 P
Table 3. Inter group comparison using Multiple Scheff test

Groups KOSADLS MD A-B A-C B-C -9.38 -2.90 6.48 P 0.035 0.709 0.190 Flexion MD -10.06 19.20 -9.13 P 0.213 0.006 0.227 ROM Extension MD -10.06 -19.20 -9.13 P 0.213 0.006 0.227
DISCUSSION Results of the study were focused on the improvement of knee range of motion and percentage of activity of daily living based on knee outcome survey of activity of daily living scale Score. It was notified
that there was recovery of all the above parameters in all the three groups. Both the three groups had equal number of participants and showed no statistical significance with respect to their gender distribution, which could
have altered the results of the study and were well matched. The average age in the present study was 34.82, ranging from 18-50 years. When compared between the three groups showed equal distribution and has no statistically significant difference in age between the group. A study conducted by Peter J. Millett(2004) has taken the age group of 18-57 years with average of total participants was 35.6, which coincides with the present data.11 . Macrae and wright in 1969 showed a substantial difference in stiffness between male and female knee joint. Males are much stiffer than females even when age, size of thigh, and size of knee is taken into account. It is interesting to note that while this work shows that females are less stiff than males. The finding of this study correlates with the above reference since maximum number of patients was males, showing more stiffness than females.12 Hutchinson M studied on gender difference in active knee joint stiffness concluded that females have reduced active stiffness compared to age matched males. The present study correlates with the above study in gender differences and has no effects on altering the results between the groups.13 When the intra group mean values of active knee range of motion of flexion was analysed, it showed statistically significant improvement in knee flexion range of motion in both the groups pre to post intervention, with the p values of 0.000 in both the groups, but when comparison was done inter-group, group C showed more improvement in knee range of motion as compared to group A and B. In the present study increase in range of motion, with the application of continuous passive motion in one group and joint mobilization in another group is consistent with the findings of previous studies. This is the first study till date has compared the combined effect of continuous passive motion and joint mobilization. Present results showed that continuous passive motion with joint mobilization is better than giving individually. In the present study the application of moist heat for 15 mins in all three groups prior to CPM and joint mobilization showed increase in range of motion. Knight et al. Investigated the effect of 15 min hot pack application paired with static stretching on plantar flexor extensibility over four weeks and noted increases in range of motion. These findings suggest that hot pack application may be a beneficial modality when increased range of motion is desired.14 The results of the present study group receiving CPM, has shown that alone CPM is not a beneficial method to mobilize post-operative knee stiffness. As suggested by Bearpre et. al., (2001), a prospective,
investigator-blinded RCT compared three rehabilitation regimens in patients who had undergone primary TKA for osteoarthritis. The results suggest that adjunct CPM and adjunct SB may not provide additional therapeutic benefit in an active mobilization regimen following TKA for osteoarthritis. Hence the present study consistent with the above study as the result concluded the same. The study done by Beaupre et. al., hypothesized that continuous passive motion may not provide therapeutic effect in active mobilization of post-operative knee stiffness.15 In the present study, group receiving CPM only, showed an average increase in ROM for post operative knee stiffness of 49.733, which was less compared to the other 2 groups ie., group B-59.80 and group C-68.93. The present study correlates with the study done by Engstrom et al. (1995) reported on a prospective randomized study of 34 patients with unilateral anterior cruciate ligament ruptures. Engstrom et al concluded that after six weeks followup, there was no difference in ROM between the two groups, and joint swelling was more pronounced in the early active motion group. The data suggests that CPM did not improve ROM.16 Randall et al, showed that in patients with supracondylar fracture, mobilization and exercise led to a greater increase in joint movement than exercise alone. The present study is in consistent with the above study as the results concluded the same. Hence the effect of joint mobilization has an effect in increasing range of motion17. Michael A. Hunt, Stephen R. found the effect of anterior tibiofemoral glides on knee extension during gait in patients with decreased range of motion after anterior cruciate ligament reconstruction. The authors concluded that a single session of anterior tibiofemoral glides increases maximal knee extension during the stance phase of gait in patients with knee extension deficits. In the present study 21 sessions of mobilization increased maximal knee extension range of motion and could not comment on the immediate effect of joint mobilization18. In the present study closed kinetic chain exercises were performed by the participants for 10 repetitions per session with each contraction held for 10 seconds, which is consistent with the findings of Cristina Maria and Nunes Cabral.19 Study done by Mei Hwa Jan MS et al to investigate the effect of weight bearing exercises on function, pain and knee strength in patients with knee stiffness. The results showed that weight bearing exercises were effective in decreasing pain and disability and increasing knee strength.20
The findings of the present study show that improving ROM by joint mobilization is effective which was due to stimulation of biological activity by moving synovial fluid, which brings nutrients to the avascular articular cartilage of the joint surfaces and intraarticular fibrocartilage of the menisci21. CONCLUSION In conclusion, the present randomized clinical trial provided evidence to support the physical therapy regimen in the form of continuous passive motion with joint mobilization in improving range of motion, improving functional performance in subjects with post operative knee joint stiffness LIMITATIONS Intermediate readings of the outcome measures was not noted. There was no control group in the present study REFERENCES 1. Thieme Atlas of anatomy; Anatomy and musculoskeletal system, Thieme.2006, ISBN 158890-419-429. Cole PA, Ehrlich MG. Management of the Completely Stiff Pediatric Knee. J Ped Orthop; 1997; 17:67-73. L J Donaldson , Acook. Incidence of fractures in a geographically defined population. Journal of Epidemiology and Community Health; 1990;44:241-245 Lastayo, PC; Continuous passive motion for the upper extremity. In Hunter, JM, Mackin, EJ. Callabon AD (eds) Rehabilitation of the Hand; Surgery and Therapy, 1995. ed 4. O Driscoll, SW, Giori, NJ; Continuous Passive Motion Theory and Principles of Clinical Application. J Rehabil Res Dev 2000.37 (2);179. Norkin , C, Levangie, P; Joint Structure And Function ;A comprehensive analysis, ed 2, FA, Davis, Philaephia.1992;56-70. Akeson, WH, Billot JR. Effects of immobilization of joints. Clinical Orthop 1987:219:28. Donatelli , R, Owens- Burkhart, H; effects of immobilization on extensibility of particular
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connective tissue; J Orthop Sports Physical Therapy.1981.3:67. Enneking, WF, Horowitz,M; The intra-articular effects of immobilization on the human knee. J Bone Joint Surgery Am.1972. 54:978. G. D. Maitland. Peripheral Manipulation, 3rd edition. 2003:250-255. Peter J. Millet, MD. Early ACL reconstruction in combined ACL-MCL injuries, Journal Knee Surgerie. 2004. 17:94-98. Macrae IF. The measurement of stiffness human joint, 2000, 24:43-47 Hutchinson M. Gender differences in active knee joint stiffness. Sports Med, 1995:19:288-302 Knight CA, Rutledge CR. Effect of superficial heat, deep heat and active exercise warm up on the extensibility of plantar flexors. Phys Therapy, 2001.81:1206-1214. Beaupre CA et al. Exercise combined with continuous passive motion or slider board therapy compared with exercise only. Physical Therapy, 2001:81(4); 1029-1037. Engstrom B, Sperber A, Wredmark T. Continuous passive motion in rehabilitation after anterior cruciate ligament reconstruction. Knee Surg Sports Traumatol Arthrosc. 1995;3(1):18-20. Randall T, Portney L, Harris BA: Effects of joint mobilization on joint stiffness and active motion of the metacarpal phalangeal joint. J Orthop Sports Phys Ther 1992, 16:30-36. Michel A. Hunt. Stephen R. Effect of anterior tibiofemoral glides on knee extension during gait in patients with decreased range of motion after anterior cruciate ligament reconstruction; 2010. Vol-6 Pages 235-241. Cristina Maria, Nunes Cabral, Effect of a closed kinetic chain exercise protocol on patellofemoral syndrome rehabilitation, 2007 XXVISBS Symposium. Mei-Hwa Jan MS PT, Effect of weight bearing versus non weight bearing exercise on function, walking speed and position sense in participants with knee osteoarthritis. Archives of physical medicine and rehabilitation; 2009. vol 90, issue 6: 897-904 Norkin, C, Levangie, P; Joint Structure and Function: A Comprehensive Analysis, ed 2. FA Davis, Philadelphia, 1992.
Comparison of Blood Pressure and Heart Rate between Young Males and Females During Dominant and Non-Dominant Single-Leg Stance
Ankita Samuel1, Manish Rajput1, Chhavi Gupta1, Sumit Kalra2 Student-Bachelors of Physiotherapy, 2Assistant Professor, Banarsidas Chandiwala Institute of Physiotherapy ABSTRACT Background: It has been observed that Blood Pressure and Heart Rate of an individual changes with posture. This study is performed to study the change in Blood Pressure and Heart Rate while standing on dominant and on non-dominant single -leg stance in males and females. Objective: The objective of this study is to compare the significant changes in Blood Pressure and Heart Rate in young college going males and females while standing on there dominant and non-dominant lower limb (single-leg stance). Subjects: 200 subjects (100-males, 100-females) of the age group of 18 to 25yrs Study Design: Co-relational Data Analysis: P-Value was calculated for the systolic and diastolic blood pressure separately and as well as of Heart Rate in resting, single-leg stance on dominant leg and single-leg stance on nondominant leg in both Males and Females. Conclusion: From The study it can be concluded that while training any individual on single -leg stance on dominant and non-dominant a therapist should take care of the blood pressure and Heart Rate specially while working on hypertensive's, amputees, individuals with cardio-vascular, neurological, psychological and neuro muscular disorders. Keywords: Heart Rate, Blood Pressure
INTRODUCTION Human Heart rate can vary as the bodys need to absorb oxygen and excrete carbon dioxide changes, such as during exercise or sleep. The one-leg stance is a valid measure to assess postural steadiness in a static position by temporal measurement. The examination of balance with oneleg stance test is a functional and logical approach, since transient balancing on a single limb is essential for normal gait and critical activities of daily living such as turning, stair climbing and dressing and it is also essential for sports person who need good proprioception to be good in their field of sports. In addition to identifying single-leg balance testing as a reliable indicator of functional instabilities. Freeman and colleagues provided sound support for the use of single-leg proprioceptive training to decrease the effects of functional instabilities. Since that time,
clinicians have continued to use single-leg stance manipulations for both the evaluation and rehabilitation of proprioceptive deficits related to orthopedic injury. During rehabilitation, this method is used both for a baseline measurement of balance and to progress patients as they recover. Short-term cardiovascular responses to postural change involve complex interactions between the autonomic nervous system, which regulates blood pressure, and cerebral auto regulation, which maintains cerebral perfusion. A physiologically based change is used to describe effects of gravity on venous blood pooling during postural change. Two types of control mechanisms are included: 1) Autonomic regulation mediated by sympathetic and parasympathetic responses, which affect heart
rate, cardiac contractility, resistance, and compliance, and 2) Auto regulation mediated by responses to local changes in myogenic tone, metabolic demand, and CO2 concentration, which affect cerebrovascular resistance. The change on Heart Rate are due to muscular activity changes when posture changes, abdominal wall tension increases while standing on single leg, the aortic pressure increases according to Mareys law and also due to carotid sinus reflex. The Blood Pressure and Heart Rate vary in respiratory, neurological, psychological and in cardiovascular disorders. BMI also plays a major role when it comes to one leg standing, the individuals with BMI more than of 25cm2/kg has a higher Blood Pressure and Heart Rate while standing on single leg. Static contraction of muscles on a large scale, e.g. with the knees bent as described, soon causes a remarkably large rise of systolic and diastolic bloodpressures, comparable to what may be induced by strenuous muscular exercise, but differing in certain respects in the mechanism of its production. Assumption of the upright posture requires prompt physiological adaptation to gravity .There is an instantaneous descent of ~500 ml of blood from the thorax to the lower abdomen, buttocks, and legs. In addition, there is a 10-25% shift of plasma volume out of the vasculature and into the interstitial tissue. This shift decreases venous return to the heart, resulting in a transient decline in both arterial pressure and cardiac filling. This has the effect of reducing the pressure on the bar receptors, triggering a compensatory sympathetic activation that results in an increase in heart rate and systemic vasoconstriction (countering the initial decline in blood pressure). Hence, assumption of upright posture results in a 10-20 beat per minute increase in heart rate, a negligible change in systolic blood pressure, and a ~5 mmHg increase in diastolic blood pressure. Assumption of the upright posture requires prompt physiological adaptation to gravity. The response of blood pressure to change in body position is well suited as a measure of cardiovascular reactivity for epidemiological studies. Several experimental studies have suggested a differential response of blood pressure to standing due to ethnicity1 and gender2, 3.
As it always seen that men have more muscle power as compared to women, indirect evidence indicates19,20 that women will experience less compressive force and intramuscular pressure in the muscle21,22,23, allowing greater perfusion and oxygen supply compared with the men during the sustained contraction during the change in posture. It also seen that women have lower risks of cardiovascular events than men. They are also characterized by different spectral indexes of HRV24, and by higher HRV entropy25. The need of this study is to have a better understanding that how does Blood Pressure and Heart Rate changes in young individuals who are under going physiotherapy to increase their proprioception, balance and co-ordination, a hypertensive individual ,an individual using prosthesis or an amputee (any limb), an individual under going any cardio-vascular, neurological, psychological or neuro-muscular disorder when they stand on there single lower limb (dominant or non-dominant) and does the gender of the individual plays in any significant role in it. METHODOLOGY RESEARCH DESIGN- Co-relational SAMPLE SIZE- 200 (male-100, female-100) SOURCE OF SUBJECTS - Students from various colleges in Delhi. SAMPLE DESIGN- Random sampling INCLUSION CRITERIA27, 28: 1. Males and Females in the age group of 18 to 25years 2. BMI between 18 to 25 kg/m2 EXCLUSION CRITERIA 1. BMI less than 18 and more than 25 kg/m2 2. A diagnosed case of any cardio-vascular, respiratory, psychological or neurological disorder. 3. Any bony/Muscular deformity present of upper limb, lower limb or spine 4. Any pain in upper limb, lower limb or spine 5. Use of any limb prosthesis 6. Any limb amputation 7. Subjects are not involved in any physical or muscular activity in last one hour before testing.
INSTRUMENTATION 1. The Omron M6 (HEM-7001-E) digital blood pressure and heart rate monitor. 2. A stop watch 3. Football 4. measuring tape 5. weighing tape
S. No.
FEMALES
Table 1. Resting and Dominant
S. No. 1 2 3 Systolic Diastolic Heart Rate P-Value 0.014 0.890 0.291
Table 2. Resting and Non-Dominant

P-Value Systolic Diastolic Heart Rate 0.000 0.480 0.056
INDEPENDENT VARIABLES 1. Age 2. Height 3. Weight DEPENDENT VARIABLES 1. Blood pressure (both systolic and diastolic) 2. Heart rate PROCEDURE Total of 265 subjects were taken out of which 200 subjects fulfilling the inclusion criteria and after checking that they had not gone for any vigorous physical or muscular activity in last one hour were taken into consideration. The procedure was explained to the subjects and a written consent was taken after explaining the benefits and clearing the doubts of the subject regarding study. To check the lower limb dominance subjects were asked to kick a football and the leg from which he/she kicked was considered as his/her dominant leg. After this subjects BP and HR was taken while sitting on chair. They were given a rest period of 5 minutes then, they were made to stand on their dominant leg for a minute. After which their BP and HR was recorded in seated position, and they were made to rest for 5 minutes again. Post rest period the subjects were asked to stand on their non-dominant leg for a minute this time again their BP and HR were taken in seated position. RESULT P-value of the collected data was calculated using SPSS software version 16
1 2 3
Table 3. Dominant and Non-Dominant

MALES

Table 6. Dominant and Non-Dominant

MALES AND FEMALES


Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 9 Table 9. Dominant and Non-Dominant
Table 10. Dominant (male & female)

respective of the postural change, i.e. standing on dominant and non-dominant leg there was a significant increase in HR and decrease in BP. Although muscle activity increases body oxygen consumption and energy expenditure, the temporal increase in HR and decrease in BP associated with changing position suggests that it is likely to have resulted from the metabolic or hormonal consequences of increased muscle activity. We speculate that this increase was largely induced by the skeletal muscle reflex15-17. Although anticipation of exercise may also cause a rapid increase in heart rate18. The changes in BP and HR were significantly seen with respect to gender also. Both the systolic and diastolic BP in males increases while standing on there single-leg and that too on there non-domianat leg whereas there was increase in HR in case of females on their non-dominant leg. REFERENCES 1. Ventner CP, Joubert PH. The relevance of ethnic differences in hemodynamic responses to the head-up tilt maneuver to clinical pharmacological investigations. J Cardiovasc Pharmacol. 1985;7:1009 1010. Gotshall RW, Tsai PF, Bassett Frey MA. Genderbased differences to the cardiovascular response to standing. Aviat Space Environ Med. 1991;62:855859. Schondorf R, Low PA. Gender related differences in the cardiovascular responses to upright tilt in normal subjects. Clin Auton Res. 1992;2: 183187. Hollander, A.P. and Bouman, L.N. Cardiac acceleration in man elicited by a muscle-heart reflex. J. Appl. Physiol. 38: 272-278 ,1975. Iellamo, F., Legramant, J.M., Massaro, M., Galante, A., Pigozzi, F.,Nardozi, C. and Sangilli, V. Spontaneous baroreflex modulation of heart rate and heart rate variability during orthostatic stress in tetraplegics and healthy subjects. J. Hypertens. 19: 2231-2240,2001. Jacob, G., Ertl, A.C., Shannon, J.R., Furlan, R., Robertson, R.M. and Robertson, D. Effect of standing on neurohumoral responses and plasma volume in healthy subjects. J. Appl. Physiol. 84: 914-21,1998. Pump, B., Christensen, N.J., Videbaek, R., Warberg, J., Hendriksen, O. and Norsk, P. Left atrial distension and antiorthostatic decrease in arterial pressure and heart rate in humans. J. Am. Physiol. 273: H2632-H2638, 1997. Pump, B., Gabrielsen, A., Christensen, N.J., Bie, P., Bestle, M. and Norsk, P. Mechanisms of inhibition of vasopressin release during moderate antiorthostatic posture change in humans. Am. J. Physiol. 277: R229-R235, 1999.
Table 11. Non-Dominant (male & female)

DISCUSSION Variation of heart rate is associated with postural change26. In accord with previous reports, this study showed that HR was highest in standing on NonDominant leg compared to sitting or lying positions4-11. Thus, the hypothesised that the increase in HR with standing follows a decease in venous return due to venous pooling in the lower limbs due to gravitational effects12. The increase in peripheral venous volume is accompanied by an increase in both venous and arterial pressure in the lower extremities. The shift in blood volume from the central to the peripheral system induces a decrease in venous return and central venous pressure. The smaller the venous return, the smaller the end-diastolic and subsequent stroke volume. A reduction in venous return will lead to a reduced cardiac output, which in turn will lead to a reduction in baroreceptor stimulation in the aorta and carotid arteries13. This reduction in baroreceptor firing results in decreased parasympathetic and increased sympathetic activity14, 11. These two actions directly affect the cardiovascular centre in the medulla oblongata which increases the HR, the arteriolar and venous tones, and the cardiac contractility to compensate for the decrease in stroke volume and provide a cardiac output which can meet body demands. Upon returning the posture from sitting to lying, the increase in venous return increases the stroke volume through the Frank Starling mechanism, thus a lower heart rate is sufficient to maintain the cardiac output demanded by the body. In present study we can conclude that not only the HR but BP also changes significantly while on standing on dominant single-leg and on non-dominant single-leg in Males and Females. Haemodynamics can be disturbed even by slight movements 15. In accord with previous findings4-11, our results showed that with
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Pump, B., Kamo, T., Gabrielsen, A. and Norsk, P. Mechanisms of hypotensive effects of a posture change from seated to supine in humans. Acta. Physiol. Scan. 171: 405-412, 2001. Saborowski, F., Krahe-Fritsch, G., Krakau, M., Wallbrueck, K. and Schaldach, M. The effects of orthostasis on the ventricular-evoked response. Eur. J. Appl. Physiol. 2: 333-338, 2000. .Shamsuzzaman, A.S.M., Sugiyama, Y., Kamiya, A., FU, Q. and Mano, T. Head-up suspension in humans: effects on sympathetic vasomotor activity and cardiovascular responses. J. Appl. Physiol.84: 1513-1519, 1998. Borst, C., Wieling, W., van Brederode, J.F.M., Hond, A., de Rijk, L.G. and Dunning, A.J. Mechanisms of initial heart rate response to postural change. Am. J. Physiol. 243: H676-H681, 1982. Mohrman, D.E. and Heller, L.J. Cardiovascular Physiology 4thEdition. McGraw-Hill Health Professions Division, 1997: pp 179-183. Ewing, D.J., Hume, L., Campbell, I.W., Murray, A., Neilson, J.M. and Clarke, B.F. Autonomic mechanisms in the initial heart rate response to standing. J. Appl. Physiol. 49: 809-814, 1980. Kjaer, M., Hanel, B., Worm, L., Perko, G., Lewis, S.F., Sahlin, K., Galbo, H. and Secher, N.H. Cardiovascular and neuroendocrine responses to exercise in hypoxia during impaired neural feedback from muscle. Am. J. Physiol. 277: R 76R85, 1999. Leshonower, B.G., Potts, J.T., Garry, M.G. and Mitchell, J.H. Reflex cardiovascular responses evoked by selective activation of skeletal muscle ergoreceptors. J. Appl. Physiol. 90: 308-316, 2001. McArdle,W.D., Katch, F.I. and Katch, V.L. Essentials of Exercise Physiology. 2nd Edition. Philadelphia: Lippincott Williams & Wilkins. 2000. Heather k. Vincen, PhD, Kelley M. Lamb, BS, Tim i. Day, PT, Susan M. Tillman, PT, Kevin R. Vincent,MD, PhD, Steven Z. George, PT, PhD. Morbid Obesity is Associated with FEAr of Movement and Lower Quality of Life in Patients with Knee Pain- Related diagnosis. Volume 2, Issue 8, August 2010, pg713-722
19. . Hicks AL, Kent-Braun J, and Ditor DS. Sex differences in human skeletal muscle fatigue. Exerc Sport Sci Rev 29: 109112, 2001. 20. . Hunter SK and Enoka RM. Sex differences in the fatigability of arm muscles depends on absolute force during isometric contractions. J Appl Physiol 91: 26862694, 2001. 21. Sadamoto T, Bonde-Petersen F, and Suzuki Y. Skeletal muscle tension, low, pressure, and EMG during sustained isometric contractions in humans. Eur J Appl Physiol 51: 395408, 1983. 22. Sejersted O, Hargens A, Kardel K, Blom P, Jensen O, and Hermansen L. Intramuscular fluid pressure during isometric contraction of human skeletal muscle. J Appl Physiol 56: 287295, 1984. 23. Barnes WS. The relationship between maximum isometric strength and intramuscular circulatory occlusion. Ergonomics 23: 351357, 1980. 24. Sztajzel, J., Jung, M., and Bayes de, Luna A.Reproducibility and gender-related differences of heart rate variability during all-day activity in young men and women. Ann Noninvasive Electrocardiol 2008;13:270-277. 25. Ryan, S. M., Goldberger, A. L., Pincus, S. M., Mietus, J., and Lipsitz, L. A. Gender- and age-related differences in heart rate dynamics: are women more complex than men? J Am Coll Cardiol 1994;24:1700-1707. 26. Oida, E., Kannagi, T., Moritani, T. and Yamori, Y. Physiological significance of absolute heart rate variability in postural change.Acta. Physiol. Scan. 165: 421-422, 1999. 27. Heather k. Vincen, PhD, Kelley M. Lamb, BS, Tim i. Day, PT, Susan M. Tillman, PT, Kevin R. Vincent,MD, PhD, Steven Z. George, PT, PhD. Morbid Obesity is Associated with FEAr of Movement and Lower Quality of Life in Patients with Knee Pain- Related diagnosis. Volume 2, Issue 8, August 2010, pg713-722 28. Stewart, Manual of Physiology, Toronto, 1918, p. 107.
Effectiveness of Transcutaneous Electrical Nerve Stimulator (TENS) in Reducing Neuropathic Pain in Patients with Diabetic Neuropathy
Apeksha O. Yadav1, G. J. Ramteke2 Assistant Professor, Director & Principal, Department of Physiotherapy, Ravi Nair Physiotherapy College, DMIMS (DU) Sawangi (M) Wardha
2
ABSTRACT Objective: To evaluate the effectiveness of TENS in reducing neuropathic pain in patients with Diabetic Neuropathy. Design: Prospective Experimental Study. Participants and Outcome Measure: 20 Patients with a diagnosis of Diabetic Neuropathy were included in the study and they were explained regarding the treatment & its duration. Outcome measures were recorded before & after the treatment session using numerical pain rating scale. Result: After collecting data statistical analysis was done using Student's paired t test to determine the effect of TENS and it showed a significant difference in reduction in pain post treatment. Conclusion: It can be concluded that High frequency TENS can be given to Diabetic Neuropathy patients for three weeks to achieve pain reduction. Keywords: Diabetes, Neuropathic Pain, Transcutaneous Electrical Nerve Stimulator. INTRODUCTION Diabetes mellitus is caused by an insufficient insulin-mediated response to blood glucose. People with the disorder are classified as being insulin dependent (ie, having type I diabetes) or non-insulin dependent (ie, having type II diabetes) depending on whether they require exogenous insulin for survival. A frequent sequella of both types of diabetes is the development of peripheral neuropathy in either motor or sensory nerves, or both.1 Crawford2 estimated that 13 million people in the United States have diabetes, and 30% to 40% of these people are believed to have at least sensory neuropathy.3 A consequence of any neuropathy affecting motor and sensory peripheral nerves is reduction or loss of strength and sensation. Another potential consequence of peripheral neuropathy in people with diabetes is severe, unremitting pain.1, 4 People with painful diabetic neuropathy describe their pain as constant, burning, or searing. Allodynia, to light touch, the experience of light touch as painful, frequently develops, and even contact with bedclothes can be painful. Deep pain, described as being located in the centre or marrow of the bone, can also occur. When pain is severe, people with diabetic neuropathy may have difficulty sleeping and can experience depression and weight loss.1 Diabetic peripheral neuropathy (DPN) endoneurial hypoxemia is the most common complication of diabetes, estimated to affect 50% to 90% of patients, depending on the criteria used for diagnosis5-10. Its prevalence increases with the patients age, duration of diabetes, and poor glycemic control.11-14 DPN is often referred to as the forgotten complication because, despite how commonly it occurs, it is the chronic diabetes complication that is least often addressed by health care providers.15 Results of the 2005 American Diabetes Association (ADA) National Survey found that only one in four patients surveyed who experience symptoms of DPN have been diagnosed with the condition. 16 This is partly because many practitioners have had very little success with its treatment as well as a lack of awareness of available treatment strategies. A wide range of treatments are available for neuropathic pain, however, many patients remain inadequately treated. This prescribing pattern suggests that no one treatment addresses all factors. Foot complications are the greatest burden of all serious chronic complications among patients with diabetes.
As many as 40% to 60% of lower-extremity amputations (LEAs) are related to DPN, and more than 50,000 LEAs are performed each year in this country. 17,18 Approximately 15% of patients with diabetes will develop a foot ulcer and one in six will need to have an amputation. Additionally, half of those patients who develop an ulcer will have one on the opposite foot within 3 years 19-21. Short of ulceration and amputation, DPN limits mobility, impairs sleep, and seriously affects overall QoL. It is a progressive disease that may actually begin before any alteration in sensation is detected. For reduction of the symptoms of diabetic peripheral neuropathy some modalities have been used are; - TENS - Micro vascular therapy - Monochromatic near infrared treatment. By using high frequency TENS, reduction in the symptoms of diabetic peripheral neuropathy can be achieved. David & Somers in a case study stated that by using high frequency TENS for 20 minutes daily for 3 weeks over lumbar region relieves pain of neuropathy of a 73 years old lady the outcome were measured by the regular assessment and by using VAS as it is reliable and valid tool for the quantification of perceived pain, the intensity of perceived pain was reduced from 7.4 to 4.6 cm on the VAS and reduction of pain was gradual in given 3 weeks22.
Dinesh Kumar, MD, Inderjeet S. Julka, MD, Michael S. Alvaro, DPM & Howard J. Marshall, DPM, did three independent studies utilizing TENS & amitriptyline to relieve DPN pain was reviewed. There were 14 patients in this group. Two of them did not tolerate amitriptyline. Symptomatic improvement occurred in 12 (85%) patients; 11 received the combination of amitriptyline and electrotherapy and 1 received electrotherapy only. Three patients improved by 3 pain grades, 8 by 2 grades, and 1 by 1 grade. Five (36%) of them experienced complete symptomatic relief. Material and Methodology: This is a Prospective experimental study carried out in Physiotherapy OPD in Tertiary Care Hospital. Material used were TENS apparatus. 20 subjects were selected with a diagnosis of Diabetic Neuropathy. Both Males and Females were included. Patients recently underwent surgery for lower limb fracture with an implant and patients with pacemakers were excluded from the study. Study was explained to them & written consent was taken from them to undergo treatment for three weeks. Observations were recorded using numerical pain rating scale pre treatment i.e. 1week before the commencement of program and post treatment i.e. third week after the completion of treatment program. Patient was assessed before starting the treatment. Patient was made to lie in prone position and then the TENS electrodes were applied on the lumbar region with the use of aqua sonic gel. Frequency used was 80 Hertz. Duration of treatment was 20 mins daily for three weeks.
STATISTICAL ANALYSIS
Table 1: Comparison of Numerical Pain Rating Scale before and after treatment A: Descriptive Statistics
Mean Before Treatment After Treatment Paired Differences Mean Std. Deviation 0.88 Std. Error 95% Confidence Interval Mean of the Difference Lower Before t/t-After t/t 2.35 0.19 1.93 Upper 2.76 11.81 19 0.000 S, p<0.05 t df p-value 6.46 4.11 N 20 20 Std. Deviation 0.88 0.56 Std. Error Mean 0.19 0.12
B: Students paired t test
20 patients diagnosed of diabetic neuropathy between the age group of 60 to 80, were given treatment with high frequency TENS for 3 weeks, showed a mean
rating of pain before the treatment was 6.46cms on NPRS and mean reduction of the symptoms after 3 weeks was 4.11cms on the same scale showing improvement.
CONCLUSION It can be concluded that, treatment with high frequency TENS for 3 weeks given to patients with a diagnosis of diabetic neuropathy shows significant reduction of neuropathic pain. REFERENCES Watkins PJ. Natural history of diabetic neuropathies. QJ Med. 1990; 77:1209 1218. 2. Crawford JM. The pancreas. In: Kumar V, Cotran RS, Robbins SL, eds. Basic Pathology. 6th ed. Philadelphia, Pa: WB Saunders Co; 1997:557578. 3. Harris M, Eastman R, Cowie C. Symptoms of sensory neuropathy in adults with NIDDM in the US population. Diabetes Care. 1993; 16: 1446 1452. 4. Horowitz SH. Diabetic neuropathy. Clin Orthop. 1993; 296:7885. 5. Dyck PJ, Kratz KM, Karnes JL, et al. The prevalence by staged severity of various types of diabetic neuropathy, retinopathy, and nephropathy in a population-based cohort: the Rochester Diabetic Neuropathy Study. Neurology. 1993; 43: 817824. 6. Tavaloki M, Mojaddidi M, Fadavi H, Malik RA, Pathophysiology and treatment of painful diabetic neuropathy. Curr Pain Headache Rep. 2008; 12: 192197. 7. Shaw JE, Zimmet PZ. The epidemiology of diabetic neuropathy. Diabetes Rev. 1999; 7: 245252. 8. Gregg EW, Sorlie P, Paulose-Ram R, et al. Prevalence of lower-extremity disease in the US adult population e40 years of age with and without diabetes: 19992000 National Health and Nutrition Examination Survey. Diabetes Care. 2004; 27: 15911597. 9. Daousi C, MacFarlane IA, Woodward A, et al. Chronic painful peripheral neuropathy in an urban community: a controlled comparison of people with and without diabetes. Diabet Med. 2004; 21: 976982. 10. Davies M, Brophy S, Williams R, Taylor A. The prevalence, severity, and impact of painful diabetic peripheral neuropathy in type 2 diabetes. Diabetes Care. 2006; 29: 15181522. 11. Boulton AJM. Management of diabetic peripheral neuropathy. Clin Diabetes. 2005; 23: 915. 12. Tamer A, Yildiz S, Yildiz N, et al. The prevalence of neuropathy and relationship with risk factors 1. 13.
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in diabetic patients: a single-center experience. MedPrinc Pract. 2006; 15: 190194. Valensi P, Giroux C, Seeboth-Ghalavini B, Attali JR. Diabetic peripheral neuropathy: effects of age, duration of diabetes, glycemic control, and vascular factors. J Diabetes Complications. 1997; 11: 2734. Booya F, Bandarian F, Larijani B, et al. Potential risk factors for diabetic neuropathy: a case control study. BMC Neurol. 2005; 5:24. Marks JB. The forgotten complication. Clin Diab. 2005; 23: 34. American Diabetes Association survey finds most people with diabetes dont know about highly prevalent, serious complication. w w w. d i a b e t e s . o r g / f o r - m e d i a / 2005pressreleases/ diabeticneuropathy.jsp. Accessed Sept. 21, 2009. Borssen B, Bergenheim, Lithner F. The epidemiology of foot lesions in diabetic patients aged 15-50 years. Diabetic Med. 1990; 7: 438444. Reiber GE, Boyko EJ, Smith DG. Lower extremity foot ulcers and amputation. In Diabetes in America. 2nd ed. 1995. Washington, DC. Department of Health and Human Services. Gordois A, Scuffham P, Shearer A, et al. The health care costs of diabetic peripheral neuropathy in the U.S. Diabetes Care. 2003; 26: 17901795. Reiber GE, Vilekyte L, Bokyo EJ, et al. Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings. Diabetes Care. 1999; 22: 157162. Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care.1990; 13: 513521. Somers DL, Somers MF. Treatment of neuropathic pain in a patient with diabetic neuropathy using transcutaneous electrical nerve stimulation applied to the skin of the lumbar region. Phys Ther. 1999; 79: 767775. Dinesh Kumar, MD, Inderjeet S. Julka, MD, Michael S. Alvaro, DPM & Howard J. Marshall, DPM. Diabetic Peripheral Neuropathy. Effectiveness of electrotherapy and amitriptyline for symptomatic relief Diabetes Care. Diabetes Care.1998; 21: 13221325.
Evaluation of effects of Nebulization and Breathing Control in Asthmatic Patients

Kesharia1, Amita Mehta2 M.P.Th., Cardiovascular and Respiratory Sciences, 2Professor & Head, P.T. School and Centre, Seth G.S.M.C. and K.E.M. Hospital, Parel, Mumbai. ABSTRACT Background: Asthma is a disease characterized by airflow limitation that is either fully or partially reversible. There is a growing realization that in asthma the airflow limitation leads to further mechanical consequences that result in dyspnea which is also a very important domain along-with airflow limitation to build up strategies to effectively cope up with asthma. To treat asthma effectively means to achieve a better level of control of asthma. Various strategies have been adopted by the patients themselves to keep their asthma level in control and avoid frequent exacerbations. Asthma has many dimensions to it rather than only airway obstruction. Asthma is affected by anxiety, cold, emotional quotient & also by the level to which other nonpharmacological means to control asthma adopted by the patient like yoga, meditation and various breathing strategies. It was seen that pharmacological measures though were very essential to treat asthma, but along-with its long term use; factors like adverse effects of medications, patient's non-compliance, cost effectiveness of treatment, patients sense of satisfaction of their disease control came into focus. Hence, various non-pharmacological measures were researched in the past trials, of which breathing control was one of the measures used. Purpose: The purpose of our study was to evaluate the effects of nebulization and breathing control (N+B combination) as against only breathing control(B) on airway obstruction [by measuring peak expiratory flow rate(PEFR), forced expiratory volume in 1st second(FEV1) and dyspnea [by measuring respiratory rate (RR) and rate of perceived exertion (RPE)] in asthmatic patients. Method: In total, 60 patients were selected according to the inclusion and exclusion criteria. Written informed consent was taken from the patients and asthmatic patients were randomly allocated to two groups either N+B or only B. Parameters PEFR, FEV1, RR and RPE on Borg's modified 10 point category ratio scale were obtained before and after the treatment session. Data was analyzed using SPSS 15. For statistical significance, p value of <0.05 was considered. Results: There was a statistically significant improvement in PEFR, FEV1, RR and RPE in both the groups. However, there was no statistically significant difference in PEFR and FEV1 i.e. airway obstruction between the two groups. But, there was a statistically significant difference in RR and RPE i.e. dyspnea between the two groups, with breathing control showing greater improvement in dyspnea. Conclusion: Thus, asthmatic patients not only could reverse their airway obstruction (PEFR, FEV1) with Breathing control but also improved in terms of dyspnea (RR, RPE) as compared for Nebulization and Breathing control group. Nebulization and Breathing control group though it showed statistical significant improvement in airway obstruction(PEFR,FEV1) than only Breathing control; but the overall energy expenditure and thermogenic effect of nebulization with salbutamol did not help reverse dyspnea(RR and RPE)to the effect the breathing control could to. Keywords: Asthmatics, Nebulization, Breathing control, Airway obstruction, Dyspnea.
INTRODUCTION Asthma is a problem world wide, with an estimated 300 million affected individuals. 1 The WHO has estimated that 15 million disability adjusted life years (DALYS) are lost annually due to asthma. Absence from school and days lost from work are substantial social & economic consequences of asthma in studies from India.1
In Asthma, the predominant feature clinically is episodic shortness of breath, physiologically episodic airway obstruction characterized by expiratory airflow limitation & pathologically airway inflammation, which persists even during the asymptomatic periods. Airway narrowing is the final common pathway leading to symptoms and physiological changes in asthma.
Severity determines both the severity of the underlying disease and its responsiveness to treatment, but it may change over months or years. Therefore, periodic assessment of asthma control is more relevant and useful. Asthma is a growing problem with a huge economic burden. The annual cost of asthma to the NHS, constitutes about 83% i.e. Majority of it is due to medications. Accordingly, the development and evaluation of interventions to prevent asthma, to reduce its severity or improve its prognosis are the priority researches.2 Pharmacotherapy is the mainstay of asthma management, but the outcomes remain suboptimal for complex reasons including under treatment and noncompliance. 3 Also, many patients have concerns about regular medications and many use nonpharmacological and complementary therapies including breathing modification techniques. 3 There has recently been renewed interest in the breathing techniques used in asthma. 3 A 2000 systematic review of breathing techniques concluded that too few studies had been carried out to warrant firm judgments, but that collectively the data implied that physiotherapeutic breathing techniques may have some potential benefit4. A 2004 Cochrane review of breathing exercises for asthma concluded that, due to the diversity of breathing exercises and outcomes used, it was impossible to draw conclusions from the available evidence5. A 2007 RCT demonstrated that breathing retraining and relaxation significantly reduced respiratory symptoms and improved health-related quality of life in a cohort of patients with asthma.6 A 2008 RCT adds further strong support to this work, also finding significant reduction in asthma symptoms.7 Thus, various Physical therapy interventions aimed at overcoming dyspnea by overcoming early airway closure were chosen: Nebulization with selective B-2 sympathomimetic bronchodilator i.e. Salbutamol & Breathing control- wherein during inspiration normal tidal volume breaths are taken; with more effective use of diaphragm as it itself is an active inspiratory muscle during inspiration and during expiration, use of Pursed lip Breathing is emphasized. Thus, it was important to understand the effect of physiotherapeutic techniques on dyspnea as a result of airway obstruction in asthmatic patients & to appropriately emphasize breathing control techniques
in addition to pharmacological treatment & hence the above study was undertaken. Methodology Study design- Experimental study- A Randomized controlled trial. Study settingPhysiotherapy department, Seth G.S.M.C and K.E.M.H, Mumbai. Sample size- 60 patients with asthma who satisfied the inclusion criteria were selected. Inclusion criteria- Clinically diagnosed asthmatics in the age group of 18-35 8 years, either sex included, who were referred for physiotherapy treatment. Exclusion criteriaAsthmatics with acute exacerbation in previous week1. Asthmatics with status asthmaticus 9 . Use of bronchodilator puff, oral medications within last 6 hours and patients on intravenous medications 9. Patients having cardiac impairments, cardiac failure, hypertensives, those receiving Digitalis, in Cor Pulmonale9. Patients with other respiratory conditions, neurological, musculoskeletal and orthopedic limitations. Duration of study-2010-11 PROCEDURE The study was approved by the ethics committee for research on human subjects (ECRHS) of the institute & written informed consent was taken from patients. Patients were assigned randomly in two groups by computer generated random number chart and given a 30 minutes session: Group I: Nebulization for 10 minutes and breathing control for 20 minutes.(N+B) Group II: Breathing control for 30 minutes. (B) Starting position for both the groups-Patient sitting supported with back support and hip knee flexed and both hands placed just below the xiphisternum. GROUP I: Asthmatic patients were given nebulization and all the factors affecting deposition of drug particles in the airways was taken into consideration.9 Asthmatic patients were nebulized using salbutamol (Asthalin) with saline in the ratio of 1:1 i.e. 2 ml of Asthalin in 2 ml of saline; with Pulmomist nebulizer in relaxed sitting position with head and neck adequately supported. Patients were asked to inhale the aerosol generated with a slight pause after inspiration9. Nebulization was given for 1 st 10 minutes and same patients were given breathing control for next 20 minutes (during which time the peak effect of nebulization was also reached). Patients were given Breathing control immediately by using8
a) Proper relaxed sitting position-sit with hip knee flexion and lower back supported creating a posterior pelvic tilt position which facilitates use of diaphragm more effectively. b) During inspiration-controlled diaphragmatic breathing (only tidal volume breaths i.e.-normal inspiration was emphasized). c) Relaxation of upper chest and shoulders by giving verbal commands and proprioceptive feedback where necessary. d) During expiration-pursed lips breathing (PLB) was given. Group II: Patients in this group were given 30 minutes session of breathing control only 10. The procedure for the breathing control technique is same as above. Parameters like PEFR and FEV1 (using Mini-Wright Digital Peak flow meter), RPE on Borgs 10 point scale,
Parameters No. of Cases (N) Age(years)* Male:Female** Severity (I:Mp:Mop:Sp)** Pefr*( Liters/ Minute) Fev1*(Liters) Rr *(Breaths/ Minute) Rpe** (on Borgss 10 Point Scale At The Mark of 0:0.5:1:2:3:4) N+B 30 30.33[27.33, 33.33] 10:20 7:9:9:5 256.50[213.08,299.92] 1.31[1.06, 1.56] 32.267[30.185, 34.349] 2:0:5:12:9:2
RR using watch were taken before and after the procedure time for both the groups. Both the PEFR and FEV1 were taken in the standing position and the best of the three efforts was taken.1 BTS Guidelines 11 were followed: PEF was recorded as the best of the three forced expiratory blows from total lung capacity with a maximum pause of 2 seconds before blowing, with patient in standing position. Further blows were done if the larger of the 2 PEFR was not within 40 L/min. RESULTS Statistical analysis was done using software SPSS version 15.The normal distribution of data was found out with Kolmogorov-Smirnov Test. The collected data was analyzed statistically with Paired t Test, Unpaired t Test, Mann Whitney U Test and Chi Square Test as appropriate. Characteristics of 60 asthmatic patients (Mean [95% C.I.]), Median (Range) is:
B 30 31.37[29.21, 33.53] 9:21 9:9:7:5 278.00[235.14,320.86] 1.60[1.34, 1.86] 32.667[30.572,34.581] 2:0:5:10:10:3 P Value 0.498 0.781 0.919 0.474 0.112 0.774 0.75 Significance Ns Ns Ns Ns Ns Ns Ns
I:-Intermittent, MP:-Mild persistent, MoP:-Moderate persistent, SP:-Severe persistent, NS-Non-Significant. Thus, the data for each of the parameter in N+B and B group is statistically not significant & hence were
comparable. Following is the graphical representation of comparison within & between groups for all the parameters taken in the study.
1) Evaluation of peak expiratory flow Rate (PEFR) in N+B and B group
2) Evaluation of forced expiratory volume in 1st second (FEV1) in N+B and B group
3) Evaluation of Respiratory Rate (RR) in N+B and B group
4) Evaluation of perceived exertion (RPE) in N+B & B group
DISCUSSION To reduce the airway obstruction; two physiotherapy modalities mainly nebulization with bronchodilator and breathing control were used. Thus, the overall comparison between the two groups stated that: For Airway Obstruction in two groupsThe difference in PEFR between both the groups i.e.; in nebulization and breathing control (N+B) and breathing control (B) was not statistically significant (p=0.10). Similarly, the difference between the % change PEFR in (N+B) and (B) was not statistically significant (p=0.381). The difference in FEV1 between both the groups i.e.; in nebulization and breathing control (N+B) and breathing control (B) was not statistically significant (p=0.906). Similarly, the difference between the % change FEV1 with (N+B) and (B) was not statistically significant (p=0.21). For Breathing control in two groupsThe difference in RR between both the groups i.e.; in nebulization and breathing control (N+B) and
breathing control (B) was statistically significant (p<0.001); indicating that breathing control (B) group improved better post intervention. The difference in RPE between both the groups i.e.; in nebulization and breathing control (N+B) and breathing control (B) was statistically significant (p=0.028); indicating that breathing control (B) group improved better post intervention. Hence, both the maneuvers help effectively in improving airflow obstruction (PEFR, FEV1) and dyspnea (RR, RPE). Breathing control is more effective in relieving dyspnea. In a study done by Kendrick, et al it was found that the Modified Borgs Score(MBS) is a valid and reliable assessment tool for dyspnea and correlated well with other clinical parameters and could be useful when assessing and monitoring outcomes in patients with acute bronchospasm. In asthmatics, the mean MBS rating decreased from 5.1 at baseline to 2.4 after treatment. The mean PEFR increased from 286 at baseline to 414 after treatment. In the asthma group, there was a significant negative correlation between
change score in MBS & change scores in the PEFR from pre-scores to post-scores (r = -.31, P < .05). As the PEFR score increased, the MBS score decreased; thus the better the patients peak flow scores, the lower the patients dyspnea ratings12. Thus, the above may be one of the reasons the improvements in our study of decrease in airway obstruction and improvement in dyspnea go hand in hand. Ambroso et al, found that inhaled salbutamol significantly increases the resting metabolic rate of the patient due to thermogenic effects of salbutamol nebulization which may not effectively help to decrease the perceived exertion and thus respiratory rate13.The above may be one of the reasons why nebulization component may have added the energy expenditure and hence dyspnea in terms of RR and RPE. This also emphasizes that PLB in our study does not increase the energy cost of breathing as the dyspnea in terms of RR and RPE improve. By learning and understanding Breathing control, patients control their own breath, thus anxiety is also reduced; which is also one of the factors why they perceive less dyspnea. However, Lewis et al in a systematic review evaluated the short term effects on outcomes related to the mechanism of intervention and physiological outcomes. A beneficial effect was found for abdominal movement, diaphragm excursion, respiratory rate, tidal volume, arterial oxygen saturation. However, breathing control had a detrimental effect on the work of breathing and dyspnea. The study proposed that when used as a sole intervention, there was a beneficial effect on outcomes related to the mechanism of intervention and physiological outcomes. Only in people with severe respiratory disease, breathing control resulted in a detrimental effect on dyspnea and work of breathing. There was no clear evidence on gas exchange and energy cost of breathing14. Thus, the physiotherapeutic techniques used in various above studies helps control the symptoms of asthma and hence their manifestation. Also, most of the studies have evaluated the long term i.e. At least 1 month and 6 month results of lung function and overall asthma control; but immediate effects of breathing control were not studied. Thus, the improvements in lung function measures of PEFR and FEV1based on breathing control techniques suggest that there is immediate improvement in lung function measures. Asthma is a chronic disease; the goal of treatment should be to decrease its overall manifestation and achieve a better level of control and hence improve the
overall Quality of life. Though, nebulization by B-2 agonists showed immediate improvement in asthma symptoms and lung function in terms of PEFR and FEV1. However, regular inhalation of B-2 agonists was associated with deterioration of asthma control and such trends in treatment may be an important causal factor in the worldwide increase in the morbidity from asthma. Whereas, when intervention with breathing control was performed not only was there immediate improvement in measures of PEFR and FEV1 and overall symptoms; but also studies support the view of regular use of breathing control techniques helps to achieve both the goals of treatment i.e. Decrease in overall manifestation of asthma and improve Quality of life. In view of all the above, breathing control is an important technique to intervene dyspnea along-with proper pharmacological treatment. CONCLUSION All 30 patients in (N+B) and all 30 patients in (B) group responded and improved with intervention. Asthmatic patients showed statistically significant improvement in airway obstruction and dyspnea with nebulization and breathing control and with only breathing control also. There was no statistically significant difference between the groups in terms of airway obstruction as measured by PEFR and FEV1 .There was a statistically significant difference between the groups in terms of dyspnea as measured by RR and RPE. Breathing control is more effective to reduce dyspnea. Acknowledgement - None Conflict of interest- None Source of support - Professor and Head of Physiotherapy Department. REFERENCES 1. Global Initiative for asthma: global Strategy for Asthma Management and Prevention: GINA 2008 Update. Bethesda, MD: National, Heart, Lung and Blood Institute, National Institutes of Health. Definition and Overview, Diagnosis and classification, pg. 1-23. Available from URL: http:/ /www.ginasthma.org Cristopher A Kellett, Jacqueline A Mullan. Breathing Control Techniques in the Management of Asthma.Volume 88, Issue 12, Pages 751-758 (December 2002). M Thomas, R K McKinley, S Mellor, G Watkin, E Holloway, J Scullion, D E Shaw, A Wardlaw, D
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Price, I Pavord. Breathing exercises for asthma: a randomised controlled trial .Thorax 2009; 64: 55-61. E. Ernst. Breathing techniques - adjunctive treatment modalities for asthma? A systematic review Eur Respir J 2000; 15: 969-972. Hollway E, Ram FS. Breathing exercises for asthma. Cochrane Database Syst Rev 2004; 1):CD001277. Elizabeth A Holloway, Robert J West. Integrated breathing and relaxation training (the Papworth method) for adults in asthma with primary care: a RCT. Thorax 2007; 62: 1039-1042. Cowie RL, Conley DP, Underwood MF. A RCT of the Buteyko technique as an adjunct to conventional management of asthma. Respir Med 2008:726-732. Donna Frownfelter, Elizazbeth Dean. Cardio pulmonary Pathophysiology. In Marjory Frazer, Donna Morrisey editors. Principles and practice of Cardio pulmonary physical therapy; 3rd edition, Mosby Inc; 2006. P. 77,391,420-421. R.B. Cole. Bronchodilator Drugs. In: editors. Respiratory Diseases. 2 nd edition. Churchill Livingstone Inc.; 1981:pg. no.190.
10) C A Slader, H K Reddel, L M Spencer, E G Belousova, C L Armour, S Z Bosnic-Anticevich, F C K Thien, C R Jenkins. Double blind randomised controlled trial of two different breathing techniques in the management of asthma Thorax 2006;61: 651-656. 11) Diagnosis of Asthma. Evidence 2.5.2.Peak Expiratory Flow Monitoring. Edinghburgh: SIGN 2009.Available from url:http://www.sign.ac.uk/ 12) Usefulness of the modified 0-10 Borg scale in assessing the degree of dyspnea in patients with COPD and asthma Authors: San Diego, California. Karla R. Kendrick, Sunita C. Baxi, Robert M. Smith, Emergency Department and Urgent Care Clinic, Veterans Administration San Diego HealthCare System, San Diego, Calif. 13) P Amoroso, S R Wilson, J Moxham, J Ponte. Acute effects of inhaled salbutamol on the metabolic rate of normal subjects .Thorax 1993;48: 882-885. 14) Lewis LK, Williams MT, Olds T. Short-term effects on outcomes related to the mechanism of intervention and physiological outcomes but insufficient evidence of clinical benefits for breathing control: a systematic review. Aust J Physiother. 2007;53(4):219-227.
Effect of Neuromuscular Electrical Stimulation Combined with Cryotherapy on Spasticity and Hand Function in Patients with Spastic Cerebral Palsy
Chandan Kumar1, Vinti2 Assistant Professor, M.p.t (Neurology-student)), M. M. Institute Of Physiotherapy And Rehabilitation, Mullana, Ambala
2
ABSTRACT Purpose: To determine the effectiveness of Neuromuscular electrical stimulation combined with Cryotherapy on spasticity and hand function in patients with spastic Cerebral Palsy. Children with CP often demonstrate poor hand function due to spasticity in wrist and finger flexors. Methodology: This was an experimental study of 30 spastic CP patients aged 5-15 yr with mild to moderate spasticity. All the subjects were divided into two groups (A & B) with equal subject number in each group. Group A were treated with passive stretching, cryotherapy followed by Neuromuscular Electrical Stimulation (NMES) and Group B treated with passive stretching and cryotherapy, 3 times a week on alternate days for 6 weeks. Spasticity and hand function were assessed pretreatment and post treatment using the Modified Ashworth Scale (MAS) and Manual Ability Classification System (MACS). We tried to find out the additional effect of NMES on spastic CP patients. Results: Showed that both the group improved significantly but group A improved much better than group B. Conclusions: This study suggests that NMES combined with cryotherapy is more effective as compared to cryotherapy alone in reducing spasticity and improving hand function in spastic CP patients. Keywords: Spasticity, Cerebral Palsy, Neuromuscular Electrical Stimulation, Cryotherapy.
INTRODUCTION Cerebral palsy is a well-recognized neurodevelopmental condition beginning in childhood & persisting throughout the lifespan. Cerebral palsy is a group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain. The motor disorders of cerebral palsy are often accompanied by disturbances of sensation, perception, cognition, communication, and behavior; by epilepsy, and by secondary musculoskeletal problems.1 Cerebral palsy is the commonest physical disability in childhood, occurring in 2.0 to 2.5 per 1000 live births.2 The causes are congenital, genetic, inflammatory, infections, anoxic, traumatic & metabolic. The injury to the developing brain may be prenatal, natal or postnatal.3 Causes of CP were prenatal in 50% of the cases, perinatal in 33%, postnatal in 10%, and mixed in 7%.4 75% of children with CP have spastic cerebral palsy.3 Spasticity is classically defined as a tonal abnormality of skeletal muscle characterized by a velocity-dependent
resistance to passive stretch.5 Studies done to find out development of spasticity with age shown that the degree of muscle tone increased upto 4 year of age. After 4 year of age the muscle tone decreased each year upto 12 year of age.6 Physiotherapy Treatment For Spasticity Various treatment approaches & modalities to manage spasticity associated with spastic cerebral palsy include the use of oral neuropharmacological agents or injectable materials such as botulinum-A toxin7, surgical treatment through tendon transfer8 or selective rhizotomy 9. The other treatment approaches are application of cryotherapy10, progressive resistive exercises to improve muscle strength, repetitive passive range of motion exercises to improve & maintain joint mobility. Passive, static, gentle stretches are performed on individual joints to decrease & prevent joint contractures. Neurodevelopmental treatment (NDT), sensory integration, electrical stimulation, constrained induced therapy & orthosis are also used in management of cerebral palsy.11, 12
CRYOTHERAPY Cold application has been used for some time to reduce spasticity clinically. Decrease in resistance to passive stretch lasts from a few minutes up to 24 hours. Cold anesthesia of peripheral sensory end-organs changes the balance of facilitatory-inhibitory influences playing on the anterior horn cell in favor of inhibition. Unmasking of spasticity permits strengthening of voluntary mechanisms normally snowed under by undesired reflexes.10 Neuromuscular Electrical Stimulation Neuromuscular electrical stimulation has gained support since its inception as a treatment for cerebral palsy in the 1970s. With neuromuscular electrical stimulation, electrical stimulation of sufficient intensity generally to produce visible muscle contraction is applied at the muscle motor point. Electrical stimulation is thought to improve strength, reduce spasticity of the antagonist muscle, reduce co-contraction, and create soft-tissue changes permitting increased range of motion. 13 There are few studies that report the effectiveness of NMES and cryotherapy on reduction of spasticity & improvement of hand function in patients with spastic cerebral palsy and found that both the modalities used are effective and none of the two modalities is superior to other.14 Therefore, aim of this study is to determine the effectiveness of Neuromuscular electrical stimulation combined with Cryotherapy on spasticity and hand function in patients with spastic Cerebral Palsy. In present study, hand function is measured using the Manual Ability Classification System (MACS) instead of Zancolli system 14 because a review of classification systems of upper limb function & deformity in cerebral palsy supports the use of MACS to classify upper limb function and Zancolli system is recommended to classify thumb, hand &wrist deformity.15 METHODOLOGY 30 subjects were selected by means of convenience sampling based on inclusion and exclusion criteria. All the parents received a written explanation of the trial before entry into the study and then gave signed consent to participate their children in the study. The patients were randomly allocated into 2 groups.
INCLUSION CRITERIA 1. Patient diagnosed with spastic cerebral palsy (quadriplegic and hemiplegic). 2. Patient having wrist flexor spasticity upto Grade 3 according to Modified Ashworth Scale. 3. Age 5-15 yr, both male & female. 4. Patient who can comprehend and comply with instructions. 5. Normal skin sensation of upper limb. EXCLUSION CRITERIA 1. Dermatological problems 2. Seizures 3. Patients on muscle relaxing medications 4. Patient having contracture or deformity of upper limb 5. Patient undergone any surgery for upper limb PROCEDURE Thirty patients of CP who fulfill the inclusion criteria were included in this study. Total numbers of patients were equally divided into two groups (A & B). Each group contained 15 patients. All participants were evaluated by modified ashworth scale for wrist flexor spasticity and manual ability classification system for hand function. Modified Ashworth Scale measure spasticity and is applied manually to determine the resistance of muscle to passive stretching. This scale has been shown too valid and reliable.16 Manual Ability Classification system describes how children with cerebral palsy (CP) use their hands to handle objects in daily activities. MACS describe five levels. The levels are based on the childrens self-initiated ability to handle objects and their need for assistance or adaptation to perform manual activities in everyday life. The objects referred to are those that are relevant and age-appropriate for the children, used when they perform tasks such as eating, dressing, playing, drawing or writing.17 MACS has shown to be valid and reliable.18 All patients were assessed by modified ashworth scale and manual ability classification system before and after giving intervention.
The technique for application of passive stretching was based on passive range of motion (PROM) therapeutic exercises described by Kisner and Colby.19 The PROM consists of moving the elbow, wrist, fingers and thumb passively and holding it in position for 60 seconds. This procedure was repeated 5 times giving duration of 5 minutes bout. The procedure of passive stretching was given prior to every treatment session in all the subjects, both in group A & B. Treatment procedure for group A subjects The subject was placed in sitting position. The entire forearm from elbow to the fingers was carefully and decently exposed. The area was cleaned with cotton wool and with methylated spirit. The upper limb of the subject was positioned on a pillow on the plinth with the shoulder in mild abduction. The forearm was also positioned in mid flexion and supination with the fingers and thumb in anatomical position .The ice lollipop was applied to the flexor compartment of the forearm and gently massaged using stroking technique from the proximal to the distal end of the forearm. This was applied continuously for 20 minutes. The sequence of treatment was 3 times a week on alternate days for 6 uninterrupted weeks. After cryotherapy, subjects received electrical stimulation to the dorsum of the forearm. The electrical stimulation was consist of a dual channel devise with current outcome between 0 and 100 MA , pulse width of 200 microseconds and the pulse set between 30 and 40 Hz to produce tolerable muscle contraction. The electrical stimulation was applied for duration of 30minutes, 3 times in a week on alternate days for a period of 6 uninterrupted weeks. Treatment procedure for group B subjects Following the application of passive stretching, the subjects received Cryotherapy as describe for the subjects in group A. Data and Statistical Analyses
RESULTS Patients in both the groups were assessed at baseline level for spasticity with modified ashworth scale & hand function with manual ability classification scale prior to the commencement of the treatment sessions. Post-test measurements were taken after 6 weeks after completion of treatment sessions. There were no drop outs in the study. A total of 16 female and 14 male subjects participated in the study. Demographic characteristics of both the group are shown in table 1.
Table: 1 Demographic characteristic of the subjects
VARIABLES Sex F:M Mean Age Spastic CP (Type) Quadriplegic (%) Right Hemiplegic (%) Left Hemiplegic (%) Dominating hand (number) Right hand 15 15 8 (53%) 5 (33.3%) 2 (13.3%) 7 (46%) 5 (33.3%) 3 (20%) GROUP A 7:8 7.53 1.35 GROUP B 9:6 7.66 1.63
Above table showing that subjects in both the groups are matched for baseline level
Table: 2 Baseline score of MAS and MACS of both the group
MAS
A Mean S.D P value (<0.05) 2.460.611 0.59 B 2.330.587 A 4.600.632
MACS
B 4.530.639
0.77
Above table showing mean value of baseline scores of MAS & MACS of both groups. After analysis, the p value is >0.05 which is statistically non-significant.
Table: 3 Pre and Post value of MAS and MACS of group A
GROUP A
Comparison was performed between the groups first at baseline level. Then again, comparisons were done after treatment at 6 week as well as from baseline to 6 week and results were noted. Wilcoxon signed rank test and Mann Whitney U test was used to analyze the pre and post treatment values of MAS scores and MACS scores within the groups and between the groups respectively. The level of significance was set at p<0.05. Data were analyzed using SPSS 17.0.
Variables
Mean S.D Pre value Post value 1.3330.408 2.530.833
p value (<0.05)
MAS MACS
2.4660.611 4.600.632
0.0003 0.0003
Above Table showing mean value of pre MAS and post MAS & pre MACS and post MACS of group A. After analysis, p value is <0.05 which is statistically significant.
24 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 Table: 4 Pre & post value of MAS and MACS of group B
GROUP A Variables Mean S.D Pre value MAS MACS 2.3330.587 4.530.639 Post value 1.6660.308 3.460.828 0.0008 0.0005 p value (<0.05)
Above Table showing mean value of pre MAS and post MAS & pre MACS and post MACS of group B. After analysis, p value is <0.05 which is statistically significant.
Table: 5 Post intervention MAS and MACS value of group A & B
MAS
A Mean S.D P value (<0.05) 1.330.408 0.02 B 1.660.308 A 2.530.833
The results of this study are supported by previous studies which tell that the neuromuscular electrical stimulation is helpful in increasing muscle strength by increasing cross sectional area of the muscle & by increasing recruitment of Type 2 muscle fibers.12 With NMES, unused muscles can be stimulated when needed and the sensory input from NMES can give added sensory awareness of what is happening in the hand to allow motor learning to occur and to permit motor control.20 Neuromuscular electrical stimulation, when applied to the peripheral muscles has a direct effect on the cerebral cortex.21 In group A as we have given cryotherapy first and after that NMES, combined effect of both the modalities leads to significant improvement in experimental group. Result of this study showed that improvement is more significant in subjects of group A treated with cryotherapy followed by neuromuscular electrical stimulation when compared with subjects of group B treated with cryotherapy alone (table 5). This showed that additional improvement in group A is because of neuromuscular electrical stimulation. First cryotherapy has reduced spasticity in wrist flexors and then NMES applied to wrist extensors has further reduced spasticity in wrist flexors via reciprocal inhibition and increased strength in wrist extensors. Few studies have been done on neuromuscular electrical stimulation and cryotherapy in isolation which shows their effectiveness but the result obtained from this study is novel that proves the combined efficacy of neuromuscular electrical stimulation and cryotherapy on spasticity. Neuromuscular electrical stimulation is a non-invasive therapy and offers a better clinical outcome. CLINICAL IMPLICATION The results of the present study enlighten the use of combination therapy approach (NMES+Cryotherapy) as an more effective approach than the either intervention alone in the clinical settings for the management of spasticity and hand function in patients with spastic cerebral palsy. Limitations of the study Subjective measures used for measuring spasticity and hand function challenges the results obtained. No follow up was taken to see the long term effects. Dominating hand was only treated in quadriplegics to avoid collecting paired data.
MACS
B 3.460.828 0.01
Above Table showing mean value of post intervention scores of MAS & MACS of both groups. The result obtained from the study data showed that there was significant difference within group A and B in reducing spasticity and improving hand function. Group A showed more significant difference in outcome measures in comparison to group B. DISCUSSION In this experimental design study, result showed the combined effect of neuromuscular electrical stimulation and cryotherapy on spasticity and hand function in patients with spastic cerebral palsy. The results support the hypothesis that NMES along with cryotherapy produce good results as compared to cryotherapy alone. Cold facilitates alpha-motor neuron activity and decreases gamma motor neuron firing through stimulation of cutaneous afferents. There is also a decrease in the afferent-spindle discharge by direct cooling of the muscle. When nerves are cooled, synaptic transmission are impeded or blocked by altering the transmembrane ionic flow. The possible explanation of the mechanism of relief of spasticity can be that cold anesthesia of peripheral sensory endorgans changes the balance of the sum of facilitatoryinhibitory influences playing on the anterior horn cell in favor of inhibition. Unmasking of spasticity permits strengthening of voluntary mechanisms normally snowed under by undesired reflexes.10
Future Research Suggestion Future research can be done using objective measures for measuring spasticity and hand function. There should be long term follow up of the patient to determine the sustained effects of combination therapy (NMES+Cryotherapy). CONCLUSION This study describes the management of spastic cerebral palsy patients with hand function impairments, who responded favorably to an intervention program focused NMES and cryotherapy. REFERENCES 1. R peter, P. Nigel, G murray, G martin. The Definition and classification of cerebral palsy. Developmental Medicine & Child Neurology. 2007; 49(109):814. 2. Reddihough Dinah S, Collins Kevin J. the epidemiology and causes of cerebral palsy. Australian Journal of Physiotherapy. 2003; 49: 7-12. 3. S. chitra, M nandani. Cerebral palsy-definition, classification, etiology and early diagnosis. Indian journal of pediatric. 2005: 865-868. 4. Holm Vanja A. the Causes of Cerebral Palsy. JAMA. 1982; 247:1473-1477. 5. R Susan, G Joan T. Non operative management of spasticity in children. Child nervous system. 2007; 23:943-956. 6. H Gunnar, W philippe. Development of spasticity with age in a total population of children with cerebral palsy. BMC Musculoskeletal Disorder. 2008; 9:150-159. 7. Patel Dilip R, S olufemi. Pharmacological intervention for reducing spasticity in cerebral palsy. Indian journal of pediatrics . 2005; 72: 896-872. 8. Das Shakti P, Mohanthy Ram N, Das Sanjay K. Management of upper limb in cerebral palsy-role of surgery. IJPMR. 2002 April; 13:15-18. 9. F Jean P, J abdulrehman. Selective dorsal rhizotomy in the treatment of spasticity related to cerebral palsy. Child nervous system. 2007 July 21; 23: 991-1002. 10. Mead Sedwick, Knott Margaret. Topical Cryotherapy: Use for Relief of Pain and Spasticity. California Medicine. 1966; 105(3):179-181
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Sharan Deepak. Recent advances in management of cerebral palsy. Indian journal of pediatric. 2005; 72:969-973. Patel Dilip R. Therapeutic intervention in cerebral palsy. Indian journal pediatrics. 2005; 72:979-983. Kemper Derek G, Yasukawa Audyer M. Effects of neuromuscular electrical stimulation treatment of cerebral palsy on potential impairment mechanism. Pediatric physical therapy. 2006; 18:31-38. Akinbo S R A, Tella B A, Otunla A. Comparison of the effect of neuromuscular electrical stimulation and cryotherapy on spasticity and hand function in patient with spastic cerebral palsy. Nigerian medical practitioner. 2007; 51:128-132. K McConnell, L Johnston, C Kerr. Upper limb function and deformity in cerebral palsy: a review of classification systems. Dev Med Child Neurol. 2011; 53(9): 799-805. Bohannon Richard W, Smith Melissa B. Interrater Reliability of a Modified Ashworth Scale of Muscle Spasticity. Physical Therapy 1987 Feb; 67(2): 206-207. Kuijper M. A, Ketelaar M. Manual ability classification system for children with cerebral palsy in a school setting and its relationship to home self-care activities. American Journal of Occupational therap. 2010; 64:614-620. Eliasson Ann-Christin, Krumlinde-Sundholm Lena, Rosblad Birgit, Beckung Eva, Arner Marianne, Ohrvall Ann-Marie, Rosenbaum Peter. The Manual Ability Classification System (MACS) for children with cerebral palsy: scale development and evidence of validity and reliability. Developmental Medicine & Child Neurology 2006; 48(7):549-554. DOI: 10.1017/S0012162206001162 Kisner C, Colby L. A. Therapeutic Exercise: Foundation and Techniques. 4thed. New Delhi: Jaypee Brothers, Medical Publishers (P) Ltd; 2003. Scheker L R, Ramirez S. Neuromuscular electrical stimulation and dynamic bracing as a treatment for upper extremity spasticity in children with cerebral palsy. Journal of hand surgery. 1999; 24:226 -232. Han BS, Jang SH, Chang Y, Byun WM, Lim SK, Kang DS. Functional magnetic resonance image finding of cortical activation by neuromuscular electrical stimulation on wrist extensor muscles. Am J Phys Med Rehabil. 2003 Jan; 82(1):17-20.
Phonophoresis in Continuous Mode Ultrasound has Significant effect in the Reliving Pain in Upper Trapezius Tender Point
Chhavi Gupta1, Manish Rajput1, Ankita Samuel1, Sumit Kalra2 Student-bachelors of Physiotherapy, 2Asst Professor, Banarsidas Chandiwala Institute of Physiotherapy ABSTRACT Purpose: The aim of this study was to find the significance of continous mode on the immediate effect on pain threshold and range of motion which follows a single treatment of tender points in the upper trapezius muscle among using diclofenac sodium as coupling medium. Methods: 30 subjects presenting with upper trapezius muscles spasm, aged 20-30 years old, participated in this Study. Subjects underwent a screening process to establish the presence of tender points in upper trapezius muscle. Subjects were divided randomly into 2 groups. Group A = continuous mode of ultrasound (0.8 w/cm2 for 5 minutes) Group B = pulsed mode of ultrasound (0.8 w/cm2 for 5 minutes) Visual Analogue Scale and Range of Motion is assessed pre treatment and immediately post treatment. Result the p value of VAS (post treatment) and ROM (post treatment) in continous mode was 0.000 Conclusion: continous mode of ultrasound is better for immediate pain relive as compared to pulsed mode when diclofenac sodium is used as the coupling medium. Keywords: Tender Point, Phonophoresis, Ultrasound, Diclofenac Gel. INTRODUCTION Neck pain is common and can limit individuals ability to participate in normal daily activities. Neck pain frequently becomes chronic1. Tender point is defined as the places on muscles that when touched with enough pressure, elicits a feeling of sensitivity in the location of point. Pain does not refer anywhere else in the body; pain is confined to tender point itself. They are usually no bigger than 1 cm 2. The presence of tender points in patients is closely associated with their current anxiety, and patients with a history of psychological trauma associated with anxiety (for example, childhood trauma or sexual abuse) have an increased number of tender points.4 US is a modality which involves the generation of high frequency sound waves, and their transmission through the skin to the structures desired to be affected. US generators used clinically are limited by government regulation to approximately 1,000,000 Hertz (1 megahertz).5 Phonophoresis was first used to treat polyarthritis of the hand by delivery of hydrocortisone ointment into inflamed areas in 1954. Since then it has been reported to be used in the treatment of various dermatological and musculoskeletal disorders.7 The mechanism by which ultrasound enhances the transdermal penetration of substances is not entirely clear. One could think of the vasodilation observed on macroscopic examination, but this would certainly not be enough on its own, since it does not imply any change of the waterproof keratin layer of the skin, which should necessarily be altered.8 Sodium Diclofenac was chosen for the experiment for being a well-known and widely used nonsteroidal anti-inflammatory drug whose analgesic effects manifest quickly after administration.8 Evidence from clinical and pharmacological studies imply that Diclofenac exerts its actions by inhibiting cycloxygenase
(COX) enzyme. Inhibition of COX reduces the production of inflammatory mediators such as prostaglandins, interleukin-6 and substance P. It is also suggested that Diclofenac can alter G-protein mediated signal transduction pathways and exerts an enhanced effect on hyperalgic muscle by directly interacting with nociceceptors.11 Reliability of the visual analogue scale for measurement of pain A VAS is measurement instrument that tries to measure a characteristic or attitude that is believed to range across a continuum of values and cant easily be directly measured.9 Operationally a VAS is usually a horizontal line, 100mm in length, anchored by word descriptors at each end. The patient marks the line the point they feel which represents their perception of their current state. The VAS score is determined by measuring inn millimetres from left hand end of the line to the point that the patient marks.9 Reliability of the VAS for acute pain measurement as assessed by the ICC appears to be high. Ninety percent of the pain ratings were reproducible within 9 mm. These data suggest that the VAS is sufficiently reliable to be used to assess acute pain.10 Reliability of Goniometer The full-circle goniometer, or universal goniometer (UG), is a versatile device for recording measurements of peripheral joint ROM in healthy subjects and in patients. Based on a clinical study of 60 patients with orthopaedic disorders in a physical therapy outpatient department, conclusion was drawn that AROM measurements on the cervical spine made by the same physical therapist have good to high reliability, regardless of whether the therapist used the CROM device or the UG. Repeated measurements with the UG had poor to fair between tester reliability.15 The purpose of this study is to compare the effectiveness of pulsed and continuous ultrasound with topical Diclofenac gel as the coupling medium in the immediate pain relive of tender point. METHODOLOGY Number and Source 30 subjects were taken from young population.
Inclusion Criteria 1. Male or Female with age of 20-30 years. 2. Subjects with upper trapezius muscle spasm. Exclusion Criteria 1. Subjects with trigger point of trapezius muscle. 2. Subjects with musculoskeletal disorder that would limit performance in these subjects. 3. Skin disorders which would irritate by either increase in warmth of the part or by the lubricants which might be used, e.g. eczema. 4. In presence of malignant tumours. 5. In case of any previous fracture or surgery at neck. 6. All contraindications of ultrasonic therapy. Method of selecting & assigning subjects to groups 40 subjects having an upper trapezius muscle spasm were considered for this study. They were then screened to remove the subjects who did not fulfil the criteria for the study. After screening, the subjects they were randomly divided into two groups. Instruments and Tool used 1. Ultrasound machine Meditek Ultrasonic digital , Meditek cooperation 2. Diclofenac sodium gel 3. Ultrasound gel Research Design It is an experimental design. Variables Independent variables- Ultrasonic Therapy Dependent variables- Visual Analogue Scale PROCEDURE Subjects fulfilling the inclusion criteria were taken into consideration. The procedure was explained to the subjects and a written consent was taken after explaining the benefits and clearing the doubts of the subject regarding study. After pain level assessment by help of visual analogue scale (VAS) and Range of Motion using the universal goniometer they were randomly divided into two groups namely, A and B.
Group A were given pulsed ultrasound with diclofenac sodium as coupling medium and Group B were given continuous ultrasound with diclofenac sodium as coupling medium. The ultrasound was given for 5 minutes at 0.8 w/cm2 16. After the treatment pain level and Range of Motion is taken again. RESULT A paired sample t test reveal a statistically reliable difference between the mean number of VAS pre and post in continous mode (M= 6.7333, s =1.03280) and (M= 3.9333, s =1.48645) that the t(14)=12.582, P()= .000 at two tail test. A paired sample t test reveal a statistically reliable difference between the mean number of ROM pre and ROM post in continous mode (M=27.0000, s=5.29150) and (M= 37.0667, s = 4.19977) that the t(14) = -11.093, P()= .000 at two tail test. A paired samples t test reveal a statistically reliable difference between the mean number of VAS pre and VAS post in pulsed mode (M=-6.8000, s = 1.32017) and (M 4.4000, s=1.50238) that the, t(14) =8.806, P() = .000.at two tail test. A paired samples t test reveal a statistically reliable difference between the mean number of ROM pre and ROM post in pulsed mode (M=-23.7333, s=10.73357) and (M=33.7333, s=9.51290) that the, t(14) = -10.569, P() = .000.at two tail test. An independent-samples t-test was conducted to compare VAS post treatment in pulsed mode and continous mode. There was a significant difference in the scores for pulsed (M=4.4, SD=1.5) and continous (M=3.93, SD=1.48) conditions; t(28)=0.855, p = 0.400. the result suggest that VAS decreases more in continous mode than in pulsed mode. An independent-samples t-test was conducted to compare ROM post treatment in pulsed mode and continous mode. There was a significant difference in the scores for pulsed (M=33.73, SD=9.51) and continous (M=37.06, SD=4.19) conditions; t(28)=-1.24, p=0.225. The result suggest that ROM increases more in continous mode.
Hence it can be said that continuous mode has more of a thermal effect rather than non-thermal. Mild heating has the effect of reducing pain and muscle spasm and promoting healing process. Kramer (1987), investigating the increase in conduction velocity in motor and sensory nerves following therapeutic ultrasound, concluded that this was likely to be related to the heating effect of ultrasound.12 Diclofenac sodium is a very commonly used nonsteroidal anti-inflammatory drug (NSAIDs). It is an analgesic-anti-pyretic-anti-inflammatory drug, similar in efficacy to naproxen. It inhibits PG synthesis and is somewhat COX-2 selective.13 The mechanism by which ultrasound enhances the transdermal penetration of substances is not entirely clear. One could think of the vasodilation observed on macroscopic examination, but this would certainly not be enough on its own, since it does not imply any change of the waterproof keratin layer of the skin, which should necessarily be altered.18 No volunteers presented any complication of any kind nor did they report any discomfort with the treatment at any time, all of them resuming normal life immediately after the end of treatment Apart from slight redness and a temperature increase on touch, no sign of local irritation was detected by macroscopic inspection of the irradiated areas.8 CONCLUSION The study concludes that continous mode of ultrasound is better for immediate pain relive as compared to pulsed mode when diclofenac sodium is used as the coupling medium for immediate pain relive in tender point in muscles all over the body. REFERENCES 1. Ali Gur; Physical Therapy Modalities in Management of Fibromyalgia; Current Pharmaceutical Design, 2006 12, 29-35 Haraldsson B, Gross A, Myers CD, Ezzo J, Morien A, Goldsmith CH, Peloso PMJ, Brnfort G, Cervical Overview Group. Massage for mechanical neck disorders. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD004871. DOI: 10.1002/14651858.CD004871.pub3 Sheila Kitchen, Electrotherapy Evidence-based Practice, Eleventh Edition, pg 221-228
DISCUSSION According to the unpaired t test done between post values of VAS in case of pulsed mode and continous mode the p value is <0.005. The post value of ROM in pulsed mode and continous mode the p value is <0.005. In this study, the clinical efficacy of diclofenac gel as a coupling agent using continuous mode of was compared with pulsed mode. According to the study, by using continuous mode of ultrasound there is more pain relive rather than by using pulsed mode. Continuous mode has been recommended for muscular cellular disorders such as muscle spasm, joint stiffness or pain whereas pulsed mode is preferred for soft tissue repair.12 This could be because in pulsed mode the time average intensity is reduced which reduces the amount of energy available to heat the tissues while ensuring that the energy available in each pulse is high enough for mechanical or non-thermal effects rather than the thermal effects to predominate.12
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Sangita Chakrabarty, Md, Msph, Roger Zoorob, Md, Mph; Fibromyalgia; American Family Physician; Volume 76, Number 2 July 15, 2007 Sunday Akinbo, Oluwatoyosi Owoeye, Sunday Adesegun; Comparison of the Therapeutic Efficacy of Diclofenac Sodium and Methyl Salicylate Phonophoresis in the Management of Knee Osteoarthritis; Turk J Rheumatol 2011;26(2):111-119 Peter Croft, Jonathan Burt, Joanna Schollum, Elaine Thomas, Gary Macfarlane, Alan Silman; More pain, more tender points: is fibromyalgia just one end of a continuous spectrum?; Annals of the Rheumatic Diseases 1996; 55: 482-485 Giovana c. Rosim, Cludio Henrique Barbieri, Fernando Mauro Lanas, and Nilton Mazzer; Diclofenac Phonophoresis In Human Volunteers; Ultrasound in Med. & Biol., Vol. 31 No. 3 pp. 337343, 2005 Russell Rothenberg, MD; Fibromayalgia, pathophysiology and treatment; Fibromyalgia frontiers, 2010, vol. 18, No. 1 Prerna Paul et. al.; Effect of Lumbar Stabilization Exercise in Treatment of Young Individuals With Non Specific Low Back Pain; The Physiotherapy Post; July-September 2011. Vol 3, No. 3
10. Afyonkarahisar, Turkey; Effectiveness of Ultrasound Therapy in Cervical Myofascial Pain Syndrome: A Double Blind, Placebo-Controlled Study; Turk J Rheumatol 2010; 25: 110-5 11. Robert D Gerwin; A review of myofascial pain and fibromyalgia factors that promote their persistence; ACUPUNCTURE IN MEDICINE 2005; 23(3):121-134. 12. John low BA(Hons.), FCSP, DipTP, SRP, Ann Reed BA, MCSP, DipTP, SRP; Electrptherapt Explained Principles and Practice, 3rd edition, pg 172-196 13. KD Tripathi; Essentials of Medical Pharmacology; 6th edition; page 184-194 14. Bijur PE, Silver W, Gallagher EJ.; Reliability of the visual analog scale for measurement of acute pain; Acad Emerg Med. 2001 Dec;8(12):1153-7 15. James W Youdas, James R Carey and Tom R Garrett; Reliability of Measurements of Cervical Spine Range of Motion-comparison of Three Methods; PHYS THER. 1991; 71:98-104 16. Kamal Dua, V.K.Sharma, UVS Sara, D.K.Agrawal, M.V.Ramana; Penetration Enhancers for TDDS: A Tale of the Under Skin Travelers; Adv. in Nat. Appl. Sci., 3(1): 95-101, 2009
Prediction of Relationship of Visual Attention Deficits to Balance and Functional Outcome in Persons with Subacute Stroke
Chintan Shah1, Hasmukh Patel2, Komal Soni1, Dhaval Desai1, Harshit Soni1 Lecturer, Spb Physiotherapy College, Surat, 2Clinical Therapist, U. N. Mehta Institute of Cardiology and Research Centre, Ahmedabad ABSTRACT Background: Stroke is a focal neurological disorder lasting for more than twenty-four hours, giving rise to functional disabilities in speech, vision, balance and ADL. As stroke has been found to impair vision, balance and ADL, this study is done to predict the relationship of visual attention deficits to balance and functional outcomes in persons with subacute stroke. Awareness of such relationship may be of useful assistance to the physiotherapists in planning treatment interventions in persons with subacute stroke. Objective: To predict and estimate strength of the relationship of visual attention deficit to balance and functional outcomes in persons with subacute stroke. Materials and Methods: 50 subjects with subacute stroke were selected for the study. All the patients were assessed on the basis of Star Cancellation Test (SCT), Berg Balance Scale (BBS) and Barthel Index (BI) for visual attention, balance and functional outcomes respectively both at the time of discharge from the hospital and also after 6 months post-stroke. At the end of the study, visual attention scores were correlated (using Pearson product correlation "r" value) with the balance scores and functional outcome scores obtained at the time of discharge from the hospital and 6 months post-stroke. Result: MeanSD of scores for Star Cancellation test, Berg Balance scale and Barthel index measured at the time of discharge from hospital and 6 months post stroke was 48.092.04, 49.861.91, 40.002.00, 42.601.90, 70.0010.00, 75.109.92 respectively. Moreover, there was strong positive and highly significant correlation of SCT scores with BBS scores and BI scores both at the time of discharge and 6 months post stroke. Interpretation & Conclusion: Visual attention deficit is an important factor to predict the balance and functional outcomes in persons with subacute stroke. Keywords: Stroke, Visual Attention Deficit, Balance, Functional Outcome. INTRODUCTION Stroke is an acute onset of neurological dysfunction due to an abnormality in cerebral circulation with resultant sign and symptoms that correspond to involvement of focal areas of brain.1 Cognitive deficits are common after stroke2,3 and have been linked to poor recovery of ADL (Activities of Daily Living) abilities and rehabilitation outcome.4,5 For many people, these impairments are the major obstacles preventing their return to independence and quality of life.6 Corresponding author: Chintan Shah B-701, Aagam Vihar Apt, Opp Lakhoz Club, Umra, Surat-07, Gujarat, India E-mail: chintoo601@gmail.com Attention is one of the aspects of cognitive functioning that has been reported as the basis for other components of cognition.7 Visual attention is a type of selective attention that lays a very important role in balance because balance is maintained mainly by feedback through eyes, ears and vestibular apparatus. In this visual contribution is inevitable and if there is visual inattention, then there will be difficulty in feedback mechanism and this will directly affect the balance and eventually ADLs. Visual impairments commonly encountered by patient with hemiplegia include poor eyesight, diplopia, homonymous hemianopia, damage to visual cortex and retinal damage. 8 In its purest form, unilateral spatial inattention is defined as a condition in which an individual with normal sensory and motor system fails
to orient toward, respond to, or report stimuli on the side contralateral to the cerebral lesion.9 Attention is also a key component in learning new motor skills, particularly in the early stages of learning.10 This clearly portraits that attentional component plays a very important role in motor learning and also depicts importance of attention in rehabilitation of stroke patients especially in Motor Relearning Programme which is the latest approach in physiotherapy rehabilitation. In stroke, physical impairments include motor, sensory, balance, urinary impairment, speech disorder, perceptual problems, etc. Balance has been defined as the ability to maintain upright posture.11,12 In stroke, ones ability to balance may be impaired because of deficits of strength, range of movements, proprioception, vision, vestibular function and endurance.13 Studies have showed that balance and perceptual disturbance are found as risk factors for falls in stroke patients.14 ADL are the activities necessary for daily self care, personal maintenance and independent community living such as feeding, bathing, dressing, hygiene, and physical mobility.15 Studies have reported decline in cognition, mobility and functional daily activity after stroke.16 Also the presence of visual field deficit is being reported as a significant prognostic sign, predicting both a higher death rate following stroke and poor performance in ADLs, even following rehabilitation.17,18 Further, attention deficits being common among hospitalized people with stroke, a study describing association between distractibility, auditory selective attention, balance and function impairments shown that those who scored well on the auditory selective test had better balance scores at the final assessment than those with auditory selective attention deficits or distractibility.19 However there are no clear cut studies that show that whether visual attention deficits correlate with balance, and eventually functional outcomes in subacute stroke patients. Keeping in view the above point, this study is set out to predict the relationship of visual attention deficits to balance and functional outcome in patients with subacute stroke. The aims and objectives of the study were 1. To find out the relationship between visual attention deficits and balance at the time of discharge and after 6 months post-stroke.
2. To find out the relationship between visual attention deficits and functional performance at the time of discharge and after 6 months post-stroke. METHODOLOGY Study design: An Observational Correlation study Sample size: 50 individuals Sampling method: Purposive sampling technique Study Setting: Laxmi Memorial College of Physiotherapy and A.J. Hospital and Research Centre, Mangalore Study duration: 6 months (from the time of discharge of patient from the hospital upto 6 months post-stroke). Inclusion criteria 1. Above 50 years of age. 2. Both sexes. 3. All type of stroke and first time stroke. 4. Attention deficits should be present in the patient. 5. Deemed to be fit by the physician and medically stable. 6. Subjects should undergo continuous conventional physiotherapy. Exclusion criteria 1. Major musculoskeletal problems (amputation or recent joint replacement surgery). 2. Any other neurological disorders in addition to stroke. 3. Severe perceptual disorders. 4. Severe cognitive deficit (Mini Mental State Examination score < 23/30). Materials used: Test paper of size 8.5 inch x 11 inch with 52 large stars, 13 letters and 10 short words interspersed with 56 small stars for the testing of visual attention. Other materials included were pencil, stop watch/wrist watch, ruler, two standard chairs (one with and one without arm-rest), foot-stool or step. (Fig: 1)
Fig: 1 Tools Used
Outcome Measures Star Cancellation Test (SCT) to assess visual attention,

Fig. 3 stepping activity for Barthel Index
Berg Balance (BB) scale to assess balance and Barthel Index (BI) to assess functional performance (ADL). PROCEDURE After signing the written informed consent (to participate in the study and to allow reproduction of their photographs) subjects were made to participate in study and baseline measurements of demographic factors and outcome measures were recorded. Every patients were given proper instructions (but no training) prior to assessing the outcome measures viz. Star Cancellation Test (Fig: 2), Barthel Index (Fig: 3) and Berg Balance Scale (Fig: 4)
Fig. 4 Therapist Testing Berg Balance Scale
All outcome measures were taken at the time of discharge from hospital and later 6 months after stroke. Following the recording of the above parameters, the obtained scores were tabulated and compared among both the study groups. Ethical Consideration: Procedures followed were in accordance with the ethical standards of Helsinki Declaration of 1975, as revised in 2000.20
Fig. 2 Star Cancellation Test
Statistical Analysis Of the 50 participants who participated in the study, none were lost to follow up assessment at the end of the study. At the end of the study, visual attention scores were correlated with the balance scores and functional outcome scores both at the time of discharge from the hospital and also after 6 months post-stroke. Pearson product correlation r value was used to find the relationship among the variables. P value< 0.01 was taken up for statistical significance. Data analysis software SPSS 13.0 version has been used for the data analysis of present study.
RESULTS Graph 1: Age & Gender distribution of the subjects
Table 1: Descriptive statistics for Outcome measures

Star Cancellation test Time of Discharge Min Max Mean Std. Deviation 45 47 48.06 2.045 After 6 months 51 53 49.86 1.917 Berg Balance Scale Time of Discharge 37 40 40.00 2.000 After 6 months 43 46 42.60 1.906 Barthel Index Time of Discharge 55 60 70 10.000 After 6 months 85 90 75.10 9.923
Table 2: Correlation of SCT scores with the BBS scores & BI scores at the time of discharge from the hospital
r value P Level of Significance/ Interpretation HS HS
Star Cancelation test (Time of Discharge)
Berg Balance Scale (Time of Discharge) Barthel Index (Time of Discharge)
.978 .978
.000 .000
As shown in table 2, there is strong positive and highly significant (p<0.01) correlation between SCT scores (at the time of discharge) and BBS scores (at the time of discharge) and also between SCT scores (at the time of discharge) and BI scores (at the time of discharge).
Table 3: Correlation of SCT scores with the BBS scores & BI scores after 6 months post stroke
r value Star Cancelation test (After 6 months) Berg Balance Scale (After 6 months) Barthel Index (After 6 months) P Level of Significance HS HS
.951 .966
.000 .000
As shown in table 3, there is strong positive and highly significant (p<0.01) correlation between SCT scores (6 months post stroke) and BBS scores (6 months
post stroke) and also between SCT scores (6 months post stroke) and BI scores (6 months post stroke).
Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 35 Table 4: Correlation of SCT scores at the time of discharge with the BBS scores & BI scores after 6 months post stroke
r value Star Cancelation test (Time of Discharge) Berg Balance Scale (After 6 months) Barthel Index (After 6 months) .944 P .000 Level of Significance HS
.970
.000
HS
As shown in table 4, there is strong positive and highly significant (p<0.01) correlation between SCT scores (at the time of discharge) and BBS scores (6 months post stroke) and also between SCT scores (at the time of discharge) and BI scores (6 months post stroke). DISCUSSION Stroke is a focal neurological disorder lasting for more than 24 hours, giving rise to functional disabilities in speech, vision, balance and ADL. Hence, in our study we have tried to predict the relationship between visual attention deficits, balance and functional outcomes in persons with subacute stroke. Results from our study indicates that attention deficits were present among the persons with subacute stroke, Sinclair R (1995) also reported similar findings using some of the same subtests among subacute stroke patients.19 Moreover, the visual attention deficits have a significant influence on the balance both at the time of discharge from the hospital and also after 6 months post-stroke. Sebstina and Vyas (2001)21 also concluded that cognitive and perceptual deficits following stroke influences sitting and standing balance among patients. Visual attention has directly proportional relation with balance. However, findings of Stapleton and colleagues (2001) suggested a weak or no relationship between attention deficits and balance control, but their sample size being too small (n=13) the results can be doubted for being statistically significancant.22 There was significant correlation between the SCT scores at the time of discharge from the hospital with the BBS score and BI score after 6 months post-stroke. Thus, the present study not only finds the relationship between visual attention, balance and functional outcome but it also predicts the balance and functional outcome after 6 months with the visual attention score at discharge. However, present study showed that visual attention deficits affect the balance and functional outcome significantly but visual attention deficit is not the only factor that can affect the balance
and functional outcome. The assessment of such attention deficits post-stroke may be a useful tool in predicting functional recovery and response to rehabilitation. Awareness of possible deficits of attention may be of assistance to physiotherapists in planning interventions with patients recovering from stroke. Limitations of the study The study was done on a small sample size. The study only included visual attention among the various types of attention. Only old aged i.e. above 50 years patients with subacute stroke were assessed to find the prediction, young age stroke patients were not at all assessed.
Scope of further studies In future studies, all types of attention (sustained attention, divided attention, etc.) other than visual attention can be taken as predictor of balance and functional outcomes. Same study can be done in subacute stroke patients without ongoing physiotherapy. BBS does not include gait items so some other scale can be used to assess the dynamic balance of subjects with stroke. CONCLUSION Visual attention deficits are an important factor responsible for predicting balance and functional outcomes in persons with subacute stroke. There is significant one to one relationship between visual attention deficit to balance and functional recovery in persons with subacute stroke. ACKNOWLEDGMENTS We are thankful to all our subjects who participated with full cooperation and showed voluntary interest
REFERENCES Susan B. OSullivan, Thomas J. Schmitz, Physical Rehabilitation: Assessment & treatment, 4 th Edition: Jaypee Brothers, 2001:519-581 2. Hom J, Reitan RM. Generalized cognitive function after stroke. J Clin Exp Neuropsychol. 1990 Oct;12(5):644-654. 3. Pedersen PM, Jrgensen HS, Nakayama H, Raaschou HO, Olsen TS..Orientation in the acute and chronic stroke patient: impact on ADL and social activities. The Copenhagen Stroke Study. Arch Phys Med Rehabil. 1996 Apr;77(4):336-339. 4. Wade DT, Skilbeck C, Hewer RL. Selected cognitive losses after stroke. Frequency, recovery and prognostic importance. Int Disabil Stud. 1989 JanMar;11(1):34-39. 5. Benson C, Lusardi P.Neurologic antecedents to patient falls. J Neurosci Nurs. 1995 Dec;27(6): 331-337. 6. Polly Laidler, Stroke Rehabilitation-structure and stratergy, 1st Edition, 1994: 99-114 7. Whyte J .Attention and arousal: basic science aspects. Arch Phys Med Rehabil. 1992 Oct;73(10):940-949. 8. Susan B. OSullivan, Thomas J. Schmitz, Physical Rehabilitation: Assessment & treatment, 4 th Edition: Jaypee Brothers, 2001: 961-99 9. Dascy Umphred, Neurological rehabilitation, 4th Edition:821-851 10. Schmist R, Motor Control and Learning: A behavioral emphasis (2nd Edition)Champaing, IL: Human Kinetic Publisher 11. Nashner LM (1989) Sensory, neuromuscular and biomechanical contributions to human balance. In: Proceedings of the American Physical Therapy Association Forum. Nashville. TN. pp. 5-12. 12. Roberta Newton. Review of tests of standing balance abilities. Brain Injury 1989; 3(4):335-43 1.
13. Nashler L: Evaluation of postural stability, movement and control. In Hasson(ed): Clinical exercise physiology, Philadelphia, CV Mosby, 1994 14. Lars Nyberg, Yngve Gustafson. Patient Falls in Stroke Rehabilitation: A Challenge to Rehabilitation Strategies. Stroke, 1995;26:838-42 15. Susan B. OSullivan, Thomas J. Schmitz, Physical Rehabilitation: Assessment & treatment, 4 th Edition: Jaypee Brothers, 2001:328-329 16. Medline plus, a service of the us national library of medicine and the national institute of health, 15th may, 2008 17. Pak R and Dombrovy ML: Stroke. In Good, DC and Couch JR(eds): Handbook of Neurorehabilitation. Marcel Dekker, Newyork, 1994:461 18. Armin F. Haerer. Visual Field Defects and the Prognosis of Stroke Patients, Stroke 1973; 4: 163-168 19. Sinclair R, A study examining sitting balance and the presence of attention deficit post-stroke, Msc Thesis, University of Southampton, UK, 1995. 20. WMA Declaration of Helsinki - Ethical Principles for Medical Research Involving Human Subjects. [59th WMA General Assembly Seoul, Korea, Oct 2008]. Available from: http://www.wma.net/en/ 30publications/10policies/b3/ 21. Sebstina A. Borges, Ona A. Vyas. Study addressing the impact of cognitive and perceptual deficits on sitting and standing balance following CVA. Journal of occupational therapy;33(1): april- july 2001. 22. Stapleton, T., Ashburn, A. and Stack, E. (2001) A pilot study of attention deficits, balance control and falls in the subacute stage following stroke. Clinical Rehabilitation;15(4):437- 444.
The effects of Therapeutic Application of Heat or Cold Followed by Static Stretch on Hamstring Flexibility Post Burn Contracture
Emad T. Ahmed1, Safa S. Abdelkarim2 Assistant Professor of Physical Therapy , Physical Therapy Department for Surgery, Faculty of Physical Therapy, Cairo University, Egypt, 2 Physical Therapist, Naser Hospital, Cairo , Egypt ABSTRACT Objective : The purpose of this study was to determine the best warming up modality prior to static stretching exercises to increase flexibility in post burn contracture of the hamstring muscle, as measured by knee extension range of motion. Materials and methods: Thirty male patients ranging in age from 18 to 27 years and who had decreased hamstring muscle flexibility as a result of partial thickness burn were classified into 3 equal groups 10 of each, Group (1): received 1 minutes of stretching exercise in addition to ultrasound , Group (2): received 1 minutes of stretching exercise in addition to cold application. And Group (3): received 1 minutes of sating stretching only. All groups received stretching exercises 5 days per week for 8 weeks. Measurements of knee extension range of motion were conducted before treatment, post 2 weeks of treatment, and after 4 weeks of treatment. Results: The one way analysis of variance was used to compare knee extension range of motion which revealed that both treatment group (ultrasound and cold application) had significant (P< 0.05) gains in knee extension ROM after 2 and 4 weeks post stretching exercises. Conclusion: The results of this study suggest that either deep hot or cold application in addition to stretching exercise is more effective than static stretching alone to improve a hamstring muscle. Keywords: : Burn, Contracture, Range of motion, Ultrasound, Cold application, Flexibility. INTRODUCTION Contractures are defined as an inability to perform full range of motion of a joint.1 They result from a combination of possible factors- limb positioning, duration of immobilization and muscle, soft tissue, and bony pathology. Individuals with burn injuries are at risk for developing contractures. Patients with burns often are immobilized, both globally, as a result of critical illness in the severely burned, and focally, as a result of the burn itself because of pain, splinting, and positioning. Burns, by definition, damage the skin and also may involve damage to the underlying soft tissue, muscle, and bone. All of these factors contribute to contracture formation in burn injury. Contractures place patients at risk for additional Corresponding author: Emad T.Ahmed Designations: Faculty of Physical Therapy, Cairo University, Cairo, Egypt Address: Taif, KSA, Box: 2425 medical problems and functional deficits. Contractures interfere with skin and graft healing. Functionally, contractures of the lower extremities interfere with transfers, seating, and ambulation. Contractures of the upper extremities may affect activities of daily living, such as grooming, dressing, eating, and bathing, as well as fine motor tasks.2,3 Ill treatment or inadequate splinting and rehabilitation after burn injuries inevitably result in debilitating post burn contractures that impair various functional abilities of the involved limb. Among these, hamstring post burn contracture remain a frequent problem due to difficulties of knee extension against the contractile evolution of the scar 4. Historically, clinicians have prescribed different static stretching techniques as a means of increasing flexibility 5. Research has shown static stretch to be effective in increasing the length of connective tissue6. Warren et al explored the effects of stretching on rat tail tendon6.They found that low-load, long duration
stretching of rat tail tendon was more effective in increasing rat tail tendon length than high load, short duration stretching6. Therapists often use deep heating modalities to increase tissue extensibility to allow for increased efficacy of stretching techniques. Wessling et a1 found that static stretch combined with ultrasound increased the extensibility of triceps surae muscle (measured by changes in dorsiflexion) more than static stretch alone 7. Laboratory studies also indicate that passive warming of the musculotendinous unit increases its extensibility 8.9. Noonan et al and Strickler et al interpreted their research as evidence that passive warming may decrease the possibility of strain injury secondary to extensibility changes 8.9. The basis for using cold in combination with stretching, like heat, is pain reduction and decreased muscle guarding. Cold may relieve pain by acting as a counterirritant10 The purpose of our study was to determine if the application of a superficial heating or cooling modality, followed by a 1-minute static stretch to the hamstring muscle, increases the efficacy of the hamstring stretch alone. Subjects material and method Subjects Patients treated from burn injuries at El-Hussein teaching hospital were randomly selected for participation in this study. This study eligibility required that patients be more than 18 years of age; 3 to 8 months after the occurrence of the burn injury; had unilateral scars across popliteal fossa of the knee and the percentage of burn did not exceed 20%, and had no history of other lower extremity pathology. Inclusion assessment to participate in the study, subjects must have exhibited unilateral tight hamstring muscles. Operationally defined as having greater than 30 degrees loss of knee extension . In addition, subjects who were not involved in any exercise activity at the start of the study had to agree to avoid lower extremity exercises and activities other than those prescribed by the research protocol. During the 8 weeks of training 20 male subjects, with age range from 18 to 32 years, met the established criteria and completed the study. Group assignment To ensure equal distribution of hamstring muscle contracture, the patients were stratified into three groups based on their degree of hamstring muscle
contracture. Patients assigned to group 1 (n=10 patients, age=23.80 years, and range=60.2) served as treatment group 1 and received deep heat in addition to static stretch for 1 minute. Patients assigned to group 2 (n=10 patients, age=24.30 years, and range=60.2) served as treatment group 2 and received cold in addition to static stretch for 1 minute. Patients assigned to group 3 (n=10 patients, age=24.30 years, and range=60.2) served as control group 3 and received stretch only for 1 minute. INSTRUMENTATION Measurement tools A double-arm (30.5 cm) clear plastic goniometer was used to measure knee extension ROM. Prior to data collection; we performed a pilot study to establish intratester reliability of measurements of knee extension ROM. A test-retest design was used on 10 subjects of similar hamstring contracture, with measurements taken week a part. Reliability was determined using an intraclass correlation coefficient. An ICC of 0.96 was considered appropriate for continuing the study. Treatment tools A sonopulse 434 ultrasound unit was used to administer the deep heat as warming up prior to stretching, on the other hand, Enraf nonius chilling unit C5 was used to deliver cold at temperature average from -12C to - 6C prior to stretch. Experimental procedure Measurement protocol Measurement of knee extension ROM was made with the subject lying supine with the opposite lower extremity extended and the lower extremity being measured positioned at 90 degrees of hip flexion. The greater trochanter and lateral epicondyle of the femur and the lateral malleolus were palpated and served as landmarks during measurement. We attempted to maintain hip flexion at 90 degrees while the tibia was moved into the terminal position of knee extension, which was defined as the point at which the subject reported feeling of discomfort. Zero degree was considered to be 90 degrees of knee flexion. The goniometric value was recorded. The measurement of knee extension ROM was considered to be an indirect measure of hamstring muscle flexibility, with hamstring muscle tightness being the purported cause of a lack of knee extension ROM. All subjects were measured on the same day and at the same time, before they had stretching for that day. Measurements were taken before
treatment, post 2 weeks of treatment and post 4 weeks of treatment. Treatment protocol Ultrasound treatments were performed using an sonopulse 434 ultrasound unit at a frequency of 1 MHz with an intensity of 1.5 W/cm2. A water based gel, maintained at room temperature, was used as a conducting medium. A template was placed over the musculotendinous junction of the hamstring muscle group to ensure that the treatment area remained at four times the effective radiating area of the transducer head. The principle investigator performed all treatments using the same ultrasound unit which had been recently calibrated. Each US treatment lasted seven minutes. If subjects complained of intense heat or any abnormal sensations, treatment was discontinued. The cold treatment consisted of a -12C gel pack wrapped in one layer of a wet terry cloth towel applied to the posterior thigh for 20 minutes. The stretch only group received no modality. All subjects were in a prone position for the duration of their treatments. At the end of 20 minutes, the hot or cold treatments were removed. All subjects then performed the static stretch to the hamstrings by the following method. In a long sitting
position, each subject rested the heel of the untreated lower extremity along the medial surface of the treated thigh. The subject then reached forward to grasp the ankle of the treated lower extremity. Each subject then performed one continuous stretch to pain tolerance, without bouncing, for 1 minute. DATA ANALYSIS The equivalence of treatment groups regarding the amount of knee flexion contractures prior to the study was checked by conducting one way analysis of variance on knee range of motion. Inferential analysis of the data obtained in this study was done via 2 X 3 analysis of variance experimental design for treatmentsby-treatments by subjects. For all statistical tests and all follow-up tests, the 0.05 level of probability was used. RESULTS The descriptive characteristics of the subjects in both treatment groups and control group are shown in table (1) There was no statistical difference between the two treatment groups and control group regarding the age, depth of burn, percentage of burn and the duration post burn.
Table (1): Descriptive characteristics of patients in the three groups .

Comparison Age in years s Depth of burn in millimeters Duration post burn in months % of burn G1 Mean SD 22.8802.064 2.5190.3644 4.1250.8345 16.3880.5463 G2 Mean +SD 22.7602.589 2.4880.3672 4.750 1.035 16.3750.9223 G3 Mean +SD 23.420 2.669 2.620 0.5714 4.3750.9161 16.5501.589 P value P>0.05 P>0.05 P>0.05 P>0.05 Significance NS NS NS NS
Table (2): Comparison between two treatment groups and control group mean results measured before the application of any treatment modality.
Comparison G1 Mean SD Sig. P-value 60.780 2.619 NS P>0.05 G2 61.620 1.844 Pre treatment measurement G1 60.780 2.619 NS P>0.05 G3 62.520 1.085 G2 61.620 1.844 NS P>0.05 G3 62.520 1.085
S= Significant, HS= Highly significant , NS= not significant
In the first treatment group (ultrasound and stretching), the mean values for knee extension were 60.7 degrees (SD = 2.619), for the pre-test measurement, 61.620 degrees (SD = 1.844), for the second treatment group i.e: cold application and
stretching, and 62.520 degrees (SD = 1.085) for control group i.e: stretching only. One way analysis of variance demonstrated no statistically significant difference between the two treatment groups and control group knee extension range of motion (P>0.05) table(2).
40 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 Table (3): Comparison between two treatment groups and control group mean results measured after 2 weeks of the application of any treatment modality.
Comparison G1 Mean SD Sig. P-value 73.450 2.061 S P<0.01 G2 70.190 1.996 Post (1) treatment measurement G1 73.450 2.061 HS P<0.001 G3 67.380 1.248 G2 70.190 1.996 S P<0.05 G3 67.380 1.248
In the first treatment group (ultrasound and stretching), the mean values for knee extension were 73.450 degrees (SD = 2.061), for the post(1) treatment measurement, 70.190 degrees (SD = 1.996), for the second treatment group i.e: cold application and stretching, and 67.380 degrees (SD = 1.248) for control
group i.e: stretching only. One way analysis of variance demonstrated a statistically significant difference between the two treatment groups and control group regarding knee extension range of motion (P<0.01) table(3).
Table (4): Comparison between two treatment groups and control group mean results measured after 2 weeks of the application of any treatment modality.
Comparison G1 Mean SD Sig. P-value 93.290 2.418 S P<0.001 G2 87.960 1.435 Post (2) treatment measurement G1 93.290 2.418 HS P<0.001 G3 84.830 1.760 G2 87.960 1.435 S P<0.05 G3 84.830 1.760
In the first treatment group (ultrasound and stretching), the mean values for knee extension were 93.290 degrees (SD = 2.418), for the post(2) treatment measurement, 87.960 degrees (SD = 1.435), for the second treatment group i.e: cold application and stretching, and 84.830 degrees (SD = 1.760) for control group i.e: stretching only. One way analysis of variance demonstrated a statistically significant difference between the two treatment groups and control group regarding knee extension range of motion (P<0.01) table(4). DISCUSSION Our study was designed to obtain a more thorough understanding of stretching protocols for increasing ROM and how the use of therapeutic physical agents can affect these protocols in the clinical setting. According to the data, in a treatment lasting 4 weeks or less, cold packs, or ultrasound prior to stretching or stretching alone achieved similar results in increasing knee extension ROM. The results of the current study support the findings of other studies that static stretching is effective in increasing hamstring length11,12.
The results indicated that either deep heating or cold application followed by static stretching for one minute was more effective in increasing knee extension ROM than static stretching alone for one minute after 3 to 8 months post burn contracture. These results goes hand in hand with those of Wessling et al13, who claimed that a significant increase in ankle dorsiflexion with the use of ultrasound combined with static stretch compared to static stretch alone. Ultrasound and other deep heating modalities are believed to cause collagen to become more extensible, thus increasing the efficacy of a stretch13,14.Fischer and Solomon suggest that heating of the skin reduces gamma motor neuron excitability 15 . This would decrease the sensitivity of muscle spindles, which may decrease muscle guarding. On the other hand, Brodowicz et al16 observed that ice application during stretching increased hamstring flexibility, whereas heat and static stretching was not effective. Cold may reduce muscle guarding by reducing the activity of the muscle spindles. Knuttsson and Mattsson suggest that superficial cooling can cause reduction in gamma motor neuron activity through the stimulation of skin receptors17. On the other hand , Newton found
the use of vapocoolants, in a spray and stretch technique, did not increase passive hip flexion in healthy adults18. CONCLUSION All experimental groups in this study produced increases in the extensibility of the hamstring muscle, resulting in increases in PROM when compared with the control group. The group receiving ultrasound prior to stretching obtained the greatest increases in knee extension PROM over a 4-week period. This study will allow clinicians more options in effectively increasing the extensibility of the hamstring muscles. In addition, the results of this study will permit the clinician the choice of a cost-effective treatment alternative in an era of more stringent reimbursement. ACKNOWLEDGEMENT We are indebted to Cairo University, Cairo, Egypt, Faculty of Physical Therapy, Department of Physical therapy for Surgery, for their permission to commencement the study in the El-Hussein Teaching Hospital / physiotherapy departments and to the participants. Conflict of interest We certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript. Source of funding This research received no specific grant from any funding agency in the public, commercial, or not / for profit sectors. Ethical clearance We certify that this study involving human subjects is in accordance with Helsinky declaration of 1975 as revised in 2000 and that it has been approved by the relevant ethical committee. REFERENCES 1. 2. Mosbys Dictionary. 6th ed. St. Louis: Mosby, Inc.; 2002. Palmieri TL, Petuskey K, Bagley A, et al. Alterations in functional movement after axillary burn scar contracture: a motion analysis study. J Burn Care Rehabil 2003;24:1048. Kowalske KJ, Voege JR, Cromes GF Jr., et al. The relationship between upper extremity contractures and functional outcome after burn injury (abstr). Proc Am Burn Assoc 1996;28:55.
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Pulsed Electromagnetic Therapy Improves Functional Recovery in Children with Erb's Palsy
Reda Sarhan1, Enas Elsayed2, Eman Samir Fayez2 Physical Therapy Department, Al-Hussien University Hospital, Al-Azhar University, 2Department of Physical Therapy for Neuromuscular Disorders & Surgery, Faculty of Physical Therapy, Cairo University, Egypt ABSTRACT Purpose: The purpose of the study was to evaluate the influence of pulsed electromagnetic field therapy (PEMFT) on functional recovery in Erb' palsy. Design: Randomized controlled trial. Subjects: Thirty patients were included (16 males and 14 females) with age ranged from six to twelve months (mean=7.31.1). Methods: Children were divided randomly into two equal groups, control and experimental. Both groups received a physiotherapy training program; in addition, the study group received PEMFT for 30 min. Treatment regimen was once a day, three times/ week for three months. Measurements of the affected upper extremity (length, girth and width, muscle strength and range of motion) were carried out before and after treatment. Results: There was significant improvement in most of the measured test parameters in the study group compared to those of the control group. Conclusion: Pulsed electromagnetic therapy, in conjunction with conventional therapy program, was effective in improving functional recovery in children with Erb's palsy. Keywords: Pulsed electromagnetic therapy, Brachial plexus injuries, Erb's palsy. INTRODUCTION Obstetric brachial plexus lesions (OBPLs) are typically caused by traction to the brachial plexus during labor. The incidence of OBPL is about 2 per 1000 births. Most commonly, the C5 and C6 spinal nerves are affected. The prognosis is generally considered to be good, but the percentage of children who have residual deficits may be as high as 20% to 30%1. The incidence ranges from 0.38 to 3 per 1000 live births in industrialized countries. The difference in incidence may depend on the type of obstetric care and the average birth weight of infants in different geographic regions .Improvements in obstetric technique have lowered the prevalence of obstetrical brachial plexus palsy to the range of 0.19-2.5 per 1000 2. The incidence of permanent impairment is 3-25% and the rate of recovery in the first few weeks is a good indicator of final outcome. Complete recovery is unlikely if no improvement is noted in the first two weeks of life 3.The neonatal injury is clinically classified according to the nerve roots involved. Injuries affecting the upper plexus(C5,C7 roots) or so-called Erbs injuries are dominant, compared to injuries in which the C8eT1 nerve roots are also affected 4. Children with BPL are at risk for developing complications such as progressive contractures, bony deformities, scoliosis and posterior shoulder dislocation5. Most infantile injuries to the brachial plexus predominantly involve the upper trunk (C5,6); the classic Erbs palsy which results from excessive lateral traction on the head away from the shoulder. The infant with upper plexus palsy (C5, 6, 7) keeps the arm adducted and internally rotated with the elbow extended, forearm pronated, wrist flexed and the hand in a fist. In the first hours of life, the hand also may appear flaccid but strength soon returns 5. Papazian and associates 6 reported that unfavorable functional outcome is related more often to aberrant reinnervation than to lack of reinnervation. Aberrant reinnervation is especially common in brachial plexus lesions secondary to the close proximity of the nerves involved.
The application of pulsed electro-magnetic field therapy (PEMFT) for treating specific medical problems such as arthritis, chronic pain syndromes, wound healing, insomnia, headache and others has steadily increased during the last decade7. Results from basic science research demonstrated certain biological effects of PEMFT that provide a rationale for investigating more potential clinical benefits. Human and animal organisms consist of a large number of cells which function electrically .These cells have rest potential that is necessary for normal cellular metabolism. Diseased or damaged cells have an altered rest potential. If the ions move into an area of pulsating magnetic fields, they will be influenced by the rhythm of the pulsation. The rest potential of the cell is proportional to the ion exchange occurring at the cell membrane. The ion exchange is also responsible for the oxygen utilization of the cell 8. Pulsating magnetic fields can dramatically influence the ion exchange at the cellular level and thereby greatly improve the oxygen utilization of diseased or damaged tissues. The deterioration of the oxygen utilization is known to be a problem in several medical branches, especially delayed healing. There are no contraindications to magnetic therapy except in cases of hemorrhage or where electrical implants are in use. Previous studies indicated that PEMF of proper frequency, intensity and duration provides beneficial effects in a wide variety of cellular processes and mechanisms9. In the field of nervous tissue injuries, previous studies found positive effects of PEMF therapy. Byers et al 10 reported that PEMF stimulation enhanced early regeneration of the transected facial nerve in rats. AIM OF THE STUDY The purpose of the study was to evaluate the effectiveness of PEMF in improving functional recovery of the affected upper extremity in patients with Erbs palsy. MATERIAL AND METHOD Thirty patients were included (sixteen boys and fourteen girls) suffering from Erbs palsy. Regarding the side of injury, there were 19 patients (57%) with right side and 11patients (33%) with left side. They were selected from different pediatrics out-patient clinics. The children were divided into two equal groups (control and study groups). Inclusion Criteria: All patients were between six to twelve months in age, asymmetry Erbs palsy was the sole reason for referral to the physical therapy out-patient clinic, onset of the injury was from
birth, all participants were having free passive ROM in all joints of the affected upper extremity, active movement score grades ranged from two to four. Exclusion Criteria: History of malignancy, inflammatory diseases or any surgical intervention of the affected upper extremity. Informed consent was obtained for all patients separately and signed by the parents of the patients. EVALUATION All children participated in one measurement session before and after the suggested period of treatment in warm environment with the affected arm undressed. The affected arm length, forearm and hand length (cm), arm and forearm girth (cm) were measured and recorded by means of tape measure. Range of motion of shoulder abduction and external rotation, elbow flexion and wrist extension was also evaluated by using goniometer. The paediatric physiotherapist facilitated maximal shoulder abduction and external rotation, elbow flexion, forearm supination and wrist extension of the affected upper extremity through play, and quantified them on the active movement scale and joint movement grading scale. TREATMENT The control group was assigned for conventional physical therapy exercise program consisting of positioning, facilitatory stimuli, functional strengthening exercises, passive range of motion exercises, stretching exercises, scapular mobilization, manipulative exercises and splinting. The study group was assigned for PEMF followed by the previously mentioned physical therapy program. During PEMF application, the patient was placed in the supine position and the affected arm was comfortably placed inside a closed pediatrics circuit coil, using PEMF device (EL0064 MAGNETO II). The device generated a pure magnetic field output signal that employed direct current with unidirectional biological frequencies 20 Hz and intensity 0.3 mT (0.03 mT=30 Gauss). Induction of treatment took place for 30 minutes. Treatment for both groups continued for three months, three sessions per week, each session lasted about one hour. Statistical Analysis Data was presented as mean and standard deviation. Paired t-test was used to analyze the data within each group and unpaired t- test was used to analyze the data between study and groups. The p-value was <0.05.
RESULTS Upper extremity length and girth The findings revealed significant increase in mean values of arm and forearm length, and arm and forearm
girth in the study group after treatment compared to that before treatment (p=0.0001, 0.01, 0.01, 0.0001 respectively). Moreover, a significant difference was shown between the study and control groups after treatment (table 1).
Table (1): Comparison between study and control groups regarding upper extremity length and girth mean values before and after treatment.
Test Parameters(cm) Control group Arm length Forearm length Arm girth Forearm girth 16.275.27 13.43333.28 16.302.10 14.032.33 Pre(MeanSD) Study group 15.334.53 12.933.19 15.552.1 13.652.30 t -0.4 -0.42 -0.69 -0.47 p 0.6 0.7 0.5 0.6 Control group 16.904.1 13.73333.06 16.703.51 14.332.60 Post(MeanSD) Study group 21.603.60 17.034.15 20.706.03 19.033.70 t 2.96 2.48 2.22 4.04 p 0.001 * 0.02 * 0.03 * 0.0001 *
Upper extremity muscle strength The results showed significant increase in mean values of strength of deltoid, external rotators, biceps brachii, supinator, and wrist flexors of the affected arm
in the study group after treatment compared to that before treatment (p= 0.001, 0.0001, 0.02, 0.0001 and 0.002 respectively). Additionally, a significant difference was shown between the study and control groups after treatment (table 2).
Table (2): Comparison between study and control groups regarding upper extremity muscle strength mean values before and after treatment.
Muscle Strength Control Deltoid External Rotators Biceps Brachii Supinator Wrist Extensors 3.000.84 2.600.74 3.000.93 2.530.83 3.670.49 Pre(MeanSD) Study 3.130.92 2.66670.72 3.130.91 2.670.72 3.670.49 t -0.33 -0.3 -0.44 -0.45 -1.5 p 0.77 0.77 0.66 0.7 0.1 Control 3.250.70 2.870.83 3.330.72 2.870.74 3.870.64 Post(MeanSD) Study 4.80.77 4.66670.70 4.130.1 4.400.91 4.60.5 t -4.05 -3.7 -2.24 -3.83 -2.94 p 0.0001 * 0.0001 * 0.04 * 0.0001 * 0.007 *
Upper extremity active ROM There was significant improvement in the mean values of active ROM of the affected upper extremity in
the study group after treatment compared to those before treatment (table 3).
Table (3): Comparison between mean values of active range of motion before and after treatment in the study and control groups
ROM (degrees) Shoulder abduction Post 0.68 0.34 t p 9.54 0.06 Pre 1.27 0.88 Shoulder external rotation Post 0.680.34 Pre 1.193 0.27 8.80 0.16 Post 0.63 0.32 Elbow flexion Pre 1.31 0.26 Forearm supination Post 0.65 0.33 -9.28 0.3 Pre 1.32 0.18 Wrist extension Post 1.13 0.3 Pre 1.67 0.19
-8.80 0.7
-2.62 0.002
DISCUSSION Obstetric brachial plexus palsy (OBPP) is a complication of childbirth, which is characterized by one or more nerve conduction blocks within the brachial plexus . These blocks range in severity and location within the plexus and primarily affect the childs ability
to move and effectively use their affected upper extremity 5. Thirty children with OBPP participated in the study. All were able to perform elbow and shoulder movements with gravity eliminated. Most of those children presented to the out-patient clinics with slightly
different degrees of injury and respond differently to therapeutic interventions. Experience in treating children teaches that children who present at six months of age with no signs of recovery generally are subjected to development of sequelae, including mild scapular winging, inability to fully supinate the forearm, limitation in shoulder abduction and forward flexion. In the current study, there was no need for electrophysiological monitoring or guide as muscle strength can be considered as an indicator for prognosis and recovery. This is supported by Yilmaz and coworkers 11 who compared magnetic resonance imaging (MRI), electrophysiologic studies, and muscle strength scoring in infants with BPP to determine which indicator provided the most accurate prognosis of the outcome at one year. They found that scoring of muscle strength (eg, elbow flexion; wrist, finger, and thumb extension) was the most reliable measure, with 94.8% confidence at 3 months. There have been few reports about the effect of PEMF therapy on muscle strength and functional activities in children with brachial plexus injuries (Erbs palsy). The results of the present study showed clearly the beneficial effects of PEMFT on improving muscle strength, range of motion and functional activities of the affected upper limb. These findings coincide with that of Zborowski et al12 who evaluated the effects of a low frequency electromagnetic field on fast axonal transport changes in speeds and densities of retrograde fast organelle transport in the rat sciatic nerve. Preparations were measured in vitro upon exposure to 15 and 50 Hz pulsed magnetic fields with peak intensities of 4.4 and 8.8 mT. They reported that strong effects were observed in myelinated axons. Such effects may eventually be used as part of a neuroprosthesis to noninvasively modify or couple to various parts of the nervous system. These findings also, are supported by Sharrard et al14who concluded that pulsed electromagnetic fields have encouraged healing of fractured bones and benefited re-anastomosis of peripheral nerves after transection. Many mechanisms could explain the improvement in children with Erbs palsy as biological stimulation by PEMF exposures can modify cellular functions in bone and nervous tissue, and evidence is accumulating that the regeneration capacity of the tissue may be affected6. For example, selective changes in levels of calcium , cyclic adenosine monophosphate, the synthesis of collagen and proteoglycans, DNA, and RNAhave been demonstrated in osseous, nervous, and mesenchymal tissue 12,13,15,16,17,18.
CONCLUSION The results of the present study showed that the main advantages of PEMFT are the enhancement and acceleration of the recovery of injured nerve tissue. Also, it indicates that PEMFT is a low-cost, non-invasive, non thermal method of physical therapy modalities and should be recognized as standard additional treatment for improving the functional recovery in patients with Erbs palsy. ACKNOWLEDGMENT The invaluable assistance of the paediatric physical therapists in the out patients clinics to the study are much appreciated REFERENCES 1. Martin TA and obestetric brachial plexus injuries.Neurosurg clin N Am.2009; 20, 1:14. 2. 3-Pollack RN, et al. Obstetrical brachial palsy: pathogenesis, risk factors, and prevention. Clin Obstet Gynecol 2000;43:236-46. 3. Gilbert WM, Nesbitt TS, Danielsen B. Associated factors in 1611 cases of brachial plexus injury. Obstet Gynecol. 1999; 93(4):536-40. 4. Else Spaargaren et al , Aspects of activities and participation of 7-8 year- old children with an obstetric brachial plexus injury ,European journal of pediatric neurology.2011; 1 5, 345-352. 5. Alphonso DT . Causes of Neonatal Brachial Plexus Palsy. Bull NYU Hosp Jt Dis. 2011;69: 11-16 6. Papazian O, Alfonso I, Yaylali I, Velez I, Jayakar P. Neurophysiological evaluation of children with traumatic radiculopathy, plexopathy, and peripheral neuropathy. Semin Pediatr Neurol. 2000; 7(1):26-35. 7. Marko S. Expanding Use of Pulsed Electromagnetic Field Therapies. Electromagn Biol Med. 2007; 26: 257-274 8. M. Cifra et al. Electromagnetic cellular interactions. Progress in Biophysics and Molecular Biology , 2011;105 : 223-246 9. R. Lightwood. The remedial electromagnetic field. J. Biomed. Eng. 1989, 1 I:429-436. 10. Byers J, Clark K, Thompson G. Effect of pulsed electromagnetic stimulation on facial nerve regeneration. Arch Otolaryngol Head Neck Surg. 1998;124(4):383-9. 11. Yilmaz K, Caliskan M, Oge E, Aydinli N, Tunaci M, Ozmen M. Clinical assessment, MRI, and EMG in congenital brachial plexus palsy. Pediatr Neurol. 1999; 21(4):705-10.
12. Zborowski M , Atkinson M , Lewandowski JJ , Jacobs G , Mitchell D , Breuer A, Nos Y. In vitro low frequency electromagnetic field effect on fast axonal transport. ASAIO Trans. 1988 JulSep;34(3):669-7. 13. Bassett CA, Chokshi HR, Hernandez E, Pawluk RJ, Strop M. The effect of pulsing electromagnetic fields on cellular calcium and calcification of nonunions. Brighton GT, Black J, Pollack SR. eds. Electrical Properties of Bone and Cartilage: Experimental Effects and Clinical Applications New York, NY Grune & Stratton Inc1979;427. 14. Sharrard WJ, Sutcliffe ML, Robson MJ, MacEachern AG. The treatment of fibrous nonunion fractures by pulsing electromagnetic stimulation. J Bone Joint Surg Br. 1982;64: 189-193.
15. +Fitton-Jackson S, Bassett CA. The response of skeletal tissues to pulsed magnetic fields. Richards RJ, Rajan KT.eds. Tissue Culture in Medical Research (International Symposium on Tissue Culture in Medical Research) .New York, NY Pergamon Press Inc1980; 21. 16. Eugene M.Goodman et al. Effects of Electromagnetic Fields on molecules and cells, International review of cytology.1995; I58:279-338. 17. Fitton-Jackson S, Farndale R. The influence of pulsed magnetic fields on skeletal tissue grown in organ culture. Trans Orthop Res Soc. 1981;6300+ 18. Shteyer A, Norton LA, Rodan GA. Electromagnetically induced DNA synthesis in calvaria cells. J Dent Res. 1980;59A:362.
Effectiveness of PNF Stretching and Self Stretching in Patients with Adhesive Capsulitis - A Comparative Study
Harshit Mehta1, Paras Joshi2, Hardik Trambadia3 Physiotherapist, Samarpan Orthopedic Hospital, Jamnagar, 2Lecturer, K K Sheth College of Physiotherapy, 3 Lecturer, Parul Institute of Physiotherapy, Vadodara ABSTRACT Background: Adhesive capsulitis of shoulder is characterized by insidious and progressive pain and loss of active and passive mobility of glenohumeral joint. In many physical therapy programs for subjects with adhesive capsulitis of shoulder mobilization techniques are an important part of the intervention. The purpose of this study is to compare the efficacy of PNF stretching techniques and Self stretching techniques in subjects with adhesive capsulitis. Objective: To compare the effectiveness of PNF stretching and self stretching in improving ROM, shoulder pain & disability index in patients with adhesive capsulitis. Method: 30 subjects diagnosed by an orthopedic surgeon as having adhesive capsulitis of shoulder joint and who showed a typical restriction of external rotation and abduction were selected. Subjects were randomly taken, divided into two groups each of 15 subjects. Group A: (n=15):- Treated with PNF stretching. Group B: (n=15):- Treated with self stretching. Analysis was based on ROM and Shoulder Pain and Disability Index (SPADI) sub scores and total scores. Outcome measures: The following outcome measures were measured at baseline, 2nd week and 4th week follow up. 1. Active ROM of shoulder External rotation and Abduction. 2. Shoulder pain and disability index (SPADI). Results: The ROM and SPADI percentage across baseline, 2nd week and 4th week follow up showed a significant improvement statistically in their mean scores within Group A and Group B. Statistically significant greater changes in score were found in PNF Stretching (Group A) for ROM and SPADI as compared to Self Stretching (Group B). Conclusion: The results indicate that PNF Stretching (Group A) and Self Stretching (Group B) are significantly effective in improving ROM and SPADI (sub scores and total scores). However PNF Stretching (Group A) appears to be more effective in improving glenohumeral joint mobility and reducing disability as compared to Self Stretching (Group B). Keywords: Adhesive Capsulitis, PNF Stretching, self stretching, SPADI. INTRODUCTION ADHESIVE CAPSULITIS is a common but poorly understood syndrome of painful shoulder stiffness.1 It is most common cause of pain & disability in shoulder in general population.2 Frozen shoulder syndrome was first describe by Duply in 1872. He used the term periarthritis scapula-humerale. In 1934 Codman used the term FROZEN SHOULDER first time to describe the condition.1 In 1945, Nevieser termed condition as ADHESIVE CAPSULITIS based on surgically explored cases of frozen shoulder finding absence of the glenohumeral synovial fluid as well as thickening & contraction of capsule which had become adherent to humeral head.3 The prevalence of frozen shoulder is 2% to 3% of general population it starts between age of 40- 70 years. It is more commonly seen in females than males.2 Currently adhesive capsulitis & frozen shoulder are the preferred terms and can be used interchangeably.4 Adhesive capsulitis has typically been classified into 2
forms, primary & secondary. In the primary form, no known precipitating factors can be identified, so it is also known as idiopathic type. The secondary form is associated with other illness or events such as some trauma or surgery.4 The classic frozen shoulder has 3 stages Stage 1: Painful stage or Freezing phase (Lasts for 2 to 9 months) 2, 6 Stage 2: Stiffness or Frozen phase (Lasts for 4 to 12 months) 2, 6 Stage 3: Thawing phase (Lasts for 6 to 9 months) 2, 6 Stage 1:- The freezing or painful stage, in which the patient has diffuse lateral shoulder pain begins gradually and insidiously. Pain is the main initial complaint. The pain is worse at night & exacerbated by lying on the affected side, is often associated with significant disability.2 Stage 2:- The stiff or frozen stage, in which stiffness with decreased range of motion predominates. Pain, though still present with extreme movement, subsides and loss of movement becomes the patients chief complaint. Ability to care for oneself and to work might be significantly affected, especially if the patients dominant arm is involved.2 Stage 3:- The thawing stage during which, exacerbations of pain still occur, often because of excessive activity. Gradually pain subsides and movement becomes almost normal. Five methods developed to improve flexibility have emerged: ballistic stretching, static stretching, proprioceptive neuromuscular facilitation stretching techniques (PNF), dynamic range of motion using active contraction and eccentric training.14 OBJECTIVES OF THE STUDY 1. To study the effectiveness of PNF stretching in improving ROM, shoulder pain and disability index in patients with adhesive capsulitis. 2. To study the effectiveness of self stretching in improving ROM, shoulder pain & disability index in patients with adhesive capsulitis.
3. To compare the effectiveness of PNF stretching and self stretching in improving ROM, shoulder pain & disability index in patients with adhesive capsulitis. HYPOTHESIS Null Hypothesis (H0) There is no significant difference between the effectiveness of PNF stretching and self stretching in improving ROM, shoulder pain and disability index in patients with adhesive capsulitis. Alternate Hypothesis (H1) There is a significant difference between the effectiveness of PNF stretching and self stretching in improving ROM, shoulder pain and disability index in patients with adhesive capsulitis. METHODOLOGY Study design: Experimental study. Inclusion criteria Symptomatic subjects between the age group of 4060 (both male and female). Subjects having stiff and painful shoulder for more than 1 month. Minimum 50 % of restriction in abduction and external rotation of shoulder joint. Unilateral involvement and stage 2 adhesive capsulitis. Exclusion criteria History of recent shoulder trauma in and around shoulder joint. Rotator cuff injuries or previous surgery Intrinsic glenohumeral pathology such as glenohumeral arthritis. Diabetic patients. Tools used for the study: Universal Goniometer Shoulder pain and disability index
Method of data collection The patients were evaluated using shoulder evaluation form. The patients were informed about the whole procedure, the treatment merits and demerits and a written consent were obtained from them for voluntary participation in the study. They were randomly divided in two Group A and Group B of 15 subjects each. The base line data of ROM of all the movements of shoulder was obtained using universal goniometer. The pain and disability data were obtained using SPADI to check for the functional outcome. The ROM and SPADI were taken at the baseline, after 2 weeks of the treatment and after 4 weeks on follow up. Study Duration: 4 weeks. Techniques of application Group A: PNF stretching. Starting position: Patient is in sitting position and therapist in sitting at the side of the patient. (PNF stretching) Therapist will passively move the shoulder joint in external rotation until the stretch begin to feel uncomfortable to the subject. Then subjects will be asked to perform a maximal isometric contraction for 6 seconds followed by 10 seconds of relaxation. During the 10 seconds of relaxation a tester slowly externally rotates the subjects shoulder joint, if the subjects still consider the stretch to be uncomfortable; it is kept as previous position. The subjects then perform 2 more 6 seconds maximal contraction (total 3 contractions) with 10 second relaxation period in between.
Same procedure is done to improve shoulder abduction. In this patient is in sitting position and therapist stands at the back of the patient on the affected side. Duration : It is given once in a day for 5 days in a week for 4 weeks. Group B: Self stretching. Starting position: Patient is in standing position. Subjects is asked to place the upper extremity on a firm surface at 90 of forward elevation and greater than 90 of horizontal abduction while turning the trunk in the opposite direction to improve the external rotation. Subjects is asked to pull the elbow overhead with the opposite arm to improve the abduction Duration : The stretching is given 3 times for 30 seconds and 10 second relaxation between 2 stretch 5 days in a week for 4 weeks. Both the groups were given short-wave diathermy before stretching procedure at the therapeutic frequency of 27.12 MHz for 10 to 15 min.13
Statistical Analysis Post hoc analysis (Bonferroni test) is used to compare the baseline, 15th day and 30th day scores of ROM and SPADI within Group A and Group B. Two way ANOVA test is used to compare the mean difference across the time periods (Baseline, 15th day and 30th day) between Group A and Group B. P value < 0.05 is taken up for statistical significance.
RESULTS
Table 1:-Multiple comparisons of ACTIVE EXTERNAL ROTATION scores across different periods within Group A and within Group B using post hoc analysis- Bonferroni test.
Period AER in Group A Baseline 2nd week AER inGroup B Baseline 2nd week Periods 2nd wk 4th wk 4th wk 2
nd
Mean -21.667 -31.733 -10.067 -14.400 -21.800 -7.400
Std. Error 2.065 1.850 .658 2.908 2.694 .466
p-value .000 .000 .000 .001 .000 .000
Level of significance HS at p < 0.01 HS at p < 0.01 HS at p < 0.01 HS at p < 0.01 HS at p < 0.01 HS at p < 0.01
wk
4th wk 4th wk
50 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 Table 2:- Multiple comparisons of ACTIVE ABDUCTION scores across different periods within Group A and within Group B using post hoc analysis- Bonferroni test.
Period AAB inGroup A Baseline 2nd week AAB inGroup B Baseline 2
nd
Periods 2nd wk 4 wk 4th wk 2nd wk 4th wk 4 wk

th th
Mean -38.200 -48.533 -10.333 -23.000 -31.600 -8.600
Std. Error 3.151 2.862 .779 2.556 2.124 1.125
p-value .000 .000 .000 .000 .000 .000
Level of significance HS at p < 0.01 HS at p < 0.01 HS at P < 0.01 HS at p < 0.01 HS at p < 0.01 HS at p < 0.01
week
Table 3:- Multiple comparisons of Total SPADI scores across different periods within Group A and within Group B using post hoc analysis- Bonferroni test.
Period Total SPADI in Group A Baseline 2nd week Total SPADI in Group B Baseline 2nd week Periods 2nd wk 4th wk 4th wk 2nd wk 4th wk 4th wk Mean 46.800 50.067 3.267 37.867 40.000 2.133 Std. Error 2.387 2.566 .330 1.612 1.721 .291 p-value .000 .000 .000 .000 .000 .000 Level of significance HS at p < 0.01 HS at p < 0.01 HS at P < 0.01 HS at p < 0.01 HS at p < 0.01 HS at p < 0.01
From the above Table 1, 2 & 3 multiple comparison of active external rotation, active abduction and total SPADI scores shows that difference is statistically significant from baseline to 2nd week and 2nd week to 4th week, but the difference from baseline to 2nd week and 2nd week to 4th week is significantly higher in group A than group B DISCUSSION Primary adhesive capsulitis affects 2% to 3% of the general population and is the main cause of shoulder pain and dysfunction in individuals aged 40 to 70 years. The etiology and pathology of this syndrome remains enigmatic. The physical therapy is commonly prescribed for this condition. For predominant adhesive capsulitis and associated soft tissue tightness, mobilizations techniques, PNF stretching techniques have been most commonly address in clinical treatment approaches and research studies. The result of present study examined the efficacy of PNF stretching to self stretching in subjects with adhesive capsulitis both within groups and between groups. 30 subjects are taken who were diagnosed as adhesive capsulitis of shoulder by orthopedic and were normally assigned to either PNF stretching (Group A) or Self stretching (Group B). PNF stretching utilizing a shortening contraction of the opposing muscle to the place the target muscle on stretch, followed by a static contraction of the target muscle, The inclusion of a shortening contraction of
the opposing muscle appears to have the greatest impact on enhancing ROM.17 Some researchers have found that the alteration of stretch perception plays a important role in success of contract relax PNF stretching and contract relax stretch are recommended to get greatest ROM gain.7 PNF stretching and soft tissue mobilization is the application of specific and progressive forces with the intent of promoting changes in the myofascia, allowing for elongation of shortened structures. PNF stretching combined with soft tissue mobilization and both are used to effect changes in myofascial length. Contract relax PNF procedures have been shown to be effective in increasing ROM. The immediate effects of PNF stretching and soft tissue mobilization interventions were demonstrated in a another study using healthy subjects, where improvements were made in hip ROM.8 One study done on overhand athletes for the effects of proprioceptive neuromuscular facilitation shows that Contract relax and hold relax PNF stretching techniques are effective in increasing ROM in overhand athletes.9 Stretching import physiological changes such as remodeling of elastin and collagen molecules, these changes may be associated with alterations on the muscle tendon units and fascia, caused by increase on tissue elasticity. In other words, the range of motion would be influenced by the increase on the length of the tissue.10
In one study researchers have concluded that PNF stretching produce more tension in muscle and also provide greatest potential for muscle lengthening than static stretching. In another study researchers have concluded that PNF stretching shows greater ROM gains than static stretching.11 In one study researchers concluded that 30 seconds static stretch was more effective then dynamic ROM training for improving ROM. Given the fact that 30 seconds static stretch increase ROM more than 2 times that of dynamic ROM training.12 Limitations 1. In present study only 2 ROM (External Rotation and Abduction) are taken in outcome measures. 2. In this study there is no control group is present. 3. Its a short duration study as study duration is 4 weeks. 4. In the present study the sample size is 30 that are small. CONCLUSION PNF Stretching and Self stretching produced significant improvement in ROM and shoulder Pain and Disability (SPADI Sub scores and Total scores) values in patients with adhesive capsulitis when applied individually. However PNF Stretching showed a significant improvement in ROM and shoulder Pain and Disability Index (SPADI sub scores and total scores), when compared to Self Stretching in individuals with adhesive capsulitis. REFERENCES Giggs SM, Ahm A and Green A. Idiopathic Adhesive Capsulitis. A Prospective Functional Out Come, Study of non operative Treatment. J Bone Joint Surg, Vol. 82, Oct-2000, 1398-1407. H.A. Anton. Frozen Shoulder. Can Fam Physician 1993;39:1773-1777. R.A Donatelli, Physical Therapy of the Shoulder, 3rd edition, CHARCHILL LIVINGSTONE. Pp 257- 278.
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Rick Sandor. Adhesive Capsulitis; Optimal Treatment Of Frozen Shoulder. THE PHYSICIAN AND SPORTSMEDICINE, Vol.28, No.9, SEP-200. Henricus M Vermeulen, Wim R Obermann, Bart J Burger, Gea J Kok, Piet M Rozing, CorneliaHMvan den Ende. End- Range Mobilization techniques in Adhesive Capsulitis of the Shoulder joint: A Multiple- Subject Case Report. S.B.Brotzman, K.E.Wilk, Clinical Orthopaedic Rehabilitation, 2nd edition, Shoulder Injuries, page 125-250. Mitchell UH, Myrer JW, Hopkins JT, Hunter I, Feland JB, Hilton SC acute stretch perception alteration contributes to the success of the PNF contract-relax stretch. J Sports Rehab. May 2007; 16(2):85-92. Godges JJ, Matson-Bell M ,Thorpe D; Shah D, The immediate effect of soft tissue mobilization with PNF on gleno humeral external rotation & overhead reach; J Orthop Sports Phys Ther, Dec 2003; 33 (12) : 713-718. Decico PV, Fisher MM, The effects of PNF stretching on shoulder ROM in overhead athletes. J Sports Med Phy Fitness, Jun 2005; 45(2):183-187. Lus Viveiros, Marcos Doederlein Polito, Roberto Simo and Paulo Farinatti Immediate and late responses of flexibility in the shoulder extension in relation to the number of series and stretching duration. Rev Bras Med Esporte. Nov/Dec 2004; Vol 10, N 6:464-467. Funk DC, Swank AM, Mikla BM, Fagan TA, Farr BK. Impact of prior exercise on hamstring flexibility: a comparison of proprioceptive neuromuscular facilitation and static stretching. J Strength Cond Res. 2003 Aug; 17(3):489-92. Bandy WD, Irion JM, Briggler M. The effect of time and frequency of static stretching on flexibility of the hamstring muscles. Phys Thera. 1998 Mar; 78(3):321-2. Leung MS, Cheing GL. Effects of deep and superficial heating in the management of frozen shoulder. J. Rehabil Med. 2008 Feb; 40(2):145-50. Murphy DR.A critical looks at static stretching; are we doing our patient harm? Chriopract sport med, 1991; 5:67-70.
Effect of Modified Hold-Relax and Active Warm-Up on Hamstring Flexibility

Swapnil U Ramteke1, Hashim Ahmed2,Virenderpal Singh3, Piyush Singh4 Research Student, Jamia Hamdard, New Delhi, 2Head department of Physiotherapy, Shreya Hospital, Shalimar Garden Extension, Ghaziabad, U.P, 3Head of Department of Physiotherapy, Mata Gujri Charitable Hospital, New Delhi , 3Assistant Profesor, Indian Spinal Injury Center of Rehabilitation, New Delhi ABSTRACT Objective: The study aimed to find out how long the flexibility lasted after a one time modified hold relax stretching & active warm up and its comparison with modified hold relax technique alone. Design: Pre-test, Post-test comparative study with repeated measures. Setting: Mata Gujri Fitness center, Kailash colony, New Delhi. Method: 30 male subjects were randomly assigned to two groups; Group A- Modified Hold Relax: On the 15 subjects a one time modified hold-relax stretching was performed. Group B: 15 male subjects completed an active warm up on treadmill followed by modified hold relax stretching. The pre stretch measurement was taken by Active Knee Extension (AKE) test. After both the interventions the post stretch measurements were taken at following intervals, 0, 6, 12, 18, 24 min, respectively. Results: A significant improvement in ROM was observed when post stretch measurements were compared to pre test in both groups respectively. However, the flexibility lasted for longer duration that is 12 min in group B when compared to group A that is 6 min. Conclusion: Both the methods are equally effective to improve the range of motion. But the improved ranges can be maintained for larger duration when active warm up was implemented prior to Modified hold relax stretching. Keywords: P.N.F, Active Warm up, AKE, Flexibility, INTRODUCTION Flexibility is an essential component for normal biomechanical functioning in sports. The length of the muscle tissue is thought to play an important role in efficacy and effectiveness of human movement. 1 Theoretically, a more flexible muscle-tendon unit should be more compliant to external loads, less stiff, and less likely to be injured.2 In sports even small change in performance can have a drastic effect on the outcome of an event. Besides hamstrings strains in the athletic population, hamstrings tightness as shown in some studies have shown that reduced hamstring flexibility is considered to be one of the leading cause/risk factor for patellar tendinopathy and patellofemoral pain etc..3 In the ACSMs guidelines,a clinical evidence for relationship between hamstring inflexibility with avulsion fractures of ischial tuberosity ,muscle strain, low back ache and increased sway back or round back posture has been mentioned. 4 Proprioceptive neuromuscular Facilitation (PNF) exercises are designed to promote the neuromuscular response of the proprioceptors.There exists a limited data regarding the lasting effects of increased ROM post stretching. The duration of increased flexibility in the previous research conducted by De pino et al, after one time static stretching was found to be of 3 minutes, further Spernoga et al carried out similar study in which, after one time modified hold relax lasting effects remained for 6 minutes, but this is a very short span of time, till date limited studies have carried out to improve the lasting effects. 5, 6. Hamstring flexibility has been measured by active knee extension test, passive knee
extension test, the sit and reach test and the assessment of hip flexion. Range following the straight leg raise, however reliability of these methods has not been demonstrated. An active knee extension test is however a reliable method for assessment of hamstrings.7 Warm up consists of active or passive warming of body tissues in preparation of physical activity. 8. There is a wide spread belief that a warm up contributes to improved athletic performance.9 Active warm up involves exercise and is likely to induce greater metabolic and cardiovascular changes than passive warm up.10 To our knowledge no specifically warm up oriented studies with regards to modified P.N.F hold relax technique has been carried out to assess the lasting effects after a specific warm up intensity. Thus present study aimed to extract the information that for how much duration the flexibility would be retained after a warm up and modified hold relax technique. In many clinical situations, patients may be seen by practitioners once or twice a week, or even less commonly in non-acute situations. It is therefore important to examine whether modified hold relax stretching produce either a greater or longer lasting effect on range of motion. The objective of this study was to investigate whether the application of a single session of modified hold relax was more effective, and has longer lasting effect, than a single session of modified hold relax stretching with warm up on the extensibility of the hamstring muscles measured by AKE over 6 different time interval (pre-treatment, immediately, 6, 12, 18 and 24 minutes) using goniometer. METHOD The 30 subjects were randomly allotted to Two groups viz group A- Modified hold relax ,& Group B active warm up and modified hold relax. STUDY DESIGN Pre test post test design with comparison in the two groups with repeated measures. Instrumentation Goniometer, Treadmill (Sports Art Fitness), Stop watch. Procedure In prestretch measurements, subjects in both the groups performed a total of 6 AKEs with a 60second rest period between repetitions. The sixth AKE was recorded as the prestretch measurement. For Post stretch Measurement : AKE measurement were taken
at 0 minutes (immediately) and at 6, 12, 18, and 24 minutes after the final stretch in the group A The group B underwent the same post stretch measurement protocol immediately after performing warm up on a treadmill for 5 minutes followed by stretching. The measurement of the angle of knee joint ROM was recorded .The deficit (tightness) was calculated by subtracting the available range from the full range.5 For each stretch, the investigator passively stretched the hamstrings until the subject first reported a mild stretch sensation and that position was held for 7 seconds. Next, the subjects were asked to perform maximal isometric contractions of the hamstrings for 7 seconds by attempting to push their leg back toward the table against the resistance of the investigator.5 after the contraction, the subjects were instructed to relax for 5 seconds. The investigator then passively stretched the muscle until a mild stretch sensation was reported. The stretch was held for another 7 seconds. This sequence was repeated 5 times on each subject in these experimental groups.5 Group B- Active Warm up and Modified hold Relax Maximal heart rate was calculated by the formula, M.H.R=220-age. The difference between maximum heart rate and resting heart rate is known as heart rate reserve(HRR). Target heart rate = (HRR fraction) (HR max HR at rest) +HR rest .The intensity fraction of HRR was selected at 60 %. As per the ACSMs position stand this percentage represents lower intensity values enough to produce the adequate training effects for cardio respiratory fitness of warm up. 11.
Fig.1: The Modified hold relax stretching technique.
Subject characteristics The subjects had following characteristics as mean and standard deviations values: Group A (Age = 23.00 1.73) (Height=166.40, 5.72) (Weight= 62.80 6.75)(BMI= 22.672.16) GroupB (Age = 22.601.29) (Height=161.86, 9.69)( Weight= 61.60 6.21)(BMI= 23.313.49)
Table 1.Active Knee Extension Measurements in Group A and Group B
Time intvl Prestretch 0 6 12 18 24 Group A Mean 39.26 31.13 33.20 36.06 36.93 38.13 s.d 3.76 3.75 3.87 3.36 3.80 3.48 Group B Mean 38.66 28.73 31.20 34.20 35.60 37.46 s.d 4.23 3.86 3.74 4.34 4.11 4.65
Fig. 2: The subject performing active warm up on the treadmill under the supervision.
DATA ANALYSIS The alpha level of pd 0.05 was accepted as significant for all analyses. Mean values and their standard deviations were calculated for each variable. The one way ANOVA (analysis of variance) was carried for both the groups to compare the ROM within each groups to pre stretch measurements. A t-test was performed to compare ROM within both the groups. The data was further analyzed by Dunnets post hoc test. RESULTS The ONE way analysis of variance revealed a significant difference between pretest and post test ROM measurements within groups respectively. However a Dunnets post hoc analysis indicated that a significant (p<0.05) increase in hamstring flexibility was maintained in modified hold relax group for 6 min after stretching protocol. Similarly increase in hamstring flexibility was maintained in Active warm up & Modified hold relax group for upto 12 min.
Pre Test 0 min 6 min 12 min 18 min 24 min
Figure.3: Comparison between pre-test and post-test value of range of motion between the groups.
Table.2: Between Group Comparison of Range of Motion using t and p values

Time period t-test for Equality of Means t 0.41 1.72 1.43 1.31 0.92 0.44 p-value 0.68 0.09 0.16 0.19 0.36 0.66
The subjects had following characteristics as mean and standard deviations values:
Group A (Age = 23.00 1.73) (Height=166.40, 5.72) (Weight= 62.80 6.75)(BMI= 22.672.16) GroupB (Age = 22.601.29) (Height=161.86, 9.69)( Weight= 61.60 6.21)(BMI= 23.313.49)
Table.3: Dunnett Post hoc analysis for comparing group B
Post Treatment 0 min 6 min 12 min 18 min 24 min Pre treatment Pre treatment Pre treatment Pre treatment Pre treatment Pre treatment Mean Difference (I-J) -9.93 -7.46 -4.46 -3.06 -1.20 pvalue 0.000 0.000 0.019 0.172 0.896
The musculotendinous unit deforms or lengthens as it is being stretched and goes through elastic and then plastic deformation before completely rupturing. Our results suggest that a single session of hold-relax stretching does not deform tissues enough to produce a permanent change (i.e., a plastic deformation in the musculotendinous unit). Therefore, the temporary improvement in hamstring flexibility may be attributed to changes in the elastic region caused by a single session of hold-relax stretching.5 Thixotropic Properties Thixotropy is the property of a tissue to become more liquid after motion and return to a stiffer, gel like state at rest. The thixotropic property of muscle is thought to result from an increase in the number of stable bonds between actin and myosin filaments when the muscle is at rest. Hence, the stiffness of muscle increases. Because we asked our subjects to lie still in between the readings, the thixotropic properties of muscle may have played a part in reducing the time that hamstring flexibility was increased. A linear relationship exists between the time a muscle remains still and the stiffness of that muscle in response to a stretch, and indeed, flexibility decreased in both groups as time passed .However, with activity, the muscle becomes more fluid-like because the stable bonds are broken or are prevented from forming. Based on thixotropic properties, we would expect the temporary increase in flexibility to bemaintained during periods of activity and to decrease during periods of inactivity. The present study revealed that there was no statically significant difference in ROM gains in both the groups. This shows that there is no extra improvement/change in ROM when the modified hold relax stretching was performed after the warm up. This findings are similar to that of Cornelius et al in which they concluded that effective increases in tissue length were not affected by warm up when a modified hold relax technique was used.27 In the present study, flexibility lasted for larger duration i.e. 12 minutes in Group B (modified hold relax and active warm up) which may be due to the various factors. These findings are similar to that of various studies conducted by Cornelius which stated that raised tissue temperature, coupled with stretch, would result
DISCUSSION Various studies have been conducted in the past to assess the effects of various interventions on improving hamstrings flexibility. However limited studies have been performed which evaluated the lasting effects.5,6,12 These recently conducted studies on checking acute effects of stretching revealed that the flexibility would last for 3 min after static stretching & for upto 6 min after one time modified hold relax stretching. These lasting effecs were present for very less duration. The relatively short time of increased hamstring flexibility may be due to several factors The most prominent are the viscoelastic, thixotropic, and neural properties of the musculotendinous unit. Neural properties The proposed neural inhibition reduces reflex activity, which then promotes greater relaxation and decreases resistance to stretch, and hence greater range of movement 13 moreover, other research has found PNF techniques to promote greater relaxation.14 Viscoelastic properties Previous researchers have attempted to explain improvements in flexibility with viscoelastic properties, overcoming the stretch reflex, or increasing the stretch tolerance23. Musculotendinous units function in a viscoelastic manner, and, therefore, have the properties of creep and stress relaxation. Creep is characterized by the lengthening of muscle tissue due to an applied fixed load. Stress relaxation is characterized by the decrease in force over time necessary to hold a tissue at a particular length.
in effective tissue elongation and longer lasting flexibility.27 However; these studies did not measured lasting effects. Influence of active warm up An increase in intramuscular tissue temperature has a beneficial effect on ability of collagen and the myotendinous junction to deform. The effect of temperature must also be considered in relation to the innervations of the muscle tendon unit. There are reports in the literature that sensitivity of GTO to sustained stretch is increased with increase in temperature and that the GTOs sensitivity to tension is inversely correlated with the mechanical stiffness of the musculotendinous structure in which it lies. Possible effects of warm up due to elevated temperatures are decreased resistance of muscles and joints, Greater release of oxygen from haemoglobin and myoglobin,Speeding of metabolic reactions, Increased, nerve conduction rate, Increased thermoregulatory strain. These all factors would have played an important role in improvement of the flexibility for group B by reducing the resistance to stretch. 28 CONCLUSIONS The result of our study leads to conclude that both the techniques were equally effective for improving ROM acutely. The important finding from this study was that if subject specific active warm up was performed prior to modified hold relax stretching ,the flexibility would last for about double the duration ,than that of modified hold relax technique. REFERENCES 1. Maximal Length and Resistance to Passive Stretch of Short Hamstring Muscles Volume 14 Number 6 December 1991 JOSPT,250-55. Magnusson SP, Simonsen EB, Aagaard P, Gleim GW, McHugh MP, and Kjaer M. Viscoelastic response to repeated static stretching in the human hamstring muscle. Scand J Med Sci Sports 5: 342347, 1995 Hopper D, 2005, S Deacon, S Das, A Jain, D Riddell, T Hall, K Briffa ,Dynamic soft tissue mobilization increases hamstring flexibility in healthy male subjects, Br J Sports Med 2005;39:594598.
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ACSMs guidelines,1997.Exercise testing and Prescription,Lippincott Wilkins & Williams , 1997 page13- 19. Spernoga S.G , Timothy L. Uhl, Brent L. Arnold, and Bruce M. Gansneder Duration of Maintained Hamstring Flexibility After a One-Time, Modified Hold-Relax Stretching Protocol ,J Athl Train. 2001 JanMar; 36(1): 4448. DePino G.M,2000, Duration of Maintained Hamstring Flexibility After Cessation of an Acute Static Stretching Protocol Journal of Athletic Training 2000;35(1):5659 Gajdosik R,1983,Hamstring Muscle Tightness Reliability of an Active-Knee-Extension Test Volume 63 / Number 7, July 1983,1085-1088 Knudson D ,2005, NSCA Guidelines, Warm up & Flexibility , LWW,166-181. Bishop, 2003 Warm Up II ,Performance Changes Following Active Warm Up and How to Structure the Warm Up, Sports Med 2003; 33 (7): 483-498 Bishop D, 2003 Warm Up I ,Potential Mechanisms and the Effects of Passive Warm Up on Exercise Performance, Sports Med 2003; 33 (6): 439-454. ACSM Position Stand on The Recommended Quantity and Quality of Exercise for Developing and Maintaining Cardiorespiratory and Muscular Fitness, and Flexibility in Adults. Med. Sci. Sports Exerc., Vol. 30, No. 6, pp. 975991, 1998. Draper D.O.2002;The Carry-Over Effects of Diathermy and Stretching in Developing Hamstring Flexibility ,Journal of Athletic Training 2002;37(1):374 Hutton R S 1993 Neuromuscular basis of stretching exercises. In: Komi P V (ed). Strength and power in sport, 1st edn, Vol 1. Blackwell Scientic Publications, Oxford, pp 29-38;cross refPhysical Therapy in Sport (2001) 2, 186-193. Etnyre B R, Abraham L D 1986b H-reflex changes during static stretching and two variations of PNF techniques J Athl Train. 2001 JanMar; 36(1): 4448. Tanigawa MC. Comparison of the hold-relax procedure and passive mobilization on increasing muscle length. Phys Ther .1972; 52 (7): 725-35 Markos P.D.Ipsilateral & contra lateral effects of PNF techniques on hip motion and electromyographic activity. Phys Ther 1979; 59 (11): 1366-1373 Katz R, Penicaud A, Rossi A. Reciprocal Ia inhibition between elbow flexors and extensors in the human. J Physiol 1991; 437(1): 269-86
18. Day BL, Marsden CD, Obeso JA, et al. Reciprocal inhibition between the muscles of the human forearm. J Physiol 1984; 349 (1): 519-34 19. Etnyre BR, Abraham LD. Gains in range of ankle dorsiflexion using three popular stretching techniques. Am J Phys Med pas1986; 65 (4): 189-96 20. Osternig LR, Roberston RN, Troxel RK, Muscle activation during proprioceptive neuromuscular facilitation (PNF) stretching techniques. Am J Phys Med 1987; 66 (5): 298-307 21. Moore MA,1980, Hutton RS. Electromyographic investigation of muscle stretching techniques. Med Sci Sports Exerc 1980; 12(5): 322-9 22. Osternig LR,1990, Roberston RN, Troxel RK, et al Differential responses to proprioceptive neuromuscular facilitation (PNF) stretch techniques. Med Sci Sports Exerc 1990; 22 (1): 106-1011 23. Garrett, WE. Muscle strain injuries: Clinical and basic aspects. Med. Sci Sports Exerc. 22:436-443. 1990
24. Magnusson SP, Simonsen EB, Aagard P, et al. Mechanical and physiological responses to stretching with and without preisometric contraction in human skeletal muscle. Arch Phys Med Rehabil 1996; 77: 373-8 25. Magnusson SP. Passive properties of human skeletal muscle during stretching maneuvers. Scand J Med Sci Sports 1998; 8: 65-77 26. Halbertsma JP, Goeken LN. Stretching exercises: effect on passive extensibility and stiffness in short hamstrings of healthy subjects. Arch Phys Med Rehabil 1994; 75: 976-81 27. CorneliusW.L,1992 ,The Effects of a Warm -up on Acute Hip Joint Flexibility Using a Modified PNF Stretching technique.,1992, Journal of athletic Training . volume 27, number 2,112-114 28. McCardle ,Katch and Katch, 2001 , special aids to exercise training and performance ,Exercise physiology, 5 th edition , Lippincott wilkins and Williams, 574-575.
A Comparative Study of effectiveness between Superficial Heat and Deep Heat along with Static Stretching to Improve the Plantar Flexors Flexibility in Females Wearing High Heel Foot Wears
Hasmukh Patel1, Dhaval Desai2, Harshit Soni2, Komal Soni2, Chintan Shah2 1 Clinical Therapist, U. N. Mehta Institute of Cardiology & Research Centre, Ahmedabad. 2 Lecturer, SPB Physiotherapy College, Surat ABSTRACT Background: Lower extremity overuse injuries commonly occurs due to decreased flexibility of plantar flexor muscles in females wearing high heeled foot wears. Plantar flexors shortening are treated by various physiotherapeutic techniques. Superficial heat (moist heat) and Deep heat (ultra sound) along with static stretching are treatment techniques used in physiotherapy. Objective: To compare the effectiveness of superficial heat and Deep heat in combination with static stretching in improving the plantar flexors flexibility in females wearing high heeled footwears. Method: The study included a sample of 40 individuals those who were wearing high heel > 2 inch. Out of that 20 individuals were in superficial heating group (group A) where moist heat was administered for 15 minutes to Achilles tendon, and remaining 20 individuals were in deep heating group (group B) where continuous ultrasound with frequency of 1 MHz at an intensity of 1.5 W/Cm2 was administered for 7 minutes to the Achilles tendon. Both the groups received 30 seconds of static stretch with 4 repetitions performed 5 times per week. The duration of entire study was 3 weeks and both the group received 1 session per day. Analysis was based on the Goniometer test score. Result: Both the group A and group B showed improvement in ankle ROM postintervention when compared with preintervention measurement and 't'calculated value for pre-postintervention measures was statistically significant as it was above the 't' tabulated value. Moreover, MeanSD of pre-post difference in right ankle dorsiflexion ROM for group A was 2.901.37 and for group B was 4.250.85 and MeanSD of pre-post difference in left ankle dorsiflexion ROM for group A was 3.601.04 and for group B was 4.350.74. 't'calculated value for pre-post ROM difference was statistically significant as it was above the 't' tabulated value of 1.96. Interpretation & Conclusion: There was significant difference between the two groups. In conclusion both the treatment programs are highly significant and effective in improving the ankle joint ROM, but ultrasound with deep heating property was found to be more superior as compared to moist heat pack with superficial heating property in improving plantar flexors flexibility in females wearing high heel foot wears. Keywords: Flexibility, Ultrasound Therapy, Moist heat, Static Stretching. INTRODUCTION Flexibility as defined by Gummerson1 is The absolute range of movement in a joint or series of joints that is attainable in a momentary effort with the help of a partner or a piece of equipment. Corresponding author: Hasmukh Patel D-3 Kalyan Kunj, Radhaswami Road, Ranip, Ahmedabad, Gujarat, India E-mail: hasmukhphysio@gmail.com The different types of flexibility according to Kurz are: 1) Dynamic flexibility 2) Static-active flexibility 3) Static-passive flexibility Tightness is a nonspecific term referring to mild shortening of a healthy musculotendineous unit. In the human body some muscle or a muscle group gets tightness due to lack of proper exercise.2 The plantarflexor muscles play an important role in the gait cycle
and in postural control. Lack of extensibility in this muscle group may cause or be related to decreases in ankle dorsiflexion, and it has also been hypothesized to contribute to Achilles tendinitis, shin splints,3 plantar fasciitis,4 and muscle strains.5 Use of high heeled footwear has become a common trend nowadays. Biomechanical problems which seem to be associated with long term use of such foot wears results in shin pain, ankle sprain and altered gait pattern.6 According to the American Orthopedic Foot and Ankle Society, heel > 2 inches are consider as high which creates three to six times more stress on the front of the foot than a shoe with a modest one-inch heel, and can lead to bunions, heel pain, toe deformities, shortened Achilles tendons, and Back Pain. 7 AL DALI Waleed et al. confirmed significant reduction in calf flexibility and ankle dorsiflexion range of motion (ROM) in 80 healthy college female students wearing high heeled shoes.8 Many therapeutic maneuvers like different stretching techniques namely static stretching, ballistic stretching, PNF stretching and cyclic stretching are useful to increase ROM by enhancing soft tissue extensibility. Worrell TW demonstrated significant increase in ankle dorsiflexion ROM in 11 female and 8 male subjects who received 20 seconds of calf stretching repeated over 10 sessions followed by 10 close kinetic chain gastronemius/soleus stretching sessions.9 Heating modalities used in clinical setup for enhancing flexibility of muscle and promoting relaxation are briefly divided into superficial and deep heating modalities. Ultrasound, SWD and MWD fall in the category of deep heating modalities. David Draper evaluated tissue temperature rise during ultrasound treatment in 20 males and concluded that application of continuous ultrasound with 1MHz frequency and 1.5 W/cm2 intensity at the medial gastronemius muscle for 10 minutes in humans raised the mean temperature to 40.3 C, which was an increase of 4.9 C.10 Moist pack, IRR, Wax, etc fall in the category of superficial heating modalities. Funk D found that 20 minute moist heat application produced significantly more hamstring flexibility than 30 seconds of static stretching.11 Individual studies have been done on Superficial heat combined with static stretching and Deep heat combined with static stretching for improving flexibility of plantar flexors muscles. But no study has been done
comparing the efficacy of these two treatment techniques, which signifies the need of the present study. The aims and objectives of the study were; 1. To evaluate the effectiveness of superficial heat with Static Stretching towards improving plantar flexors flexibility in females wearing high heel footwears. 2. To evaluate the effectiveness of Deep heat with Static Stretching towards improving plantar flexors flexibility in females wearing high heel footwears. 3. To compare the effectiveness amongst the two groups of females who were administered the above mentioned therapies. METHODOLOGY Study design: Cohort Comparative Study Sample size: 40 individuals Sampling method: Randomized sampling Study Setting: Shree Devi College of Physiotherapy, Mangalore Inclusion criteria 1. Female wearing high heel footwears >2 Inches. 2. Age: between 18 years to 30 years. 3. Individual who have ankle dorsi flexion active ROM (AROM) less than 10 Degrees with knee extension Exclusion criteria 1. Individuals with Impaired sensation. 2. Individuals with any orthopedic problem. 3. Individuals those who are having neuromuscular disorder of hip, knee and ankle. 4. Lower extremity malignancy. 5. Individuals with ankle pathology. E.g. fractures. Tools used 1) 360o Universal Goniometer. 2) Ultrasound, 1 MHz frequency, SL No. 2506, Ultrasonic Gel 3) Moist pack
1.5 W/Cm2 for 7 min by using Ultra sound machine in transverse manner. (Fig. 4) Static stretching to be administered to both the groups: Calf stretch was performed for 20 seconds with the knee in full extension, followed by a 10-second rest. This sequence was repeated three more times, 5 days per week for a period of 3 weeks. (Fig. 5)
Fig. 1. Tools Used
Outcome Measures AROM Measurements for ankle dorsiflexion of both legs with knee extension was taken by using a Universal Goniometer. (Fig. 2) The Measurement was taken Pre-treatment and Post-treatment i.e. after 3 weeks of intervention. PROCEDURE Prior to procedure individual those who met the inclusion criteria were assessed and evaluated thoroughly by using the questionnaire. After signing the consent form they were made to participate in study. 40 Individuals of 18-30 years were randomly assigned into two groups. Group A: Consisted of 20 Individual who were administered moist heat for 15 min to Achilles tendon for 3 weeks. Group B: Consists of 20 Individual who were administered continuous ultrasound with frequency of 1 MHz at an intensity of 1.5 W/Cm2 for 7 min to the Achilles tendon for 3 weeks. Both the groups received 30 seconds of static stretch with 4 repetitions performed 5 times per week for 3 weeks. Superficial heat administered to Group A persons Superficial heat was administered by hot pack which was placed on subjects Achilles tendon. Two layers of terry cloth padding were placed between the hot pack and the subject. (Fig. 3) Deep heating for persons belonging to Group B Ultrasonic gel, the coupling medium for treatment was applied to Achilles tendon followed by continuous ultrasound with frequency of 1 MHz at an intensity of
Fig. 2. Ankle ROM with knee extension
Fig. 3. Superficial heat (Moist pack)
Fig. 4 Deep heat (Ultra sound)
Statistical Analysis All participants received full treatments and there were no drop outs. Data analysis was done by using SPSS 13.0 version software for present study. Unpaired t tests were used to find out homogeneity of two groups for all the parameters at baseline and to compare the outcome measurement data between two groups. Paired t tests were conducted to determine whether ankle dorsiflexion ROM was significantly different before and after the intervention. Each calculated t-value is compared with t-table value to test two tailed hypothesis at 0.05 level of significance. RESULTS MeanSD of age for group A was 21.001.55 and for group B was 21.101.68 and tcalculated value was -0.195 at n1+n2-2 degree of freedom.
Fig. 5. Static Stretching
Following the recording of the above parameters, the obtained scores were tabulated and compared among both the study groups for ROM change. Ethical Consideration: Procedures followed were in accordance with the ethical standards of Helsinki Declaration of 1975, as revised in 2000.12
Table 1: shows descriptive statistics of age distribution among both groups. Descriptive Statistics
N Group A Group B 20 20 Minimum 19.00 19.00 Maximum 24.00 25.00 Mean 21.0000 21.1000 Std. Deviation 1.55597 1.68273
tcalculated value for right and left ankle dorsiflexion ROM preintervention among both the groups was 0.718 and 1.637 respectively at n1+n2-2 degree of freedom. All the descriptive data for both the
groups was not significantly different, so both the groups were homogenous for all possible confounding factors and were valid for comparison.
Table 2: Pre and Post Intervention Comparison of both the Groups in terms of ankle dorsiflexion ROM
Variable Pre Right ankle dorsiflexion ROM 7.310.59 7.370.49 Left ankle dorsiflexion ROM GROUP A Post Change Pre 7.180.56 7.080.59 11.200.90 2.901.37 11.270.70 3.601.04 GROUP B Post 11.690.64 11.560.51 Change 4.250.85 4.350.74
Table 2 shows changes in terms of ankle dorsiflexion ROM of both sides pre and post intervention for both the groups.
62 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 Table 3: Paired t test for outcome measures of both the groups
tcalculated value in all these cases is statistically significant as it is above the t tabulated value; hence both the treatments were effective in improving Ankle dorsiflexion ROM.
Table 4: Unpaired t test for outcome measures of both the groups
Both the groups showed improvement in ankle dorsiflexion ROM postintervention. MeanSD of prepost difference in right ankle dorsiflexion ROM for group A was 2.901.37 and for group B was 4.250.85 and tcalculated value was -3.73 at n 1+n 2-2 degree of freedom. MeanSD of pre-post difference in left ankle dorsiflexion ROM for group A was 3.601.04 and for group B was 4.350.74 and tcalculated value was 2.61 at n1+n2-2 degree of freedom. tcalculated value in all these cases is statistically significant as it is above the t tabulated value of 1.96. DISCUSSION Number of clinical methods and techniques are available to improve flexibility, viz. therapeutic application of heat in form of superficial and deep heating modality, different stretching technique, pre exercise warm up, etc. In stretching, static stretching is the simplest, useful and most effective technique. This
study consisted of 40 individuals, who were divided into 2 groups - Group A and Group B. Group A consisted of 20 individuals with mean age of 21.00 1.55 and group B consisted of 20 individuals with mean age of 21.10 1.68. Group A was treated with superficial heat (moist heat pack) along with static stretching and group B with deep heat (ultrasound) along with static stretching for duration of 3 weeks. Ankle dorsiflexion ROM with knee in extension was measured as an outcome measure to evaluate the effect of superficial and deep heating on calf flexibility and thereby on dorsiflexion ROM. After retrieving the values, data was statistically compared using paired and unpaired t test for comparison within and between the groups respectively. The result demonstrated that the individuals treated with both interventions showed improvement in means of plantar flexors flexibility postintervention which was evident from higher t calculated value. Moreover
statistically when both groups were compared, Group B showed more plantar flexor flexibility as it showed much greater improvement in dorsiflexion ROM as compared to that in Group A and also the t calculated value was higher than t tabulated value (1.96). This effect of ultrasound can be attributed to the sufficient increase in tissue temperature brought by it and hence thereby promoting greater relaxation of muscle as compared to superficial heating modalities. These findings are in line with those by David Draper (1993 and 1998).13,14 Moreover findings of Hendricson et al. (1984),15 Wessling et al. (1987)16 and Rather Aijaz et al. (2007)17 also support the fact that ultrasound when combined with static stretching as compared to static stretching alone is more effective in improving soft tissue flexibility. Hence it is more suggestible to use a combination of ultrasound and static stretching to improve soft tissue extensibility. Limitations of the study The study was done on a small sample size. Study was conducted for a short period of time.
ACKNOWLEDGMENTS We are thankful to all our subjects who participated with full cooperation. We are also grateful to authors/ editors/ publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. REFERENCES 1. Brad Appleton, Stretching and Flexibility. Version: 1.18, Last Modified 94/10/12. 2. Kisner C, Colby LA. Therapeutic Exercise: Foundation and Techniques. Philadelphia, Pa: FA Davis Co, 1985:172. 3. Reynolds NL, Warrell TW. Chronic Achilles peritendinitis: etiology, pathophysiology and treatment. J Ortho Sport Phys Ther.199; 13(4): 171-176. 4. Middleton JA, Kolodin EL: plantar fasciitis-heel pain in athletes. J Athl Train.1992; 27: 70-75. 5. Millar AP: strains of posterior calf musculature (tennis leg). Am J Sports Med.1992; 7: 172-174. 6. Franklin ME, Chenier TC, Brauninger L, et al. Effect of positive heel inclination on posture, J Ortho Sports Phys Ther. 1995; Feb: 21(2):94-9. 7. Wearing high heel- Effect on body. Personal health zone, February 2009. 8. AL DALI Waleed A, OLUSEYE Kamaldeen A .Effect of high-heeled shoes and culturally habitual posture on calf muscle flexibility, Arab gulf journal of scientific research. 1999; vol.17 (3): 326-33 9. Worrell TW, McCullough M, Pfeiffer a. Effect of foot position on gastrocnemius/soleus stretching in subjects with normal flexibility. J Ortho Sports Phy Ther. 1994; 19: 352-356. 10. Draper DO, Sunderland S. Examination of the law of grotthus-draper: Does ultrasound penetrate subcutaneous fat in humans? J Athl Train 1993a; 28: 246-250. 11. Funk D, Swank A, Adams K, et al. Efficacy of moist heat pack application over static stretching on hamstring flexibility. J Strength Cond Res. 2001; 15: 123-126. 12. WMA Declaration of Helsinki - Ethical Principles for Medical Research Involving Human Subjects. 59th WMA General Assembly Seoul, Korea, Oct 2008. http://www.wma.net/en/30publications/ 10policies/b3/
Scope of further studies The study on the same treatment approaches with large treatment groups can be done. The study of same treatment approaches with the inclusion of control group can be done. A long term follow up study should be done to check the recurrence rate and to know the long term effects of interventions. CONCLUSION The individuals were treated with superficial heat along with stretching and deep heat along with stretching for 3 weeks and were found to be effective in improving the ankle joint ROM in both the groups. Statistically when both the groups were compared, group B individuals showed more improvement as compared to group A. In conclusion both the treatment programs are highly significant and effective in improving the ankle joint ROM, but ultrasound with deep heating property is found to be more superior as compared to moist heat pack with superficial heating property in improving plantar flexors flexibility in females wearing high heel foot wears.
13. Draper DO, Sunderland S, Kirkendall DT, Ricard M. A comparison of temperature rise in human calf muscles following applications of underwater and topical gel ultrasound. J Orthop Sports Phys Ther 1993;17: 247251. 14. David O. Draper, Chad Anderson et al. Immediate and Residual changes in dorsiflexion range of motion using an ultrasound heat and stretch routine. Journal of Athletic Traning 1998; 33(2):141-144. 15. Hendricson A, Fredriksson K, Persson I, et al. The effect of heat and stretching on the range of hip
motion. J Ortho Sports Phys Ther. 1984; 13: 110-115 16. Wessling KC, DeVane DA, Hylton CR. Effects of static stretch versus static stretch and ultrasound combined on triceps surae muscle extensibility in healthy women. Phys Ther 1987; 67: 674-679. 17. Rather Aijaz Y, Pooja Chaudhary. Ultrasound and prolong long duration stretching increase triceps surae muscle extensibility more than identical stretching alone. Indian Journal of Physiotherapy and Occupational Therapy, vol. 1, no. 3 (2007-07 2007-09).
Influence of different Types of Hand Splints on Flexor Spasticity in Stroke Patients

Eman Samir Fayez, Hayam Mahmoud Sayed Assistant Professor in Department of Physical Therapy for Neuromuscular Disorders and its Surgery, Faculty of Physical Therapy, Cairo University, Egypt ABSTRACT Objective: The aim of this study is to evaluate the efficacy of each static and dynamic splint on hand flexor spasticity and to compare between their effectiveness on hemiplegic patients. Design: Randomized controlled trial. Subject: 29 hemiplegic (stroke) patients (45-65 Y/o) with mild to moderate spasticity of upper limb. The onset of stroke was from 6 month to one year before starting the study. Intervention: The patients were randomly assigned into two equal study groups of 15 (A and B). The assessment were performed pre and post application of static splint for group A and dynamic splint for group B. The duration of splint application was one hour for both groups. All participants were receiving designed program of treatment of hemiplegia after application of splint. Outcome measures: (1 The mean of active and passive range of motion for wrist extension using goniometer, and 2) Grip strength by using digital hand dynamometer. Keywords: Stroke ,Spasticity ,Static Splint And Dynamic Splint.
INTRODUCTION Stroke, is defined as a cerebrovascular accident (CVA), it is the rapidly developing loss of brain functions due to disturbance in the blood supply to the brain. As a result, the affected area of the brain is unable to function, leading to inability to move one or more limbs on one side of the body, inability to understand or formulate speech, complications, and may lead to death.1 Spasticity caused by an upper motoneuron syndrome is usually defined as a velocity-dependent increase in muscle resistance against passive lengthening because of a supraspinal disinhibition of both tonic and phasic stretch reflexes. This muscle over activity may result in muscle imbalance and shortening, leading to abnormal postures 4. Pain in the hemiplegic upper limb is also widely reported to be a complication of spasticity.2 Production of an effective powerful grip or even to manipulate objects requires the wrist to be held in a functional position of slight extension maintained by activity of the wrist extensors4 .The inability to open the hand when reaching for or releasing an object and limited grip is a common functional problem after stroke.
It may be due to weakness of the finger extensor muscles, spasticity and stiffness of the finger and wrist flexor muscles. Grip can be limited not only because of an inability to activate finger flexors but also because of weakness of the wrist extensors (extensor carpi radialis longus, extensor carpi ulnaris).3 Splinting is commonly used by both physical and occupational therapists to prevent joint deformities and to reduce muscle hypertonia of hemiplegic upper limbs after stroke.4 Orthoses and splints are commonly used to improve and correct the position, range, quality of movement, and function of a persons arm or hand 5. It is proposed that inhibition results from the application of splint can be due to altered sensory input from cutaneous and muscle receptors during the period of splint or cast application. Immobilization, applying gentle continuous stretching of the spastic muscle at submaximal passive range of motion (PROM), is seen to reduce spasticity by altering the threshold response to stretch of the muscle spindle and Golgi tendon organs in the antagonist and agonist muscles. The effects of neutral warmth and circumferential contact are also thought to contribute to modification of spasticity seen following casting.4
The biomechanical effects of splinting relate to changes in the length and extensibility of muscle and connective tissue. Application of low-load prolonged stretch to the contracted tissues at the end of their available range allows histological changes to occur in the tissues in response to the position imposed6. It was suggested that the increase in passive ROM seen after removal of casts in hemiplegic and cerebral palsy clients results from the lengthening of connective tissue elements along with addition of sarcomeres to the muscle fiber5. The types of splint designs commonly used are dynamic splint and static splint. The dynamic splints designed to maintain wrist joint alignment with allowing movement at the wrist would improve performance while maintaining activation of the forearm muscles that control the wrist. In addition, the dynamic splints would preserve and perhaps enhance grip and manual dexterity skills7. Otherwise static splints are designed to be rigid for controlled immobilization of the involved joint for improved function8. In a study comparing muscle activation patterns during perturbed balance when static and dynamic ankle splints were worn, investigators reported that static splints decreased muscle activation in ankle musculature7. In contrast, dynamic splints allowed activation of ankle muscles while improving balance function. In addition, proximal muscles in the trunk and thighs were more active with the static splints than with the dynamic splints, suggesting increased muscle activation proximal to the joint, which is fixed or immobilized during static splint conditions 6. Many studies concluded the effects of dynamic splints on upper limb in hemiplegic patients that they could reduce swelling, improve wrist posture, and reduce wrist and finger flexor spasticity9. Other study recommended that daily use of static splint in poststroke upper limb spasticity over an extended period is associated with reduction of spasticity and pain, and with an increase in wrist PROM8. Also an overnight splint-wearing regimen with the affected hand in the functional position does not produce clinically beneficial effects in adults with acquired brain impairment10. For optimal efficacy, therapies aimed to improving function should address both muscle shortening and muscle over activity; measures to relax overactive muscles should be combined with physical treatment to lengthen them9. Therefore, the goal of the current study is to evaluate and compare between the short term efficacy of
dynamic and static splints on hand flexor spasticity in stroke patients. MATERIALS AND METHOD Subjects Twenty nine stroke patients (17 women, 12 men) were recruited from outpatient departments in King Fahad Hospital of the University. Subjects were required to meet the following inclusion criteria:(1) post stroke hemiplegia with duration ranged from 6 months to one year before the study; (2) upper-limb mild to moderate spasticity (Modified Ashwarth Scale 1+ to 3 at the wrist), and (3) age between 45 and 65 years . Exclusion criteria were : (1)cognitive impairment, (2) major contracture affecting muscles of the spastic arm at the time recruitment; (3) Joint pathology of the upper limb (eg, previous fractures, articular blocks); (5) Patients under antispastic drug . Informed consent was obtained for all patients separately . Subjects were arranged randomly into two groups; group I (G1) and group II (G2). Group I consisted of 14 patients (9 males and 5 females) and group II consisted of 15 patients (8 males and 7 females). INSTRUMENTATION Hand digital dynamometer was used to measure the grip strength of affected hand. Goniometer was used to measure active and passive range of motion of wrist extension. Two types of splints were used in this study. The static splint made from a low-temperature, nontoxic, biodegradable material produced from a strictly controlled cotton tissue, the splint held the hand in the functional resting position (wrist positioned between at 30 degree extension), thumb in abduction 2. The dynamic splint was costumed made from thermoplastic material and allowed 30 degrees of movement at the wrist and the fingers were free 9. INTERVENTION All patients of both groups were evaluated at the beginning and at end of one-hour period of splint application. Patients of G1 were wearing static splint for one hour while, patients of G2 were wearing dynamic splint for one hour .Changes occurring with static splint were then compared with changes occurring with dynamic splint. Because the way in which the splint is fitted to the arm may be important, the fitting was performed by the same trained investigator. All assessments were performed in a quiet room while the patient was sitting with the shoulders relaxed and arms resting comfortably on chairs arm support.
OUTCOME MEASURE Three outcome measures were recorded, which were active range of motion, passive range of motion and grip strength .These measures were obtained before and after application of static and dynamic splints in both study groups. Clinical and instrumental outcome goniometric measurements of wrist extension from full flexion of the patient were obtained in degrees to calculate the active and passive range of motion. Each patient was then cued to start grip strength using digital dynamometer, elbow flexed 90 degree with hand and forearm in mid position while rested on the table. For statistical analysis, mean of 3 consecutive measurements were taken to reduce possible measurement errors, the number of repetitions given were according to standardized methods established during previous studies 2, 9. STATISTICAL ANALYSIS For parametric data (AROM, PROM, grip strength) differences of the changes occurring after wearing static and dynamic splints for 1-hour period of time were measured and compared using 2-tailed paired t tests. Statistical analysis was performed using SPSS with level of statistical significance at Pd0.05. RESULTS This study was performed to evaluate the effect of each static & dynamic splints on hand flexor spasticity in stroke patients. There were not statistical significant differences between both groups before treatment, Demographic characteristics of both groups, were shown in Table, 1.
Table 1: Demographic Data and Clinical Data of the Study Population
Comparison Group I Mean SD Age(year) Height(cm) Weight(kg) Male Female Duration of stroke(months) #: Not significant. 63.5 8.1 170.35.13 8313.4 9 5 8.6 Group II Mean SD 60.83 6.5 173.98.4 85.510.6 8 7 7.9 0.693# 0.432# 0.649# P value
Comparison between pre and post-application of static splint in group I, the results revealed that there were statistical significant improvement in grip strength and active ROM, while there was highly significant improvement of passive ROM, after application of static splint; data were shown in Table, 2.
Table 2: Comparison of G.S, AROM and PROM mean values before and after static splint application for group1.
Variables Grip strength AROM PROM Pre Mean SD 3.96 0.61 55.24 6.65 101.665.6 Post Mean SD 4.9 0.83 60.7 3.5 115.636.36 0.003* 0.001* 0.0001** P value
AROM: Active Range Of Motion; PROM: Passive Range of Motion; SD: standard deviation; *: significant; **: highly significant. Comparison between pre and post-application of static splint in group I, the results revealed that there were statistical significant improvement in grip strength and active ROM, while there was highly significant improvement of passive ROM, after application of static splint; data were shown in Table, 3.
Table 3: Comparison of G.S, AROM and PROM mean values before and after dynamic splint application for group2.
Variables Grip strength AROM PROM Pre Mean SD 4.8 0.53 57.01 7.76 116.3312.5 Post Mean SD 5.53 0.49 70.52 9.6 135.5616.7 0.001* 0. 01* 0.001** P value
AROM: Active Range Of Motion; PROM: Passive Range of Motion; SD: standard deviation; *: significant; **: highly significant. Comparison between G1 and G2, regarding active ROM, passive ROM and grip strength, the results revealed that dynamic splint had significant improvement in wrist AROM and PROM when compared to results of static splint. However, patients who wore dynamic splint had improvement in grip strength when compared with those of static splint but this improvement was not statistically significant, data were shown in Table, 4 and figure, 1.
68 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 Table 4: Comparison between static and dynamic splint mean values of both groups pre and post splint
Variables Pre (Mean SD) Group I Grip strength AROM PROM 3.96 0.61 55.246.65 101.665.6 Group II 4.8 0.53 57.01 7.76 116.3312.5 0.14 0.32 0.17 P value Post (Mean SD) Group I 4.9 0.83 60.7 3.5 115.636.36 Group II 5.53 0.49 70.52 9.6 136.5616.7 0.13 0.05* 0.001* P value
AROM; Active Range of Motion, PROM; Passive Range of Motion; SD: standard deviation; *: significant.. DISCUSSION This study was designed to investigate the short term efficacy of dynamic and static splints on hand flexor spasticity in stroke patient and compare between them by changes in degrees of active and passive range of motion and grip strength. The result showed that patient with spastic hand in both groups had demonstrated improvement after application of both types of splints .However; the dynamic splint had significant improvement in wrist AROM, PROM & grip strength compared with static splint. Because dynamic splints have moving parts that allow the individual a range of voluntary controlled movement, it has been proposed that their use may prevent contractures while allowing opposing antagonist muscle force to counter the force of the spastic muscle16 . Muscle activation patterns of the upper extremity muscles of ten children with CP were compared during reaching with and without a hand-positioning device. Results suggested more normalized muscle activation with the device application16 .In contrast, another study using static splints that immobilize wrists reported decreased muscle activation, which over time may lead to disuse atrophy in the wrist muscles and overuse of more proximal muscles.17 In contrast, dynamic wrist splints that provide wrist support for more optimal hand function allowed some movement, may not produce this additional strain on proximal muscles19. These finding agree with (Assunta,et al,2005)2 that studied the effect of volar static splint in post stroke spasticity of the upper limb .The author found that there was an increase in wrist PROM after application of a custom volar static splint for 2 to 3 hours a day in poststroke spasticity of the upper limb . The results of the current study come in accordance with (Jean , et al ,2000)7 that studied the short term effects of dynamic lycra splints on upper limb in hemiplegic patients , the
study reported reduction in wrist and finger flexor spasticity when lycra garments were worn over 3 hours. Our results disagree with (Natasha, etal 2003)6 that studied the effect of splinting the hand in the functional position after brain impairment, the study indicated that subjects with acquired brain impairment who were participating in routine motor training and upper-limb stretches did not showed detectable or important changes in wrist flexor extensibility after wearing a splint daily for 4 weeks. Also , the current results counteract with (Turton and Britton 2006)11 that found that application of an intensive 4-week splinting program to prevent contractures in the arm after stroke did not increase the extensibility of the wrist and long finger flexor muscles in adults after stroke, this trial evaluating stretch positioning in the upper limb, reported a loss of 13 of wrist extension range at 8 weeks. RECOMMENDATION Further investigation is necessary to determine efficacy of the different splints over time and in different functional activities to more clearly understand splinting use for spastic hand in hemiplegic patient. CONCLUSION The study findings suggested that spastic hand in hemiplegic patient may experience improvement in PROM , AROM and hand grip strength as a result of static and dynamic splint application , but better results were found when dynamic splint were worn during the same time of application . REFERENCES 1. 2. Donnan GA, Fisher M, Macleod M, Davis SM. Stroke. Lancet 2008; 371 (9624): 16121623. Assunta Pizzi, Giovanna Carlucci, Catuscia Falsini, etal. Application of a volar static splint in poststroke spasticity of the upper limb. Arch Phys Med Rehabil 2005; 86:1855-1859. Ruth Turk, Jane H. Burridge, Ross Davis, etal.
3.
Therapeutic Effectiveness of Electric Stimulation of the Upper-Limb Poststroke Using Implanted Microstimulators. Arch Phys Med Rehabil 2008; 89:1913-1922. 4. Katz R, Rymer WZ. Spastic hypertonia: mechanism and measurement. Arch Phys Med Rehabil 1989; 70:144-155. 5. Wilton JC: Splinting and casting in the presence of neurological dysfunction. In: WIlton JC, Hand splinting: principles of design and fabrication. London: WB Saunders 1997; 168-197. 6. Patricia A. Burtner, Janet L. Poole, Theresa Torres, etal. Effect of wrist hand splints on grip, pinch, manual dexterity, and muscle activation in children with spastic hemiplegia: A Preliminary Study. J HAND THER 2008; 21:3643. 7. Collins K, Oswald P, Burger G, Nolden J. Customized adjustable orthoses: Their use in spasticity, Arch Phys Med Rehab 1985;66:397-8. 8. Langlois S, Pederson L, MacKinnon J: The effects of splintingon the spastic hemiplegic hand: report of a feasibility study. Canadian J Occup Ther 1991; 58(1):17-25. 9. Neeman R, Neeman M: Rehabilitation of a poststroke patient with upper extremity hemiparetic movement dysfunction by orthokinetic orthoses, J Hand Ther 1992; 3(5):147-155. 10. Natasha A. Lannin, Sally A, Horsley, etal. Splinting the Hand in the Functional Position after Brain Impairment: A Randomized, Controlled Trial. Arch Phys Med Rehabil 2003; 84:297-302. 11. Jean-Michel Gracies, Jeno Emil Marosszeky, Roger Renton, etal. Short-term effects of dynamic lycra splints on upper limb in hemiplegic patients. Arch Phys Med Rehabil 2000 ;( 81):1547-1555.
12. Lannin NA, Cusick A, McCluskey A, etal. Effects of splinting on wrist contracture after stroke: a randomized controlled trial. Stroke 2007; 38(1): 111-116. 13. Patricia A. Burtner, Jennifer Bradley Anderson, Michelle Lee Marcum, etal. A comparison of static and dynamic wrist splints using electromyography in individuals with rheumatoid arthritis. J HAND THER 2003 ;( 16):320325. 14. Stern EB, Yterberg SR, Krug HE, Mullin GT, Mahowald ML. Immediate and short-term effects of three commercial wrist extensor orthoses on grip strength and function in patients with rheumatoid arthritis. Arthritis Care Res 1996 ;(9):4250. 15. Turton AJ, Britton E. A pilot randomized controlled trial of a daily muscle stretch regime to prevent contractures in the arm after stroke. Clin Rehabil 2005 ;( 19):600612. 16. Feldman P.Upper extremity splinting and casting. In: Glenn MB,Whyte J (eds). The Practical Management of Spasticity in Children and Adults. Malvern, PA: Lea & Febiger 1990; pp 59166. 17. Reid DT, Sochaniwskyj A. Influences of a hand positioning device on upper extremity control of children with cerebralpalsy. Int J Rehabil Res 1992; (15):1529. 18. Bulthaup S, Cipriani DJ, Thomas JJ. An electromyography study of wrist extension orthoses and upper extremity function. Am J Occup Ther 1999 ;(53):434440. 19. Jansen CWS, Olson SL, Hasson SM. The effect of use of a wrist orthosis during functional activities on surface electromyography of the wrist extensors in normal subjects. J Hand Ther 1997 ;(10): 283289.
Interferential Current Therapy versus Narrow Band Ultraviolet B Radiation in the Treatment of Post Herpetic Neuralgia
Intsar Salim.Waked Lecturer of Physical Therapy, Department of Physical therapy for Surgery, Faculty of Physical Therapy, Cairo University, Egypt. ABSTRACT Objective: To compare the efficacy of interferential current therapy versus narrow band ultraviolet B radiation in the treatment of post herpetic neuralgia. Subjects: Forty nine patients suffering from distressing post herpetic neuralgia. assigned randomly into 2 groups; interferential group and narrow band ultraviolet B group. Intensity of pain was recorded before and after therapy using numerical rating scale. Results: The results of this study showed no significant difference in pain intensity post treatment between both groups in acute and subacute neuralgia as p value > 0.05 while there was significant difference between both groups in established neuralgia as p value< 0.05. Conclusion: The study concluded that interferential current and narrow band ultraviolet B were effective in acute and subacute neuralgia, while only interferential is effective in established neuralgia. Keywords: Interferential Current Therapy, Narrow Band Ultraviolet B Radiation, Numerical Rating Scale, Post herpetic neuralgia.
INTRODUCTION Herpes zoster ( HZ ) infection is caused by a reactivation of the latent varicella zoster virus that causes chicken pox. It appears predominantly in older adults whose immunity for the virus has waned. Postherpetic neuralgia (PHN) is described as sharp, burning, aching, or shooting constantly present in the dermatome that corresponds with the herpes rash1. Pain in HZ evolves in three phases: acute, subacute, and chronic. The acute phase occurs with the onset of the herpetic rash and lasts for less than 30 days, the subacute phase lasts for 1-3 months after the onset of the rash, and the chronic phase, or PHN, lasts for 3 months or longer after the onset of the rash2. Post herpetic neuralgia (PHN) is a common, debilitating complication of herpes zoster that has a major impact on patients quality of life. It can cause insomnia, fatigue, depression. Predictors of PHN are greater age, acute pain and rash severity, prodromal pain, the presence of virus in peripheral blood, as well as adverse psychosocial factors3. The treatment of PHN is medically challenging and often frustrating in some situation as the exact
mechanism of neuralgia is poorly understood and multiple and complex pathophysiology is postulated requiring poly pharmacy, which itself leads to many side effects4. Interferential current (IFC) is a common electrotherapeutic modality used to treat pain. IFC therapy is the application of alternating mediumfrequency current (4,000 Hz) amplitude modulated at low frequency (0250 Hz). Despite IFCs widespread use, information about it is limited. A review of the literature reveals incomplete and controversial documentation regarding the scientific support of IFC in management of post herpetic pain5. The inflammatory response plays a major role in the pathogenesis of acute zoster pain and PHN. Ultraviolet B radiation (UVB) may affect the course of PHN through its suppressing effect on the inflammatory response in the acute zoster attack, thus decreasing the neuronal damage contributing to PHN 6. The purpose of this study was to evaluate the efficacy of interferential current therapy versus narrow band ultraviolet B radiation in the treatment of post herpetic neuralgia.
PATIENTS AND METHOD Subjects Forty nine patients (24 male, 25 female) with distressing post herpetic neuralgia were recruited from department of dermatology and the study conducted in outpatient department of physical therapy- ElMataria Teaching Hospital after approval of the institutional ethical committee. The history & clinical examination were done for all patients. Subjects who fulfilled the following criteria were eligible for enrollment in the study; (1) age ranged from 50 to 80 years, (2) elapsed time since the beginning of pain less than 6 months. Patients were excluded if they had (1) disseminated zoster, (2) malignancy, (3) diabetes, (4) pregnancy (5) pacemakers (7) Patients were taking immunosuppressive medication. The patients were randomized into two groups of equal number. (1) interferential group and (2) narrow band ultraviolet B ( nbUVB) group. Pain was assessed by numerical rating scale before starting of the treatment and at the end of the therapeutic period for all patients. At the time of this study, Human Research Ethics Committee had not been established in the faculty of physical therapy, but the study was approved by the departmental council of physical therapy for surgery and all patients signed an informed consent at the first visit to the physical therapy clinic . Outcome measures Measurement of pain intensity by Numeral Rating Scale Numeral Rating Scale (NRS) is a common and practical method for assessing pain severity. It is the most widely used pain rating scale in clinical practice. There is evidence, which supports the validity and reliability of the NRS in younger. and older patients. The reliability of the NRS is acceptable and it has a high internal consistency, with a Cronbach range of 0.86 to 0.88 7. The NRS is an 11-point pain scale, where patients are requested to quantify the intensity of their pain on a scale from zero to 10 (from 0 = no pain to 10 = worst pain imaginable). The NRS scale can also be used visually with both words and numbers along a vertical or horizontal line. Patients are asked to express a number that relates best to their pain intensity8. Treatment procedures Interferential current Therapy (IFC) Description of apparatus SONOSTIM ( Class 1-type BF, Norm: 601-1) was a
combined unit used to introduce interferential current for group 1. This unit introduced a quadripolar IF as well as bipolar mode. The unit was provided with two output channels for interferential currents. Treatment parameters The parameters used were; frequency 250 Hz, a pulse duration 120, 30 minutes. The treatment was given for 3 sessions per week for 5 weeks. Intensity of the impulse varied according to the patients tolerance9. Electrodes placement The dermatome that was affected by the shingles is the treatment path for electrotherapy. Each channel has one electrode that emits electricity and the other electrode is the ground. One electrode, from channel 1, was placed directly beside the origin point where the dermatome exits the spinal cord. The other electrode for channel 1 was placed about 2/3rds of the way down the dermatome. On channel 2 one electrode was placed between the two electrodes of the first channel approximately 1/3rd down, and the other electrode from channel 2 was placed at the distal end of the dermatome,. This electrode placement now covers the entire dermatome 5.
Narrow Band Ultraviolet B Radiation Therapy (nUVB) Narrow band UVB apparatus (Waldmann - UV 100L) was used to introduce nbUVB (311-312nm) to patients in group 2. The starting dose was 0.21 J/cm2 and gradually increasing the dose by 10 mJ/cm2 each session to a maximum dose of 100 mJ/cm2. (as long as there is no adverse effects reported such as persistent erythema, burn, itching)10. Patients were instructed to expose the involved body part while the rest of the body was covered using clothing. Patients were instructed to wear protective goggles to avoid damage of the cornea. Treatment sessions were repeated three times a week. Statistical Analysis Data were coded and entered to a statistical package of social science (SPSS, version 16). Mann-Whitney U test was used to assess the difference in sex, type of pain, type of neuralgia, affected dermatome as well as the intensity of pain in acute, subacute and established neuralgia between both groups, while wilcoxon test was used to assess the intensity of pain within each group. All p values less than 0.05 were considered to be statistically significant.
RESULTS A total of 49 patients was screened for eligibility, and 47 subjects fulfilled the inclusion criteria. Three subjects of 47 reported poor adherence to the treatment, (a participant with poor adherence to the program defined as missing more than three consecutive sessions or more than 20% of all sessions) and excluded from
the study, and their data were not used in the statistical analysis. A total of 44 subjects completed the study and were initially randomized into two groups of equal number. IF group (n=22), and nbUVB group (n=22). Table (1) presents the characteristics of the patients completing the study. Both groups were comparable at the baseline regarding to the demographic and clinical characteristics.
Table 1: Demographic and clinical characteristics

Variables Age (years) (mean SD) Duration of pain (day) (meanSD) Type of neuralgia (%) Acute Subacute Established Sex (Male - Female) Affected dermatome Male Female Cervical Thoracic Lumbar Rt upper limb Lt upper limb Type of pain ( %) Continuous burning Intermittent burning Continuous stabbing Intermittent stabbing Intensity of pain (medianSD) Acute Subacute Established * No significant differences IF group 60.907.19 103.0562.00 5(22.7%) 5(22.7%) 12(54.5%) 10(45.5%) 12(54.5%) 3(13.6%) 7(31.8%) 2(9.1%) 6(27.3%) 4(18.2%) 8(36.4%) 6(27.3%) 5(22.7%) 3(13.6%) 8.00.8366 8.00.8366 8.00.866 SD; standard deviation acute subacute established Male Female Cervical Thoracic Lumbar Rt upper limb Lt upper limb Continuous burning Intermittent burning Continuous stabbing Intermittent stabbing Acute Subacute Established nbUVB group 59.908.39 98.5068.84 7(31.8%) 4(18.2%) 11(50%) 11(50%) 11(50%) 5(22.7%) 5(22.7%) 1(4.5%) 6(27.3%) 5(27.7%) 7(31.8%) 5(22.7%) 6(27.3%) 4(18.2%) 8.001.11 8.500.577 8.000.894 0.932* 0.190* 0.558* 0.591* 0.891* 0.765* P values 0.673* 0.819* 0.633*
Measurements of pain intensity In table (2); The results showed significant reduction in pain intensity post treatment in IF group whatever type of neuralgia ( acute, subacute, chronic) as p value
<0.05. In nbUVB group; the results showed significant reduction of pain intensity post-treatment in acute and subacute neuralgia as p value <0.05 however no significant difference in established neuralgia as p value > 0.05..
Table 2: pain intensity within both groups pre and post treatment.
Acute neuralgia pre IF Group P value NBUVB P value * No significant difference 8.01.11 8.00.83 0.043** 3.00.899 8.00.57 0.039** 0.018** * * Significant difference post 2.01.14 Subacute neuralgia pre 8.00.83 0.041** 3.50.96 post 3.00.84 Established neuralgia pre 8.00.87 8.00.89 0.55* 0.002** 7.51.00 post 2.00.94
IF group
nbUVB group
Percentage of improvement in acute neuralgia
IF group
nbUVB group
Percentage of improvement in subacute neuralgia
IF group
nbUVB group
Percentage of improvement in established neuralgia
In table (3); The results showed no significant difference in pain intensity post treatment between both groups in acute and subacute neuralgia as p value > 0.05 but significant difference between both groups post treatment as regard to established neuralgia as p value< 0.05.
Table 3: Comparison of pain intensity between both groups post treatment
IF Group Acute neuralgia Subacute neuralgia Established neuralgia * No significant difference 2.01.14 3.00.84 2.00.94 NBUVB 3.00.899 3.00.96 7.51.00 P value 0.442* 0.439* 0.001**
concluded that Interferential therapy is an effective, easy to use therapy with minimal side effects in patients suffering from trigeminal neuralgia that not responding to conventional treatment. In a study compared IF with transcutanous electrical nerve stimulation (TENS) Cheing and HuiChan;16confirmed the analgesic effects of IF and TENS in their study and concluded that both TENS and IF increased the heat pain threshold to a similar extent during stimulation. However, the post-stimulation effect of IF lasted longer than that of TENS. As regard to the efficacy of nbUVB; the results of study showed that there was significant reduction of pain intensity in acute and subacute neuralgia however non significant differences in chronic neuralgia. The improvement in acute and subacute neuralgia may be attributed to the anti-inflammatory effect of UVB. UVB may affect the course of PHN through its suppressing effect on the inflammatory response in the acute zoster attack thus decreasing the neuronal damage contributing to PHN17. Langerhans cell (LCs) play an important role in PHN as several molecules that sensitize cutaneous nociceptors are released by LCs. And the langerhans may be activated in acute PHN. UVB radiation suppresses antigen presentation of LCs in different ways. It stimulates keratinocytes and mast cells to secrete immunosuppressive cytokines such as IL-10, TNF-, IL-4, PG-E2, -MSH or CGRP, which inhibit the antigen-presenting function of LCs. Furthermore, it causes depletion of the LCs in the epidermis 18, which may also explain the improvement induced by UVB in PHN. Also UVB modifies the T-cell response to persistent VZV particles in nerve fibers, which might be involved in the pathogenesis of PHN. UVB induces a shift from a Th-1 immune response to a Th-2 response in different ways19. Two studies correlate with the results of this study. Jalali et al;20 who reported 58.33 and 83.33% complete pain relief at 1 month and 3 months follow up, respectively. And concluded that UVB phototherapy in the acute stage of zoster rash might reduce the incidence and severity of PHN. Treatment after 3 months does not seem to have a significant beneficial effect. Also ElNabarawy; 10 who used nbUVB for 17 patients with post herpetic neuralgia and the results showed more than 50% improvement was achieved in 6 (35.29%) and 8 (47.06%) patients, at the end of therapy and after 3
* * Significant difference
DISCUSSION Postherpetic neuralgia is the major chronic complication and is a difficult management problem. The aim of this study was to compare the effects of interferential current therapy versus narrow band ultraviolet B radiation in the treatment of post herpetic neuralgia. A prospective study of forty nine subjects was carried out. Subjects were divided into two groups; IF group that received interferential therapy and nbUVB group that received narrow band UVB sessions. Outcome measures were assessed using numerical rating scale to assess pain intensity pre and post treatment. The results of the study showed that there was significant reduction in pain intensity post treatment in IF group in acute, subacute and chronic neuralgia as p value <0.05. This support the efficacy of interferential for minimizing pain and this may be attributed to analgesic effects of interferential therapy. The analgesic effect of interferential therapy can be explained in part by Wednesky inhibition of Type C nociceptive fibres, although other mechanisms are certainly involved. Pain gate theory, proposed by Malzack and Wall11 remains central to this explanation. Another system that helps to reduce pain is the descending pain suppression mechanism, which is mediated by the endogenous opiates12. Number of previous studies demonstrated the effectiveness of inferential current therapy in order to reduce neuropathic pain. Babu and Murali;13 and Burchiel;14 analyzed analgesic effects of IFC in chronic and acute neuropathic pain. Natarajan;15 also found positive results of interferential currents in diabetic neuropathy and post-herpetic neuralgia. Nabila; et al;9
months follow up, respectively. And concluded that nbUVB may provide a potential tool in the management of PHN. To the best of our knowledge, there is no study comparing the efficacy of interferential therapy versus narrow band ultraviolet B radiation. The results of this study showed no significant difference in pain intensity post treatment between both groups in acute and subacute neuralgia as p value > 0.05 but significant difference in established neuralgia as p value< 0.05. This confirm the efficacy of both interferential and nbUVB for acute and subacute neuralgia, while only interferntial is effective in established neuralgia. The limitations of our study were no control group included and no period of follow-up. Further studies including control group and follow-up are needed to further validate our findings. Conflict of interest There is no interest of conflict with any organization, and this research is not funded ACKNOWLEDGEMENTS We express our gratitude to all those who have contributed in completing this research work, especially all the subjects who willingly agreed to participate in this study. REFERENCES 1. De Benedittis G, Besana F, Lorenzetti A A new topical treatment for acute herpetic neuralgia and post-herpetic neuralgia: the aspirin/diethyl ether mixture. An open-label study plus a double-blind controlled clinical trial. Pain; (1992); 48 (3): 383390. Dworkin RH, Portenoy RK. Proposed classification of herpes zoster pain. Lancet 1994;343:1648. Johnson RW, Whitton TL. Management of herps zoster (shingles) and postherpetic neuralgia. Expert Opin Pharmacother (2004);5:551-9. Fashner J, Bell AL. Herpes zoster and postherpetic neuralgia: prevention and management. Am Fam Physician. (2011) Jun 15;83(12):1432-1437. Kitchen S, Palmer S, Martin D,. Interferential current for pain control. In: KitchenS ed. Electrotherapy Evidence-based Practice. 11th ed. Edinburgh, Scotland: Churchill Livingstone; 2002:287298.
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EL-Ghor AA, Norval M. Biological effects of narrow-band (311nm TL01) UVB irradiation: a review. J Photochem Photobiol B 1997;38:99-106. Lara-Munoz C, De Leon SP, Feinstein AR, Puente A, Wells CK: Comparison of three rating scales for measuring subjective phenomena in clinical research, Use of experimentally controlled auditory stimuli. Arch Med Res 2004, 35(1):43-48. Hartrick CT, Kovan JP, Shapiro S: The numeric rating scale for clinical pain measurement: a ratio measure? Pain Pract 2003, 3(4):310-316. Nabila S; Muhammad H; Faisal Y; Rukhsana B; Efficacy of interferential current on trigeminal neuralgia. 2012; NEURALGIA MC Vol. 19 - No.2; 33 35. El-Nabarawy E. The use of narrow band ultraviolet light B in the prevention and treatment of postherpetic neuralgia (A pilot study). Indian J Dermatol;2011;56:44-7. Kloth, L. Interference current. In: Clinical Electrotherapy Nelson, R.M., Currier, D.P. (Ed.) Ch 9, 183-207, Appleton and Lange, 1987. Norwalk, Connecticut, USA. Watson, J. Pain mechanisms: a review. 3. Endogenous pain mechanisms Aust J. Physiother 1982, 28 (2), 38-45 Babu R, Murali R. Arachnoid cyst of the cerebellopontine angle manifestingas contralateral trigeminal neuralgia: case report, Neurosurgery 2010; Jun; 28(6): 886-7. Burchiel KJ. A new classification for facial pain, Neurosurgery 2001; Nov; 53(5):1164-6. Natarajan, M Percutaneous trigeminal ganglion balloon compression: experience in 40 patients. Neurology (Neurological Society of India) (2001);48 (4):3302. Cheing GL, Hui-Chan CW. Analgesic effects of transcutaneous electrical nerve stimulation and interferential currents on heat pain in healthy subjects. J Rehabil Med. 2003 Jan;35(1):15-9. Misery L. Langerhans cells in the neuron-immunocutaneous system. J Neuroimmunol 1998;89:83-7. Shreedhar V, Giese T, Sung VW, Ullrich SE. A cytokine cascade including prostaglandin E2, il4, IL-10 is responsible for UV-induced systemic immunosuppression. J Immunol 1998;160:3783-9. Schwarz T. Mechanisms of UV-induced immunosuppression. Keio J Med 2005 ; 54:165-71. Jalali MH, Ansarin H, Soltani-Arabshahi R. Broadband ultraviolet B phototherapy in zoster patients may reduce the incidence and severity of postherpetic neuralgia. Photodermatol Photoimmunol Photomed. 2006 Oct;22(5):232-7.
Effect of the Duration of Play on Pain Threshold and Pain Tolerance in Soccer Players
Shahid Raza1, C.S. Ram2, Jamal Ali Moiz3 Physiotherapist, Centre for Physiotherapy and Rehabilitation Sciences, Jamia Millia Islamia, 2Director, Department of Physiotherapy ITS Paramedical college, Ghaziabad, 3Assistant Professor, Centre for Physiotherapy and Rehabilitation Sciences, Jamia Millia Islamia ABSTRACT Background: The athlete's capacity to tolerate pain is one of the most important features of sporting success. Research suggest that a verity of pain suffers can benefit from exercise. Duration of play may increase in pain threshold and pain tolerance in soccer players. Objective: The purpose of this study was to evaluate the effect of pain threshold and pain tolerance on participation in playing soccer. Design: This was a same subject pre-test post-test trial. Setting: The study was conducted at Siri Fort Sports Complex and Jawaharlal Nehru Stadium (Sports Authority of India) New Delhi. Participants: Thirty healthy male district level soccer player (aged 17-22 years) participated in the study. Measurements: A gross pressure device was used to induce pain, and to measure pain threshold and pain tolerance. It consisted of a sphygmomanometer and rubber coated steel cleat. Cleat along with shin guard was placed of the medial surface of the tibia approximately in the middle portion. Pain was induced by inflating the sleeve at 10 mmHg every 10 seconds. The subjects were asked to inform when they first sense pain. The pressure was noted as pain threshold reading. Pressure was further increased till the subject cannot endure it readings were noted as pain tolerance and pressure was released. The readings were taken before, between and after the game. Results: Compared with three readings of pain threshold and pain tolerance a repeated measure of ANOVA showed a significant difference. A bonferroni test was used for post hoc pair wise comparison among all three conditions showed a significant difference among three possible pairs. Limitations: Further work is needed to determine whether sex differences in pain coping mechanism exist before, during after competition. Conclusion: The present data suggest that changes in pain threshold and pain tolerance in soccer player depend on the duration of play. The result of this study proves that the participation in game to improve the pain threshold and pain tolerance in soccer players. Keywords: Soccer, Pain Threshold, Pain Tolerance Introduction. INTRODUCTION The athletes capacity to tolerate pain is among the most important features of sporting success. Researchers contended that the pain tolerance is the Corresponding author: Jamal Ali Moiz Assistant Professor, Centre for Physiotherapy and Rehabilitation Sciences, Jamia Millia Islamia (Central University), New Delhi-110025,India, E-mail: jmoiz@jmi.ac.in Phone: +91 (011) 26980544, Fax: +91 (011) 26980544 most critical differentiator between successful and unsuccessful athletes in endurance sports. The ability to tolerate pain is often inherent in competitive sports success. Performing physical skills at the optimal efforts, particular when the movement involves contact with other participants, virtually maintaining other effort and skilled performance after experiencing pain during the contest, and after rehabilitation.1 Dramatic anecdotes of dancers or athletes who continue strenuous exercise in the face of severe injuries and later report that they felt no pain have contributed to the notion that exercise can increase pain tolerance.
Such anecdotal evidence has been linked to theory to data which indicate that exercise releases endorphins and that endorphins reduce pain. This proposed linkage has, intern, led to a belief that exercise-induced analgesia is an established phenomenon.2 Ronalds Melzack,3 founder of pain gate theory had described pain in his own words in the following ways it is not a fixed response to a noxious stimulus ;its perception is modified by past experiences, expectations and even by culture. It has a protective function, warning us that something biologically harmful is happening. But anyone who has suffered prolonged pain would regard it as Evil, punishing affection that is harmful in its own right. It has been reported by Raithel that most pain management programmers prescribe some kind of exercise regimen, some include aerobic exercise, others include resistance exercise, and still others use a combination of aerobic and resistance exercise. Research has been conducted into whether aerobic exercise, such as cycling and running , is associated with an analgesic effect, and has indicated that aerobic exercise at a sufficient intensity (>70% of maximum aerobic capacity) has been associated with increases in pain threshold.4 The Literature regarding whether or not exercise induced analgesia is an established phenomenon in humans is equivocal. Haier et al (1981)5 have reported changes in pain threshold following exercise, while others have not. a number of investigators have studied changes in pain threshold using a dental pulp stimulation. Pertovara et al. (1985)6 al investigated changes in dental pain threshold during exercise at different intensities and found that dental pain threshold tends to increase with increasing workload. The experiments are typical studies investigating post-exercise analgesia. Their emphasis was not on supporting the casual role of exercise in the analgesic effect, but instead focused on whether the analgesic effect is mediated by release of endorphins. However, while these studies appear to support the analgesic effect of exercise, a causal interpretation is limited by the failure to include a no exercise control group.7 Willium P. Margan(1984)8 examined the effective beneficence of vigorous physical activity and concluded that distraction, release of monoamine as well as endorphins during vigorous physical activities, act synergistically to produce the analgesic effect. Ashley Grossaman and John R. Sutton(1984) 9
investigated the relationship between the endorphin relies and their role in exercise and found that the endorphin concentration in the blood increases considerably with exercise and play an important role in regulation of ventilation especially at higher intensity exercise , where they appear to inhibitory. Another study by Conard Droste (1990) 10 on experimental pain threshold and plasma beta endorphine level dosages does not correlate significantly with pain threshold, though short term, exhaustive physical exercise can evoke transient pain threshold. This exercise induced elevation in pain threshold does not however, appear to be directly related to plasma endorphine level. Maria Gurevich (1994)11 and colleagues found that submaximal exercise intensity produces analgesia suggesting the possibility of using moderate exercise in therapeutic intervention. Another study by Mark HA and Kenith Russel (1994)1 confirmed that resistive aerobic exercises can result in greater pain tolerance. Though the growing body of research suggest that a variety of pain sufferer can benefit from exercise, and a greater reliance upon exercise as an effective , healthy and less intrusive pain management alternatives, or adjunctive, to pharmacological analgesics can be laid. However relatively little research has been devoted to examining the effectiveness of exercise on influencing the persons threshold and tolerance of pain, particularly acute. PURPOSE The purpose of this study was to evaluate the effect of pain threshold and pain tolerance on participation in playing soccer. HYPOTHESIS Duration of play will increase the pain threshold and pain tolerance in soccer players. METHOD Subjects A total number of 30 healthy male district level soccer players were selected for the study from Siri Fort sports complex and Jawaharlal Nehru stadium (sports authority of India) New Delhi. Ethical approval was obtained from the university ethical committee prior to recruiting subjects. The mean age of the selected sample
was 18.6 +1.4 ranging from 17to 22 years of age. An informed consent was taken from all the participants after describing in detail the procedure and purpose of the study to all of them. The subjects were selected according to the following inclusion and criteria. Inclusion criteria Age group between 16 to 25 years Healthy district level soccer players Only males
to consume alcohol or caffeine at least two hours before the game. The subjects were made to lye supine on the ground to make them comfortable and also to ensure that they cannot see the sphygmomanometer readings to avoid giving any visual feedback. A gross pressure device was used to induce pain, and measure pain threshold and pain tolerance. It consisted of a sphygmomanometer and rubber coated steel cleat along within the shin guard was placed on the medial surface of the tibia approximately in the middle portion. The sleeve of the sphinomanometer was fastened around the shin guard and was inflated. Pain was induced by inflating the sleeve at 10 mmHg every 10 seconds, which compressed the steel cleat against the shin causing pain. The subjects were asked to inform when the first sense the pain. the pressure reading of the mercury column of the sphygmomanometer was noted as pain threshold reading. The pressure was increased further till the subject cannot endure it. At this point again the sphygmomanometer readings were noted as pain tolerance and pressure was released. Methods of instruction was standardized by giving the subjects the following commands this apparatus ,using pressure for investigation of sensitivity to pain you have to say start as soon as you are not able to bear the pain . These readings were taken before game again during half time and after the end of the game. DATA ANALYSIS Data analysis was done using SPSS software. Demographic data of patient including age , sex were descriptively summarised. A repeated measure of ANOVA was performed to analysed the difference in pain threshold and pain tolerance. An alpha level of 0.05 was used to determine statistical significance. All possible pair wise post hoc analysis was conducted on the significant dependant variable in order to compare difference among duration of game. RESULTS A total thirty (n=30) district level soccer player with mean+ SD age 18.6+14 years were selected for the analysis. Before warm-up, prior to the game, during the half time of the game and at the end of the game both pain threshold and pain tolerance are summarised in mean and standard deviation in table 1.
Exclusion criteria Subjects taking pain killers or muscle relaxant drugs Any recent or previous injury Non co-operative persons Those subjects whose pain tolerance exceeded more than 300 mmHg(maximum rereading for the sphygmomanometer) during pre-test DESIGN OF THE STUDY A same subject pre-test post test design was selected for testing the hypothesis. A baseline reading was taken prior to start of the game, a second reading of the dependent variable were taken during the half time of the game and final reading immediately after the game was over. Only one subject was selected for measurement of dependent variable during a single game. These readings were then compared to find out the effect of independent variables. The outcome measure or dependent variables, selected for this study were pain threshold and pain tolerance. Instrument and tool Sphygmomanometer Rubber coated steel football cleat Soccer shin guard Digital stopwatch to record time PROCEDURE Before the warm-up a baseline measurement of pain threshold and pain tolerance was taken from the selected subject. The selected subject has been given instructions regarding not to exercise, not to smoke, not
Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 79 Table 1. Results of pain threshold and pain tolerance at before game, between game and after game
BGM+SD Pain threshold Pain tolerance 151+20.6 188.2+27.9 BTM+SD 158.5+21.8 200.2+28.6 AFM+SD F 164+25.84 209.5+30 17.05 19.69 ANOVA P 0.000 0.000 BF Vs.BT 0.002 0.001 Bonferroni BFVs.AF 0.000 0.000 BTVs.AF 0.033 0.019
Significant at p<0.05; BF= before game; BT= between game; AF= after game
To find out the difference among all the three readings of pain threshold and pain tolerance a repeated measure of ANOVA shows statistically significant difference among all the three readings of both pain threshold (F=17.05,p<0.0001)and pain tolerance (F=19.69, p<0.0001). A bonferonnin post hoc pair wise comparison shows significant difference among three pairs before game vs. between game (pain threshold p=0.02,pain tolerance =0.001) before game vs. after game (pain threshold p<0.0001, pain tolerance p<0.0001) and between game vs. After game (pain threshold p=0.033, pain tolerance p=0.019) which is presented in figure 1. DISCUSSION The results of this study suggest that competition modulate pain threshold and pain tolerance responses to noxious stimuli. Soccer player exhibits higher pain threshold and pain tolerance during and after the game compared to before the game. We believe that the stress component of competition contributes to the pain inhibition associated with physical exertion. In soccer scoring chances are rare, a defensive mistake in soccer, for example, may carry more importance and cause a higher degree of anxiety and a defensive mistake in a basketball game. If a defensive mistake in a basketball game results in a basket for the opposition, many opportunities to make up the deficit are likely to occur. Soccer is a players game, during a game, athletes are expected to make their own decisions concerning what to do in every situation. Athlete, who participated in soccer or basketball, however experienced similar levels of analgesia prior to game situations. The study provides evidence that the competitive aspects of competition and its physical stressors aroused the SIA mechanism. Much of the existing research on anxiety in sports is too focused on the characteristics of the athlete, while ignoring the characteristics of the environment in which the behaviour took place. Situational variables have been shown to effect emotions elicited by the various competitive environment.12
Winning experiences, social context, coaching style, and the nature of sports all play a role in athlete pain response to meaningful competition and should therefore be considered in athletes who claim to feel no pain following an injury. Exercise induced analgesia is only produced in humans following high level of exercise with a work load of at least 74% aerobic capacity. Each testing session was not aerobically challenging for the participants, and therefore was unlike to lead to significant changes in pain threshold and pain tolerance due to exercise.13 Athletes display a rise in pain threshold (analgesia) in response to athletic completion as compared with non competitive testing session. Hormonal levels in soccer players, in game compared to before. Cortsol has been identified as a reliable marker of stress. Both analgesia and elevated cortisol levels measured before games suggest that game situations can be considered as reliable stressors. Many outside factors also contribute to overall physiological status of a player including conditioning activities, practice schedules, academic demands, and physiological stressors, in addition to completion. Such factors consistently affect an athletes overall level of stress and confound possible cortisol elevations in anticipation of practice.14 Research suggests that environmental stress is a natural triggers of the inhibition of pain sensation. It follows the athletes experienced both analgesia prior to the game and elevated cortisol level due to the stress of athletic competition. Stress is believed to activate the endogenous opoid system which will cause the observed analgesic response.15 Cortsol the stress hormone is the dominant form of glucocorticiods in humans. ACTH and -endorphine have roles in the regulation of stress; Both ACTH and -endorphine have roles in the regulation of stress; ACTH stimulates the adrenal which releases cortisol and -endorphinebinds to opoid receptors which produce analgesia. Thus, the analgesic findings from the study could be due to the stress elicited from comparative situations, which in turn caused analgesia and subsequently higher pain threshold and pain tolerance. The study supports the
hypothesis that the duration of play increase pain threshold and pain tolerance in soccer players. 14 Competition can be considered a stressor significant enough to evoke analgesia in athletes. The study found that the soccer players have higher pain threshold and pain tolerance after the game compared to before and between games. CONCLUSION The present data suggest that changes in pain threshold and pain tolerance in soccer player depend on the duration of play. The changes may be related to stress mechanism that involves within the competition. The result of this study proves that the participation in game to improve the pain threshold and pain tolerance in soccer players. ACKNOWLEDGEMENTS The authors wish to acknowledge the co-operation of all the participants who participated in this study. The authors extend their thanks to M.S. Basins, senior Physiotherapist, Sports Authority of India, for his cooperation throughout this study process. Conflict of Interest The authors have no conflict of interest to declare. REFERENCES 1. Anshel M H , Russell KG. Effect of aerobic and strength training on pain tolerance, pain appraisal and mood of unfit males as a function of pain location. Journal of Sports Sciences (1994); 12: 535-547. Wendy J. Padawer and Fredric M. Levine Exerciseinduced analgesia: fact or artifact? Pain (1992);48:131-135 Melzack R, Wall PD. Pain mechanisms: a new theory. Science (1965); 150 (3699):9719.
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Neuromuscular Electrical Stimulation Versus Intermittent Pneumatic Compression on Hand Edema in Stroke Patients
Eman S.M.Fayez1, Hala Ezz Eldeen2 Assistant Professor in Department of Physical Therapy for Neuromuscular Disorders and its Surgery, Faculty of Physical Therapy, Cairo University, 2Professor in Department of Cardiopulmonary Rehabilitation and Geriatrics. Faculty of Physical Therapy, Cairo University
1
ABSTRACT Objective: the purpose of this study was to evaluate and compare between the effect of application of neuromuscular electrical stimulation and intermittent pneumatic compression on reducing hand edema in stroke patients. Subjects: Thirty stroke patients of both sexes (18 females and 12 males).They assigned randomly into 2 study groups each one composed of 15 patients. Method: Group I received intermittent pneumatic compression therapy and group II received neuromuscular electrical stimulation three times per week for twelve weeks. The patients were assessed for hand volume by using the volumetric measurement and by hand held dynamometer to measure hand grip strength before and after the end of treatment period. Results : The results of this study revealed that application of intermittent pneumatic compression therapy had a significant effect on reducing hand edema in stroke patients than receiving neuromuscular electrical stimulation .While hand function measured by hand grip strength was improved more significantly with receiving neuromuscular electrical stimulation than the group who received intermittent compression therapy. Conclusion: Application of intermittent pneumatic compression therapy was more effective in reducing hand edema than neuromuscular electrical stimulation while application of neuromuscular electrical stimulation resulting in greater improvement in hand grip strength and hand function. Keywords: Stroke, Hand Edema, Hand Function, Neuromuscular Electrical Stimulation and Intermittent Pneumatic Compression Therapy
INTRODUCTION In hemiplegic patients, swelling of the affected hand is a recognized phenomenon. The mechanism of swelling is uncertain, but it had many predisposing factors as immobility, dependency, impaired venous return and paralysis of the sympathetic control of vasculature.1 Edema in paretic hand may be attributed to a combination of dependency and insufficient muscle pump resulted from hemiplegia that will hamper venous return in the affected limb which in turn will increase the capillary filtration resulting in edema which can be the main mechanism of hand edema in that cases.3-4
Pain and disfigurement resulted from edema which in chronic cases may predispose to contractures. This combined with the increased weight of the limb, which may interfere with the rehabilitation of the limb and affect hand function 5. Hand edema following stroke is associated with pain and stiffness, which can lead to a decrease in active motion and disuse. The most widely accepted explanation is due to increase venous congestion related to prolonged dependency and loss of muscle pumping function in the paretic limb6. In stroke rehabilitation neuromuscular electrical stimulation (NMES) can be used to modulate neural activity to either regain voluntary muscle contraction
or to prevent abnormal muscle reaction due to weakness and spasticity7 .It was found that application of (NMES) had a significant effect in reducing hand edema post stroke because it produce an active muscle pump resulted in removing excess fluid 8-9. Others studied the application of intermittent pneumatic compression (IPC) in treating hand edema following stroke but they found that (IPC) had a limited role in reducing edema if it used solely1. The aim of this study was to evaluate and compare between effect of application of (NMES) and (IPC) on reducing hand edema and improving hand function in stroke patients. MATERIAL AND METHOD Subject selection Thirty patients of both sexes (18 females and 12 males) who were diagnosed as stroke and referred by a neurologist. All of the participants complained from wrist and hand edema. The mean age was 547 years. They were selected from the out-patient clinic of the faculty of physical therapy, Cairo University. CT was performed for all patients to confirm the diagnosis. All patients had grade 1 to 2 of spasticity according to the modified Ashworth Scale10. Subjects were excluded if they had major cognitive impairment, heart failure, myocardial infarction, lymphedema, or trauma, . The patients were assigned into 2 groups equal in number group I which composed of 15 patients (10 females and 5 males ) and they received (IPC) .Group II composed of 15 patients (8 females and 7 males ) and they received (NMES).
applied over this and attached to the compression pump. The pressure levels were set as an intermittent compression manner which composed of a pressure of 80-120 mmHg for 40 seconds as compression phase and a pressure of 40 mmHg for 20 seconds as deflation phase 1.Each patient in both study groups received treatment once a day, 3 sessions weekly for 12 weeks. The patients in (group II) were given (NMES). The surface electrodes were applied on hand flexor muscle group. This stimulation pattern will be administered to this muscle group for approximately 20 minutes. Electrodes will then be repositioned and applied to the extensor muscle group for approximately 20 minutes. The stimulation was at a frequency of 30 Hz, with a pulse width of 300 s. The amplitude of the current was adjusted to the maximal tolerance of the patient, in a range up to 90 micro ampere , with a duty cycle of 5 second on and 5 second off. The total stimuli were 180 cycles during the treatment session. Patients were focusing on the movement induced by (NMES) during the treatment. Treatment lasted for 30 min., 3 days per week for 12 weeks. The outcome data were measured as follows the volumeter was placed on a horizontal stable surface and filled with tap water to the level of the spout. The patient was asked to lower his hand into the volumeter. This made the water to displace from the spout to be collected into a graduated glass container. The collected water in the graduated container which referred to patients hand volume was measured. For measuring hand grip strength each patient was instructed to start grip strength measures by using digital dynamometer, while elbow flexed 90 degree with hand and forearm in mid position and rested on the table. The measurements were repeated three times and an average measure was taken for the hand volume and hand grip strength. Statistical analysis The data were descriptively analyzed by calculating: Mean Standard deviation. Student t. test was used to compare the mean of pre and post study measurements of hand volume and hand grip strength in each group .The statistical significance difference was determined with P value d0.05.Unpaired t.test was used to compare these findings between study groups. Pairson correlation was used to measure the relationship between hand volume and hand grip strength in each group.
Equipments Volumeter which is used to objectively measure the volume of body parts by using the fluid displacement method1. Hand digital dynamometer was used to measure the grip strength in affected hand to measure the impact of treatment on hand function12. Vasotrain 447, Enraf-Nonius apparatus for application of (IPC). The 2-channel Respond Select II electrical stimulator (Texas, USA) was used for application of (NMES) . Procedures All patients received the same standard physical therapy treatment designed for stroke patients, for 30 min on 3 days each week for 12 weeks, respectively. Group I patients received (IPC) therapy as follows, a stockinet layer was applied to the hemiplegic limb to absorb moisture and a full arm-inflatable sleeve was
RESULTS
I Anthropometric characteristics of both groups: Table (1) Anthropometric characteristics of the patients in the two groups represented in table (1)
Comparison Mean Age Height Weight Male Female BMI 47.5 170.3 83 5 10 23.7 Group I SD 6.1 5.13 13.4 4.1 48.3 173.9 85.5 7 8 25.6 2.8 Group II Mean SD 4.5 8.4 10.6 0.693 0.432 0.649 0.635 P value
II Comparison between the pre, and post hand, wrist volume and grip strength in group I.
Table (2) shows comparison between the pre, and post hand, wrist volume and grip strength in group I. There was a significant decrease in hand and wrist volume. Also, there was a significant increase in hand grip strength in group I who received (IPC)
Mean hand volume (cm) Pre Post P value **highly significant * significant 469.50 421.40 0.0001** SD (cm) 13.329 19.687 Mean hand grip strength (Newton) 4.33 6.65 0.0475* SD (Newton) 1.49 2.41
III Comparison between the pre, and post hand , wrist volume and grip strength in group II.
Table (3) shows comparison between the pre, and post hand, wrist volume and grip strength in group II. There was a significant decrease in hand and wrist volume. Also, there was a highly significant increase in hand grip strength in group II who received (NMES)
Mean hand volume (cm) Pre Post P value **highly significant * significant 464.67 447.00 0.0032* SD (cm) 15.562 14.938 Mean hand grip strength (Newton) 5.13 7.35 0.0001** SD (Newton) 1.51 1.91
IV comparison between the pre, and post values of hand, wrist edema and hand grip strength in both study groups
Table (4) reveals the pre, and post values of hand, wrist edema and hand grip strength in both study groups. There was statistically significant decrease in hand volume in group I who received (ICP) when compared with group II who received (NMES). While there was statistically significant improvement in hand grip strength in group II when compared with group I. Table (4) comparison between the pre, and post values of hand, wrist edema and hand grip strength in both study groups
Mean hand volume (cm) Group I Pre Post **highly significant * significant 469.50 421.40 Group II 464.67 438.00 0.4060 0.0356* P value Mean hand grip strength (Newton) Group I 4.33 6.65 Group II 5.13 7.35 0.1185 0.0008** P value
84 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 V- Correlation between hand volume and hand grip strength in both study groups: Table (5) There was a statistically significant correlation between hand volume and hand grip strength in group I. While there was none statistically significant correlation between hand volume and hand grip strength in group II.
Group I Hand volume 421.40 Hand grip strength 6.65 -0.6301 0.0118 R P value Hand volume 438.00 Group II Handgrip strength 7.35 -0.3979 0.1588 R P value
**highly significant * significant
Figure (4) Correlation between hand volume and hand grip strength in both study groups
DISCUSSION Edema of the hand is one of the complications that can developed after stroke. The etiology of edema formation might be due to dependency and loss of muscle pump efficiency due to hemiplegia will hamper the return of blood in the veins of the affected limb20. Because there was great contradictions about the effect of both IPC and NMES on reduction of edema in stroke patients hand . So, this study was conducted to help in determination the most effective modality with more prolonged effects on the edema of the hand in stroke patients. The study was performed on 30 stroke patients (18 females and 12 males) complicated with hand and wrist edema. Group I received therapy, while group II received (NMES). Both groups underwent their programs 3 times a week for 12 weeks. The collected data included values of hand, wrist volumes and hand grip strength which were measured before and after the treatment program. Looking for group I, showed reduction of mean value of hand volume from the statistical analysis of data of group I showed improvement of hand edema after three months of treatment. These results can be attributed to the evidence that (IPC) increases venous velocity, reduces edema, enhances fibrinolytic activity and reduces the damaging effect of white cell activity13.
It can also be due to the increased venous and lymphatic return as a result of external pressure on a limb. This external compression not only moves the lymph and fluids along, but also it may spread the intercellular edema over a larger area, enabling more lymph and venous capillaries to become involved in removing the plasma proteins and water 21. The mechanism of improving hand edema by the use of intermittent pneumatic compression therapy can also be explained as intermittent high pressure compression allows limb salvage in patients with hemostasis and limb-threatening ischemia who are not candidates for revascularization.14. The results of this study agree with (Armstrong and Nguyen 2001 )19 who reported that pneumatic compression is an effective tool for the reduction of edema. On the other hand there was contradiction with (Roper et al,1999) 1 in his previous study for the treatment of the edematous stroke hand with intermittent pneumatic compression (IPC)using a pressure of 50 mmHg, applied with 30 sec inflation and 20 sec deflation duty cycle treatment comprised daily for 1 month. This study showed no influence neither on edema reduction nor upper limb function. It seems that good results in our study were obtained because we used higher pressure levels (a pressure of 80-120 mmHg for 40 seconds as compression phase I
and a pressure of 40 mmHg for 20 seconds as compression phase II, deflation) and longer treatment periods (session period was 30 minutes, one session a day, 3 days weekly for 12 weeks). Concerning group II neuromuscular electrical stimulation, their data showed reduction hand volume. However the reduction in hand edema in group II may be resulted from production of an active muscle pump which cause removing excess fluid during application of neuromuscular stimulation induced contraction of the paralyzed muscles 7. Also, application of neuromuscular stimulation resulted in increased muscle bulk and strength. This will also lead to greater capillary density and therefore improved local blood supply and tissue condition17. Neuromuscular electrical stimulation had also been reported to modulate edema by reducing capillary permeability22. The results of the present study were in accordance with Gad e al 16 who reported that application of neuromuscular electrical stimulation can improve selected hand functions and impairment of chronic stroke survivors. This finding was also supported by previous study, which reported reduction in hand volume due to compression and squeezing of venous and lymphatic vessels caused by skeletal muscles contraction that results from the electrical stimulation. These repetitive contractions may promote reabsorption of leakage fluid and proteins with subsequent edema reduction11. Our results demonstrated that there was a significant increase in hand grip strength as an indicator of hand function 12in both groups but this improvement was significantly higher in group II than in group I. These results may be attributed to improving strength, voluntary movement, force production, and functional skill abilities in the upper extremity resulted from application of neuromuscular electrical stimulation15. Thus the present study revealed (IPC) was more significantly effective than NMES in reducing hand edema in stroke patients .Perhaps, this difference resulted from increased venous and lymphatic flow due to application of external compression was higher than that caused by muscle pumping due to electrical stimulation. Although NMES had an effect on reducing capillary permeability this effect didnt cause edema reduction as compression therapy.
RECOMMENDATION It is recommended to use intermittent compression therapy in conjunction with neuromuscular electrical stimulation especially in patients who have been failed in controlling their hand edema with standard therapy modalities. Further studies needed to compare between different types of current stimulation and the summation effect of both therapy modalities. REFERENCES 1. Roper TA, et al. Intermittent compression for the treatment of the edematous hand in hemiplegic stroke: a randomized controlled trial, Age and aging; 1999; 28:9-13. 2. Boomkamp k., et al: post stroke hand swelling and edema: prevalence and relationship with impairment and disability. Clinical rehabililtation; 2005; 19:552-559. 3. Wang JS, et al: Neuromuscular electric stimulation enhances endothelial vascular control and hemodynamic function in paretic upper extremities of patients with stroke. Arch Phys Med Rehabil; 2004; 85:1112-1116. 4. Leibovitz A, et al. Edema of the paretic hand in elderly poststroke nursing patients. Arch Gerontol Geriatr. ; 2007; 44:37-42. 5. Faghri PD, The effects of neuromuscular stimulation-induced muscle contraction versus elevation on hand edema in CVA patients. J Hand Ther; 1997; 10:29-34. 6. Chae J. A critical review of neuromuscular electrical stimulation for treatment of motor dysfunction in hemiplegia. Asst Technol; 2000; 12: 33-49. 7. Maram J, et al. Neuromuscular stimulation after stroke: from technology to clinical deployment. Expert. Rev. Neurother, 2009; 4-9. 8. Ashworth MS and Tardieu .Their Clinical Relevance for Measuring Spasticity in Adult and Pediatric Neurological Populations. Physical Therapy Reviews; 2002; 1: 53-62. 9. Griffin JW, et al .Reduction of post traumatic hand edema: A comparison of high voltage pulsed current, intermittent pneumatic compression and placebo treatments. Phys Ther; 1996; 70; 5:279-285. 10. Alan S. et al. Arm functions after Stroke .An evaluation of grip strength as a measure of recovery and a prognostic indicator. J Neurol, Neurosurg, and Psychiatry; 1989; 52:1267-1272. 11. Vowden K .The use of intermittent pneumatic compression in venous ulceration. Br. J. Nurs. ; 2001; 10; 8: 491-509.
12. Bemellen V, et al .Intermittent high-pressure compression in homeostasis. Arch Surg; 2001; 136:1280-1285. 13. Ziling L and Tiebin Y.Long term effectiveness of neuromuscular electrical stimulation for promoting motor recovery of the upper extremity after stroke. J Rehabil Med; 2011; 43:506510. 14. Gad A.et al. A home based self administered stimulation program to improve selected hand functions of chronic stroke. Neuro Rehabilitation; 2003; 18:215225. 15. Chae J, Yu D. A criical review of neuromuscular electrical stimulation for treatment of motor dysfunction in hemiplegia. Asst Techno; 2000; 12: 33-49. 16. Winsor T. et al .The effect of venous compression
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on the circulation of the extremities. Arch Phys Med Rehab; 1999; 34: 559-565. Armstrong DG, Nguyen HC .Improvement in healing with aggressive edema reduction after debridement of foot infection in persons with diabetes. Arch Surg.; 2001; 135:1405-1409. Boomkamp KH et al, Post stroke hand swelling and edema: prevalence and relationship with impairment and disability .Clinical Rehabilitation; 2005; 19:552-559. Wilkerson J External compression for control of traumatic edema. Phys Sports Med.; 2001; 13(6):97-106. Bettany JA,etal Influence of high voltage pulsed direct current on edema formation following impact injury. Phys Ther; 1990; 70(4):219-224.
A Combination Approach using Manual Therapy and Exercise in the Treatment of Shoulder Impingement Syndrome
Annamma Mathew1, Abedi Afsaneh2 Assistant Lecturer, College of Allied Health Sciences, Gulf Medical University, Ajman, UAE 2 Physiotheapist, Gulf Medical College Hospital and Research Center, Ajman, UAE ABSTRACT The purpose of this case study was to compare the effectiveness of traditional physical therapy interventions of using therapeutic modality and exercise versus a combined approach using mobilization with movement and exercises in the treatment of shoulder impingement syndrome. A total of 5 patients diagnosed with shoulder impingement syndrome were selected from the hospital. Patients then participated in the programs, which were held twice a week for two months. Main outcome measures included 24-hour pain (VAS), shoulder active range of motion (AROM), and shoulder function (SPADI). Repeated-measures analysis indicated significant decreases in pain, improved function, and increases in AROM. The MWM had a higher percentage of change from pre- to posttreatment on pain measures pain (VAS): 0.6 to 0.2 following 4 session treatment, higher percentage of change on the SPADI and in AROM. This study suggests that performing glenohumeral mobilizations with movement (MWM) in combination with a supervised exercise program may result in a greater decrease in pain and improved function although studies with larger samples and discriminate sampling methods are needed. Keywords: Exercise, Glenohumeral Mobilization, Mobilization with Movement.
INTRODUCTION Shoulder impingement syndrome, the most common diagnosis of shoulder dysfunction1, is often de-scribed as shoulder pain exacerbated by overhead activities. Primary shoulder impingement occurs when the rotator cuff tendons, long head of the biceps ten-don, glenohumeral joint capsule, and/or subacromial bursa become impinged be-tween the humeral head and anterior ac-romion. Primary impingement may be due to intrinsic factors: rotator cuff weak-ness2, chronic inflammation of the rota-tor cuff tendons and/or subacromial bursa, rotator cuff degenerative tendi-nopathy, and posterior capsular tight-ness leading to abnormal anterior/supe-rior translation of Corresponding author: Mrs. Annamma Mathew College of Allied Health Sciences Gulf Medical University Ajman, UAE Email: researchdivision2@gmail.com
the humeral head. It may also be due to extrinsic factors: possession of a curved or hooked acro-mion, acromial spurs, or postural dysfunction. Secondary shoulder im-pingement is defined as a relative de-crease in the subacromial space due to glenohumeral joint instability or abnor-mal scapulothoracic kinematics. Commonly seen in athletes engaging in overhead throwing activities, second-ary impingement occurs when the rota-tor cuff becomes impinged on the poste-riorsuperior edge of the glenoid rim when the arm is placed in end-range ab-duction and external rotation. This posi-tioning becomes pathologic during excessive external rotation, anterior cap-sular instability, scapular muscle imbal-ances, and/or upon repetitive over-load of the rotator cuff musculature. Physical therapy has been found to be effective in reducing pain and disability in patients with shoulder impingement. Effective interventions include therapeutic exercises focusing on strengthening the rotator cuff and scapular stabilizing musculature 3, stretching to decrease capsular tightness, scapular taping techniques, and patient education of proper posture.
CASE PRESENTATION The present study was conducted on five female patients, aged 32-45 (mean 39.8 years) with chief complaint of intermittent catching pain on shoulder, complaint of night pain and unable to sleep on involved side, who were diagnosed as having shoulder impingement syndrome. The effect of treatment was assessed based on the following dependent variables: pain intensity measured with VAS scale; pain-active ROM measured with a standard goniometer for flexion and abduction; and a measurement of shoulder function assessed with the Shoulder Pain and Disability Index (SPADI)4-5. These traditional interventions included TENS, posterior capsule stretching, postural correction exercises, and an exercise program focusing on rotator cuff strengthening and scapular stabilization. A manual therapy approach to treating shoulder dysfunction is the Mulligan concept of mobilization with movement (MWM)6. The goal of per-forming MWM is immediate and sus-tained improvement in joint pain and mobility. Mulligans techniques6 entail having the physical therapist apply an accessory mobilization to a peripheral joint while the patient simultaneously generates active movement. This procedure was repeated for a total of 3 sets of 10 repetitions as long as pain-free motion was sustained; if pain commenced during any repetition of any set, the technique was terminated. This technique involved the therapist applying a sustained posterior accessory glide to the glenohumeral joint while the subject simultaneously actively flexed the shoulder to the pain-free endpoint and applied a gentle overpressure force using the contralateral arm. Total abolition of pain during the technique was mandatory; if the patient started to experience pain during active motion, the therapist would investigate different force planes and/or grades of force until pain-free motion was restored.
Table 1. Baseline demographics and pre-treatment means
DVs VAS Flexion Abduction SPADI Age VAS = visual analog scale; SPADI = Shoulder Pain and Disability Index. Mobilisation with Movement 6/10 90 0 80 0 48.6% 39.8 years
The study shows, significant decrease in pain (VAS): 0.6 to 0.2 following 4 session treatment spread over 3 weeks and increases in function (SPADI): 0.48 to 0.25.2 and Abduction ROM: 96 to 166 within 8 session treatment following 5 weeks, compared to traditional intervention, which was done without manual therapy technique.
Table 2. Changes after treatment
DVs VAS Flexion Abduction SPADI Exercise 3/10 150 162
0 0
MWM 2/10 170 0 167 0 15%
34.2%
MWM = mobilization with-movement group; VAS = visual analog scale; SPADI = Shoulder Pain and Disability Index.
The MWM (mobilization with movement) had a higher percentage of change from pre- to post-treatment on pain measures pain (VAS 6/10 to 2/10) following four session treatment, and a higher percentage of change on the SPADI and in AROM. DISCUSSION The purpose of this case study was to describe the effect of exercise therapy combined with manual therapy in treatment of patients with shoulder impingement. It appears that the combined intervention of manual therapy and exercises for five weeks provided significant reductions in pain measures in subjects to those received only modality and exercise alone. It is important to note that the patients underwent traditional physiotherapy for an extended period with minimal improvement. Where as in patients who had undergone physical therapy intervention of manual therapy and exercise their end of treatment assessment score reflected improvement in the symptoms such as significant difference in the VAS, SPADI and AROM. Thus the combined treatment of manual therapy and exercises has proven to be effective in management of shoulder impingement syndrome. CONCLUSION In summary, the physical therapy inter-ventions of Manual therapy base on MWM in combination with an exercise program resulted in decreasing pain and improving function compared to traditional physical therapy intervention.
REFRENCES 1. Millar AL, Jasheway PA, Eaton W, et al. A retrospective, descriptive study of shoulder outcomes in outpatient physical therapy. J Orthop Sports Phys Ther 2006;36:403-14. McClure PW, Michener LA, Karduna AR. Shoulder function and 3-dimensional scap-ular kinematics in people with and without shoulder impingement syndrome. Phys Ther 2006;86: 1075-1090. Belling SAK, Jorgensen U. Secondary impingement in the shoulder. Scand J Med Sci Sports 2000;10: 266-278.
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Williams JW, Holleman DR, Simel DL. Mea-suring shoulder function with the shoulder pain and disability index. J Rheumatol 1995;22:727-32. Ludewig PM, Borstad JD. Effects of a home exercise program on shoulder pain and functional status in construction workers. Occup Environ Med 2003;60:841-849. Mulligan BR. Manual Therapy Nags, Snags, Mwm, etc, 4th editon. Wellington, NZ: Plane View Series Ltd, 1999.
3.
Musculoskeletal Pain among Computer Users

Shweta Keswani1, Lavina Loungni1, Tiana Alexander1, Hebah Hassan1, Shatha Al Sharbatti2, Rizwana B Shaikh3, Elsheba Mathew4 1 MBBS students, College of Medicine, Gulf Medical University, Ajman, UAE 2 Professor and Head, 3Assistant Professor, 4Professor, Department of Community Medicine, College of Medicine, Gulf Medical University, Ajman, UAE ABSTRACT Objective: The objective was to assess muscle pain as an effect of utilizing computers for more than five hours and identify the variables associated with the occurrence of pain and the measures taken to prevent. Methods: It is a descriptive study conducted on 249 subjects in different private organizations in UAE. All those who mentioned wrist, back or neck pain without any pre-existing musculoskeletal problems among those who work on computer for more than 5 hours were included in the study. Questionnaires were distributed to all those who satisfied the inclusion criteria in each of the offices identified. Results: A significant association was noticed between age and wrist pain and no significant association was observed between gender, onset of pain and wrist pain. Higher frequency of back pain was noticed in older age group compared to younger. Neck pain was found to be higher among participants between 60-69 years of age. The incidence of pain in the wrist was more in men than in women and a similar pattern was seen in hand and back pain too. Our study shows a positive relation between sleep hours and musculoskeletal pain. Conclusion: We concluded that wrist, neck and back pain is more prevalent in younger age groups and it increases as the duration of computer use increases. Pain was a problem in majority of people working on computer for more than 5 hours. Keywords: Musculoskeletal pain, Computer users, Duration of computer use INTRODUCTION Musculoskeletal disorders affect all age groups and frequently cause disability, impairments, and handicaps. They consist of a variety of different diseases that cause pain or discomfort in the bones, joints, muscles, or surrounding structures, and can be acute or chronic, focal, or diffuse. In one study among Detroit residents who kept track of daily health symptoms in a diary, musculoskeletal symptoms constituted the most frequent category of health symptoms1. Musculoskeletal disorders (MSDs) are highly prevalent; because of their association with aging, they are likely to become more prevalent as the population ages throughout the world. While many of these disorders are not devastatingly disabling to affected individuals, their prevalence is so great that more mobility and other limitations are accountable to these disorders than to any other type. While much of the substantial cost of these disorders is due to the medical care and medications and other treatments required by patients, the preponderance of costs is due to work loss, which is a frequent consequence of these disorders. Not only do MSDs cause personal suffering and loss of income, but they also cost businesses and affect national economies. Any worker can be affected, yet MSDs can be prevented by assessing work tasks, putting in place preventive measures, and checking that these measures stay effective. Most work-related MSDs are cumulative disorders, resulting from repeated exposure to high or low
Corresponding author: Shatha Al Sharbatti Professor and Head Dept. of Community Medicine Gulf Medical University Ajman, United Arab Emirates P O Box: 4184 Email: shatha_alsharbatti@yahoo.com
intensity loads over a long period of time. However, MSDs can also be acute traumas, such as fractures, that occur during an accident2. These disorders mainly affect the back, neck, shoulders and upper limbs, but can also affect the lower limbs. Some MSDs, such as carpal tunnel syndrome in the wrist, are specific because of their well-defined signs and symptoms. Others are nonspecific because only pain or discomfort exists without evidence of a clear specific disorder3. Different groups of factors may contribute to MSDs, including physical and biomechanical factors, organizational and psychosocial factors, individual and personal factors .These may act uniquely or in combination. An integrated management approach is necessary to tackle MSDs. This approach should consider not just the prevention of new disorders, but also the retention, rehabilitation and reintegration of workers who already suffer from MSDs4. Individuals with musculoskeletal complaints should be evaluated with a thorough history, a comprehensive physical examination, and, if appropriate, laboratory testing. The initial encounter should determine whether the musculoskeletal complaint is (1) articular or nonarticular in origin, (2) inflammatory or noninflammatory in nature, (3) acute or chronic in duration, and (4) localized or widespread (systemic) in distribution5. The present study was conducted to assess the musculoskeletal problems among computer users and rationalize the variables that play a part in the occurrence of the pain and, to
assess the knowledge of face such problems and, to evaluate the measures taken to tackle and prevent musculoskeletal problems. MATERIALS AND METHOD This descriptive study was conducted in the following settings viz. Ajman chamber of commerce building, Alco Shipping Services (Ajman), TNT branch (Deira), Ocean View Real Estate (Dubai), Oman Insurance (Ajman branch), AMB constructions, Gulf Chain, GMU and GMCHRC. Total 249 employees in the above settings participated in the study and the data was collected from 2009 March to 2010 January. We selected all those people who mentioned wrist, back or neck pain without any pre-existing musculoskeletal problems and those who work on computer for 5 hours or more. All those who had previous musculoskeletal problems, and who work less than 5 hours on the computer were excluded. A questionnaire was used for data collection including variables like Age, Sex, Nationality, Smoking status, Alcohol status, Diabetes, People with Wrist, Back and Neck pain. The questionnaires were distributed to different offices, selecting one office at a time to those who used the computer for 5 hours or more and the completed questionnaires were collected within two three days. The whole process was repeated in all the above mentioned offices. The data from the questionnaire was then entered in an excel sheet and analyzed using PASW 18.0 version.
RESULTS
Table- 1. Distribution of wrist pain according to gender, age and duration of computer use
Variables Group Yes Number Gender Age group Male Female 20-29 30-39 40-49 50-59 60-69 Duration of computer use < 5 hrs 5-7 hrs 7-9 hrs > 9 hrs 82 52 61 47 16 10 14 26 55 39 Percent 61.2 38.8 45.5 35.1 11.9 7.5 43.8 40.0 59.8 65.0 Number 73 42 46 34 15 13 07 18 39 37 21 Wrist pain No Percent 63.5 36.5 40.0 29.6 13.0 11.3 6.0 56.3 60.0 40.2 35.0
Table 1 shows distribution of the study subjects by wrist pain and gender. Higher frequency of wrist pain was noticed among females when compared with males. No significant association was noticed between wrist pain and gender (P>0.05). Distribution of the studied sample by wrist pain and age shows a higher frequency of wrist pain was noticed in younger age groups
compared with older ones. Statistically significant association was found between age and wrist pain (P<0.05). Distribution of the studied sample by wrist pain and duration of computer use for the onset of pain shows higher frequency of wrist pain was noticed among worker after working for more than 5 hours. No significant association was noticed between wrist pain and duration for the onset of pain. (p>0.05)
Table 2. Distribution of Back pain according to gender, age, and duration of computer use
Variables Group Yes Number Gender Age group Male Female 20-29 30-39 40-49 50-59 60-69 Duration of computer use < 5 hrs 5-7 hrs 7-9 hrs > 9 hrs 113 72 81 54 25 20 05 17 50 66 52 Percent 61.1 38.9 43.8 29.2 13.5 10.8 2.7 53.1 76.9 71.7 86.7 Number 42 22 26 27 06 03 02 15 15 26 08 Back pain No Percent 65.6 34.4 40.6 42.2 9.4 4.7 3.1 46.9 23.1 28.3 13.3
Higher frequency of back pain was noticed among females compared with males. No significant association was noticed between wrist pain and gender (P>0.05). Higher frequency of back pain was noticed in 50-60 years of age group. No
significant association was found between age and back pain (P>0.05). Higher frequency of back pain was noticed among worker after working for more than 5hours. Significant association was noticed between wrist pain and duration for the onset of pain. (p<0.05) (Table 2).
Table- 3. Distribution of neck pain according to gender, age and duration of computer use
Variables Group Yes Number Gender Age group Male Female 20-29 30-39 40-49 50-59 60-69 Duration of computer use < 5 hrs 5-7 hrs 7-9 hrs > 9 hrs 114 71 80 62 20 16 7 19 45 69 52 Percent 61.6 38.4 43.2 33.5 10.8 8.6 3.8 59.4 69.2 75.0 86.7 Number 41 23 27 19 11 7 13 20 23 08 Neck pain No Percent 64.1 35.9 42.2 29.7 17.2 10.9 40.6 30.8 25.0 13.3
Table 3 - Shows distribution of neck pain by gender. Higher frequency of neck pain was noticed among the studied females compared with males. No significant association was noticed between wrist pain and gender. (P>0.05) Higher frequency of neck pain was noticed in 60-69 years age group. Statistically no significant association was found between age and neck pain. Higher frequency of neck pain was noticed in 60-69 years age group. No significant association was found between age and neck pain. Higher frequency of neck pain was noticed among worker after working for more than 5 hours. Significant association was noticed between neck pain and duration for computer use. (p<0.05). Lowest frequency of headache was noticed in more than 60 years age group. Significant association was found between age and headache. Higher frequency of headache was noticed among the studied females compared with males. Significant association was noticed between headache and gender. (P<0.05). Highest frequency of headache was seen in the age group 30-39 years. Significant association was noticed between headache per week and age group. (P<0.05). The higher frequency of headache was noticed to be twice per week for males and four times per week for females. Significant association was found frequency of headache and gender. Higher frequency of headache was observed among participant who had neck pain. No significant association was found between headache and neck pain (P>0.05). Lower frequency of wrist pain was noticed when ergonomic facilitates were available at work place however no significant association was found between availability of ergonomic facilities at work place and wrist pain (P>0.05). No significant association was found between availability of ergonomic facilities at work place and back pain (P>0.05). Lower frequency of neck pain was noticed when these facilitates were available at work place. Significant association was found between availability of ergonomic facilities at work place and neck pain (P>0.05). No Significant association was found between availability of break in between work and wrist pain (P>0.05). Lower frequency of back pain was noticed when these breaks were available between work. Significant association was found between availability of break in between work and back pain. (P<0.05). No
Significant association was found between availability of break in between work and neck pain (P>0.05). Significant association was found between neck pain and sleep hours. (P>0.05). Higher frequency of people with wrist pain had complained of work affecting sleep. Significant association was found between wrist pain and work affecting sleep (P<0.05). Higher frequency of people with back pain had complained of work affecting sleep. Significant association was found between back pain and work affecting sleep (P<0.05). No Significant association was found between neck pain and work affecting sleep (P>0.05). No Significant association was found between change in posture during work and wrist pain (P>0.05). Lower frequency of back pain was noticed when change in posture applied during work No Significant association was found between change in posture during work and back pain (P>0.05). No significant association was seen between weight gain and breaks between work hours (P>0.05). Higher frequency of diabetics had back pain, but there is no significant association between the two (P>0.05). Higher frequency of diabetics had neck pain, but there is no significant association between the two (P>0.05). Highest frequency of moderate wrist pain was observed with alcohol consumption. There is no significant association between alcohol consumption and severity of pain. Highest frequency of moderate back pain was observed with alcohol consumption. There is no significant association between alcohol consumption and severity of pain. Highest frequency of moderate neck pain was observed with alcohol consumption. There is no significant association between alcohol consumption and severity of pain. Lower frequency of wrist pain was noticed when change in posture applied during work. Significant association was found between change in posture during work and back pain. (P<0.05). Significant association was found between change in posture during work, neck pain and job satisfaction (P>0.05). Lower frequency of neck pain was noticed among job satisfied participants. No significant association was found between neck pain and job satisfaction (P>0.05). Higher job satisfaction was noticed when facilities are available. Significant association was found between facilities and job satisfaction (P<0.05).
Figure 1: Showing distribution of study sample according to nationality
This chart shows the distributions of our study sample to gender. Female population was seen to be higher than the male population. (Fig-3) Figure 4: Showing distribution of study sample according to duration on computer
This chart shows the distribution of our sample according to nationality. The highest frequencies were found to be Indians and the lowest were Iranians. (Fig-1) Figure 2: Showing distribution of study sample according to age group
This chart shows the distribution of our study sample according to the duration on computer. A greater frequency was found among the sample working for more than 5 hours on the computer. (Fig-4) Figure 5: Showing distribution of musculoskeletal pain among the study sample
This chart shows the distribution of our study sample according to age. The highest frequencies were seen in the age groups 20-29 and 30-39 whereas the lowest frequencies were in the higher age groups. (Fig-2) Figure 3: Showing distribution of study sample according to gender
Chart showing the distribution of musculoskeletal pain among the studied sample. It was seen that back and neck pain has a greater frequency while wrist pain was lower. (Fig-5) Figure 6. Distribution of the study sample with frequency of exercise and musculoskeletal disorders
41% of population who exercised twice a month suffered from wrist pain whereas approximately 37% of the population who exercised 4 times a month suffered from back and neck pain.(Fig-6) DISCUSSION As the continuing use of machines and computers increases in todays world there is a need for the general masses to be educated about the increasing incidence of musculoskeletal disorders. Many people have the tendency to overlook all these hazards as trivial and do not get it checked and hence end up with a series of mechanically restricting injuries. MSD ranks first in prevalence as the cause of chronic health problems, long term disabilities and consultations with a healthy professional and ranked second for restricted activity all day and use of prescription medications and drugs. Hence society has come up with the intervention of ergonomics among the working masses. There were many factors that we had to take into consideration for the completion of our study. These were Age, Nationality, Sex, Duration of work, Sleep hours, Pain intensity, Exercise, Diet, Smoking / Alcohol etc. Average duration of computer use in our study was 5 hours. This was in accordance with Bureau of Labour Statistics which said that average time of employees working on computer is 35 hours per week6. Through our study showed that there was a higher incidence of pain among the males and females although affected were not so severe. The incidence of pain in wrist to be more in men (61%) than in women (39%) and a similar pattern was shown in the hand and back pain too. This was not in confirmation with the other studies that we had gone through on MSDs. A study done in Europe found a higher prevalence of disorders in women (45%) than men (39%). This difference could have occurred in the study as they used a larger population for their study whereas our sample size was comparatively smaller. Our study shows a positive relation between sleep hours and musculoskeletal pain similar results was seen in a study by the psychosomatic research7.
CONCLUSION From our study we concluded that wrist, neck and back pain is more prevalent in younger age groups and it increased as the duration of computer use increased. The variables, age, duration of computer use, facilities at work place, sleep hours, diabetes and job satisfaction did play a part in occurrence of pain. The result showed that the commonest complaints were back pain and neck pain. Wrist pain was the least complained when operating on a computer system. Pain was more severe in people working for more than 5 hours. The result of this study can help in preventing occupational injury associated with the use of computer with emphasis on good posture, work station ergonomics.
REFERENCES 1. OSHA [Online]. European Agency for Safety and Health at Work, 2010 [cited 2010 September 20]. Available from URL: http://osha.europa.eu. Gerr F, Marcus M, Ensor CBS, et al. A prospective study of computer users: Study design and incidence of musculoskeletal symptoms and disorders. Am J Ind Med 2002;41:221-35. Pillinger J, Rutherford. Computer and neck pain. Health News 2003;39:12-4. European Agency for Safety and Health at Work [Onine]. Research on work-related low back disorders, 2000 [cited 2010 September 20]. Available from URL: http://osha.europa.eu/en/ publications/reports/204. Uhlenberg P. International handbook of population aging, 1st edition. New York, Springer, 2009;772. US Deprtment og Labour [Onine]. Bureau of labour statistics, 2007 [cited 2010 September 20]. Available from URL: www.bls.gov/ news.releaseiatus.nrO.htm. Akerstedta T, Knutssonb A, Westerholmc P, et al. Sleep disturbances, work stress and work hours: A cross-sectional study. J Psychosom Res 2002;53(3):741-8.
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A Report of Body weight Supported Overground Training in Acute Traumatic Central Cord Syndrome
Asir John Samuel1, John Solomon2, Senthilkumaran3, Nicole D'souza4 Lecturer, Alva's College of Physiotherapy, Moodabidri, India, 2Associate Professor, Department of Physiotherapy, Manipal College of Allied Health Sciences, Manipal University, Manipal, India, 3Associate Professor, Department of Physiotherapy, Manipal College of Allied Health Sciences, Manipal University, Manipal, India, 4Neurophysiotherapist, Parkinson's Disease & Movement Disorder Society, Mumbai, India
1
ABSTRACT Study design: A case report of a patient with Traumatic Central Cord Syndrome (TCCS) Objective: To analyse the benefits of BWSOT in early ambulation and gait performance. Setting: Tertiary care, University teaching hospital. Methods: A 25-year old man with TCCS at the C4 level, grade B on the American Spinal Injury Association (ASIA) Impairment Scale (AIS) participated in BWSOT. Following the immobilization phase, he underwent two BWSOT sessions per day (20 minutes each), six days a week, for three weeks. AIS motor score, 10-m walk test, Walking Index for Spinal cord Injury-version II (WISCI-II), Spinal cord Independence Measure-version III (SCIM-III) and Functional Independence Measure (FIM) were recorded at the time of initiating of BWSOT and at the end of three weeks. He received regular physiotherapy and occupational therapy during the entire hospital stay. Results: Three weeks of BWSOT resulted in an increase in all the outcome measures. At the time of initiating BWSOT, AIS motor score, 10-m walk test, WISCI-II, SCIM-III and FIM were 45/100, 3 min 14 sec, 3/20, 30/100 and 60/126 and by the end of three weeks, they were 68/100, 1 min 41 sec, 17/20, 50/100 and 72/126 respectively. Conclusion: BWSOT may allow therapists to initiate gait training programs at an earlier stage among those with stable TCCS with promising outcomes. Keywords: Spinal Cord Injury, Central Cord Syndrome, Overground Training, Gait Training, Rehabilitation, Locomotor Training.
INTRODUCTION Traumatic Central Cord Syndrome (TCCS) is the most common incomplete Spinal Cord Injury (SCI) with the incidence varying from 15.7% to 25%.1 As the lower limbs (LL) are less affected, early gait training can be initiated. However, poor trunk control is a major obstacle in achieving this goal. This can be overcome by stabilizing the trunk using a body weight supported approach. To date, only a limited number of studies have compared the benefits of task specific activities like body Corresponding author: D. A. Asir John Samuel Lecturer, Alva's college of Physiotherapy, Moodabidri - 574 227, South Canara District, Karnataka, India. Contact No. +91 9481939806 Email: asirjohnsamuel@gmail.com
weight supported treadmill walking and BWSOT in incomplete SCI. However, the use of BWSOT has not been documented in incomplete TCCS. CASE REPORT A 25-year-old male presented with severe neck pain and quadriplegia after sustaining a fall from a height of 15m. He was managed conservatively and referred to the Neuro Rehabilitation Unit within 24 hours of injury. The patient was examined at the time of referral by a qualified physiotherapist. His vitals were stable. Neurological examination revealed normal higher functions and cranial nerves. His tone was flaccid in the upper limbs (UL) and increased in the LL at this time. Sensory and muscle power evaluation revealed a sensory and motor level of C4 with sacral sparing. American Spinal Injury Association Impairment Scale (AIS), motor score was 10/100 comprising 0/50 for UL and 10/50 for LL. Using AIS he was graded as AIS B. Deep tendon reflexes were absent in the UL and brisk
in the LL. He had a flaccid bladder for which he was catheterized. His cervical spine x-ray showed no bony abnormalities. Magnetic Resonance Imaging showed an area of increased signal intensity on the T2-weighted images of the sagittal sections of the cervical cord. He was immobilized with a Philadelphia collar for two weeks during which time he received conventional physiotherapy. By the end of 4th week ASI motor score improved to 45/100 with normal sensation below the level of lesion bringing him to AIS grade C. As trunk has not improved compared to lower limbs, we looked for the method to make him walk which provide supports to trunk. Hence we devised Body weight supported overground training (BWSOT) system. Fig 1 shows the BWSOT which consists of overhead suspension system and harness to support a percentage of the patients body weight as the patient walks on a parallel bar and progressively decreasing the amount of body weight supported as the gait pattern improves. The body weight unloading is high in the beginning of training and decreased gradually. The harness was attached to an overhead suspension, usually a system composed of ropes and pulleys (rope-and-pulley system) connected to a counterweight. A counterweight was used to dynamically unload part of the patients body weight.
sessions per day (20 minutes each), six days a week, for three weeks. Baseline and at the end of 3 weeks training of AIS motor score, 10-m walk test, WISCI-II, SCIM and FIM were recorded and showed improved in all the outcome measures. By 8th week he was able to walk with minimal pelvic support, Fig 2. At the time of discharge he was graded on AIS as AIS D with normal bladder function.
Fig. 2. Ambulation at the time of discharge.
DISCUSSION
Fig. 1. Gait training using BWSOT with pelvic support (a) anterior view and (b) posterior view.
Informed consent was obtained from the patient prior to initiating therapy. He performed two BWSOT
This case study highlights three important findings. First, BWSOT found to accelerate the improvements resulted in improved muscle power, gait speed, and functional independence. Second, this set up uses a
98 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 Table 1: Outcome of the patient following BWSOT
Weeks 1 4 7 ASIA MS 10/100 45/100 68/100 10-m WT NA 3 min 14 sec 1 min 41 sec WISCI-II 0/20 3/20 17/20 SCIM-III 10/100 30/100 50/100 FIM 50/126 60/126 72/126
Abbreviations: ASIA MS, America Spinal cord Injury Association Motor Score; WT, Walk Test; WISCI-II, Walking Index for Spinal cord Injury-version II; SCIM-III, Spinal cord Independence Measure-version III; FIM, Functional Independence Measure.
simple and inexpensive device which can be used in small set up. Third, it reduces the risk of secondary complications. Improvements seen in muscle power, gait and function could be due to the normal neurological recovery process due to the decrease in cord edema.2 However; the addition of BWSOT initiated within three weeks of injury could have augmented the observed changes. In developing countries, the uses of cost effective methods, which produce significant results with regard to patient outcomes are important. This simple and inexpensive device appears to play a vital role in improving the quality of rehabilitation and also in facilitating early mobilization which would in turn probably be cost-effective. Cervical cord injuries have a higher risk of secondary complications.3 Early mobilization and gait training using the BWSOT may have a role in preventing these complications. However, larger studies with long term follow up will be required to test this hypothesis. CONCLUSION This case highlights the importance of BWSOT in early rehabilitation of patients with stable TCCS in
initiation of gait training programs, as early as three weeks post injury. ACKNOWLEDGEMENT The authors express special thanks Abraham Samuel Babu, MPT, FCR, (PhD) for content review. Conflict of Interest The authors declare no conflict of interest and have no disclosures. REFERENCES 1. McKinley W, Santos K, Meade M, Brooke K: Incidence and outcomes of spinal cord injury clinical syndromes. J Spinal Cord Med 2007, 30: 215-224. Uribe J, Green B, Vanni S, Moza K, Guest J, Levi A. Acute traumatic central cord syndromeexperience using surgical decompression with open-door expansile cervical laminoplasty. Surg Neurol. 2005; 63:505510. Sekhon HS, Fehlings M G. Epidemiology, Demographics, and Pathophysiology of Acute Spinal Cord Injury. Spine 2001; 26: S2-S12.
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Effects of Ischemic Compression on the Trigger Points in the Upper Trapezius Muscle
Bhavesh H. Jagad, Karishma B. Jagad Lecturer, Shri K. K. Sheth Physiotherapy College, Rajkot, Gujarat, India ABSTRACT Background and Purpose of The Study: A myofascial trigger point has been described as a hyperirritable spot, usually within a taut band of skeletal muscles or in the muscles fascia. The myofascial trigger point in the upper trapezius is most commonly found at the midpoint of the upper boarder of the muscle. The objective of the study is to determine the effectiveness of ischemic compression for the treatment of myofascial trigger points in upper trapezius. Method: 30 subjects were randomly assigned to either treatment group (group 1) or a control group (group 2). Subjects in group 1 received ischemic compression on the primary trigger point followed by stretching of the upper trapezius muscle. Subjects in group 2 received active neck exercise followed by stretching. All the patients of group 1 and 2 received treatment for 7 days. Pressure Pain Threshold (PPT) measured by pressure algometer was used to measure trigger point sensitivity and Visual Analogue Scale(VAS) was scored as a measure of pain intensity on day 1 and day 8 in both the groups. Results: In the treatment group (group 1) significant improvement was evident in the pressure pain threshold values (t=7.02, p<0.05), however no such improvement was found in the control group (group 2). Comparison between the two groups also showed significant difference in the pressure pain threshold measurement. Significant improvement was noted in the visual analogue scale score of group 1 (T=120, p<0.001) and group 2 (T= 66, p<0.001) both; however greater improvement was noted in treatment group (group 1). Conclusion: Ischemic compression technique is highly effective in reducing the trigger point sensitivity and pain intensity in the trapezius muscle. Keywords: Ischemic Compression, Upper Trapezius, Trigger Point.
INTRODUCTION Neck pain is very commonly shown by most people to be in the region of the back of the neck and between the bases of the neck to the shoulder, primarily indicating the region of the trapezius muscle1. About two thirds of people will experience neck pain at some time.2,3 Prevalence is highest in middle age with women being affected more the men. The prevalence of neck pain varies widely between studies, with mean point prevalence of 13% (range 5.9 38.7%) and mean lifetime prevalence of 50% (range 14.2 71.0%). In some industries neck related disorders account for as many days of absenteeism as low back pain4,5. The myofascial trigger point in the trapezius is most commonly found at the midpoint of the upper border of the muscle. It has been described as a hyperirritable
spot, usually within a taut band of skeletal muscles or in the muscles fascia. The spot is painful on compression and can give rise to characteristics referred pain, tenderness and autonomic phenomena.6 There is pain with passive or active stretching of the muscles and limited range of motion.6,7 Several trigger point treatment methods have been studied for effectiveness. These methods include injection or dry needling 8,9 , spray and stretch 10 , transcutaneous electrical nerve stimulation (TENS)31,41,42, and post isometric relaxation43. Injection and spray and stretch are reported as the most common forms of therapy for trigger points.6,11,12,13,14 Ischemic compression has been studied by several authors to treat myofascial pain, fibromyalgia and paraesthesias. It is a non invasive technique and does
not produce muscle soreness. However due to difference in study population and outcome measures used to assess the effectiveness, there is lack of rigorous evidence for use of ischemic compression in clinical practice. The objective of the study is to determine the effectiveness of ischemic compression for the treatment of myofascial trigger points in upper trapezius. MATERIALS & METHOD Subjects The study was conducted in Shri K. K. Sheth Physiotherapy College, Rajkot, India. 30 volunteer subjects who participated in the study were selected from the patients attending OPD department of the college. EXCLUSION CRITERIA -History of orthopedic surgery to neck or back -Cardiovascular or neurological conditions -Clotting disorders and -Treatment of myofascial pain or trigger points at the time of the study. INCLUSION CRITERIA -A palpable tender spot in the neck or upper back -Reproduction of the subjects pain upon palpation -A jump sign characterized by patient vocalization or withdrawl5, 7 INSTRUMENTATION The pressure algometer was used in the study to measure pressure pain threshold as an index of trigger point sensitivity. It is a reliable technique, demonstrating high interrater and intrarater reliability.15,16,17 Figure-1
Form, and Assessment Form. METHOD An experimental study was conducted to study the effectiveness of ischemic compression on the trigger points in trapezius muscle. Each subject was randomly assigned to treatment group (group 1) and control group (group 2). The subject was required to complete the informed consent form. Then the subject was asked to mark a visual analogue scale with the average pain intensity for their pain over past 24 hours. The subjects were then acquainted with the sensation of pressure algometer on an unaffected part of the body before testing for pressure pain threshold of primary trigger point. The pressure algometer was placed perpendicular to the area to be tested, increasing the pressure steadily at the rate of approximately 1 Kg/sec. Examiner palpated the region of trapezius and marked all the trigger points that matched the inclusion criteria with a non permanent marker. Pressure pain threshold was measured for each marked trigger point. The trigger point with the lowest pressure pain threshold was considered as primary trigger point and was marked with Reynolds permanent marker. Figure-2 Placement of Algometer for Measurement of PPT
A Visual Analogue Scale was used to measure intensity of the subjects pain. Other materials used include Reynolds Marker, Kodak C875 Zoom Digital Camera, Paper, Pen, Consent
Group 1 - With the patient in comfortable sitting position on an armless chair and both feet firmly planted on the floor, gradual pressure was applied to the primary trigger point using the right thumb with the left thumb reinforcing it from the top. The patient was asked to side bend the neck to the opposite side in order to place mild stretch on the primary trigger point. Pressure was gradually increased to produce localized discoloration as well as symptoms in the target area. The same pressure was held till the patient reported
easing of local and referred pain followed by a release of 10 seconds. The same sequence of ischemic compression was repeated three times per session with the pressure of ischemic compression increasing as the patients tolerance increased.7,18 Ischemic compression was followed by sustained stretch to the upper trapezius. The stretch was maintained for 30 seconds followed by rest of 10 seconds. The procedure was repeated 5 times per session. Group 2 - The patients were asked to perform active neck flexion, neck lateral flexion, neck extension and neck rotation while seated near the edge on an armless chair with both the feet firmly planted on the floor. The patients performed these exercises 10 times each. Sustained stretch to the upper trapezius was given in the same manner as described above. All the patients of group 1 and 2 received treatment for 7 days. No treatment was given on the 8th day to determine the short term effects of the intervention without confounding effects from the treatment just completed. On day 8, the therapist again obtained measurements for each subject A Pressure Pain Threshold measurement of primary trigger point and a visual analogue scale score for the average pain intensity for the past 24 hours were recorded. RESULTS Wilcoxon signed rank test, wilcoxon sum rank test and students T test were used to analyze the data. The paired and unpaired t-tests were performed using SPSS statistics 17.0
Table 1. Gender distribution of 30 subjects who participated in the study.
Gender Male count% Female count% Total Group 1 533% 1067% 15 Group 2 533% 1067% 15
Table 2. Mean age of subjects in group l and group 2

Group 1 Mean age(Years) 28.73 Group 2 29.53
There was no significant age difference seen across two groups Pretreatment and post treatment means and SD of PPT value and VAS score of each group are shown in chart 2 and chart 3 respectively. The scores reflect greater improvement for group 1 than for group 2 on all the variables. Chart-1 Raw score Means for Pre-treatment and Post-treatment PPT of group 1 and group 2
Chart-2 Raw score Means for Pre-treatment and Post-treatment VAS of group 1 and group 2
Table 3. Calculated and Observed t values for difference of PPT within and between group 1 and group 2
CALCULATED Group 1 (t14) Group 2 (t14) Between Groups 1&2 (t28-) 6.910 1.871 6.40 OBSERVED 2.15 2.15 2.05 P<0.001 P>0.05 P<0.001 Highly significant Not significant Highly significant
Table 4. T value calculated by Wilcoxon Signed Rank Test for group 1 and group 2
VA S Group 1 Group 2 T value 120 66 Probability (P) <0.01 <0.01
102 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 Table-5 z value calculated by Wilcoxon Rank Sum Test for between group comparison
Score VA S z value 3.44 Probability (P) <0.0003
does not produce post treatment soreness or hemorrhage. Stretching of the affected muscle is believed by some -authors to be an integral part of trigger point therapy. 6,10,13,14,25 Techniques like post isometric relaxation, strain/ counter strain, reciprocal inhibition, passive stretching of the affected muscle and spraystretch have been found to be effective in reducing the pain intensity and trigger point sensitivity.7,18,26 Simons (1981) hypothesized that stretching a muscle releases the locked actin and myosin heads, allowing the ATP to form. The ATP allows the sarcoplasmic reticulum to return to normal and circulation to improve.27 However the stretch works better when there are nerve impulses from the skin being sent to the brain and inhibiting the reflex pathway that produces trigger point activity and pain messages. These conflicting skin impulses are most viewed as a sustained stretch to a specific point in the muscle and it gets right to the tight or restricted area in a muscle. The conclusion would seem to be that stretching alone is not enough but that as an adjunct to ischemic compression it is helpful. The present study demonstrates significant improvement in pain intensity and pain threshold in group 1 treated with ischemic compression and trapezius stretching compared to group 2 treated with active neck exercises and trapezius stretching. Research in 1993 by Hong et al lends credibility to the statement that ischemic compression is superior to other physical medicine modalities for treating trigger points. Similar result has been obtained by Jamie Dearing (2007)28 CONCLUSION The results of this study indicate that ischemic compression is highly effective in the short term management of trigger point in the upper trapezius by reducing the trigger point sensitivity and average pain intensity. Limitations And Future Suggestions The study did not examine effectiveness relative to any other outcome such as functional limitation or disability. The long term effects of the ischemic compression on the trigger point sensitivity needs to be investigated further. The study includes a small sample size The duration of pain relief associated with the
DISCUSSION Point prevalence of neck pain is nearly 13%19,20 and lifetime prevalence is 50%.21 In females, the fiber-type distribution pattern of trapezius is similar to male but the mean cross-sectional area of the fibers is considerably smaller. The significantly smaller crosssectional fiber area, which indicates a lower functional capacity, may be of importance in the development of neck and shoulder dysfunction in females. 22 Researchers also found that shoulder abduction torque and trapezius EMG amplitude were significantly lower in the women with myalgia compared with those without the muscle pain.23 Higher incidence of neck pain in female population can be accounted for the higher number of female subjects in the present study. Garvey et al found injection of a local anesthetic, injection of a local anesthetic plus steroid, acupuncture (dry needling), and acupressure with vapocoolant spray to be effective in relieving pain.8 This conclusion is also supported by authors like Rubin D (1981)12 Imich D et al (2002)24 and Hong C (1994)9. Garvey et al reported that the acupressure plus vapocoolant spray was the most effective at relieving pain. This led them to propose that relief is likely due to mechanical stimulation of the trigger point by the needle or the acupressure, not the injection of a particular substance. Hong C also suggested that, local vasodilatation and removal of metabolites along with mechanical disruption of abnormal functioning of contractile elements or nerve endings is responsible for trigger point inactivation by injection method. However the treatment involves invasive procedure and to the varying degree produces post injection soreness and muscle necrosis. When ischemic compression is used on the trigger points, local chemistry changes due to blanching of the nodules followed by hyperemia when the compression is released. This flushes out the muscle inflammatory exudates and pain metabolites, breaks down the scar tissue, desensitizes the nerve endings and reduces the muscle tone. Thus the ischemic compression has essentially the same mechanism of action on the trigger point as the injection therapy. However ischemic compression is a non invasive technique that
control of contributing factors to the development of trigger point needs to be investigated. REFERENCES 1. 2. Jennifer Chu, Neck Pain- Trapezius, http:// ezinearticles.com/?expert=Jennifer Chu Makela M et al, Prevalence, Determinants, And Consequences Of Chronic Neck Pain In Finland, Am J Epidemiol 1991; 134: 1356-1367. Cote P et al, The Saskatchewan Health and Back Pain Survey: The Prevalence of Neck Pain and Related Disability in Saskatchewan Adults, Spine 1998; 23:1689-1698. Fejer R et al, The Prevalence Of Neck Pain In The World Population: A Systematic Critical Review Of The Literature, Eur Spine J 2006;15: 834848. Peter D Aker, Anita R Gross et al, Conservative Management of Mechanical Neck Pain: Systematic Overview and Meta-Analysis, BMJ 1996; 313: 1291-1296. Travell JG et al, Myofascial Pain and Dysfunction: The Trigger Point Manual, The Upper Extremities, Baltimore, Md: Williams & Wilkins, 1983: 5-90. Siobahn Maguire, Myofacial Therapy And Podiatry: A Literature Review http:// p o d i a t r y. c u i t i n . e d u . a u / encyclopedialmyofascial/#intro Garvey TA et al, A Prospective, Randomized, Double-Blind Evaluation Of Trigger-Point Injection Therapy For Low-Back Pain, Spine, 1989, 14: 962-964. Hong C, Lidocaine Injection Versus Dry Needling To Myofascial Trigger Point: The Imvortance Of The Local Twitch Response, Am J Phys Med Rehabi1, 1994,74: 262-263. Jaeger B et al, Quantification Of Changes In Myofascial Trigger Point Sensitivity With The Pressure Algometer Following Passive Stretch, Pain, 1986, 27:203-210. Grosshandler SL et al, Chronic Neck and Shoulder Pain: Focusing On Myofascial Origins, Postgrad Med, 1985,77: 149-158. Rubin D, Myofacial Trigger Point Syndromes: An Approach To Management: Arch Phys Med Rehabil, 1981 Mar; 62(3): 107-110. Fricton JR, Management of myofascial pain syndrome. In: Fricton JR, Awad EA, eds., Advances in Pain Research and Therapy, NY: Raven Press; 1990, 17: 325-346. McClaflin RR, Myofascial Pain Syndrome: Primary Care Strategies for Early Intervention, Postgrad Med, 1994, 96: 56-73.
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15. Reeves JI et al, Reliability Of The Pressure Algometer As A Measure Of Myofascial Trigger Point Sensitivity, Pain, 1986, 24: 313- 321. 16. Fischer AA, Documentation of Myofascial Trigger Points, Arch Phys Med Rehabil, 1988, 69: 286-291. 17. Stuart Cathcart et al, Reliability Of Pain Threshold Measurement In Young Adults: The Internet Journal Of Pain, Symptom Control And Palliative Care, 2005, 4. 18. Leon Chaitow, Integrated treatment of myofascial trigger points, http://www.healingpeople.com/ i n d e x . p h p ? o p t i o n = c o m content&task=view&id=361&itemi 19. Bovim G et al, Neck Pain in The General Population, Spine 1994, 19:1307-1309. 20. Van der et al,The Associations Of Neck Pain With Radiological Abnormalities Of The Cervical Spine And Personality Traits In A General Population. J Rheumatol1991, 18: 1884-1889. 21. Peter D et al, Conservative Management Of Mechanical Neck Pain: Systematic Overview And Meta-Analysis, BMJ, 1996, 313: 1291-1296. 22. R. Lindman et al, Fiber type composition of the human female trapezius muscle: Enzymehistochemical characteristics, Am J Anat, 2005, 190: 385-392 23. Kristen J. Light, Exertion Provokes Pain In Myalgia Patients, BioMechanics Archives, 2008. 24. Irnich D et al, Is Acupuncture At Distant Points Really Superior To Dry Needling Of Trigger Points In Chronic Neck Pain?, pain, 2002, 83: 991-992. 25. Fricton JR, Clinical Care For Myofascial Pain, Dent Clin North Am, 1991, 35: 1-28. 26. Lewit D et al, Myofascial Pain: Relief by PostIsometric Relaxation, Arch Phys Med Rehabil, 1984, 65: 452456. 27. Simons D, Myofacial Trigger Points: A Need for Understanding, Arch Phys Med Rehabil, 1981, 62: 97-99. 28. Jamie Dearing, An Examination Of Pressure Pain Threshold At Myofacial Trigger Points Following Muscle Energy Technique Or Ischemic Compression Treatment, Chiropractic, Osteopathy and Physiotherapy Annual Conference, 2007, 4: 14. 29. Fricton JR, Myofascial Pain Syndrome: Characteristics and Epidemiology. In: Fricton JR, Awad EA, Advances in Pain Research and Therapy, Vo117, NY: Raven Pres; 1990: 107-127. 30. Simons DG, Muscular Pain Syndromes, In: Fricton JR, Awad EA, eds. Advances in Pain Research and Therapy, Vol17, New York, NY: Raven Press; 1990: 1-41.
31. Han SC et al, Myofascial Pain Syndrome and Trigger-Point Management, Reg Anesth, 1997, 22: 89-101. 32. Travell JG et al, Letter to The Editor, Pain, 1981, 10: 106109. 33. Travell JG, Myofascial Trigger Points: Clinical View, In: Bonica JJ, Albe-Fessard D, Eds., Advances In Pain Research and Therapy, NY: Raven Press; 1976, 1: 919-926. 34. Nice D et al, Intertester Reliability Of Judgements Of The Presence Of Trigger Points In ..T.. )patients
With Low Back Pain, Arch Phys Med Rehabil, 1992, 73: 893-898. 35. Graff-Radford SB et al, Effects Of Transcutaneous Electrical Nerve Stimulation On Myofascial Pain And Trigger Point Sensitivity, Pain, 1989, 37: 1-5. 36. Melzack R, Prolonged Relief Of Pain By Brief, Intense Transcutaneous Somatic Stimulation, Pain, 1975, 1: 357-373. 37. Hameroff SR et al, Comparison Of Bupivacaine, Etidocaine, And Saline For Trigger-Point Therapy, Anesth Analg, 1981, 60: 752-755
Prevalence of Upper Limb Dysfunction in Subjects with Chronic non Specific Neck Pain in Bangalore City, Karnataka
Kinchuk DB1, Soumya G2, Payal D3 Student, MSc. Clinical Physiotherapy, International School of Physiotherapy, a Collaborative Programme of Gokula Education Foundation and Coventry University, Bangalore, Karnataka, 2Lecturer, International School of Physiotherapy GEF - CU Collaborative Programme Bangalore, 3Lecturer, International School of Physiotherapy GEF - CU Collaborative Programme Bangalore.
1
ABSTRACT Study design: Cross sectional study Objective: To find out the prevalence of upper limb dysfunction in subjects with non specific neck pain. Summary of the background data: Non specific neck pain is highly prevalent in women particularly of working age. Upper limb disorder and disability/ dysfunction are one of the most important factors that have been discovered in the management outcome for nonspecific neck pain. Single Arm Military Press (SAMP) test has been used to measure the level of upper limb dysfunction in neck pain population. With a high prevalence of non specific neck pain in India either due to their occupation or age it becomes important to quantify the rate of upper limb dysfunction in Indian population in their working environment so that further measures can be taken to address upper limb dysfunction in the course of management of non specific neck pain. Method: Seventy two (72) subjects fulfilling the inclusion criteria and exclusion criteria were taken up for the study. The upper limb dysfunction was measured for all the subjects for both the hands. Descriptive statistical analysis was carried out for this study. Results on continuous measurements are presented on Mean SD (Min-Max) and results on categorical measurements are presented in Number (%) with level of significance set at 0.05. The comparison between the categorical measurements has been analyzed using one sample t- test. Results: Of the 72 subjects 93.1% had upper limb dysfunction as determined by the test scores. The mean and standard deviation of SAMP score for the right hand was 20.44 5.25 and for the left hand it was 18.49 4.49. The comparison between the mean scores of right and left upper limb was done to show a cumulative finding using one sample t- test and it was found to be statistically significant (p < 0.001). Conclusion: Upper limb dysfunction has been found to be highly prevalent in subjects with non specific neck pain working women in Bangalore city, India. Keywords: Ischemic Compression, Upper Trapezius, Trigger Point.
INTRODUCTION Non specific neck pain is a common occurrence in general population and the incidence appears to be rising1,2 .Most of the working aged women have been complaining of neck pain to the physicians 3,4 and the frequency has increased since past two decades 5,6. Women are found to be having lower strength of their neck muscles when compared to men 7,8,9,10. There is evidence to understand the relationship between the neck pain and upper limb dysfunction as summarized by McLean et al. 11. Any mechanical loading of the articular structures results in a protective
spasm that invariably restricts the upper limb in performing its functions. Static positioning of the upper limbs during working like using computers could lead to deconditioning of the upper limb eventually reducing the strength and endurance 12. The Single Arm Military Press (SAMP) test, which is strength and endurance performance based outcome measure, is more valid and reliable tool than DASH to quantify the level of upper limb dysfunction 13. UK Studies have found 67% of the population suffering from non specific neck pain having problems regarding upper limb functions14.
Despite the high prevalence of neck pain in India, limited literature is available regarding the presence of upper limb dysfunction among neck pain population. Thus, the present study intends to find out the prevalence of upper limb dysfunction among subjects with non specific neck pain by evaluating the strength and endurance of upper limb using SAMP test. MATERIALS AND METHOD Methods Of Data Collection Method of sampling : Type of the study Sample size Inclusion criteria Mechanical/non specific neck pain Chronic pain (i.e., should have had pain more than 3 months) No disabling pain at the time of study Working women (age 30-55 years) No previous physiotherapy treatment taken English speaking : : Convenience sampling Cross sectional 72 (seventy two)
the respective institutions. All the participants were provided with a copy of the detailed informed consent form. Purpose of the study was explained and a written informed consent was obtained from the subjects. Seventy two women of age ranging between 30 to 55 years fulfilling the inclusion criteria and exclusion criteria were taken up for the study. Following a formal introduction, a brief demographic data of the subjects participating in this study was noted. The procedure of the SAMP test was explained and demonstrated. This test required the subjects to complete as many repetitions of the SAMP technique as possible within 30 seconds using a 3kg weight [see figures (1) and (2)] with both the upper limbs separately. All participants were instructed to do the test as fast as possible but could stop and start at anytime during the 30 seconds, though the timing continues. This was one time performed technique and the cut off number of repetitions was 25, the number of repetitions subjects were able to do was documented. MEASURES To assess the baseline dysfunction of upper limb in subjects with neck pain a performance based outcome measure was used viz., Single Arm Military Press (SAMP) test. This SAMP test has a cut off point i.e. 25. This means that the scoring less than 25 was considered to be having upper limb dysfunction amongst the subjects and a score of 25 and above meant the subject did not have upper limb dysfunction. MATERIALS REQUIRED A set up was organized taking the participants privacy into consideration in the various working institutions for the study. Three kilogram dumbbell and a stop watch along with documentation sheet were arranged. STATISTICAL METHOD Descriptive statistical analysis has been carried out for the present study. Results on continuous measurements (i.e. Age and score of right and left upper limb) are presented on Mean SD (Min-Max). Percentage enumeration has been carried out for categorical measurements (presence of upper limb dysfunction) as significance is set 0.05. The comparison between the categorical measurements has been analyzed using one sample t- test. The following assumptions on data are made, Assumptions: 1. Dependent variables should be normally distributed, 2. Samples drawn from the population should be random, and 3. Cases of the samples should be independent.
Exclusion criteria Traumatic neck pain e.g., whiplash associated disorder Old/recent trauma to the shoulder, elbow and hand Acute neck pain (less than 3 months) Cervical spondylosis Radiculopathy Neurogenic pain Any other systemic illness Psychological disorders
Procedure of data collection A cross sectional study on 72 symptomatic subjects with non specific neck pain was carried out in various institutions in Bangalore city, India. The institutions included primary and secondary school, private workplace, private hospitals and clinical diagnostic centres. An ethical clearance for Research study was obtained from M S Ramaiah Medical College and Hospital, Bangalore, Karnataka, India. Approval for conducting the study was taken from the Principals of
Fig.1. Start position for SAMP test showing (a) anterior view and (b) lateral view
Fig. 2. Finish point for SAMP test showing (a) anterior view (b) lateral view
RESULTS The basic demographic characteristics of the study population: All the seventy two subjects were working symptomatic females of middle age ranging from 30 55 years (Mean 40.09 7.029 SD), right hand dominant.
Table 1: mean and standard deviation (MIN-MAX) of age.
Age (years) 30- 55yrs Mean SD 40.09 7.029
Table 2: SAMP score of right upper limb in percentage.

Right SAMP Score % of subjects with score (d24) 57 (79.2%) % of subjects with score (e25) 15 (20.8) 72 (100.0%) Total number of subjects
Table 1. Shows the mean and standard deviation of the age of the subjects who participated in the study.
Table 2. Shows the Percentage of scores of right upper limb of the subjects who participated in the study. Out of 72 (100%) subjects 57 (79.2%) of them had a score less than equal to 24 and 15 (20.8%) of them had score more than equal to 25.
108 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 Table 3: SAMP score of left upper limb in percentage.
Left SAMP Score % of subjects with score (d24) 65 (90.3%) % of subjects with score (e25) 7 (9.7%) 72 (100%) Total number of subjects
measure. The ones who performed repetitive action less or equal to twenty four (d24) were considered to have upper limb dysfunction and the ones who out performed this test twenty five or more (e25) times were considered to be not having any upper limb dysfunction. The results suggests that middle aged working women with chronic non specific neck pain presents with upper limb dysfunction with the percentage prevalence of 93.1% (67 subjects) and without upper limb dysfunction percentage prevalence of 6.9% (5 subjects) after combining the mean scores of both right and upper limb (Refer Table 5). This finding is in accordance with the literature that concluded that women older than 37 years of age independent of occupation were susceptible of acquiring chronic neck pain which could probably result in upper limb dysfunction 15,16,17 Studies have shown that with increase in age there will be a steady drop in SAMP test score11 and the assessment of work and non work related factors particularly in women is essential18. Since the present study was just to find the prevalence of upper limb dysfunction in non specific neck pain population, no other outcome measures were used other than SAMP test. This study suggests performing a detailed biomechanical and functional analysis of the specific area of problem (neck) as well as associated part (upper limb) of the musculoskeletal system, in order to plan out a rehabilitative protocol / strategy for any working individual with neck pain. Further studies can be done by Considering larger subjects with similar condition. Comparing upper limb dysfunction in dominant and non dominant hand. Further validating the clinical use of SAMP test as an outcome measure of upper limb dysfunction/ disability. ACKNOWLEDGEMENT I would like to extend my gratitude towards our Course Coordinator Prof. Savita Ravindra, Course Director Dr. Sudha Suresh, Associate prof community department Dr. Nanda Kumar B.S., internet search engines Google Scholar, PubMed Central, Mendeley, my colleagues and parents and the subjects who willingly participated in my study
Table 3. Shows the Percentage of scores of left upper limb of the subjects who participated in the study. Out of 72 (100%) of the subjects 65 (90.3%) had score less than equal to 24 and 7 (9.7%) had scores more than equal to 25.
Table 4. Comparison of Mean score between right and left upper limb.
Mean Std. Error p Value (One sample t- test) <0.001 <0.001
Score Right Score Left
Total (N = 72) Total (N = 72) Total (72)
20.44 (SD 5.25) 18.49 (SD 4.49) 1.09 (SD 0.29)
0.619 0.53 0.03516
Table 4. Shows the Mean and Standard Deviation of the scores in right and left upper limb of the study population. Since only one group of subjects were there, one sample t- test has been used to compare the Mean between the scores of right and left upper limb. With Standard of error 0.619 and for right and left upper limb respectively the p value is <0.001.
Table 5. Percentage enumeration of upper limb dysfunction in subjects after combining both right and left scores.
Total Combination Score Upper limb Dysfunction Present Total Count 72 (100%) 67 (93.1%) No Dysfunction of Upper Limb 5 (6.9%)
Table 5. Shows the Percentage of presence of upper limb dysfunction of the subjects who participated in the study. 67 persons that accounts for 93.1% of the total subjects had upper limb dysfunction and 5 persons that amount to 6.9% of the total subjects had no observed upper limb dysfunction. DISCUSSION/CONCLUSION In the present study 72 working women from various occupations with chronic non specific neck pain were taken up. These subjects were evaluated for their upper limb dysfunction using SAMP test as an outcome
REFERENCES 1. Hakala P, Rimpela A, Salminen JJ, Virtanen SM, Rimpela M. Back, neck, and shoulder pain in Finnish adolescents: national cross sectional surveys. BMJ. 2002; 325:743. 2. Bot SD, Waal JM, Terwee CB, Windt DA, Schellevis FG, Bouter LM, Dekker J. (2005) Incidence and prevalence of complaints of the neck and upper extremity in general practice. Ann Rheum Dis. 2005; 64(1):118-123. 3. Rekola K. Health service utilization for musculoskeletal disorders in Finnish primary health care. Acta Univ Oul. 1993; D259:53-59. 4. Mantyselka PT. Patient pain in general practice. 1998 Kuopio, Finland. Kuopio University Publications. 5. Ferrari R, Russell AS. Regional musculoskeletal conditions: neck pain. Best Pract Res Clin Rheumatol. 2003; 17:5770. 6. Ihlebaek C, Brage S, Eriksen HR. Health complaints and sickness absence in Norway, 1996-2003. Occup Med (Lond). 2007; 57;439. 7. Staudte HW, Duhr N. Age- and sex-dependent force-related function of the cervical spine. Eur Spine J. 1994; 3:155161. 8. Ylinen J, Takala EP, Nykanen M, Hakkinen A, Malkia E, Pohjolainen T, Karppi SL, Kautiainen H, Airaksinen O. Active Neck Muscle Training In The Treatment Of Chronic Neck Pain In Women. JAMA. 2003; 289(19):2509-16. 9. Taimela S, Takala EP, Asklf T, Seppl K. Active treatment of chronic neck pain: a prospective randomized intervention. Spine. 2000; 25(8):1021 1027. 10. Bernard B. Musculoskeletal disorders and workplace factors- A critical review of epidemiologic evidence for work-related musculoskeletal disorders of the neck, upper extremity, and low back. Cincinnati (OH): United States Department of Health and Human Sciences, National Institute for Occupational Health and Safety. 1997; 2.12.90.
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McLean SM, Taylor J, Balasoobramanien T, Kulkarni M, Patekar P, Darne R, Jain V. Measuring upper limb disability in non-specific neck pain: A clinical performance measure. International Journal of Physiotherapy and Rehabilitation. 2010; 1(1):44-52. Frank AO, De Souza LH, Frank CA. Neck pain and disability: a cross-sectional survey of the demographic and clinical characteristics of neck pain seen in a rheumatology clinic. International Journal of Clinical Practice. 2005; 59(2):173-182. McLean S. Conservative management of nonspecific neck pain: Effectiveness of treatment, predictors of treatment outcome and upper limb disability. PhD dissertation, University of Hull; Hull. 2007. McLean SM, Moffett JK, Sharp DM, Gardiner E. An investigation to determine the association between neck pain and upper limb disability for patients with non-specific neck pain: A secondary analysis. Manual Therapy. 2011; 16:434-439. Daffner SD, Hilibrand AS, Hanscom BS, Brislin BT, Vaccaro AR, Albert TJ. Impact Of Neck And Arm Pain On Overall Health Status. Spine. 2003; 28(17):2030-2035. Cassou B, Derrienmic F, Monforz C, Norton J, Touranchet A. Chronic neck and shoulder pain, age and working conditions; longitudinal results from a large random sample in France. Occup Environ Med. 2002; 59:337-544. Andersson IH, Ejlertsson G, Leden I, Rosenberg C. Chronic pain in a geographically-defined general population: Studies on differences in age, gender, social class, and pain localization. Clinical J Pain. 1993; 9:174-82. Fredriksson K, Alfredsson L, Kster M, Thorbjrnsson CB, Toomingas A, Torgn M, Kilbom A. Risk factors for neck and upper limb disorders: results from 24 years of follow up. Occup Environ Med. 1999; 56:5966.
Randomized Controlled trial of Group Versus Individual Physiotherapy Sessions for Genuine Stress Incontinence in Women
Komal Soni1, Harshit Soni2, Dhaval Desai1, Chintan Shah1, Hasmukh Patel3 (Lecturer), (Tutor), SPB Physiotherapy College, Surat, 3Clinical Therapist, U. N. Mehta Institute of Cardiology & Research Centre, Ahmedabad
2
ABSTRACT Background: Pelvic floor muscle exercises are used since 1948 as first-line treatment for management of genuine stress incontinence in women. This pelvic floor muscle exercises can be delivered simultaneously to a group of women or individually on a one to one basis. Objective: The purpose of this study was to compare the effects of group physiotherapy and individual physiotherapy sessions on the severity of incontinence & quality of life in patients with genuine stress incontinence. Materials and Methods: 40 women with chronic genuine stress incontinence were randomized into Group A - where women were delivered the pelvic floor muscle exercises in a group of 10 (n=20) & Group B - where pelvic floor muscle exercise on a conventional one to one basis, the individual approach (n=20) were administered. Outcome measures which included VAS for measuring severity of incontinence & King's health questionnaire for assessing quality of life were taken at baseline & at the end of 3 months intervention program. Results: Both the group A and group B showed improvement in severity of incontinence and quality of life postintervention when compared with preintervention measurement and 't'calculated value for pre-postintervention measures was statistically significant as it was above the 't' tabulated value. Moreover, MeanSD of pre-post change in VAS for group A was 2.020.46 and for group B was 1.940.43 and King's Health Questionnaire scores for group A was 30.095.3 and for group B was 21.516.73. 't'calculated value for pre-post changes was statistically not significant as it was below the 't' tabulated value of 2.576. Conclusion: Both group and individual physiotherapy pelvic floor muscle exercises for women with genuine stress incontinence are equally effective. One may choose anyone of it to gain benefits. Keywords: Genuine Stress Incontinence, Pelvic Floor Muscle Exercise, Group Physiotherapy, Individual Physiotherapy. INTRODUCTION GSI (Genuine stress incontinence); also known as Stress urinary incontinence is defined as an involuntary loss of urine that occurs during physical activity, such as coughing, sneezing, laughing, or exercise.1 GSI is found to be commonest, with its prevalence being greatest in 5th decade of life.2 WHOs 1st International Consultation on Incontinence estimated that bladder Corresponding author: Komal Soni 543, Jalaramnagar, GHB, Ganeshpura, Amroli, Surat - 394107, Gujarat, India, Mobile No: 9904157300 E-mail: sonikomal10@gmail.com problems affects approximately 200 million people worldwide, with 10 to 30% of women between the ages of 20 and 55 years, and in up to 40% of older women.3 Although not a life-threatening condition, GSI causes various physical, psychological & sexual problems for millions of women & their families. GSI thus has a negative impact on Quality of Life (QoL) & most affected domains are physical health & mobility.4 Hence the need for the effective management of this condition is vital, not only for the relief of symptoms but perhaps more importantly, for the prevention of recurrent episodes of leakage, personal suffering, and lost work productivity. Studies have found out that women with urinary incontinence have a significant reduction of
pelvic floor function & following a 4-month pelvic floor muscle exercise (PFME) training period, incontinence of both stress type and with an urge component can be alleviated in most of the women.5 NICE 2006 guidelines for the management of women with GSI have also outlined the evidence for the use of both pelvic floor muscle training & bladder retraining as first-line treatments for women with GSI.6 Used since 1948, PFME when employed in the treatment of GSI may be expected to give a significant improvement or cure about 50% with exercises usually having a long lasting effect.7,8 This PFME can be given on a one to one basis as with the conventional individual approach or can be given simultaneously to a group of women; a group approach. Promoting incontinence in group sessions is suggested as an effective means to educate women & to encourage active self-management. Approximately 20% of Womens Health Physiotherapists use group approach.9 Despite this there has been few Randomized Control Trials comparing the effectiveness of group intervention against individual approach which signifies the need of the present study. Thus the aim of the study was to compare the effectiveness of pragmatic group approach versus individual treatment sessions on the severity of incontinence & QoL in patients with GSI. MATERIALS AND METHOD In this Experimental study, total of 40 subjects who were sent to Bombay Maternity and Surgical Hospital, Surat were assessed for their eligibility based on the criteria for the study and following that they were randomly assigned to Group A & Group B. After signing the written informed consent (to participate in the study and to allow reproduction of their photographs) they were made to participate in study and baseline measurements were recorded. Group A: Consisted of 20 females who were administered PFME in a group of 10 for 3 weeks. Group B: Consisted of 20 females who were delivered PFME individually on a one to one basis for 3 weeks. Inclusion criteria 1. History of chronic (between 2 years to 5 years) GSI with positive cough stress test. 2. Age group of 30 to 55 years. 3. Females who have undergone full-term vaginal delivery. Exclusion criteria 1. Pregnancy.
2. Participation in Physiotherapy program for GSI in the past 12 months. 3. Disease of central nervous system (e.g. MS, CVA) or acute mental illness & dementia. 4. History of pelvic malignancy or pelvic surgery. 5. Vaginal or bladder grade 2 and 3 prolapses. Outcome Measures Visual Analogue Scale (VAS) for measuring severity of incontinence Kings Health Questionnaire (KHQ) for measuring QoL
Exercise Regimens Group intervention for female urinary incontinence (Group A) (Figure 1 & 2) Group met for nine, one-hour long sessions over a three months period. Group sizes were planned to be 10 women in a group. Session 1 Introduction to anatomy of lower abdomen & pelvic floor, explanation of normal PFM & bladder function, teaching and practice of PFMEs recruiting both fast & slow twitch fibers, encouraged to maintain contraction for 3-5 seconds, repeat 10 times. Session 2 Discussion to motivate patient, PFME practice & progression to 10 seconds with 10 repetitions plus upto 10 fast repetitions (2 sets) targeted for both slow & fast twitch fibers. PFMEs during day to day activities taught. The therapist instructed subjects to use the stress strategy. Session 3 PFME in standing position with different foot positions taught. Session 4 PFMEs progressed to 15 seconds with 10 repetitions plus 10 fast contractions (3 sets). Lighthearted quiz to reinforce knowledge gained. Session 5 PFMEs progressed to include the step & lift exercise & adoption of variety of postures. Session 6 Recruitment of transverse abdominus along with PFME taught.
Session 7, 8 & 9 PFMEs in different postures to 20 seconds with 10 repetitions plus 10 fast contractions (3 sets). The maximum exercise prescription possible by session 9 was 60 repetitions (3 sets of 20 seconds). Patients were asked to perform their respective exercises taught at every session twice a day at home.
Pelvic floor exercise booklet explaining the above procedures was given to patient in prior. In Individual treatment (Group B), once a week 30 minute long session was delivered over a three months period. The line of treatment progressed on the same lines as described for group sessions. (Figure 3 & 4)
Figure 1 & 2 Delivery of Group Physiotherapy Sessions (GROUP A)
Figure 3 & 4 Delivery of Individual Physiotherapy Sessions (GROUP B)
Following the recording of the above parameters, the obtained scores were tabulated and compared among both the study groups. Ethical Consideration: Procedures followed were in accordance with the ethical standards of Helsinki Declaration of 1975, as revised in 2000.10
Statistical Analysis All participants received full treatments and there were no drop outs. Data analysis was done by using SPSS 13.0 version software. Unpaired t tests were used to find out homogeneity of two groups for all the parameters at
baseline and to compare the outcome measurement data between two groups. Paired t tests were conducted to determine whether VAS and KHQ scores were significantly different before and after the intervention. Each calculated t-value is compared with t-table value to test two tailed hypothesis at 0.01 level of significance. RESULTS
Table-1. Demographic Data for both the groups
GROUP A MeanSD Age (years) BMI Duration of the symptoms (months) Parity 42.04.96 27.011.02 39.257.18 Range 34-52 25.01-29.14 26-57 GROUP B MeanSD 42.56.0 26.741.02 38.58.88 Range 33-51 24.89-28.14 27-54
variables viz. general health perception, incontinence impact, role limitations, physical limitations, social limitations, personal relationships, emotions, sleep/ energy, severity measures for incontinence was -0.921, -1.313, 0.000, -0.190, -0.305, -1.46, -2.53, -1.792, -0.384, 0.545 and -1.646 respectively. Hence, all the descriptive data for both the groups was not significantly different, so both the groups were homogenous for all possible confounding factors and were valid for comparison. Graph 1: Comparison of pre-post Mean VAS between both the groups
2.350.67
1-4
2.50.97
1-4
tcal value at n1+n2-2 degree of freedom for age, BMI, duration of symptoms and parity was 0.243, -0.693, 0.249 and 0.496 respectively. Also the t cal value at n1+n2-2 degree of freedom among both the groups for various preintervention measures like VAS, KHQ, KHQ
Table-2: Comparison of KHQ Scores between two groups
GROUP A Variables KHQ Mean General Health Perception Incontinence Impact Role Limitations Physical Limitations Social Limitations Personal Relationships Emotions Sleep/Energy Severity Measures Pre 52.437.78 57.518.31 54.9922.36 53.3312.79 54.1611.93 55.2714.24 40.8316.64 54.9911.66 38.3316.31 62.4915.64 Post 22.345.05 25.011.47 28.3312.21 26.668.37 24.998.55 17.2211.09 14.997.45 23.889.02 15.417.29 24.588.32 t cal value 17.01 12.36 5.81 10.46 8.81 9.12 7.21 12.07 7.75 15.25 Pre 47.059.50 57.512.07 53.3223.3 51.6616.57 48.335.27 41.1014.85 29.9913.14 53.3210.20 34.9914.59 53.3311.25 GROUP B Post 25.544.04 27.57.90 26.6614.05 28.328.05 28.328.05 25.559.14 18.325.27 31.14.68 20.827.08 23.336.57 t cal value 9.57 9.00 4.00 6.33 9.00 3.67 2.83 7.74 3.97 10.30
As evident from graph 1 and table 2, t calculated value of pre-post intervention VAS and KHQ scores were above the t tabulated value of 2.576 and hence were
statistically significant, so both the treatments were effective in improving the severity of incontinence and QoL.
Graph 2: Comparison of mean Pre-post change of VAS between both the groups
Moreover, both the strategies being equally effective, group therapy can be considered as a convenient option as it may be more cost effective, but the cost-effectiveness of group therapy needs to be assessed. The findings of studies done by LA Hill et al. (2007)13 and SE Lamb et al. (2009)14 showed cost-effectiveness of group therapy and hence gave preference towards it. As seen from our study, while considering QoL it can be seen that some domains of QoL like physical limitations, social limitations and personal relationships showed improvement better in group than individual sessions. This can be attributed to better delivery of information in group sessions and hence high level of satisfaction associated with group therapy as suggested by B Aston et al. (2007).15 Previous works done by Frances Griffiths et al. (2009)16 showed that women who had preference for individual therapy when given group sessions exhibited their experience of group sessions as good but also stated that for group sessions, its effectiveness lies in its proper designing. If the designing of group therapy is not proper than embrassement associated with group sessions may lead to failure in delivery of effective treatment. Hence, both the treatments being equally effective, either one can be used for benefit of the patients. But factors should be sought that can predict the effectiveness of therapy and thus better select those patients most likely to benefit from specific treatment program. Limitations of the Study 1. This study only included women with GSI between age group of 30-55 years as GSI is most common in that age women & also a big age difference in women receiving group therapy may lead to improper delivery of exercise to patient. 2. This study only included a smaller population as study sample & also the time duration chosen was limited, thus giving only short-term benefits. Future Implications 1. Study can be explored for both the sex and for all age groups & all types of incontinence to know the effects of these exercise interventions. 2. In future study, a larger population can be studied thus giving more standardized results. 3. In future studies, electromyography could be used concurrently to provide additional information on muscle activation associated with the Pelvic Floor Muscle Exercises.
TABLE 3 - Comparison of pre-post change in KHQ scores between two groups

Variable KHQ General Health Perception Incontinence Impact Role Limitations Physical Limitations Social Limitations Personal Relationships Emotions Sleep/Energy Severity Measures GROUP A GROUP B Pre-Post change Pre-Post change 30.095.30 32.511.75 26.6620.51 26.6612.56 29.1614.17 38.0515.42 25.8315.74 31.19.26 22.9113.21 37.9111.93 21.516.73 3010.54 26.6621.08 23.3311.65 20.0010.54 15.557.76 11.6611.25 22.229.07 14.1612.45 30.011.24 t cal value 1.63 0.56 0.00 0.00 2.30 3.30 3.00 1.50 0.80 0.80
As shown in graph 2 and table 3, t calculated value of pre-post intervention change in VAS and KHQ scores were below the t tabulated value of 2.576 and hence were statistically not significant (except for social limitations and personal relationships), so both the treatments were equally effective in improving the severity of incontinence and QoL. DISCUSSION Following a 3 months intervention with Group Physiotherapy sessions & Individual Physiotherapy sessions, the women showed significant reduction in severity of incontinence & improvement in QoL. However there were no significant differences found between the two groups treated individually or in group, thus suggesting that both individual & group physiotherapy sessions are equally effective in management of women with GSI. These findings are in line with the findings of previous studies done by Sara Demain et al. (2001),9 Janssen et al. (2001)11 & Flavia Camargo et al. (2009).12
CONCLUSION This study concluded that both the approaches group and individual are equally effective to reduce severity of incontinence & improve quality of life in women with GSI. However factors should be sort for each specific patient so that they can benefit maximum from the intervention. ACKNOWLEDGMENTS We are thankful to all our subjects who participated with full cooperation, extended thanks to Mrs. Dharti Hingarajia for her valuable help. We are also grateful to authors/ publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. REFERENCES 1. Stress Incontinence medlineplus. Available at: http://www.nlm.nih.gov/medlineplus/ency/ article/000891.htm Minassian VA, Stewart WF, Wood GC. Urinary incontinence in women: variation in prevalence estimates and risk factors. Obstet Gynecol. 2008 Feb;111:324-31. Hunskaar S, Burgio K, Diokno AC, et al. Epidemiology and natural history of urinary incontinence. Urology October 2003;62(4):16-23. Rehab Ali Mohamed, Ahmed Mahmoud Mostafa The impact of urinary incontinence on quality of life of women attending family practice center at Fanara village Ismailia governorate. Available from: http://www.scribd.com/doc/28184727/ Impact-of-Incontinence-on-Quality-of-Life Marianne Gunnarsson, Pia Teleman , Anders Mattiasson , Jonas Lidfeldt , Christina Nerbrand , Gran Samsioe . - Effects of Pelvic Floor Exercises in Middle Aged Women with a History of Naive Urinary Incontinence: A Population Based Study. Eur Urol. 2002 May;41(5):556-61. NICE guidelines for management of women with urinary incontinence (NICE 2006), Journal of the Association of Chartered Physiotherapists in Womens Health, Autumn 2007;101:37-43. H. Cammu & M. Van Nylen - Pelvic floor muscle exercises in genuine urinary stress incontinence. Int Urogynecol J, September 1997;8(5):297-300. Chantale Dumoulin, Marie-Claude Lemieux Physiotherapy for persistent postnatal SUI: a randomized controlled trial. American College of Obstetricians & Gynecologists, September 2004;104(3):504-10 .
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Sara Demain, Jan Fereday Smith, Louise Hiller, Krysia Dziedzic Comparison of group & individual Physiotherapy for female urinary incontinence in primary care. Physiotherapy, May 2001;87(5):235-42. WMA Declaration of Helsinki - Ethical Principles for Medical Research Involving Human Subjects. [59th WMA General Assembly Seoul, Korea, Oct 2008]. Available from: http://www.wma.net/en/ 30publications/10policies/b3/ C. C. M. Janssen, A. L. M. Lagro-Janssen & A. J. A. Felling the effects of physiotherapy for female UI individual compared with group treatment. BJU International(2001); 87:201-6. Flvia de Oliveira Camargo, A n d r e a M o u r a R o d r i g u e s , Raquel Martins Arruda, Marair Gracio Ferreira Sartori, Manoel Joo Batista Castello Giro and Rodrigo Aquino Castro - Pelvic floor muscle training in female stress urinary incontinence: comparison between group training and individual treatment using PERFECT assessment scheme; Int Urogynecol J, December 2009;20(12):1455-62. L. A. Hill, J. Fereday Smith, J. C. Knights, A. J. Williams, S. E. Lamb, J. Pepper, M. Clarke bladders behaving badly: a randomized controlled trial of group versus individual intervention in management of female urinary incontinence. Journal of the Association of Chartered Physiotherapists in Womens Health, Autumn 2007;101:30-36. SE Lamb, J Pepper, R Lall, EC Jrstad-Stein, MD Clark, L Hill, and J Fereday-Smith - Group treatments for sensitive health care problems: a randomised controlled trial of group versus individual physiotherapy sessions for female urinary incontinence. BMC Womens Health(2009);9:26. B. Aston & S. Moulder Is group treatment acceptable in the management of women with pelvic floor dysfunction? Journal of the Association of Chartered Physiotherapists in Womens Health, Autumn 2007; 101:37-43. Frances Griffiths, Jo Pepper, Ellen C JorstadStein, Jan Fereday Smith, Lesley Hill & Sarah E Lamb - Group versus individual sessions delivered by a physiotherapist for female urinary incontinence: an interview study with women attending group sessions nested within a randomised controlled trial. BMC Womens Health 2009;9:25.
A Study of Electromyographic Changes in Muscle Post Exercise Induced Muscle Soreness

Manish Rajput1, Ankita Samuel1, Chhavi Gupta1, Sumit Kalra2 1 Student BPT, Banarsidas Chadiwala Institute of Physiotherapy, 2 Assistant Professor, Banarsidas Chadiwala Institute of Physiotherapy ABSTRACT Aim and objective: To analyze electromyographic changes in muscle post Exercise Induced Muscle Soreness (EIMS). Methodology: 80 subjects(age group 21-30yrs, BMI 18-29kg/m2) free of any musculoskeletal/ Neuromuscular/psychological disorder, took part in the study. After checking for leg dominancy and calculation of BMI, the subjects were asked to perform one single squat up to 900 of hip and knee flexion while an EMG of the Rectus Femoris and Vastus Medialis Obliqus (both parts of quadriceps muscle) was recorded simultaneously. Another EMG reading was taken in the similar manner after confirming the development of muscle soreness on a graphic pain rating scale following the exercise protocol. Results: The mean value of peak EMG of Rectus Femoris pre exercise is 508.69mV (microvolt) and post exercise induced muscle soreness is 686.60 mV. The mean of peak EMG amplitude of Vastus Medialis Obliqus came out to be as 379.81 mV pre exercise and 472.70 mV post exercise induced muscle soreness. The p value for RF pre and post was 0.000 and for VMO pre and post was 0.034. Conclusion: The conclusion drawn from the study is that there is a significant increase in peak EMG amplitude of the muscles (RF and VMO) post exercise induced muscle soreness. Keywords: Exercise Induced Muscle Soreness (EIMS), RF, VMO, EMG
INTRODUCTION At one time or another, each one of us must have experienced muscle soreness following everyday activities that are not associated with participation in sports or in formal exercise programs for e.g.: downhill walking etc. Although muscle soreness usually occurs in less physically trained individuals, most people, including elite athletes can experience this soreness as well. Since the soreness is experienced in the time period following any strenuous work, it is termed as exercise induced muscle soreness (EIMS). Exercise-induced muscle soreness is a common occurrence in daily routine. It can be classified as acute or delayed onset muscle soreness.1-4. Acute onset occurs during exercise and may last four to six hours postexercise before subsiding. Delayed onset muscle soreness (DOMS) typically appears approximately 12 hours after activity and may last for several days following exercise.1,2 It is perhaps one of the most common and recurrent forms of sports injury.2
All forms of exercise, if carried out vigorously enough, can become painful. But only one form of exercise, eccentric exercise5, 6, if we are unaccustomed to it, leaves us stiff and sore the next day. In eccentric exercise the contracting muscle is lengthened; in concentric exercise it shortens. These eccentric actions produce micro-injury to the active muscle fibers, 7-10 exhibiting muscular soreness, loss of joint range of motion, swelling, and decreased force production.8, 11-16 The muscle soreness usually manifests as a dull, aching pain combined with tenderness and stiffness. Clinical signs of muscle soreness include increases in plasma enzymes12, 14, 16 muscular fiber degeneration, 17 and the protein degradation18 that accompanies the degeneration to favor sarcomere disruption as the starting point for the damage. As well as damage to muscle fibers there is evidence of disturbance of muscle sense organs and of proprioception.19 Accompanying the muscle soreness is muscle weakness20, 21 which persists long after the muscle
soreness has receded, prolonged strength loss, a reduced range of motion, and elevated levels of creatine kinase in the blood. These are taken as indirect indicators of muscle soreness, and biopsy analysis has documented damage to the contractile elements.22 A measure to quantify muscle soreness is a Graphic pain rating scale33 which is a 12 cm line between no pain and unbearable pain. Pain was quantified by measuring the distance (to the nearest 1/2 cm) from the extreme left to the mark made by subjects to describe their perception of pain. The length was multiplied by two, yielding scores from 0 = no pain to 24 = unbearable pain. Electro-myography (EMG) is the study of muscle function that involves recording the action potentials (or electrical currents) that activate skeletal muscle fibers23, 24. After fatiguing muscle with exercise, there is a decrease in maximal force production, which has been observed as early as l hour after exercise. The surface electromyographic (EMG) activity is modified during muscle Fatigue (Big1and-Ritcgie, 1981).The EMG power spectrum is shifted towards the lower frequencies as exemplified by the fall in mean power frequency (MPF) during static contractions as well as during dynamic exercise. The EMG spectrum from eccentric, concentric muscle contractions under human were studied as a factor of mechanical damage of muscle fiber and functional change of metabolic tissue. The primary purpose of the study was to examine the relationship between DOMS in after exercise and EMG change in during exercise. A secondary purpose was to examine their relationship to local muscle fatigue and perceived scale of DOMS. We hypothesized that if exerciseinduced muscle soreness is associated with muscle fatigue then the localized DOMS to muscle contractions would be accompanied by attenuated response in index of muscle fatigue. The quadriceps Femoris muscle plays an important role in explosive and powerful actions of the leg during sport and daily activities. Eccentric contraction is commonly used during training programs which often leads to fiber injury and muscle soreness. The dominant leg was chosen as there is enough evidence that injuries are most common on the dominant limb.25 AIMS AND OBJECTIVE To study the electromyographic changes in muscle post exercise induced muscle soreness.
H1- (EXPERIMENTAL HYPOTHESIS) There is significant change in EMG analysis of quadriceps muscle post exercise induced muscle soreness. H0- (NULL HYPOTHESIS) There is no significant change in the EMG analysis of quadriceps muscle post exercise induced muscle soreness. METHODOLOGY Research design- comparative Number and Source of subjects 80 (male) college going students took part in the study. Inclusion Criteria 1. Body Mass Index(BMI)26 should be within the range of 18-29 kg/m2 2. Asymptomatic male subjects between age group 213027 years. 3. Not involved in unaccustomed eccentric muscle action over past 6 months.28 Exclusion Criteria 1. History of lower limb injury , surgery or any implant28 2. All contraindications to EMG 3. Any visible deformity of the upper limb/lower limb 4. Obesity 5. Athletes 6. A diagnosed case of any musculoskeletal/ neurological/ psychological/ cardio-pulmonary disorder and psychiatric disease Instrumentation 1. Neurotrac EMG machine 2. Weighing machine 3. Measuring tape 4. Football 5. Barbell 6. Ice pack
Variables Dependent Variable 1. Peak value of EMG amplitude 2. Graphic pain rating scale(GPRS)33 Independent Variable 1. Height 2. Weight PROCEDURE 80 subjects volunteered for the study, out of which 61 subjects were fulfilling the inclusion criteria and 19 were excluded. The subjects who were fulfilling the inclusion criteria were explained about the topic of the research and its advantages and disadvantages. After clearing their doubts regarding the study, a written consent was obtained from them. The subjects were asked to kick a ball to check for leg dominancy29 and their body weight and height was measured for calculating the body mass index. The dominant leg was then prepared for the recording of the EMG. The skin was carefully prepared by rubbing with abrasive gel and alcohol. All standard precautions were taken before recording EMG activity of the muscle. The EMG activity of Vastus Medialis Obliqus (VMO), and Rectus Femoris (RF) (both parts of QUADRICEPS) was recorded with surface electrodes (5mm disk selfadhesive electrodes) placed approximately in parallel with the muscle fibers over the muscle bellies, based on a modification of standard proposed by Zipp30. The distances and angles were measured for optimal electrode placement.31 The subjects were asked to perform a single 2sec down and a 2sec up squat while the EMG was recorded simultaneously. After this the subjects were requested to perform squat exercises, specifically chosen to induce fatigue in the knee extensors (quadriceps) (William Retailer et al). An intermittent exercise protocol(Navrag B. Singh et al)32 was used and subjects were requested to start in an upright position with feet shoulder-width apart and with weights (approx. 40% body weight) carried on a barbell over the shoulders, squat down to approximately 90 knee flexion, and return to their start position. Each set of squat exercises consisted of eight repetitions and a 30 s rest period was provided between sets. Each subject performed a minimum of 11 sets of
squat exercises with the final set including continuous squats as long as participants could complete an entire repetition. The exercises were terminated when subjects indicated that they were unable to perform the exercise further The subjects were then required to fill up Graphic Pain Rating Scale33 after 8hrs of the exercise session to assess for the induction of DOMS. Those in which DOMS were established were again asked to perform a 2sec down and 2sec up squat and the EMG was recorded. After recording the subjects were given ice packs and were advised to take ice packs at home twice daily for next five days for the treatment of the muscle soreness. The subjects were specifically not allowed to perform any vigorous physical activities or quadriceps muscle stretching or any form of treatment for muscle soreness during the entire experimental period34. RESULT The Mean, standard deviation and two tailed Paired T-test values were obtained with the help of SPSS software (version16) The mean value of peak EMG amplitude of Rectus Femoris (RF) pre exercise is 508.69mV (microvolt) and post exercise induced muscle soreness is 686.60 mV whereas for Vastus Medialis Obliqus (VMO) it came out to be as 379.81 mV pre exercise and 472.70 mV post exercise induced muscle soreness. The two tailed p value for RF pre and post is 0.000 and for VMO pre and post was 0.034. (Table 1&2) The mean percentage for RF pre is 43% and post is 57% (Graph.1) The mean percentage for VMO pre is 45% and post is 55% (Graph.2) Graph-1 Mean percentage of EMG of RF
Graph-2Mean & standard deviation of RF
CONCLUSION The p value for pre n post exercise induced muscle soreness EMG recordings is less than 0.05 for both RF & VMO, which by conventional criteria is considered to be extremely statistically significant. Thus the experimental hypothesis for the study holds true i.e; there is significant change in the peak EMG amplitude of the muscle post exercise induced muscle soreness. The percentage increase in peak EMG activity of RF is 14 %( Graph.1)
Graph-3 Mean percentage of EMG of VMO
The percentage increase in peak EMG activity of VMO is 10 %( Graph.3) A reduction in force output by an injured part of a muscle may lead to compensatory recruitment from an uninjured area of a muscle, or from other muscles35. This leads to a marked increase in EMG activity (hyperactivity), altered EMG ratios and increased force production of the compensating muscles. FUTURE RESEARCH
Graph-4 Mean & standard deviation of VMO
1. The EMG of the non-dominant leg can be recorded after post exercise induced muscle soreness 2. A comparison can be carried out by recording the EMG activity at the origin and insertion of the muscle. 3. The same study can be carried on females. REFERENCES 1. Isabell, W.E., E.Durrant, W.Myrer, and S.Anderson. 1992. The effects of ice massage, ice massage with exercise, and exercise on the prevention and treatment of delayed onset muscle soreness. J Athl Train. 27(3):208-217. Prentice, W.E. 2009. Arnheims Principles of Athletic Training. 13th ed. Mcgraw-Hill, New York. 273pp. .Gulick, D.T., I.Kimura, M.Sitler, A.Paolone, and J.Kelly. 1992. Various treatment techniques on signs and symptoms of delayed onset muscle soreness. J Athl Train. 31(2):145-152. Kuligowski, L.A., S.M. Lephart, F.P. Giannantonio, and R.O. Blanc. 1998. Effect of whirlpool therapy on the signs and symptoms of delayed-onset muscle soreness. J Athl Train. 33(3):222-228. Armstrong RB. Mechanisms of exercise-induced delayed-onset muscular soreness: a brief review. Med Sci Sports Exerc. 1984; 16:529-538. Clarkson PM, Nosaka K, Braun B. Muscle function after exercise-induced muscle damage and rapid adaptation. Med Sci Sports Exec. 1992; 24:512-520.
Table-1 p value for RF pre-post Paired Differences

Pre-post (RF) 95% Confidence Interval of the Difference Lower -266.11 Upper -89.69 T -4.03 Sig (2-tailed) .000
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Table-2 p value for VMO pre-post

Paired Differences Pre-post (RF) 95% Confidence Interval of the Difference Lower -178.57 -7.21222 Upper -2.16 T .034 Sig (2-tailed)
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Armstrong RB, Ogilvie RW, Schwane JA. Eccentric exercise-induced injury to rat skeletal muscle. J Appl Physiol. 1983; 54:80-93. Friden J, Sjostrom M, Ekblom B. Myofibrillar damage following intense eccentric exercise in man. Int J Sports Med. 1983; 4:170-176. Kuipers H, Drukker J, Frederik PM, Geurten P, van Kranenburg G. Muscle degeneration after exercise in rats. Int J Sports Med. 1983; 4:45-51. Smith LL. Causes of delayed-onset muscle soreness and the impact on athletic performance: a review. J Appl Sport Sci Res. 1992; 6:135-141. Clarkson PM, Tremblay I. Exercise-induced muscle damage, repair, and adaptation in humans. J Appl Physiol. 1988; 65:1-6. Nosaka K, Clarkson PM. Effect of eccentric exercise on plasma enzyme activities previously elevated by eccentric exercise. Eur J Appl Physiol. 1994; 69:492-497. Rodenburg JB, Steenbeek D, Schiereck P, Bar PR. Warm-up, stretching and massage diminish harmful effects of eccentric exercise. Int J Sports Med. 1994; 15:414-419. Saxton JM, Donnelly AE. Light concentric exercise during recovery from exercise-induced muscle damage. Int J Sports Med. 1995; 16:347-351. Smith LL. Acute inflammation: the underlying mechanism in delayed onset muscle soreness? Med Sci Sports Exec. 1991; 23:542-551. Takahashi H, Kuno S, Miyamoto T, et al. Changes in magnetic resonance images in human skeletal muscle after eccentric exercise. Eur J Appl Physiol. 1994; 69:408-413. McCully KK, Faulkner JA. Injury to skeletal muscle fibers of mice following lengthening contractions. J Appl Physiol. 1985; 59: 119-126. Thompson HS, Scordilis SP. Ubiquitin changes in human biceps muscle following exercise-induced damage. Biochem Biophys Res Commun. 1994; 204:1 193-1198. U. Proske and D. L. Morgan. Muscle damage from eccentric exercise: mechanism, mechanical signs, adaptation and clinical applications. Journal of Physiology (2001), 537.2, pp.333345 Newham, D.J., Jones, D.A. and Edwards, R.H.T. Large delayed plasma creatine kinase changes after stepping exercise Muscle Nerve 1983, 6, 380385 New ham, D.J., Jones, D.A. and Clarkson, P.M. Repeated high-force eccentric exercise: effects on muscle pain and damage J Appl Physiol 1987, 63, 1381-1386 J Sports Med Phys Fitness. 1994 Sep; 34(3):20316.Exercise-induced muscle pain, soreness, and cramps. Miles MP, Clarkson PM. Basmajian & deluca: A fundamental EMG textbook. Definition Muscles Alive (2 - p. 1)
24. DE LUCA, C.J. The use of surface electromyography in biomechanics. J. Appl. Biomech. 13:135 163. 1997. 25. Kieran OSullivan et al, The relationship between previous hamstring injury and the concentric isokinetic knee muscle strength of Irish Gaelic footballers, BMC Musculoskeletal Disorders 2008, 9:30 doi:10.1186/1471-2474-9-30 26. Heather k. Vincen, PhD, Kelley M. Lamb, BS, Tim i. Day, PT, Susan M. Tillman, PT, Kevin R. Vincent,MD, PhD, Steven Z. George, PT, PhD. Morbid Obesity is Associated with Fear of Movement and Lower Quality of Life in Patients with Knee Pain- Related diagnosis. Volume 2, Issue 8, August 2010, pg713-722 27. Dawn T. Gulick, Michael Sitler, Albert Paolone, John D. Kelly. Journal of Athletic Training Volume 31 * Number 2 * June 1996 28. Michelle A. Cleary; Michael R. Sitler; Zebulon V. Kendrick. Dehydration and Symptoms of DelayedOnset Muscle Soreness in Normothermic Men. Journal of Athletic Training 2006;41(1):3645 29. Cameron M, Adams R, Maher C: Motor control and strength as predictors of hamstring injury in elite players of Australian football. Physical Therapy in Sport 2003, 4:159-166 30. ZIPP, P. Recommendations for the standardization of lead position in surface electromyography. Eur. J. Appl. Physiol. 50:4154, 1982. 31. STENSDOTTER, A.-K., P. W. HODGES, R. MELLOR, G. SUNDELIN, and C. HA GER-ROSS. Quadriceps Activation in Closed and in Open Kinetic Chain Exercise. Med. Sci. Sports Exec., Vol. 35, No. 12, pp. 20432047, 2003 32. Singh NB et al.philos transact A MATH phys.sci.2010 jun 13;368(1920)2783-98[PMID20439273] 33. Craig R. Denegar, PhD, ATC David H. Perrin, PhD, ATC,Effect of Transcutaneous Electrical Nerve Stimulation, Cold, and a Combination Treatment on Pain, Decreased Range of Motion, and Strength Loss Associated with Delayed Onset Muscle Soreness, Volume 27 * Number 3 * 1992 * Joumal of Athletic Training(pg no.200-206) 34. Philippou, M. Maridaki, G. Bogdanis, A. Halapas And M. Koutsilieris [Department of Experimental Physiology, Medical School, National and Kapodistrian University of Athens, Goudi, Athens; Department of Sports Medicine and Biology of Physical Activity, Faculty of Physical Education and Sport Science, National and Kapodistrian University of Athens, Dafni, Greece](in vivo 23: 859-866 (2009) 35. Edgerton VR, Wolf SL, Levendowski DJ, et al. Theoretical basis for patterning EMG amplitudes to assess muscle dysfunction. Med Sci Sports Exec 1996; 28 (6): 744-51
Effect of Pelvic Floor Muscle Strengthening Exercises in Chronic Low Back Pain
Manisha Rathi Associate Professor, Padmashree Dr. D. Y. Patil College of Physiotherapy, Pimpri, Pune ABSTRACT Low back pain (LBP) is a condition of localized pain to the lumbar spine. The pelvic floor muscle (PFM) have an important role in proper muscular activation for lumbar stabilization and also in unloading the spine. It was hypothesized that PFM exercise could be of benefit for patients with chronic LBP. After ethical approval, a randomized controlled trial was carried out on 30 females with chronic LBP. Patients were randomly allocated into two groups: an experimental and a control group. The control group was given conventional physiotherapy treatment including modality and exercises; and the experimental group received PFM strengthening with conventional therapy for 5 times per week upto 4 weeks. Pain intensity and functional disability by Oswestry Disability Index were measured before and after intervention . In both groups pain and functional disability were significantly reduced following treatment (p < 0.01). Also the significant difference was found between the two groups (p > 0.05). It seems that the PFM exercise combined with conventional treatment was effective over conventional treatment alone in females with chronic LBP. Keywords: Pelvic floor muscle, LBP.
INTRODUCTION Low back pain (LBP) is a condition of localized pain to the lumbar spine with or without symptoms to the distal extremities whose etiology is commonly unknown. 1 More than 80% of the population will experience an episode of LBP at some time during their lives. 2 For most, the clinical course is benign, with 95% of those afflicted recovering within a few months of onset. 3 Some, however, will not recover and will develop chronic LBP (ie, pain that lasts for 3 months or longer). Recurrences of LBP are also common, with the percentage of subsequent LBP episodes ranging from 20% to 44% within 1 year for working populations to lifetime recurrences of up to 85%. 4 In the United States it is the most common cause of job-related disability, a leading contributor to missed work, and the second most common neurological ailment only headache is more common. Lower back pain may be classified by the duration of symptoms as acute (less than 4 weeks), sub acute (4 12 weeks), chronic (more than 12 weeks).6 Causes of lower back pain are varied. Most cases are believed to be due to a sprain or strain in the muscles and soft tissues of the back.8 Others may have pain from their sacroiliac joint, where the spinal column attaches to the pelvis, called sacroiliac joint dysfunction. Physical
causes may include osteoarthritis, rheumatoid arthritis, degeneration of the discs between the vertebrae or a spinal disc herniation, a vertebral fracture (such as from osteoporosis), or rarely, an infection or tumor. In the vast majority of cases, no noteworthy or serious cause is ever identified. If the pain resolves after a few weeks, intensive testing is not indicated.9 It has been suggested that the overall mechanical stability of the spinal column, especially in dynamic conditions and under heavy loads, is provided by the spinal column and the precisely coordinated surrounding muscles. 10 The spinal stabilizing system of the spine was primarily suggested by Panjabi (1992), consisting of three subsystems: the spinal column providing intrinsic stability; spinal muscles, surrounding the spinal column, providing dynamic stability; and the neural control unit evaluating and determining the requirements for stability and coordinating the muscle response11,12 . Under normal conditions, the three subsystems work in harmony and provide the needed mechanical stability 13,14 Among various documented risk factors for LBP such as smoking 15 obesity 16, pregnancy 17, physical activity18, mental health 19, recent research done by Smith et al. 2009 and Hodges et al., 2007 has focused on the relationship between LBP and respiratory disorders,
incontinence and gastrointestinal problems from the Australia.20 A longitudinal study on womens health reported that women with pre-existing incontinence, gastrointestinal problems and breathing disorders were more likely to develop LBP than women without such problems. 21 This was considered to be a result of changes in control of the trunk muscles following involvement with incontinence, respiratory and gastrointestinal problems. Changes in morphology and altered postural activity of the trunk muscles including muscles of respiration and continence which provide mechanical support to the spine and pelvis has been shown to be related to the development and occurrence of LBP (Hides et al., 2001, Cholewicki et al., 2005). Apart from the role of pelvic floor muscle (PFM) in patients with urinary and faecal incontinence, the PFM have also an important role in proper muscular activation for lumbar stabilization and also in unloading the spine (Sapsford and Hodges, 2001, Sapsford et al., 2001). The pelvic floor forms the base of the abdominal cavity and during different tasks that elevate intra-abdominal pressure, muscles must contract to maintain continence and contribute to pressure increases (Gilpin et al., 1989). In a small experimental trial of healthy subjects, strong voluntary abdominal muscle contraction caused PFM activity at the same intensity as maximal PFMs effort (Sapsford and Hodges, 2001). Morkved et al. (2007) have investigated the effect of group training during pregnancy in prevention of lumbopelvic pain. Selfreported symptoms of lumbopelvic pain, sick leave, and functional status were measured on 301 healthy nulliparous women who were randomly allocated into a training group (148) or a control group (153). The control group received daily PFM training at home, and the training group was given weekly group training over 12 weeks including aerobic exercises, PFM and additional exercises, and information related to pregnancy. They reported that at 36 weeks of gestation women in the training group were significantly less likely to report lumbopelvic pain and had significantly higher scores on functional status but there was no difference in sick leave during pregnancy. However, they concluded that a 12-week specially designed training program during pregnancy was effective in preventing lumbopelvic pain in pregnancy. Sapsford et al. (2001) investigated the co-activation pattern of the pelvic floor and the abdominal muscles via needle electromyography (EMG) for the abdominals and surface EMG for the pelvic floor. They found that the abdominals contract in response to a pelvic floor
contraction command and that the pelvic floor contracts in response to both a hollowing and bracing abdominal command. The results from this research suggest that the pelvic floor can be facilitated by coactivating the abdominals and vice versa. However, very few published evidence was found to assess the function of PFM in patients with LBP or to evaluate the effect of PFM exercises in the treatment of such patients. The need to carry out this study was to investigate the effect of PFM exercise in the treatment of patients with chronic Low back pain specially in females . As PFM has an important role in lumbar spine stability, and lumbar instability was suggested to be one of the causes for LBP, it was hypothesized that PFM exercise could be of benefit for patients with chronic LBP. MATERIALS AND METHOD This experimental study was carried out in Physiotherapy OPD of Dr. D. Y. Patil College of Physiotherapy, Pune. Ethical approval was taken from Institutional Ethical Committee. 30 married females with chronic low back pain fallowing in the age group between 20 to 40 years were selected and divided by random allocation into two groups- group A with 15 females and group B with 15 females. Pregnant females, females with any Urogenital Dysfunction like UV Prolapsed, Pelvic Inflammatory disease, Nerve injury to pelvic floor muscle, any pathology of spine, lower limb were excluded from the study. Informed consent was obtained from all the females. Females from Group A received conventional physiotherapy treatment which included Short wave diathermy or Interferentional therapy , Abdominals and back extensors strengthening exercises, Stretching exercises along with core stabilizers (Transverse abdominals and multifidus) for 5 times per week upto 4 weeks. Females from Group B received conventional physiotherapy treatment as mentioned above along with pelvic floor muscle strengthening exercises for 5 times per week up to 4 weeks.Pelvic Floor strengthening exercises were given initially in supine position. Before starting, patients were instructed to evacuate their bladder, relax as much as possible, not to hold breathing and concentrate only at pelvic floor muscles. Patient was instructed to contract pelvic floor muscles, hold the contraction for 5 seconds and then relaxation for 5 seconds. She was further instructed to repeat the contraction for 10 times. As the strength was increasing, contraction time was increased and relaxation time was
reduced from time to time. All the pelvic floor exercises were repeated 3 times in a day(21). Pain was assessed by using Visual Analogue Scale and Functional Disability was assessed by Oswestry Disability Index on the 1 st day of visit to the physiotherapy department and at the end of 4 weeks. RESULTS Graph 1 :- Showing pre and post score of VAS in group A and B
was 24.07 + 3 .24 . This difference showed significant improvement in reduction in pain as p < 0.05 with CI at 95%. DISCUSSION Present study showed the effect of pelvic floor muscle strengthening exercises in chronic Low back ache. This study showed that PFM exercise combined with conventional physiotherapy treatment had a significant effect over the conventional physiotherapy program alone in the treatment of patients with chronic Low back pain . A study done by Eliasson et al. (2008) concluded that the prevalence of urinary incontinence and signs of PFM dysfunction were greatly increased in the LBP group compared with the reference group. It appears that LBP is a risk factor for urinary incontinence and assessment of PFM function may be of value when treating patients with LBP. Evidence suggest that the exercise of the abdominal muscles may be beneficial in maintaining PFM coordination, support, endurance, and strength. Hence these exercise has the potential to be useful in the rehabilitation of persons with symptoms of PFM dysfunction. A few studies by Sapsford et al., 2001 and Neumann and Gill, 2002 have demonstrated the synergy between abdominal muscles and PFM in healthy volunteers. EMG activity of PFM and abdominal muscles showed that during voluntary activity of PFM all abdominal muscles were activated at different levels. The PFM seems to be an integral part of trunk and lumbopelvic stability in addition to contributing continence. As there are the strong evidence supports the co-contraction of PFM and abdominal muscles, the results of the present study showed the consistent result that these co-contractions have an effect on patients with chronic LBP and reducing disability. One of the functions of PFM is to unload the spine. The static pressure created by a rigid abdominal cylinder can act to support the upper part of the body and therefore unload the spine. This involves abdominal, dorsal, diaphragmatic and PF muscles( Grillner et at 1978). Studies also indicates that the co-activation of all these muscle is an essential prerequisite for developing appropriate IAP, thus supporting the spine. When strengthening of the PFM occurs, the load on the lumbar spine decreases. This may be the cause for reliving LBP in the present study. Sapsford et al 2001 suggested that recruitment of abdominal muscles function in association with voluntary contraction of PFM may be affected by spine
Graph 2 :- Showing Pre and Post score of Oswestry Disability Index in Group A and Group B
The Graph 1 showed that the mean difference in pain in patients who received PFM strengthening exercises along with conventional therapy was 3.8 + 0.96 whereas differences in pain at VAS in group A was 2.867 + 0 .83 . This difference showed significant improvement in reduction in pain as p < 0.05 with CI at 95%. The Graph 2 showed that the mean difference in ODI in patients who received PFM strengthening exercises along with conventional therapy was 19.73 + 3.58 whereas differences in ODI in group A
position. Placing the lumbar spine in flexion or extension would change the length-tension properties of the abdominal muscles and may have an influence on their response to PFM contraction. As Sapsford et al. (2001) highlighted that increase in Transverse Abdominals activity with PFM activity was significantly greater compared with External Oblique and Rectus Abdominal in lumbar extension. It was suggested that a neutral or extended lumbar spine position is preferable for PFM exercise. In addition, these findings indicate that contraction of the PFM may be used to initiate contraction of the abdominal muscles. A RCTby Richardson et al., 1999 indicates that specific training of the Transverse Abdominals can assist with the management of LBP. The results of their investigation revealed that this could be best achieved by contraction of the PFM with the spine positioned in either a neutral or extended position. In the present study patients were instructed to perform PFM exercise in supine position ( Neutral Position). This can results in improvement in LBP by strengthening transverse abdominals. CONCLUSION This study showed significant improvement in chronic low back pain in females after giving pelvic floor strengthening exercises with conventional therapy than the conventional therapy alone. LIMITATIONS Objective outcome measures such as muscle activity and muscle thickness using EMG or ultrasound was not done. Also the measurement of pain intensity and functional disability was done in subjective way in the present study. ACKNOWLEDGEMENT The author acknowledges the Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune for financial support of this study. Conflict of interest The authors declare no conflict of interest. REFERENCES 1. 2. Rubin DI. Epidemiology and risk factors for spine pain. Neurol Clin. 2007;25(2): 353-371. Carey TS, Garrett J, Jackman A, McLaughlin C, Fryer J, Smucker DR. The outcomes and costs of
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Iranian pregnant women: prevalence and risk factors. Spine Journal. 2009;9:795801 17. Hartvigsen J, Christensen K. Active lifestyle protects against incident low back pain in seniors: a population based 2-year prospective study of 1387 Danish twins aged 70100 years. Spine. 2007;32:7681 18. Strine TW, Hootman JM. US national prevalence and correlates of low back and neck pain among adults. Arthritis and Rheumatism. 2007;57:656 665
19. Smith MD, Russell A, Hodges PW. Do incontinence, breathing difficulties, and gastrointestinal symptoms increase the risk of future back pain?. The Journal of Pain. 2009;10:876886 20. Hodges PW, Sapsford R, Pengel L. Feedforward activity of the pelvic floor muscles precedes rapid upper limb movements. Australian Physiotherapy Association Conference, Sydney; 2002, 21. J Laycock , D. Jerwood (2001) Pelvic Floor muscle assessment: The PERFECT Scheme, Physiotherapy December 2001, volume 87, no. 12
Comparing Hold Relax - Proprioceptive Neuromuscular Facilitation and Static Stretching Techniques in Management of Hamstring Tightness
Ali Ghanbari1, Maryam Ebrahimian2, Marzieh Mohamadi3, Alireza Najjar-Hasanpour4 Rehabilitation School, Shiraz University of Medical Sciences, Iran, 2Rehabilitation School, Shiraz University of Medical Sciences, Iran, 3Rehabilitation School, Shiraz University of Medical Sciences, Iran, 4Student Research Committee, Rehabilitation School, Shiraz University of Medical Sciences, Iran ABSTRACT Introduction: Hamstring tightness may result in several conditions of the knee and spine such as anterior knee pain and low back pain. Stretching is a preventive and therapeutic technique in these situations. The aim of this study is to compare the effectiveness of static stretching and hold-relax PNF on increasing the extensibility of hamstring muscles. Method & material: 51 male subjects in the age range of 18 to 30 entered to the study and randomly assigned to one of the three groups of static stretching, hold-relax PNF and control. The extensibility of hamstring was assessed by Active Knee Extension Test (AKET). The treatments in both static stretching and PNF groups were applied for six sessions during the study. Findings: At the end of the treatment period, we found a significant difference in hamstring extensibility among the study groups. Hamstring extensibility was significantly larger in both treatment groups compared to the control group (p<0.001). Moreover, the subjects in PNF group showed significantly greater hamstring extensibility compared with the static-stretch group (p=0.015). Conclusion: The present study suggests that hold relax - PNF is more effective than static stretching in increasing the hamstring extensibility. Therefore, application of this technique and education of that may be more useful for either patients with hamstring contracture or athletes. Keywords: Hamstring Extensibility, Static Stretching, Proprioceptive Neuromuscular Facilitation (PNF), Hold Relax INTRODUCTION The two-joint hamstring muscle group is the knee flexor and hip extensor. The complete range of knee flexion rarely occurs in activity daily living; therefore the complete contraction and stretching of this muscle group is rare. In this type of muscles, failure may be occur under rapid and stressful situations(1). Hamstring tightness may result in several conditions of the knee and spine. The Resultant flexion Corresponding author: Marzieh Mohamadi Rehabilitation School of Shiraz University of Medical Sciences, Abiverdi Street, Chamran Boulevard, Shiraz, Iran. Email: mohamadipt@yahoo.com Phone No.: 987116271551, Fax: 98711627249 moment following hamstring tightness may cause anterior knee pain owing to excessive patellofemoral forces(1-2). Furthermore, decrement in rang of knee extension may result in plantar fasciitis due to abnormal loading on forefoot (3). In patients with hamstring tightness, anterior pelvic tilt is decreased during trunk forward bending(4); therefore mobility in lumbar vertebrae would be increased(4), and lead to low back pain(4-6). Because of these problems, it is important to consider the length of the hamstring muscle group. Stretching is a preventive and therapeutic technique (7-8) which is applied musculotendinous structures in order to change their length, improve joint range of motion, reduce stiffness, improve performance, decrease risk of injuries, improve posture and promote relaxation(8-10). There are different types of stretching
techniques including static, active, passive, proprioceptive neuromuscular facilitation (PNF) and ballistic(7, 10-11). Static stretching is the most common form of stretching technique because of its safety, effectiveness and easy performance(10). PNF stretching involves active muscle contraction and neuromuscular reflexes which decrease the resistance against stretching(10, 12). In spite of many research studies performed on the issue of stretching, there are still disagreements about the most effective and safe method, intensity, duration and frequency of stretching(10, 13). Several studies have focused on comparing the different methods of stretching. Some of these studies have found that PNF stretching and static stretching were equally effective in improvement of muscle extensibility(7, 13-14). Others have shown that PNF is more effective than static stretching(9, 15). On the contrary, Davis et al reported that static stretching is more effective(16). The controversy around this issue was a motive for conducting the present study. One limitation of the previous studies, comparing the different techniques of stretching, was that the intervention was applied only for one Session. In this study, we aimed to compare the effectiveness of several sessions of static stretching and hold-relax PNF on increasing the extensibility of hamstring muscles. MATERIAL & METHOD Subjects We recruited a convenience sample of 51 male subjects in the age range of 18 to 30, who were the students of a local university. Exclusion criteria were musculoskeletal or neuromuscular disorders, a history of fracture or dislocation in lower extremity and active participation in sports or exercise activities that required regular hamstring stretching. We defined active participants as those who were involved in regular exercise activities in at least 2 sessions during a week. PROCEDURE After signing a consent form, the subjects were randomly assigned to one of the three groups of static stretching, hold-relax PNF and control. At the beginning of the first session, the extensibility of hamstring was assessed for every participant. We used Active Knee
Extension Test (AKET) for this purpose. The subject lied in supine position with his hip and knee in 90 degree flexion and ankle in plantar flexion. Then, he was asked to extend his knee as far as he could and in this position, popliteal angle was measured by a goniometer. To measure this angle, a long-arm goniometer was utilized. One arm was located on the line connected the greater trochanter and the lateral femoral condyle.The other arm was along the line from the lateral malleolus to the lateral condyle of tibia. After the initial measurement, the subjects in either of the two intervention groups (i.e. static stretching and PNF groups) received the treatments as following: Static stretching group The subject was supine with his hip in 90 degree of flexion. Therapist passively extended the subjects knee up to a point where the subject reported a mild to moderate stretching sensation without any pain. The therapist held this position for 30 seconds and then repeated the procedure three times with 10 seconds rest between successive stretches. PNF group The subject was supine with his hip in 90 degree of flexion. The Therapist extended the subjects knee until the subject felt a very mild stretching sensation in his hamstring muscles. Then, the therapist asked the subject to flex his knee against the resistance applied by the therapists hand. The subject was asked to use a force around 50% of his maximal strength. No movement was allowed to occur in the knee joint so that an isometric form of contraction was gained in hamstring muscles. The subject holds the contraction for 8 seconds and then, on the command of the therapist relaxed the hamstrings muscle. Immediately after the muscle relaxation the therapist stretched the hamstring muscles up to a point where the subject reported a mild to moderate stretching sensation without any pain and hold this position for 30 seconds. The therapist repeated this procedure three times in every session. The treatments in both static stretching and PNF groups were applied for three sessions in one week with one day rest between two sessions. The treatments continued for two successive weeks, and thus every subject received 6 sessions of treatment during the study. At the end of the last session, the popliteal angle was measured again in the similar way as that of the first session.
The subjects in the control group received no treatment during a two weeks period. At the end of the second week, the therapist measured the popliteal angle similar to what he did for the other two groups. Statistical analysis Due to non-normal distributions of the study data, we used Kruskal-wallis test with Bonferroni correction to compare the hamstring extensibility among the three study groups. FINDINGS The mean age of the subjects and the mean angle of knee extension at the baseline of the study were compared by Kruskal-wallis and ANOVA tests (Table1). There were no significant differences between the three groups in this regard. At the end of the treatment period, we found a significant difference in the angle of knee extension among the study groups (Table2). A post hoc test using Mann-Whitney test with Bonferroni correction showed significant differences in pair wise comparisons of the study groups. Since there were three pairs of comparison, the alpha level was set on 0.0167 ( level =.05/3= .0167). The angle of knee extension was significantly larger in both treatment groups compared to the control group (p<0.001). Moreover, the subjects in PNF group showed significantly greater angle compared with the static-stretch group (p=0.015).
Table1: The mean age of the subjects and the mean angle of knee extension at the baseline of the study.
Group number Age Angle of knee extension PNF 17 23.592.26 150.296.98 Static stretch 17 22.712.56 147.478.69 control 17 22.061.29 152.188.08 0.117 0.231 P.Value
Muscle, fascia, capsule and tendon are the primary limiting factors of joint movement. Therefore, it is necessary to consider the muscle spindle and Golgi tendon organ in the ability of muscles to lengthen in response to stretch, as well as the passive structures. PNF stretching techniques focus on active components and static stretching address the passive components which limit the range of motion(17). In static stretching, the inverse myotatic reflex results in muscle relaxation and further stretch and range of motion. In hold relax PNF, the neural inhibition reduces reflex activity(13). An inhibitory interneuron reduces -motoneuron activity of antagonist muscle(8) which results in muscle relaxation and decreased resistance to stretch(13). Our study found that hold relax PNF was more effective in increasing hamstring extensibility. The previous studies on this issue, have found no difference between these two methods of stretching (7). The discrepancy between our study and the previous ones could be explained by several issues. The subjects on our study were relatively young (i.e. 18-30), compared to the Felands study which were on 55 to 79 years old people. Feland et al, has stated that PNF stretching in the younger patients is more effective than in older ones. This is due to the age-related neurophysiologic and musculoskeletal changes such as motor neuron death and increased collagen of the skeletal muscle, in older people(13). In the OHoras study that was on 21 to 35 years old people, the results was similar to our study(15). Another explanation for the disagreement between this and the previous studies, could be that we performed the intervention techniques in several sessions, while, other studies used the techniques in only one session(7-8, 13, 15). Probably, the effects of the stretching techniques have been accumulated during the six sessions of our study. We may propose that, if there is a real difference between the two techniques of stretching, one session of treatment might not be enough in detecting that small difference. When the treatment effects are accumulated during several sessions, then, the difference between the two techniques get larger and hence statistically significant. The superiority of PNF technique on static stretching observed in our study may be due to the different effects of these techniques on the blood flow of muscles(11, 18). The resultant muscle relaxation following PNF techniques can cause changes in blood flow. PNF technique increase motor activity that can affect vascular function. The muscle activation may increase
Table2: The comparison of the angle of knee extension after treatment among the study groups
Group PNF Static stretch control Mean difference 4.591.94 31.22 00.5 Median difference 5 3 0 P.Value <0.001
DISCUSSION This study showed significant increases in the hamstring extensibility in both static stretching and hold relax PNF technique groups in comparison with the control group.
the release of vasoactive substances which results in vascular dilation(18). On the other hand, the muscle extension due to static stretching decreases muscle blood flow(11, 19) because of two physical changes: 1) longitudinal extension of blood vessels with the muscle extension and 2) the increase of intramuscular pressure during the stretching(19). Hyperactivity or hyperemia can affects the muscular temperature(20). During the exercise, muscle temperature increase from 35 to 40 degrees due to elevation in plasma ATP. The increased temperature of collagen will increase tissue elasticity(21). CONCLUSION The present study suggests that hold relax PNF is more effective than static stretching in increasing the hamstring extensibility. Therefore, application of this technique and education of that may be more useful for either patients with hamstring contracture or athletes. ACKNOWLEDGEMENT This work was based on the dissertation of the Alireza Najar Hasanpour at Shiraz University of Medical Sciences (SUMS), faculty of rehabilitation sciences. The authors are thankful to Miss Yasaman Khademolhoseini and the Rehabilitation Research Center staff. Financial support from the SUMS 88-4649 grant made this research possible. Conflict of Interest The authors declare that there is no conflict of interest REFERENCES 1. Morgan-Jones R, Cross T, Cross M. Hamstring injuries. Critical Reviews in Physical and Rehabilitation Medicine. 2000;12(4):277-82. Piva SR, Goodnite EA, Childs JD. Strength around the hip and flexibility of soft tissues in individuals with and without patellofemoral pain syndrome. J Orthop Sports Phys Ther. 2005;35(12):793-801. Harty J, Soffe K, OToole G, Stephens MM, editors. The role of hamstring tightness in plantar fasciitis2004: JBJS (Br). Norris CM. Back stability: integrating science and therapy: Human Kinetics Publishers; 2008. McGill S. Low back disorders: evidence-based prevention and rehabilitation: Human Kinetics Publishers; 2007. Hoskins WT, Pollard HP. Successful management of hamstring injuries in Australian Rules footballers: two case reports. Chiropr Osteopat.
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18. Escobar-Hurtado C, Ramrez-Vlez R. Proprioceptive neuromuscular facilitation (PNF) and its impact on vascular function. Colombia Mdica. 2011;42(3):373-378. 19. Otsuki A, Fujita E, Ikegawa S, Kuno-Mizumura M. Muscle Oxygenation and Fascicle Length During Passive Muscle Stretching in BalletTrained Subjects. International journal of sports medicine. 2011;32(07):496-502.
20. Baro VAR, Gallo AKG, Zuim PRJ, Garcia AR, Assuno WG. Effect of occlusal splint treatment on the temperature of different muscles in patients with TMD. Journal of Prosthodontic Research. 2011;55(1):19-23. 21. Lounsberry NL. Therapeutic Heat: Effects of Superficial and Deep Heating Modalities on Hamstring Flexibility the osprey journal of ideas & inquiry. 2008 All Volumes (2001-2008): 138.
Reliability and Feasibility of Community Balance and Mobility Scale (CB&MS) in Elderly Population
NagaRaju1, Arun Maiya2, Manikandan3 MPT, Department of Physiotherapy, Manipal College of Allied Health Sciences, Manipal, Karnataka, 2 Associate Dean and Head of Physiotherapy Department, Manipal College of Allied Health Sciences, Manipal, Karnataka, 3Associate Professor, Department of Physiotherapy, Manipal College of Allied Health Sciences, Manipal, Karnataka
1
ABSTRACT The objective was to determine the reliability and feasibility of Community Balance and Mobility Scale (CB&MS) as a screening instrument for identifying balance dysfunction in elderly population in an Indian situation. An observational study was conducted in community and old age homes residing elderly population, involving 33 elderly individuals aged 60 years and above, selected by convenience sampling method. CB&MS and Computerized Static Posturography measures were used for assessment. Intraclass Correlation Coefficient and spearman's correlation coefficient were used for analysis. Results showed high test-retest reliability (0.985) but no correlation with velocity moment measure of Computerized Static Posturography. Our findings demonstrated that CB&MS is reliable and feasible and hence could be applicable in the community for assessing balance and mobility of young old elderly population. Keywords: Test -Retest Reliability, Balance, Challenging Tasks, Community Setting.
INTRODUCTION Ageing, in its broadest sense is the continuous and irreversible decline in the efficiency of various physiological processes2.The average life expectancy is around 60 years now and the way health care facilities are expanding with better income levels and access to medicare, the life expectancy may rise between 70 and 75 by 20208.India had the second largest number of elderly (60+) in the world.The size of Indias elderly population aged 60 and above is expected to increase from 77 million in 2001 to 179 million in 2031 and further to 301 million in 2051. The proportion is likely to reach 12 per cent in 2031 and 17 per cent in 2051 17. A decline in all the major systems for example, cardiovascular, metabolic, respiratory, and neuromuscular contributes to weakness, fatigue, and slowing of movement that have been the hallmarks of aging14. Older adults have impaired balance recovery due to an age-related decline in the ability to rapidly and efficiently contract the muscles of the lower extremities .These physiologic changes of normal aging may increase the risk of falls13.This led to increase in the number of older persons with disability9.
Among community-dwelling older people over 64 years of age, 28-35% fall each year. Of those who are 70 years and older, approximately 32%-42% fall each year. Older people who are living in nursing homes fall more often than those who are living in the community. Approximately 30-50% of people living in long term care institutions fall each year, and 40% of them experienced recurrent falls20. Balance disturbances frequently cause elderly people to seek medical advice and admission to hospitals and residential homes3. Although a number of procedures have been described to assess balance, many of these techniques present difficulty in application due to cost, subjectivity, specificity of assessment or other problems6. In spite of laboratory measures of balance offer greater precision and potential to detect subtle or sub clinical balance impairments, Clinical and Functional tests of balance (static and dynamic) share the advantages of ease of administration, low cost and more directly interpretable functional relevance16. Computerized Posturography is the gold standard tool to evaluate postural sway and quantify balance. It is simple and efficient tool and offers technology for the objective assessment and comprehensive documentation of postural control7. Amplitude and
velocity of anterior-posterior and medial-lateral sway during standing in different positions are measured using Posturography. The general census is that computerized measures have a greater precision and potential to detect sub clinical balance impairments1. Role of Posturography in elderly population to detect balance impairments has gained importance in the recent years. However the balance measures were assessed in clinical set up where the elderly individual does not encounter barriers that challenge his balance abilities. This necessitates the assessment of balance in community environment. CB&MS is a tool used to measure balance and mobility of individual in the community setting. The scale has been used and found to be valid and reliable in high functioning patients with traumatic brain injury10. This scale has not been tested for its usefulness in Indian elderly population and no literature is available to correlate this scale with the postural sway measures of Posturography. Our study aims to find the reliability and feasibility of CB&MS and its correlation with postural sway measures using Static Posturography. MATERIAL AND METHOD An observational study with convenience sampling method was conducted at department of Physiotherapy, MCOAHS, Manipal, India. The sample size for the study was estimated from the previous existing study, consisted of 33 (20 males and 13 females) elderly persons aged above 60 years and were able to understand and follow commands. Subjects who had acute illness on the day of assessment, foot ulcers, acute labyrinthine disorders, functional hearing & visual deficits, cognitive impairments and non-cooperative participants were excluded from the study. PROCEDURE The study protocol was presented and approval was obtained to conduct the study by the ethical committee of Manipal University. Elderly subjects in the age group of 60 years and above were identified from the community and old age homes after which they were screened for inclusion and exclusion criteria. The selected subjects were explained about the study and informed consent was obtained for their participation. The subjects were assessed for the following measures as explained below. Community Balance and Mobility Scale (CB&MS) An 8 meter track with duct tape was made which is of 5cm width on the floor with a perpendicular start line and finish line. Markings done at 1m, 2m, 4m and
6m with a tape perpendicularly. A 40cm bare spot was placed for item 3 and 4 after 6m mark. The visual target for items 8 and 11 was placed at the 4m mark, at individuals eye level and 1m from the outside edge of the track. Individuals were advised to wear comfortable clothes. All items (total 13) were scored in the first trail after explaining each one task and ensuring rest periods in between tasks as required. The set up resembles as
Initial evaluation using CB&MS was done and revaluation was done after a period of one week for determining the test retest reliability. Postural sway amplitude and velocity After measuring the height, weight and age, subjects were instructed to stand with normal base of support on the force platform of Posturography machine with arms folded in front of chest. Subjects were instructed to stand relaxed on force platform, bare foot, with the head in a straight head position. They were asked to focus on specific point (2 m distance) at their eye level during eyes open conditions and the timer is started. After 30 seconds, the timer is stopped and the subject is rested for two minutes. The same procedure is repeated with subject standing with normal base- eye closed for 30 seconds, tandem stance the heel of one foot touches great toe of other foot, the foot position according to convenience of patient (eyes open and eyes closed) and both right and left single leg stance while opposite leg flexed at knee for 20 seconds. Two minutes of rest was given in between each position. The subjects who did not stand for 30 seconds in normal stance eyes open and eyes closed and 20 seconds in remaining testing positions even after two trials, the test is stopped and noted down as unable to test. After all the testing positions were done, velocity moment noted down from the computer. These readings were used to correlate with CB&MS and Tinetti POMA balance subscale measures. Data analysis Data was analyzed using SPSS version 16.Test retest reliability of CB&MS was analyzed using Intraclass Correlation Coefficient. Concurrent validity of CB&MS with posturography measure (Velocity Moment) was
analyzed using Spearmans correlation coefficient. The level of significance was kept at P value less than or equal to 0.05. RESULTS Descriptive statistic on the anthropometrics data, balance subscale of Tinetti POMA and CB&MS total scores of the study subjects is shown in table 1.
Table 1: Demographic characteristics, median CB&MS and POMA scores of elderly subjects (n=33)
Variables Gender Age in years (Mean + SD) Height in cms (Mean + SD) Weight in kgs (Mean + SD) CB&MS score (Median , IQR) Male 20 66.25+7.25 164.58+ 5.44 60.03+ 11.61 50.50 (43.25+57.00) Female 13 68.00+5.68 149.89+ 4.32 51.07+7.26 40.00 (34.50+46.00)
Above table shows high test-retest reliability of both total score and individual items. Phase 2: Correlation of CB&MS total score with posturography velocity moment in different positions
Table 3: Correlation of CB&MS total score with posturography velocity moment in different positions
Posturography conditions Correlation with CB&MS r value 0.078 -0.033 -0.092 0.307 0.556 0.049 0.308 p value
Normal stance eyes open(NSEO) Normal stance eyes closed(NSEC) Tandem stance eyes open(TSEO) Tandem stance eyes closed(TSEC) Single leg stance Rt eyes open(SL rt EO) Single leg stance Lt eyes open(SL lt EO) Single led stance Rt eyes closed(SL rt EC)
0.672 0.859 0.617 0.087 0.001 0.791 0.086
Balance subscale of Tinetti POMA
16(16+16)
16(16+16)
Above table suggests that study group population consist predominately males, scored higher in CB&MS than females. It also shows all the all subjects scored full on the balance subscale of Tinetti POMA. Phase1: Test-retest reliability of CB&MS
Table 2: Intra-class correlation coefficient (ICC) values for test retest CB&MS in elderly subjects (n=33).
Item No Item name I II III IV V VI VII VIII IX X XI XII XIII Total score Unilateral stance right Unilateral stance left Tandem walking 1800Tandem pivot Lateral foot scooting :Right Lateral foot scooting :Left Hopping forward: Right Hopping forward: Left Crouch and walk Lateral dodging Walking& looking :Right Walking& looking :Left Running and controlled stop Forward to back ward walking Walk ,look & carry: Right Walk ,look & carry: Left Descending stairs Step ups 1 step: Right Step ups 1 step: Left ICC value 0.871 0.910 0.994 0.960 0.981 0.953 0.976 0.960 0.959 0.934 0.939 0.969 0.860 0.944 0.983 0.981 0.889 1.000 0.973 0.985
Above table displays significant low positive correlation of CB&MS total score with posturography single leg stance right side in eyes open condition. In addition to that it also shows negative correlation with normal stance eyes closed and tandem stance eyes open but not statistically significant.
Table 4: Correlation of individual items of CB&MS with posturography velocity moment
Item No I III IV V Item name Unilateral stance (Left) 180 Tandem pivot Lateral foot scooting (Left ) Hopping forward Posturography r value conditions SL lt EO SL rt EO SL rt EO NSEC SL rt EO VI IX Crouch and walk Running with controlled stop SL rt EO SL rt EO 0.406 0.500 0.542 -0.423 0387 0.492 0.389 P value 0.021 0.004 0.001 0.016 0.029 0.004 0.028
Table shows significant positive correlation of individual item of CB&MS with posturography velocity moment except hopping forward with normal stance eyes closed showed negative correlation. DISCUSSION The study participants were young-old with full score in Tinetti POMA balance subscale, which implies participants were highly functional. Males scored significantly higher in CB&MS than females. Our phase 1 results showed high test-retest reliability of CB&MS in elderly subjects suggesting that it could be a reliable tool to assess balance and mobility function in them. CB&MS is simple and feasible test as
it does not require any special equipment to be performed in the community setting. Uneven surfaces in community could be utilized since people would have accommodated to that specific environment. This also leads to evaluation in actual real life setting instead of clinical setting. All subjects completed the test without any adverse events and hence it is safe to be used in young old elderly population. CB&MS has items which represents the underlying motor skills necessary for function within the community. For example Single leg stance is necessary during stance phase of gait cycle and for public transportation.,etc. In spite of being healthy elders, subjects could not attain full score in CB&MS. A number of factors could have contributed to the decrease in successful performance and not attaining full score in CB&MS. First, the tasks were challenging as certain items are time scored, in which (item no I-right and left, VI, VIIright and left, IX,X,XI-right and left ,XIII-right and left) they have to complete the tasks within the time limit in order to attain full score. Second, the complexity of tasks which include hopping forward, crouch and walk, running with controlled stop, and lateral dodging which requires good strength ,balance and coordination. These observations were supported by earlier study done by Scott J.Butcher et al 2004. Although not tested in this study, the fact that women tend to have lower muscle strength than men15 could explain their lower performance on these items in the 60 to 72 year age category (table1). Slow speed of performance, particularly for item 7(lateral dodging), could also be attributed to slowness in reaction time with increasing age5. A decrease in speed has previously been attributed to age-related reduction in muscle fibre size, particularly in type II fibres, which are primarily responsible for speed of movement 20. We observed that the subjects were motivated, enthusiastic and enjoyed the part of the test, which could be due to dynamic and challenging tasks involved in the scale. This might be the reason for adherence to retest evaluation of our study except nine participants who could not attend the retest due to personnel problems. The average time taken to complete the test administration was approximately 30 minutes.This is more compared to other assessment measures in elderly which could be explained by the progressive difficulty in task items. Some of the items were scored based on duration, which requires the subject to complete the
minimum time of 45 seconds (SLS).Some items need to be performed four (Lateral dodging) or five (Step ups) times and walk for seven consecutive steps (tandem walking) which further increased the assessment time. Rest periods given in between tasks could also have increased the test duration. In our phase results, we did not find any correlation between items of CB&MS and Posturography measures which could be explained by the difference in measurement surface, environment and nonfamiliarization of Posturography. Posturography measures were taken on force platform in well designed and organized laboratory setting as against to CB&MS which was performed in real setting. Poor correlation between CB&MS and Posturography could also be attributed to the different components of balance being assessed by two tests, that is Posturography measures static balance while, CB&MS measures dynamic balance and mobility tasks. LIMITATION Our results were restricted to young-old elderly population and hence cannot be generalized to oldold. However, we would like to recommend further studies to test the feasibility of CB& MS in old-old subjects. CONCLUSION CB&MS showed excellent test retest reliability hence it could be feasible in the community for assessing balance and mobility of young-old elderly population. REFERENCES 1. Alan H Feiveson , E Jeffrey Metter ,Williams H Paloski .member IEEE (2003). A statistical model for inter predating computerized dynamic posturography data.IEEE transactions on Biomedical Engineering.Vol49, no 4. 300-309. Balcombe NR, Sinclair A (2001). Ageing: definitions, mechanisms and the magnitude of the problem. Best Pract Res Clin Gastroenterol. 15: 835-849. Bischoff ,Hannes B.Stahelin et al(2003).Identify a cut off point for normal mobility. A comparison of the timed U....,Age and aging .32;3;proquest medical library pg 315. Faber MJ, Bosscher RJ, vanWieringen PCW (2006). Clinimetric properties of the PerformanceOriented Mobility Assessment. Phys Ther .86: 944954.
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13. Maki BE, McIlroy WE(1996). Postural control in the older adult. Clin Geriatr Med Nov. 12(4):635658. 14. Payton OD, Poland JL (1983): Aging process: Implications for clinical practice. Phys Ther. 63: 4148. 15. Pincivero DM, Goelho AJ, Campy RM (2003). Knee fiexor torque and perceived exertion; a gender and reliability analysis. Med Sci Sports Exerc.35; 1720-1726. 16. Sadashiv Ram Aggarwal, Deepak Kumar (2006): Lower extremity muscle strength and balance performance in Indian community dwelling elderly men aged 50 years and above; Indian Journal of Physiotherapy and Occupational Therapy. Vol. 0, No. 0 17. The 2001 census: Aging population of India an analysis of the 2001 census data. 18. Tinetti, M.E(1987). Factors associated with serious injury during falls by ambulatory n u r s i n g home residents. J Am Geriatr Soc. 35(7): p. 644-8. 19. Tinetti,M,et al (1988):Identifying mobility dysfunction in elderly patients :standard neuromuscular examination or direct assessment. JAMA .259:119. 20. Vandervoort A (2002). Aging of the human neuromuscular system. Muscle Nerve .25; 17-25.
Core Stability Training with Conventional Balance Training Improves Dynamic Balance in Progressive Degenerative Cerebellar Ataxia
Khan Neha Tabbassum1, Nayeem-U-Zia2, Harpreet Singh Sachdev3, Suman K4 Student (M.P.T Neurology), Dept. of Rehabilitation Sciences, Hamdard University, New Delhi, 2Lecturer, Dept. of Rehabilitation Sciences, Jamia Hamdard, New Delhi, 3Consultant physiotherapist, Neurology Dept., A.I.I.M.S., New Delhi, 4Co- Guide, Associate Professor, Neurology Dept., IHBAS hospital, New Delhi ABSTRACT Background and Purpose: Disorder of balance and gait is the commonest feature found in Cerebellar ataxia patients. Purpose was to see the effect of Core stability training along with balance training on dynamic balance in progressive degenerative Cerebellar Ataxia. Methods: 20 subjects of progressive Degenerative condition (18 SCA subjects and 2 olivopontocerebellar atrophy) were systematically assigned in two groups, group A (n=10) in core and balance training and group B (n=10) in balance and relaxation training. Treatment was given 1 hour per session for each group, 3 days a week for 4 weeks. The outcomes of the study were measured by Balance Evaluation System Test (BESTest) and Modified falls efficacy scale (MFES). Results: Core stability training group showed significant improvement on BESTest at follow up compared to conventional balance training group. There was no statistical difference found in the MFEscale among the two groups but the results were clinically significant till follow up for core stability training group. Conclusion: Core stability training can be included as an adjunct to conventional balance training in improving dynamic balance in patients with progressive degenerative Cerebellar ataxia. Keywords: Cerebellar Ataxia, Core Stability Training, Dynamic Balance, Falls INTRODUCTION Cerebellar ataxia indicates dysfunction of the cerebellum. Ataxia literally means without order. The term ataxia refers mainly to inaccuracy of movement towards a target, to rhythmic limb movements either during a sustained posture or when the patient attempts to reach a target, inability to perform smooth alternate movements and loss of coordination of muscle groups in multi joint movements.1 Patients with degenerative cerebellar lesions show global impairment of balance with greater instability in anterior- posterior direction than medio- lateral directions.2, 3 important factor contributing to instability is decreased knee and ankle flexion when tested through perturbations 3. Individuals with cerebellar ataxia show more co-contraction modes of muscles resulting in stiffness of muscles of major joints e.g. knee stiffness and result in impaired coordination during feedback and feed forward postural control 4Studies reveal cerebellar gait ataxia is more related to balance deficits than voluntary leg coordination deficits.5 Systems approach describes, dynamic balance is a result of interaction of the individual, task & environment. Ankle, hip, suspensory and stepping strategies keep centre of gravity over the base of support, anticipatory postural adjustments occur before the actual disturbance, volitional postural movements are under conscious control are the motor components of balance that support postural orientation & automatic postural reactions.6 The muscles stabilizing lumbar spine form the core muscles. This muscular control is required around lumbar spine to maintain functional stability.7 Core stability is defined as the ability of the lumbopelvichip complex to prevent buckling of the vertebral column and return it to equilibrium following perturbation.8 Core stability (spinal stabilization)techniques incorporated in Low Back Pain subjects have found to improve the stability of spine by improving the cocontraction of trunk muscles, recovery in the size of multifidus muscle, also resulted in motor learning by retaining appropriate coordination of deep and
superficial muscles for gaining spinal stability9,10,11. Core strengthening improves dynamic postural control in rehabilitation of athletic injury.12 The purpose of this study was to determine whether the addition of Core stability training to conventional balance training in patients with Progressive degenerative cerebellar ataxia has any benefit on dynamic balance as compared with conventional balance training alone. Dynamic balance is a problem in patients with Progressive Degenerative Cerebellar Ataxia. The trunk muscles form the basis of core which acts as the powerhouse for force production and coordinated limb movements during locomotion.13 Core Stability training it is aimed to create awareness of muscle contractions around the spine which have eventually weakened due to chronic nature of disease.2,3 Also in progressive degenerative Cerebellar Ataxia the synergies required for maintaining Dynamic Balance are altered.4 The synergies can be strengthened through training of Core muscles.14 If the study reveals positive effects of core stability training on dynamic balance, treatment protocols can be developed to improve dynamic balance with ease in every clinical setting. METHOD A sample of 20 subjects with progressive degenerative Cerebellar ataxia (18 subjects were SCA and 2 were olivopontocerebellar atrophy) participated in the study. Out of 20, 15 were male whereas 5 were female. 18 subjects suffered from SCAs (type 1, 2, 3) and two from olivo-ponto cerebellar atrophy. A sample of convenience was taken. Subjects in group A were treated with core stability training which included back stabilization exercises, single leg slides, leg loading, facilitation of Transversus abdominis, bridging, Pelvic floor exercises and diaphragmatic Breathing while balance training included turning, walking sideways, heel to toe walking, sit to stand, heel lifts, toe lifts, single leg standing ,leg swings, stair climbing. Subjects in Group B treated with balance training and relaxation training15, 16,17,18,19 at Institute of Human Behaviour and Allied Sciences Hospital, Delhi. Subjects with Progressive degenerative ataxia of cerebellar origin diagnosed by neurologist, age range from 18-50, MMSE score e 24,Chronic cases having symptoms more than a year, SARA score 15-23,20 Subjects should be able to walk minimum distance of 10 meters with or without walking aid were included in the study.20 Subjects diagnosed as Afferent/ sensory ataxia, any other neurological or orthopaedic disorder affecting gait or balance, severe Low back pain, Already undergoing
physiotherapy intervention for last 3 months, Uncorrectable visual or hearing loss, Subjects unwilling to follow the exercise regime were excluded. It was a prospective repeated measure experimental group design. Instrument used for exercise regime was pressure biofeedback device16, 21 (Chattanooga group). A duly signed consent form was obtained from the subjects. A detailed assessment of every subject was done using neurological evaluation form. All the subjects were assessed for inclusion and exclusion criteria. The mini mental status examination was done. Demographic data of the subjects were collected. Subjects were assigned systematically into two groups group A experimental and group B conventional treatment groups. The treatment sessions for both the groups were given for 1 hour per day, 3 times per week for 4 weeks The performance of the two groups was examined on the following scales: Dynamic Balance was tested on Balance Evaluation System Test(BESTest)22 and for fear of Falls Modified Falls efficacy scale (MFES) 23was used..The outcomes were taken 3 times during treatment first before treatment, second immediately after the 4 weeks of treatment and third after a months follow up. The treatment was given n the physiotherapy department of the IHBAS hospital. The study was reviewed by the ethical board of Jamia Hamdard University, New Delhi. DATA ANALYSIS The data was analysed using SPSS software version 15. Independent T-test was used to see the difference between the effects training between group A and B.Effectiveness of treatment within the groups was measured using repeated measure ANOVA. The results were checked at P<0.05 level of significance. RESULTS The change in the Dynamic Balance and Fear of falls was measured at three levels of the treatment phases, initially at pre treatment, then post treatment and last at follow up BETWEEN GROUP The Mean SD values for BESTest in experimental group after 1 month of treatment was 63.50 15.757 and conventional group was 50.00 11.981.This difference in values was statistically significant p=0.045. The Mean SD values for experimental group from pre intervention to Follow Up was 55.60 17.602 the result was statistically significant (P=0.024) and conventional group was 40.10 9.327.This difference in values was statistically significant (p=0.024), indicating that the
experimental group showed more improvement in Balance than the conventional group. Although there was no statistically significant improvement in the scores at post treatment (p=0.433) and at follow up (p=0.154) after treatment.
Table. 1.1 Comparison between pre, post and follow up scores of experimental and conventional groups on BESTest scale
Dependent variables Pre BESTest total Post BESTest total Follow up BESTest total Experimental Mean SD 35.60 12.616 63.50 15.757 55.60 17.602 Conventional Mean SD 38.10 10.503 50.00 11.981 40.10 9.327 P value 0.636 0.045* 0.024*
into tasks that includes coordination of deep and superficial trunk muscles is maintained in functional context balance.14 Konin JG et al. al described diagonal orientation of core muscles resemble a serape, producing a serape effect connecting the stability for upper and lower extremities and maintaining muscular control around the spine and maintaining functional stability.25 In this study the pressure biofeedback was used for core training including abdominal hollowing a basic exercise taught initially and then hollowing associated with lower limb movements. It activated Transversus Abdominis (TrA) muscle, which is important muscle forming core.26 It is found that the patient with cerebellar ataxia uses restricted synergies i.e. stiffening of pelvis, knees, and ankles during challenging tasks.27 It has also been found that practice could lead to transition from co-contraction to reciprocal patterns on the basis of uncontrolled manifold (UCM) hypothesis.28 This study included patients with chronic progressive disease, as above study mentioned that these patients use restricted synergies to maintain balance. Practice of core training along with lower limb activities provided in this study might have helped patients to develop reciprocal muscle pattern rather than the stiffening of the joints.28 resulting in reduction of synergies and their strengthening which are essential for dynamic balance control.28 The rationale behind the fact that patients did not return to pre treatment level or their condition did not decline due to progression of disease, is that the natural progression of degeneration in Cerebellar ataxia is 0.62.5 points 1 year as found on SARA scale depending on genotypes (data of EUROSCA natural history. Thomas Klockgether, 2008).5 Long term effects of intensive exercise training have been proven in research on progressive degenerative cerebellar disease even after a year of training.29 There was no statistical significance in improvement of the falls score at post treatment (p=0.433) and at follow up (p=0.154).However experimental group showed clinical improvement in falls score. When baselines (fig.1.2) were compared for both the groups it can be observed that the difference for improvement was more in Experimental group than the conventional group. The results obtained may be attributed to the 1) gender differences, in experimental group there were 3 females and conventional group there were 2 females, because the females were seen to have less confidence than males of same severity.23, 30 2) Considering age differences, in conventional group 3 patients were of age 45years and above, while in experimental there were 4 patients having age 45years and above. 3) Considering
Table 1.2 Comparison between pre, post and follow up scores of experimental and conventional groups on MFE Scale
Dependent variables Pre MFES Post MFES Follow Up MFES Expt Mean SD 52.80 20.137 77.80 30.724 78.50 32.857 Conv Mean SD 59.10 14.395 68.80 17.725 59.90 21.957 P value 0.431 0.433 0.154
DISCUSSION The key findings that emerged from the study were that core stability training is effective in improving Dynamic balance in progressive degenerative cerebellar ataxia. Core stability training group showed significant improvement on BESTest till follow up compared to conventional balance training group. There was no statistical difference found in the MFEscale among the two groups but the results were clinically significant at follow up for core stability training group. Liebenson found trunk stabilization exercises resulted in reduction of low back pain, by increasing the kinaesthetic awareness necessary to maintain safe neutral spine which is ideal for rehabilitation.24 Nicole L et al. studied on dynamic balance testing among young healthy adults and found that core strengthening improves dynamic postural control during rehabilitation of athletic injury.12 The diaphragm serves as the roof of the core; stability is augmented on the lumbar spine by contraction of diaphragm and increasing intraabdominal pressure.13 Pelvic floor musculature is co activated with the Transversus abdominis contraction.13 The results found this study are supported by the work of Paul W. Hodges which provided the rationale of core stability training, that stability of spine depends on both the muscle activation and CNS control.14 The core stability training results in motor learning sequentially through skill learning, precision training, activation in variety of contexts, integration of skills
disease severity, in conventional group 4 subjects were above 16 scoring of SARA scale, while in experimental there were 5 subjects scoring more than 16. The above factors may be the possible causes of difference of MFEs score at pre treatment level that led to no statistical significance even though the experimental group improved more than conventional group. CONCLUSION The results obtained show that the core stability training improves dynamic balance. However it was seen that although there was clinical improvement of scores on MFEScale, but no statistical significance was observed. Thus it is concluded that in rehabilitation of dynamic balance in patients with progressive Cerebellar ataxia, core stabilization programme can be included as an adjunct to conventional balance training. LIMITATIONS OF STUDY 1. The subjects included in this study were moderately disabled (rated on SARA scale). The results of this study cannot be generalized to severely disabled patients. 2. Scale for measurement of fear of falls taken was subjective. 3. The sample size was smaller. ACKNOWLEDGEMENTS Sincere thanks to Physiotherapy Dept. IHBAS, Jamia Hamdard, New Delhi. REFERENCES 1. 2. M.Halliet.Hand book of Clinical Neurophysiology.Elsevier2003; 1: 498. Ganesan Mohan, Pramod Kumar Pal,Kumar R. Sendhil, Kandavel Thennarasu, B.R. Usha. Quantitative evaluation of balance in patients with spinocerebellar ataxia type 1: A case control study. Parkinsonism and Related Disorders 2009; 15: 435439. Maaike Bakker, John H.J. Allum, Jasper E. Visser, Christian Grneberg, Bart P. van de Warrenburg, Berry H.P. Kremer, et al. Postural responses to multidirectional stance perturbations in cerebellar ataxia. Experimental Neurology 2006; 202: 2135. Asaka T, Wang Y, Fukushima J, Latash ML. Learning effects on muscle modes and multi-mode postural synergies. Exp Brain Res. 2008 Jan; 184(3):323-38. Susanne M.Morton, AmyJ.Bastain. Relative contributions of balance and voluntary leg-
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21. Sullivan.P, Towmey.L, Allison.G. Altered abdominal muscle recruitment in patients with chronic low back pain following a specific exercise intervention. Journal of Sports Physical Therapy, 1998; 27(2):114-124. 22. Horak FB, Wrisley DM, Frank J.The Balance Evaluation Systems Test (BESTest) to differentiate balance deficits. Phys Ther. 2009 May; 89(5): 484-98. 23. Hill KD, Schwarz JA, Kalogeropoulos AJ, Gibson SJ. Fear of falling revisited. Arch Phys Med Rehabil. 1996 Oct; 77(10):1025-9. 24. C. Libenson. Spinal stabilization training. Journal of bodywork and movement therapy 1997; 1(2): 87-90. 25. Konin JG, Beil N, Werner G. Functional rehabilitation. Facilitating the serape effect to enhance extremity force production. AthlTher Today 2003;8:54-6 26. Carolyn Richardson, Gwendolen Jull, Rowena
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Restoration of Normal Length of Upper Trapezius and Levator Scapulae in Subjects with Adhesive Capsulitis
Pandit Niranjan Hemant1, Mhatre Bhavana Suhas2, Mehta Amita Anil3 Physiotherapist - Mumbai Cricket Association, Cricket Centre, Wankhede Stadium, 'D' Road, Churchgate, Mumbai, - Jaslok hospital & Research Centre, 15 - Dr. Deshmukh Marg, Pedder Road, Mumbai, 2 Associate Professor, P.T School and Centre, Seth Dhurmal Bajaj Orthopaedic Centre, 3Professor and Head, P.T School and Centre, Seth Dhurmal Bajaj Orthopaedic Centre, Seth G.S.Medical College and KEM hospital, Parel, Mumbai
1
ABSTRACT Study Design: Prospective clinical trial of subjects with Adhesive Capsulitis Objective: To find the effect of restoration of length of the shortened upper trapezius and levator scapula muscle with muscle energy technique and sustained passive stretching techniques along with Maitland joint mobilization for glenohumeral joint as compared to Maitland joint mobilization alone on range of motion and scapular position at rest in subjects with unilateral adhesive capsulitis. Background: The glenohumeral hypomobility in adhesive capsulitis causes excessive scapular motion to compensate for the reduced gleno-humeral motion. The resulting tightness of upper trapezius and levator scapula causes an altered scapular position at rest. Restoring normal length of upper trapezius and levator scapulae will help to restore an optimal length-tension relationship and scapular position resulting in better improvement of glenohumeral range of motion. Methods and measures: 60 male subjects with unilateral adhesive capsulitis were divided into group I and group II of 30 each. Baseline outcome measures assessed were shoulder ROM of flexion, abduction and external rotation and resting position of the scapula using the Lennie test. Group I received Muscle Energy Technique (MET) for upper trapezius and levator scapula along with Maitland joint mobilization for the glenohumeral joint. Group II received Maitland mobilization for the gleno-humeral joint. Outcomes were reassessed at 6 weeks. Results: The results showed statistically significant improvement ROM in both groups with improvement being more in group I as compared to group II. However scapular position showed statistically significantly improvement only in group I with no improvement in group II. Conclusion: Adding muscle energy techniques to the treatment of adhesive capsulitis gives better outcomes compared to treating with joint mobilization alone. Keywords: Adhesive Capsulitis, Muscle Energy Techniques, Upper Trapezius, Levator Scapula, Joint Mobilization
INTRODUCTION Adhesive capsulitis is a condition causing painful and restricted motion of the glenohumeral joint. Normally the entire glenohumeral joint in the resting position (arm dependent at the side) is surrounded by a large, loose capsule that is taut superiorly and slack anteriorly and inferiorly (redundant folds or axillary pouch) 1. Hyaluronic acid with water is the lubricant between the collagen fibres that allows the free gliding to occur 2.The pathogenesis of adhesive capsulitis involves the entire capsule with more involvement of the antero-inferior axillary folds which are shrunken and fibrosed 3,4.
The impairments are pain and loss of active and passive mobility of the glenohumeral joint. Abnormal scapular motion, such as excess elevation and increased outward rotation of the scapula during elevation of the arm, is generally thought to be a compensation strategy for a limited glenohumeral motion, muscle imbalance and pain 3. In a trial of ten patients with unilateral frozen shoulder syndrome for 3 months early scapular lateral rotation of the frozen shoulder during elevation of the arm using an electromagnetic tracking device was documented 5. Research supports the view that patients suffering from frozen shoulder syndrome compensate for
impaired glenohumeral motion via the use of accessory musculature i.e. increased trapezius muscle activity 6. The upper trapezius and levator scapulae are considered to be postural muscles and hence undergo shortening in response to stress or overuse 7. The scapula on the involved side is usually elevated, laterally rotated and abducted 2. Studies on treatment of adhesive capsulitis concentrate on treating glenohumeral joint. But little attention is paid to normalize scapular static and dynamic mechanics which are essential for normal glenohumeral rhythm. Hence the focus of this study was to find the effect of restoration of length of the shortened upper trapezius and levator scapula muscle with muscle energy technique and sustained passive stretching techniques along with Maitland joint mobilization for glenohumeral joint as compared to Maitland joint mobilization alone on pain scores, range of motion and scapular position at rest in subjects with unilateral adhesive capsulitis. We begin with the null hypothesis that there is no relation between combining muscle energy techniques for upper trapezius and levator scapula and Maitland joint mobilizations for glenohumeral joint as compared to treating glenohumeral joint alone with Maitland joint mobilization. MATERIALS AND METHODOLOGY Prospective clinical trial of 60 male subjects with adhesive capsulitis from the outpatient department of physiotherapy at Seth G.S. Medical college & K.E.M. hospital Mumbai.
of or around shoulder Adhesive capsulitis along with neurological conditions like hemiplegia
The material used Universal goniometer Vernier caliper Wrist watch Skin markers Manual therapy table 10 centimeter visual analogue scale (VAS) Assessment proforma.
Informed consent was obtained from subjects prior to their inclusion in the study. Approval was taken from Ethics Committee for Research on Human subjects (ECRHS) of K.E.M. Hospital Mumbai. The following outcome measures were assessed on day 1 and at the end of 6 weeks (18th treatment session). Flexion, abduction and external rotation ROM using goniometer. Position of the scapula on the thorax at rest using the Lennie test 8 (Fig 1)
Markers were put on the skin overlying the affected and non-affected scapulae for the superior angle, root of the scapular spine and inferior angle. Three measurements of scapular position in the frontal plane were obtained for both sides. Midline to superior angle distance Midline to root of the spine of scapula distance Midline to inferior angle distance. In addition, height difference between scapulae (defined as difference between the vertical positions of the inferior angles of the affected and the nonaffected scapula) was measured with the caliper using the midline marks corresponding to the two inferior angles.
Inclusion criteria Patients with unilateral adhesive capsulitis.
Exclusion criteria Bilateral adhesive capsulitis Dorsal spine scoliosis as spine was taken as the midline reference Associated pathology of the cervical spine. Post fracture stiffness Rotator cuff tendinosis or tears Shoulder instability Complex regional pain syndrome Neurovascular neoplastic or infectious conditions
Subjects were divided into group I and group II of 30 each and assigned alternately into groups i.e. even numbers into group I and odd numbers in Group II. Group I received: Muscle energy techniques for upper
trapezius and levator scapulae along with Maitland joint mobilization Muscle Energy Technique for upper trapezius and levator scapula 7: (Fig 2)
3 sets of 30 oscillations per minute per glide 9.
Both groups were given hydrocollator packs for the shoulder joint for 10 minutes in sitting position before treatment 10. Home exercise program 11 Both the groups were given home exercise program with the following exercises: 1) Shoulder girdle retraction and depression(scapular setting). 2) Wand exercise to improve shoulder flexion and shoulder rotation with both hands. 3) Active assisted shoulder extension in standing. The subjects were asked to repeat each exercise ten times twice a day. They were told to take hot packs at home before exercising to reduce pain and relieve spasm. Data analysis and results 56 patients completed the study. Two subjects in each group were lost to follow up before 6 weeks. So there data was not taken into consideration in statistical analysis. For the values of shoulder range of motion and scapular position, paired t test (pre-post within group comparison) and unpaired t test (inter-group comparison) was used.
Subject performed a sub-maximal isometric contraction in supine position for the respective muscle against resistance commencing with the muscle at the resistance barrier and maintained it for 10 seconds. Following relaxation, muscle was stretched beyond the barrier till a new barrier was reached and stretch was maintained for 30 seconds. The sequence was repeated 3 times for upper trapezius and levator scapula. Maitland joint mobilization: (Fig 3) Anteroposterior (AP), posteroanterior (PA) and inferior glide Grade 3 and 4 Maitland joint mobilizations for the gleno-humeral joint. 3 sets of 30 oscillations per minute per glide 9.
Group II received: Maitland joint mobilization. Maitland joint mobilization: (Fig 3) Anteroposterior (AP), posteroanterior (PA) and inferior glide Grade 3 and 4 Maitland joint mobilizations for the gleno-humeral joint.
Table 1: Baseline values of the two groups - unpaired t test. The baseline mean values for the parameters did not show a statistically significant difference (p > 0.05).
Variables Mean ROM FlexionActivePassive AbductionActivePassive External rotationActivePassive Scapular position SA IA I I 6.3368 7.2882 0.9811 0.2099 0.3194 0.1765 6.2829 7.2261 0.9779 0.1700 0.2593 0.1734 0.2955 0.4276 0.9576 NS NS NS 102.86112.14 78.9388.75 7.1414.46 13.5013.57 14.3012.22 7.266.98 98.93108.57 73.7585.36 4.8212.14 12.3510.35 10.8510.09 4.615.17 0.26090.2731 0.13270.2622 0.15880.1632 NS NS NS Group I SD Group II Mean SD p value Significance
NS Not Significant, SA Superior angle, IA Inferior Angle, I I Difference in Inferior angle levels
Analysis of scapular position change

Table 2. Inter-group comparison of reduction of distance of Superior and Inferior Angle from midline and Difference between Inferior angles
Mean Group I Group II t- value # p- value SA Pre 6.3368 6.2829 1.05 0.2955 SA Post 6.2418 6.2821 1.39 0.1697 IA Pre 7.2882 7.2261 0.79 0.4276 IA Post 6.7500 7.2175 6.43 0.0001 II Pre 0.9811 0.9779 0.05 0.4276 II Post 0.3836 0.9729 15.66 0.0001
* - Results analysed using paired t test # - Results analysed using unpaired t test
These results indicate that only treatment received by group I was effective in bringing about change in the scapular position (p < 0.05) while no statistically Analysis of abduction range of motion
significant effect was seen in scapular position by intervention given in group II (p > 0.05).
Table 3. Intergroup comparison between abduction ROM before and after treatment. Mean
Group I Group II t value # p value * - Results analysed using paired t test # - Results analysed using unpaired t test
Active Pre
78.93 73.75 1.52 0.1327
Active Post
110.54 100.00 2.70 0.0091
Passive Pre
88.75 85.36 1.13 0.2622
Passive Post
121.07 111.79 2.81 0.0068
Shoulder ROM of abduction showed extremely statistically significant improvement within both the groups post treatment (p < 0.05). In intergroup Analysis of flexion range of motion
comparison, group I showed more highly statistically significant improvement in abduction as compared to group II (p < 0.05).
Table 4 Intergroup comparison between flexion ROM before and after treatment.
Mean Group I Group II t - value p - value * - Results analysed using paired t test # - Results analysed using unpaired t test Active Pre 102.86 99.64 1.13 0.2609 Active Post 137.86 114.82 6.21 0.0001 Passive Pre 112.14 108.57 1.10 0.2731 Passive Post 146.96 125.89 6.42 0.0001
Shoulder ROM of flexion showed extremely statistically significant improvement within both the groups post treatment (p < 0.05). In intergroup
comparison, group I showed more highly statistically significant improvement in flexion as compared to group II (p < 0.05).
Analysis of external rotation range of motion

Table 5 Intergroup comparison between external rotation ROM before and after treatment.
Mean Group I Group II t value # p - value * - Results analysed using paired t test # - Results analysed using unpaired t test Active Pre 7.14 4.82 1.42 0.1588 Active Post 35.54 23.04 4.46 0.0001 Passive Pre 14.46 12.14 1.41 0.1632 Passive Post 43.57 33.75 4.71 0.0001
Shoulder ROM of external rotation showed extremely statistically significant improvement within both the groups post treatment (p < 0.05). In intergroup comparison, group I showed more highly statistically significant improvement in external rotation as compared to group II (p < 0.05). DISCUSSION Both the groups showed a significant improvement shoulder range of motion. Intergroup comparison indicates that group I showed significant improvement post treatment at the end of 6 weeks (18th session) on the above mentioned outcome when compared to group II. However, the improvement of scapular position post treatment was seen only in group I Scapular position improvement was seen secondary to the treatment of the upper trapezius and levator scapula muscle using muscle energy technique could be attributed to the therapeutic effects of muscle energy techniques. Many authors have proposed that MET techniques facilitate stretching by producing neurological reflex muscle relaxation 7 following isometric muscle contractions mediated by Golgi tendon organs. Connective tissue elongation is time dependent, and if a constant stretching force is loaded on the tissue, the tissue will respond with slow elongation or creep causing greater deformation i.e. there is viscoelastic or muscle property change 7. Myofascial structures have two distinct connective tissue arrangements: elastic parallel fibres, arranged parallel to the muscle fibres, and the stiffer in series fibres that lie perpendicular to muscle fibres and found mainly at the tendinous junctions. Passive stretching would elongate the parallel fibres but have little effect on the in series fibres; however, the addition of an isometric contraction would place loading on these fibres to produce viscoelastic or plastic change above and beyond that achieved by passive stretching alone. Literature suggests that MET methods produce a greater change in stretch tolerance 7 than passive stretching by decreasing an individuals perception of muscle pain.
Stretching and isometric contraction stimulate joint muscle and joint mechanoreceptors and proprioceptors, and it is possible that this may attenuate the sensation of pain. The above mentioned mechanisms contributed to reduce over activity and increased length of the upper trapezius and levator scapula muscle. This was reflected on the scapular position in Group I on the Lennie test. Literature supports the view that abnormal compensatory scapular movements in patients with shoulder stiffness can be reduced. In a particular study, it was demonstrated that with simple motor control instruction, the subjects reduced the amount of scapular elevation and retained relative timing and control 12. The primary role of mobilization is to restore joint play and facilitate joint movement by restoring arthrokinematics. The neurophysiologic effect is based on the stimulation of the peripheral mechanoreceptors and inhibition of nociceptors. The biomechanical effect is based on breaking up adhesions in the capsule, collagen fibre realignment and improving interfibre glide 2. A multiple-subject case report concluded that there seems to be a role for intensive mobilization techniques in the treatment of adhesive capsulitis 13. Hence there was increase in ROM of the shoulder over a period of 6 weeks. The underlying basis for the use of hot packs is the ability of heat to elevate pain threshold, alter nerve conduction velocity and change in muscle spindle firing rate 10. Thus the null hypothesis was rejected and the experimental hypothesis was proved. CONCLUSION Restoring length of upper trapezius and levator scapula is essential when treating patients with adhesive capsulitis. While assessing patients with adhesive capsulitis attention needs to be given to assessment of abnormal scapular position. Treatment
should be focused on treating the glenohumeral joint alone but also incorporate techniques to restore altered scapular mechanics. Limitations of the study The study did not take into account the strength of muscles like middle and lower trapezius, rhomboids, serratus anterior. Also the influence of other muscles which become tight in adhesive capsulitis like pectorals, subscapularis, and teres major on glenohumeral range of motion was not taken into account. Implication for future studies Studying the EMG activity before and post intervention for the upper trapezius and levator scapula would be helpful in understanding the mechanism of improvement in the length of these muscles post MET. Interest of conflict: We, Pandit N, Mhatre B and Mehta A state that there is no conflict of interests with other people or organizations about our work.
ACKNOWLEDGEMENTS We are heartily thankful to the staff of PT School and Centre, KEM hospital, who supported us from the preliminary stages of the project. Fig. 1. Lennie test
Fig. 2. Muscle energy techniques Levator scapula Upper trapezius
Fig. 3. Glenohumeral mobilization Anteroposterior glide Posteroanterior glide
Inferior glide
REFERENCES 1. 2. 3. 4. Norkin C. and Levangie P. 3rd edition. Jaypee Brothers 2001. Donatelli R.A. Physical therapy of the shoulder, 3rd edition; Churchill Livingstone 1997. Reeves B. Arthrographic changes in frozen shoulder and post traumatic stiff shoulders. Proc Soc Med 59:827, 1966. Neviaser J. S. Adhessive capsulitis of the shoulder:
A study of the pathological findings in periarthritis of the shoulder. JBJS Am. 1945;27:211-222. 5. Vermeulen H.M. Stokdijk M. Eilers P.H.C. Meskers C.G.M. Rozing P.M. Vliet Vlieland T.PM. Measurement of three dimensional shoulder movement patterns with an electromagnetic tracking device in patients with a frozen shoulder. Ann. rheum. Dis. 2002;61:115-120 6. Jiu-Jenq Lin. Ying-Tai Wu. Shwu-Fen Wang. ShiauYee Chen. Trapezius muscle imbalance in individuals suffering from frozen shoulder syndrome. Clin Rheumatol 2005;24:569575. 7. Chaitow L. Muscle energy techniques, 3rd edition; Churchill Livingstone 2006. 8. Sobush D. C. Simoneau G.G. Deitz K.E. Levene J.A. Grossman R.E. Smith W.B. The Lennie Test for measuring scapular position in healthy young adult females: A reliability and validity study, JOSPT Vol. 23 No. 1 Jan 1996. 9. Maitland G.D. Peripheral manipulation, 3rd edition. 10. Michlovitz S. Thermal agents in rehabilitation. 3rd edition FA Davis Co. Philadelphia 1990 11. Kisner C. and Colby L. Therapeutic exercise, 5th edition 2007. 12. 15 Babyar S. R. Excessive scapular motion in individuals recovering from painful and stiff shoulders: Causes and treatment strategies, Phys Ther. 1996;76:3.226-238. 13. Vermeulen H.M. Obermann W.R. Burger B.J. Kok G.L. Rozing P.M. van den Ende C.HM. End-range mobilization techniques in adhesive capsulitis of the shoulder joint: A multiple-subject case report. Phys Ther. 2000;80:12.1204-1213.
Comparison of VMO/VL Ratio in Patello-Femoral Pain Syndrome (PFPS) Patients: A Surface EMG Study
Nishant H Nar Consultant Physiotherapist Wockhardt Hospital, Rajkot ABSTRACT Background: PFPS describes anterior and retro patellar knee pain in the absence of other pathology. PFPS is one of the most common disorders of the knee accounts for 25% of knee injuries in sports medicine clinics. Prevalence rate is 20% in USA students and morbidity is directly related to activity of patients. EMG studies of normal subject have revealed that VMO /VL ratio is about 1:1 (power CM et al) Objective: To study the VMO/VL ratio during ECCENTRIC, CONCENTRIC, ISOMETRIC exercise and Q-angle in PFPS patients and control groups. Materials & Method: SUBJECTS; 25 diagnosed with PFPS and 25 asymptomatic control were recruited for study. EMG activity of VMO VL was recorded by surface electrodes.EMG data were analyzed in three activities for both groups, ISOMETRIC, CONCENTRIC and ECCENTRIC exercise. Outcome measure was EMG MUAP amplitude and Q-angle. Results: Results showed that VMO/VL ratio is lower in PFPS subjects. And static and dynamic Qangle is higher for PFPS groups. Conclusion: There was significant difference in VMO/VL ratio and Q-angle in both groups. Keywords: VMO, Surface EMG, Q-angle. In orthopedics sports medicine, the most common reasons for anterior knee pain are, [4] Overuse Mal-alignment Trauma Studies on the natural history of PFPS report that in general it is a benign condition that may improve or persist over time serious disability is uncommon. PFPS is a condition of both malalignment and muscular dysfunction. Rehabilitation exercises can restore PF joint homeostasis although the anatomical malalignment of PFPS may not be corrected. [5] Symptoms of anterior knee pain are brought on by overuse stress; PFPS is an ideal condition for prerehabilitation. [6] Total or near total recovery was noted in 22% at 16 years ( Noman et al 1998) 70 % at 3 years (Kanmus et al 1994), 81% at 12 years ( jensssen et al 1990), 85% at 11 years (Karlsson et al 1996 ).
INTRODUCTION PFPS describes anterior or retro patellar knee pain in the absence of other pathology. PFPS which is one of the most common disorders of the knee accounts for 25% of all knee injuries treated in sports clinics. [1] Female patient are particularly more affected than male [2]. Incidence rate is 7% and 10% in young male and female. [2] Prevalence rate is 20% in students in USA and morbidity is directly proportional to activity of Patients
[3]
In one study done by Winslow et al 1995 out of 16,748 patients presenting with sports related musculoskeletal problems, 11.3% had an anterior knee pain. Incidence of PFPS in general population is reported in some studies to be high as one in four with proportion increase in athletes. (Levine 1979, Outbridge 1984)
The basic origin and exact pathogenesis of PFPS are unknown but many predisposing factors have been proposed including[7] Acute trauma, knee ligament injury, instability, overuse, immobilization, overweight, malalignment of extensor mechanism. In many cases, however there are no obvious reasons for the symptoms, there is no clear association between severity of the symptoms and the radiologic and arthroscopic findings. Some theories for the origin of non- traumatic gradual onset of PFPS are [8] Neuromuscular imbalance of VMO VL, Tightness of lateral retinaculum, Hamstrings , Iliotibial band, Overpronation of subtalar joint. Several authors have exposed the theory that abnormal patellar alignment is the root of pain [8] Patients usually complain of insidious onset of vague, activity related pain coupled with evidence of wasting of Vastus medialis.[9] EMG studies of normal subjects have revealed that VMO/VL activity ratio is about 1:1, Whereas EMG recording in patients having PFPS has shown that the ratio of VMO/VL is le than 1:1. [10] [11]. Controversy exist in the literature as to the normal relationship between the timing of EMG activity of the VMO and VL and whether this difference in population with PFPS.[12, 13] Many rehabilitation strategies have implemented for patients with PFPS. In general the goals of patella femoral rehabilitation are to maximize quadriceps strength while minimizing the patella femoral joint reaction force and stress.[14, 15] Recently EMG biofeedback is also useful method to activate VMO muscle. Selina Lm Yip et al concluded that EMG biofeedback + exercise programme is beneficial than alone exercise in PFPS patients.[16] Other investigators [17, 18] have examined VMO and VL EMG levels in the patients with PFPS, but have not used control groups. Approximately 70% of patella femoral disorder will improve with conservative management.
Also in outpatient department the cases of PFPS is increasing day by day, and so the clinical assessment and treatment of the condition are extremely challenging because of the multiple forces affecting the patella femoral joints. MATERIALS AND METHODOLOGY STUDY DESIGN Cross sectional study STUDY SETTING This study was conducted at Physiotherapy Institute of Ahmedabad. All the patients were referred from Orthopedic Out patient Department of V.S Hospital, Ahmedabad. SAMPLE SIZE: 25 Subjects in each group SUBJECTS: Male and Female with clinical diagnosis of PFPS who were referred to physiotherapy OPD INCLUSION CRITERIA 1) Age between 25-40 year 2) Anterior knee pain more than 1 month 3) Knee pain atleast 2 of the following activities Ascending stairs Descending stairs Squatting Kneeling 4) Diagnostic tests were positive for PFPS 5) Subjects willing to participate in study EXCLUSION CRITERIA 1) Any trauma around knee joint 2) Any previous surgery around knee joint 3) Neurological disorder 4) Skin abrasion around knee 5) Previous physiotherapy taken in past 6 months for knee
MATERIALS USED IN STUDY Electrode, electrode gel, goniometer, measure tape, micro pore, plinth, consent form, Pencil, Papers assessment charts and recording sheets. APPARATUS USED IN STUDY EMG Machine with Neuro Perfect Plus Software Computer System with printer OUTCOME MEASURES EMG amplitude Q- Angle: static and dynamic PROCEDURE Twenty five subjects diagnosed with PFPS on the basis of clinical examination and referred from orthopedic OPD, and 25 asymptomatic controls were recruited for the study. Subjects were selected on the basis of inclusion and exclusion criteria. Detailed assessment of patients with diagnostic tests for PFPS and radiological examination was done. All subjects were provided written informed consent. Then patients data was entered to EMG programme (Neuro Perfect plus Software) in computer. Then EMG surface electrodes with gel were placed over the selected muscle. Micropore tape was used to adhere the electrodes on skin. EMG parameters were SWEEP -10ms, SENSITIVITY 100micro volts, LOW CUT 100Hz, HIGH CUT 5 KHz, PULSE/ SEC- 1, PULSE WIDTH-0.02ms VMO placed over the muscle belly approximately 4 cm superior to and 3 cm medial to the superomedial patellar border and oriented 55 degrees to vertical. [19] (Fig 2) EMG amplitude was recorded during ISOMETRIC, CONCENTRIC and ECCENTRIC exercises. EMG MUAP Amplitudes were identified from individual trials and averaged over the 5 repetition. After that electrodes were removed and placed for VL muscle and MUAP amplitude was recorded during above described three exercises. The electrode for VL was placed 10 cm superior and 6-8 cm lateral to the superior border of the patella, and oriented 15 degrees to vertical. [19] (Fig 1)
Averaged EMG Amplitude was taken for both VMO and VL and then VMO/VL ratio was calculated manually. Static and Dynamic Q-angle was measured for both groups. For static Q-angle measured with knee in full extension with subject in supine position. ASIS (anterior superior iliac spine), centre of patella and tibial tuberosity was marked with pencil. The angle formed by the intersection of line from ASIS to centre of patella with centre of patella to tibial tuberosity was measured in degrees with universal goniometer. [Fig-3] Dynamic Q-angle was measured with static quadriceps contraction in supine position with knee extended. Procedure of measurement was same as for static Q-angle. VL electrode placement
Fig. 1. VMO electrode placement
Fig. 2. Q-angle measurement
To analyze the dynamic Q-angle between groups mann-whitney U- test was used as the data is non parametric. To analyze the value of VMO/VL ratio between control and PFPS groups during isometric exercise unpaired t-test was used, as the data is normally distributed. To analyze the value of VMO/VL ratio between control and PFPS groups during concentric exercise unpaired t-test was used, as the data is normally distributed. To analyze the value of VMO/VL ratio between control and PFPS groups during eccentric exercise unpaired t-test was used, as the data is normally distributed.
Table-1 Age distribution of both group patients
Groups Control Experimental Mean 32.56 33.12 SD 5.324 4.825
Fig. 3
RESULTS In this study all the tests were performed manually as well as with the use of Graph pad software. To analyze the value of static and dynamic Q-angle within the groups for control and PFPS groups paired t-test was used, as the data is normally distributed. To analyze the static Q-angle between groups mannwhitney U-test was used as the data is non parametric.
The mean age of the control group was 32.56 5.324 and in the PFPS patients, the mean age was 33.12 4.825 No significant difference was seen across the two groups.
Table 2. Comparison of static and dynamic Q-angle in PFPS patients

Q-angle Static Dynamic mean 16.12 19.52 SD 2.789 3.709 Test used paired t-test t-value t=3.663 p-value P=0.0006 significance Extremelysignificant
Here the paired t-test was used as the data is normally distributed. Mean value for static and dynamic Q-angle were respectively 16.12 2.789 and 19.52 3.709. t=3.663 and p=0.0006 so the difference was extremely significant at 95% confidence interval.
Table -3 Comparison of static and dynamic Q-angle in control group
Q-angle Static Dynamic mean 14.36 15.12 SD 3.390 3.321 Test used paired t-test t-value t=0.8088 p-value P=0.4272 significance Not significant
Here the paired t-test was used as the data is normally distributed. Mean value for static and dynamic Q-angle were respectively 14.36 3.390 and 15.12 3.321. t=0.8088 and p=0.4272 so the difference was not significant at 95% confidence interval.
Table -4 Comparison of static Q-angle in PFPS and control groups
Q-angle PFPS Control mean 16.12 14.36 SD 2.789 3.390 Test used Mann whitney U test U-value U= 210 p-value P=0.0475 significance Considered significant
Here the Mann Whitney U test was used as the data is non-parametric. Mean value of static Q-angle for control and PFPS groups respectively were 16.12 2.789 and 14.36 3.390. Difference was significant at 95% confidence interval.
Table -5 Comparison of dynamic Q-angle in PFPS and control groups Q-angle PFPS Control mean 19.52 15.12 SD 3.709 3.321 Test used Mann whitney U test U-value U= 120.50 p-value P=0.0002 significance Extremely significant
Here the Mann Whitney U test was used as the data is non-parametric. Mean value of static Q-angle for control and PFPS groups respectively were 19.52 3.709 and 15.12 3.321. Difference was significant at 95% confidence interval.
Table 6. Comparison of VMO/VL ratio during ISOMETRIC exercise in PFPS and control
Groups Control Experimental mean 0.9260 0.8124 SD 0.0482 0.0995 Test used Unpaired t-test t-value t=5.136 p-value P=0.0001 significance Extremely significant
Here the un paired t-test was used. Mean value of VMO/VL in control group was 0.9260 0.0482 and PFPS group was 0.8124 0.0995. t=5.136 and p < 0.0001. so the difference was extremely significant at 95% confidence interval.
Table 7. Comparison of VMO/VL ratio during CONCENTRIC exercise in PFPS and control groups
Here the un paired t-test was used. Mean value of VMO/VL in control group was 0.9484 0.0300 and PFPS group was 0.8336 0.1113. t=4.976 and p < 0.0001. so the difference was extremely significant at 95% confidence interval.
Table -8 Comparison of VMO/VL ratio during ECCENTRIC exercise in PFPS and control groups
Here the un paired t-test was used. Mean value of VMO/VL in control group was 0.9505 0.0374 and PFPS group was 0.8126 0.0844. t=7.457 and p < 0.0001. so the difference was extremely significant at 95% confidence interval. Graph 1. Comparison of mean of VMO/VL ratio between control and experimental groups
CONCLUSION This is a cross sectional study comparing the VMO/ VL ratio and Q-angle in PFPS and control groups on 50 total subjects. There was a statistically significant difference in VMO/VL ratio between control and PFPS subjects during ISOMETRIC, CONCENTRIC and ECCENTRIC exercise, so null hypothesis was rejected and experimental hypothesis was accepted. There was a statistically significant difference in static and dynamic Q-angle in both groups. Static and dynamic Q-angle value was higher in PFPS patients. ACKNOWLEDGEMENTS I would like to thank Dr Nehal shah (PG teacher) and I am grateful to all my patients for their kind cooperation and willingness to participate in this study, without whom this study would not have materialized.
Conflict of Interest : Nil REFERENCES 1. Baquie P, Brukner P: Injuries presenting to an Australian sports medicine centre: A 12-month study. Clin J Sport Med 1995;7:2831 2. Fulkerson JP, Arendt EA: Anterior knee pain in females. Clin Orthop 372: 6973, 2000 3. Wilk KE ,Davies GJ, Mangine et al: patella femoral disorder, A classification system and clinical guidelines for non-operative rehabilitation ,j orthop physiotherapy 1998,28 : 307-22. 4. Powers CM , Mortensons , Nishimoto d,Simon D : criterion relaterd validity of clinical measurement to determine medial/lateral component of patella orientation, J orthop sports phys ther 1999; 29 : 372-377 5. Salaki N,Luo Z-P,Rand JA,An K-N: The influence of weakness in the i. vastus medialis oblique muscle on the patella femoral joint: an vitro ii. biomechanical study.clin biomech 2000;15:335339. 6. Mirzabeigi E,Jordan C,Groneley JK et al: Isolation of vastus medialis oblique muscle during exercise. Am J Sports Med 1999; 27: 50-53 7. Natri A, Kannus P, Jarvinen M. Which factors predict the longterm outcome in chronic patellofemoral pain syndrome? A 7-yr prospective follow-up study. Med Sci Sports Exerc 1998; 30 1572-7. 8. Blond L, Hansen L. Patellofemoral pain syndrome in athletes: a 5.7 year retrospective follow-up study of 250 athletes. Acta Orthop Belg 1998;64:393-400 9. Garrick JG: Anterior knee pain (chondromalacia patella). The physian and sports Medicine, 1989, 17: 75-84. 10. Powers CM, Landel DR perry J:timing and
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intensity of vastus muscle activity during functional activities in patients with and without patellofemoral pain.Phys Ther,1996,76:946-955 Miller JP,Sedory D,Croce RV:vastus medialis obliquus and vastus lateralis activity in patients with and without patellofemoral pain syndrome.J sports Rehabil,1997a,6:1-10. Voight M, Weider D. Comparative reflex response times of the vastus medialis and the vastus lateralis in normal subjects and subjects with extensor mechanism dysfunction. Am J Sports Med 1991;10:131-7. Witvrouw E, Sneyers C, Lysens R, Victor J, Bellemans M. Reflex response times of vastus medialis oblique and vastus lateralis in normal subjects with patellofemoral pain syndrome. J Orthop Sports Phys Ther 1996;24:160-5. Braddom R. Physical medicine and rehabilitation. In: Casazza B,Young J, editors. Musculoskeletal disorders of the lower limbs 2nd ed. Philadelphia: WB Saunders; 2000. p 834-7. Bechman M, Craig R, Lehman RC. Rehabilitation of patellofemoral dysfunction in the athlete. Clin Sports Med 1989;8:841-60. Selina Lm Yip et al; Biofedfback supplementation to physiotherapy programme for rehabilitation of patellofemoral pain syndrome: Clinical Rehabilitation, Vol. 20, No. 12, 1050-1057 (2006) Wild J , franklin T,woods W.patellar pain and quadriceps rehabilitation : an EMG study.Am J sports Med .1982; 10:12-15 Moller B, krebs B, Tidermand Dal c,aaris k, isometric contractions in the patella femoral pain syndrome.arch orthop trauma a surg,1986: 105: 24-27 Lam PL,Ng GYF: Activation of quadriceps muscle during semisquatting with different hip and knee positions in patients with anterior knee pain. Am J Phys Med Rehabil,2001,80:804-808
A Study to Check Added effects of Electrical Stimulation with Task Oriented Training in Hand Rehabilitation among Stroke Patients
Paras Joshi Assistant professor, Shree K K Sheth Physiotherapy College, Rajkot ABSTRACT Back ground: stroke patients are having variety of disable functions, including limited hand functions which has key role to do activities of daily living. Objective: To determine the added effects of electrical stimulation combined with task oriented training in stroke patients. Methods: 30 subjects were selectively divided in to two groups. Group A received Eletrical stimulation with Task oriented training while Group B received only task oriented training. Outcome measures were grip strength, Box and Block test, 9 hole peg and ROM. Findings: statistical significant difference found for all the variables used in methods in between the groups. Conclusion: Electrical stimulation with task oriented training improves hand functions more effectively compared to only task oriented training in stroke patients. Keywords: Electrical Stimulation, Task Oriented Training, Hand Rehabilitation
INTRODUCTION Stroke is an acute onset of neurological dysfunction due to an abnormality in cerebral circulation with resultant sign and symptoms that correspond to involvement of focal areas of the brain. The term cerebrovascular accidents (CVA) are used interchangeably with stroke to refer to the cerebrovascular conditions that accompany either ischemic or hemorrhagic lesions. To be classified as stroke, focal neurological deficits must persist for at least 24 hours. 1 Stroke is the third leading cause of death in industrialized countries and the leading cause of adult disability. Half of all stroke survivors are left with major functional problems in their hands and arms.2 Although initial neurological loss in arm is generally thought to be predictive factor for overall recovery it has been reported that the recovery of the upper extremity function is independent of the overall level of stroke severity. 3
Numerous studies have suggested that electrical stimulation improve muscle strength motor control range of motion and reduced the spasticity of paretic limb 4, 5 Electrical stimulation of spastic wrist flexor muscles was compared with passive stretch of wrist flexor by king who reported a significantly greater effect of electrical stimulation on flexor spasticity.6 However alfier10 stated that no direct stimulus must be allowed to reach spastic muscle and he reported a reduction in flexor spasticity after electrical stimulation of extensor muscles. Electrical stimulation at wrist in combination with other rehabilitation strategies can result in increase grip strength and improve motor function.7 The exact mechanism underline the action of electrical stimulation has not been elucidated but neurophysiologic models produce arguments in favor of each strategy improvement in extensor muscle strength through electrical stimulation of extensor
might provide sufficient power to overcome flexor spasticity.8 Its central tenet is the idea that the interacting systems within the CNS are organized around essential functional tasks and the environment in which the task is performed. Thus an understanding of tasks, the essential elements within each task, and the environment is key to understanding and promoting motor control. This approach is also based on the theory that action system within the CNS are organized to control function9. Patients are instructed to practice those tasks that present difficult for them, and to practice them in varying environments. Different strategies may be used by the different individual and should be allowed if they achieve the desired functional outcome.11 So the aim of this study was to check the added effects of electrical stimulation combined with task oriented training in hand rehabilitation in stroke patients. METHOD AND MATERIALS Study design: Experimental study. Sampling technique: Purposive sampling technique. Samples: A total of 30 subjects were included from K K Sheth Physiotherapy center, Rajkot and surrounding the city in 2 years framework. Prior to participation in study the subjects were explained about the procedure of physiotherapeutic treatment with therapeutic electrical stimulation of the muscle and task related training. Informed consent was obtained from all the subjects. Inclusion Criteria Unilateral ischemic stroke Grade 4 or 5 Brunnstrom assessment scale MMT of muscle around the shoulder and elbow joint minimum grade 3 Above 40 years of age, both the sexes
Severely impaired cognition and communication Traumatic brain injury Clinical evidence of limited joint range of motion of wrist joint Clinical evidence of shoulder subluxation
The 30 subject selected were randomly divided into the group (group A and B of 15 each). Group A Fifteen subjects received electrical stimulation along with task related training. Group B Fifteen subjects received only task related training. Subjects were kept blind about the different treatment protocols for two groups Measurements for grip strength was taken by hand held dynamometer and hand functions were taken by Box and block test12, 9 hole peg test13, wrist extension and radial deviation pre intervention(baseline) and post intervention (4th week) Experimental procedure Electrical stimulation technique: The researcher himself performed the electrical stimulation of wrist extensor. Subjects were seated in straight backed chair with the feet flat on the floor. Subject was seated next to the supported surface and the forearm rest on supported surface. The wrist remains freely suspended at the edge of the plinth to allow for movement due to electrical stimulation. The bipolar electrode placement was used to deliver a motor level stimulus to the wrist and finger extension. One electrode was placed over the lateral epicondyle of humerus and active electrode was placed distally on wrist and finger extensor (extensor carpi radialis longus and bravis, extensor carpi ulnaris, extensor digitorum communis). The electrode skin coupling medium was an electrolytic gel. To fix the electrodes elastic Velcro straps were used. The stimulus was provided by an electrical stimulation (vectorstim) providing a maximum output intensity of 50 MA. This stimulator operated on pre programmed protocols which were enlisted in the user manual provided by the manufacture. The researcher used protocol for the experimental group A protocol no 14 (50 HZ) was employed for stimulation of wrist and
Exclusion Criteria Sensory impairment Chronic stroke patients. (> 1 year of stroke) Uncontrolled blood pressure
finger extensor. The intensity was gradually increased as per the tolerance of each subject, achieving the maximal intensity to produce motor response. Electrical stimulation parameters type of current : short interrupted direct current (faradic) waveform: monophasic current modulation: surged pulse duration: 0.7ms inter pulse duration:19 ms (50 hz) surge duration: 0.07ms inter surge duration:3ms on/off time:0.5 sec/3 sec (1:6) intensity : as tolerated by patients Duration of treatment: 30 min/day
Goal is to push the glass along the table by extending wrist with forearm in mid position. Subjects were asked to practiced picked up polystyrene cup around the rim without deforming it between thumb and each finger. Peg board exercises.
Subjects performed their most difficult exercise for 10 repetitions each. Unsuccessful attempt was not counted; however a subject is advised to change the exercise if he/she is not able to do at al. Treatment was given for 5 times in a week for 4 weeks. Paired an unpaired t tests were used for the statistical analysis. FINDINGS
Treatment was given for 5 days in a week to each subject for 4 weeks. TASK RELATED TRAINNING Subjects were asked to identify daily activities that could be difficult to perform and that they would like to improve. The four or more of the following tasks were administered / trained for the subjects. manipulate tools for specific purpose ( tooth brush, comb ,knife, fork, coin, clothpin ,button) Grasp and release the different objects, or different shapes, sizes. Transport an object from one place to another. Subjects were asked to lift glass up and to lower it without loosing control at his wrist. Graph 1. The female count in group A was 5 (33%) and that of the group B was 6 (40%). The male count in group A was 10 (67%) and that of the group B was 9 (60%). The total count of females in this study was about 11 (36%) and male was about 19(63%). The total count of male and female subjects in this study was about 30 (100%).
Table I. Comparison of Strength scores within Group A and within Group B

Group A B Intervention Period Pre Post Pre Post N 15 15 15 15 Mean 7.84 9.46 7.79 8.81 Standard Deviation 1.62 1.50 1.62 1.40 8.93 SS SS at p < 0.05 t- value 8.98 SS Level of significance SS at p < 0.05
Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 157 Table II. Comparison of Box N Block and 9 Hole Peg Test Scores within Group A and within Group B
Group A Variables Box N Block 9 Hole Peg Test B Box N Block 9 Hole Peg Test Intervention Period Pre Post Pre Post Pre Post Pre Post N 15 15 15 15 15 15 15 15 Mean 16.53 19.27 2.04 1.78 16.80 18.47 2.08 1.99 Standard Deviation 2.41 2.21 .33 .30 2.24 2.03 .31 .31 14.10 SS SS at p < 0.05 7.17 SS SS at p < 0.05 11.50 SS SS at p < 0.05 t- value 17.83 SS Level of significance SS at p < 0.05
Table III. Comparison of Wrist Extension and Radial Deviation Scores within Group A and within Group B
Group A Variables Wrist extension Radial deviation B Wrist extension Radial deviation Intervention Period Pre Post Pre Post Pre Post Pre Post N 15 15 15 15 15 15 15 15 Mean 26.93 30.07 5.80 7.87 27.20 29.00 7.13 7.73 Standard Deviation 2.46 2.63 1.01 .91 2.51 2.29 1.06 4.58 SS .79 SS at p < 0.05 8.08 SS SS at p < 0.05 11.37 SS SS at p < 0.05 t- value 13.25 SS Level of significance SS at p < 0.05
Table IV: Comparison of Change in Strength, Box N Block , 9 Hole Peg Test , Wrist Extension and Radial Deviation scores across the Intervention Period between Group A and Group B
Change in Variable between Pre & Post Intervention Change inStrength Change in BoxN Block Change in9 Hole Peg Test Change in Wrist Extension Change in Radial Deviation Group N Mean Difference 1.62 1.02 2.73 1.67 .26 .08 3.13 1.80 2.07 .60 Standard deviation .69 .44 .59 .90 .08 .02 .91 .86 .70 .50 6.55 SS SS at p < 0.05 4.11 SS SS at p < 0.05 7.67 SS SS at p < 0.05 3.83 SS SS at p < 0.05 t-value Level of significance SS at p < 0.05
A B A B A B A B A B
15 15 15 15 15 15 15 15 15 15
2.81 SS
SS: Statistical significant
Graph 1. The female count in group A was 5 (33%) and that of the group B was 6 (40%). The male count in group A was 10 (67%) and that of the group B was 9 (60%). The total count of females in this study was about 11 (36%) and male was about 19(63%). The total count of male and female subjects in this study was about 30 (100%). DISCUSSION Within the two groups, both electrical stimulation combined with task related activity ( groupA) and task
related activity alone (group B ) proved to be effective. This was reflected in the pre intervention and post intervention measurements of grip strength, box and block test, 9 hole pack test and active wrist extension and radial deviation range of motion. However between group comparisons of mean scores of wrist extension and radial deviation ( AROM ), grip strength , box and block test , 9 hole peg test sub scores and total percentage showed that subjects receiving electrical stimulation combined with task related training ( group A) had clinically and
statistically significant improving in wrist extension and radial deviation ( AROM) grip strength , box and block test, 9 hole peg test sub score and total percentage when compared to subjects receiving task related training ( group B) across base line and 4th week (table ) (p<0.05). Electrical therapy has been applied as a therapy in humans with central nervous system (CNS) injuries although there is no conclusive direction as to which technique works the best for a given indication. There are convincing studies available to show that electrical stimulation can strengthen atrophied muscles, change in muscles property, increase the muscle bulk, and improve the circulation and the change in the metabolism.10 There is evidence that repetitive active movement, mediated by neuromuscular stimulation can enhance motor relearning after CNS damage. The additional component of movement provides augmented sensory feedback and propioceptive afferent stimulation. There is reorganization of cortical representations for body parts basal upon the afferent input that they contribute as well as the amount of motor activation they undergo. With electrical stimulation there is evidence that it equally influence this reorganization. This can be highly advantageous in limbs that are impaired to such a degree that a voluntary movement could be impossible. Because of significant amount of hemiparesis that is caused by stroke, the use of electrical stimulation to generate movement provides the means of inducing positive motor changes associated with motion.16 Cauraugh et al focused on less severely affected subjects, like those in the present trial spasticity were not assessed; they reported improvement in sustained contraction of wrist extensor muscles and in function (box and block test) but no effect on motor control. From the publication, it is not clearly whether there was no gain in motor control or no difference in gain. In a letter trail function improvement was confirmed but the clinical relevance of this improvement was not discussed. In this study it seems that functional improvement can be clinically relevant for subjects. People with a brain injury have deficit in motor programmes, motor memory and associated feedback and feed forward mechanism, which largely impede their functional performance. 14 The motor relearning approach promotes the regaining of normal motor skill through task oriented training with appropriate feedback and the active participants of the patients. In this study, the motor relearning program was structured
14
in such a way that patient had ample opportunity to gain this experience. First the patients were involved in identifying their own problems in performance. These problems are called the missing performance component. The selection of task used for training was meant to target those missing performance components training in the functional tasks followed through on the same missing components. The incorporation of this strategy turned the programme into a client centered intervention. The training thus become more anticipatory for the patients and hence was more selfinitiated, targeted and effective.15 Limitation of the study was absence of control group; neither patients nor the therapist were blinded. CONCLUSION Both electrical stimulation along with task oriented training and only task oriented training were useful to improve hand functions. Electrical stimulation with task oriented training improves hand functions more effectively compared to only task oriented training in stroke patients. ACKNOWLEDGEMENT I am sincerely thankful to Dr Saralaben Bhatt, Principal K K Sheth Physiotherapy College, Rajkot for their guidance and support REFERENCES 1. 2. Susan B. OSullivan, Thomas Schmitz. Physical rehabilitation: assessment of treatment Hacke W, Kaste M,Olsen TS ,orgogozo JM, Bbogousslavsky j.empfehlumg der europaesschen schjaganfall initiative zur versorgumg and behandlung des schlaganfalls.intensivmed 2001;38:454-70 Wade DT, Langeton-hewer R et al; The hemiplegic arm after stroke :measurement and recovery . J. neurol. Neurosurg. Psychetric. 1983;46:521-24 Glanz M, Klawansky S ,et al; functional electrical stimulation In post of rehabilitation : a meta analysis of randomized control trials .arch phys med rehabil 1996;77:549-53 JR de Kroon,J H Van der lee et al;theraputics electrical stimulation to improve motor functional abilities of the upper extremity after stroke clinical rehabili .2002;16:350-60 King TI: The effect of neuro muscular electrical stimulation in reducing tone.am j occupation ther 1996; 50:62-64 Joanna Powell, MCSP; A. David Pandyan,et al; Electrical Stimulation of Wrist Extensors in
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Poststroke Hemiplegia; Stroke. 1999; 30: 1384-1389.) 8. De Kroon JR, Ijzerman MJ, Lankhorst GJ, Zilvold G.:electrical stimulation of upperlimb in stroke:stimulation of extensors of the hand vs.alternate stimulation of flexors and extensors.Am.J.Phys.med.rehab. 2004;83:592-600 9. Green p:prombles of organization of motor system .In Rosan R,and Snell:Progress in theoretical biology. Academic press.San Diego 1972.p 304 10. Alfieri V: Electrical treatment of spasticity Scand J Rehabili med. 1982;14:177-82 11. Horak ,F:Assumptions underlying motor control for neurologic rehabilition .In :contemporary management of motor control problems. proceedings of the 2 step conference. APTA, Alexandri 1992 12. Desrosiers J, Bravo G, Hbert R, Dutil E, Mercier L. Validation of the Box and Block Test as a measure
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of dexterity of elderly people: reliability, validity, and norms studies. Arch Phys Med Rehabil. 1994 Jul;75(7):751-5. Mathiowetz, V., Kashman, N., et al. (1985). Grip and pinch strength: normative data for adults. Arch Phys Med Rehabil 66(2): 69-74 Chronic motor dysfunction after stroke : recovering wrist and finger extension by electro myography triggered neuro muscular stimulation .Stroke 2000 June ;30 (6) :1360-1364 Catherine M . Dean, Carol L. Richards et al .Task related circuit training improves performance of locomotor task in chronic stroke : a randomized controlled pilot trial .arch phy med rehab 2000;81:409-17 N M Salback, N E Mayo et al.A task oriented intervention enhances walking distance and speed in the 1 st year post stroke : a randomized controlled trial.Clinical rehab 2004 ;18:509-519
Relationship of Cognition, Mobility and Functional Performance to Fall Incidence in Recovering Stroke Patients
Paras Joshi1, Hardik Trambadi2 Lecturer, Shree K K sheth physiotherapy college, Rajkot, 2Lecturer, Parul institute of Physiotherapy, Vadodara ABSTRACT Background: People with stroke are at risk of falls. The majorities of individual with stroke has some degree of residual impairment, but regain walking ability and will be discharged home. Three quarters fell in the first six month after their discharge from hospital. Identify increased knowledge of incremental risk factors for falling and the assumption that some of the identified risk factors can be modified may lead to development of intervention to reduce number of falls Objective: To explore the relationship between cognition, mobility and functional performance with respect to fall incidence in recovering stroke patients. Methods: 110 subjects with stroke completed the study. Subjects were assessed on the basis of cognition, mobility and functional performance during 4th week after stroke incidence. Information regarding number of falls and characteristic of fall gained during a personal interview after six month from stroke. Number of falls correlated with baseline scores. Findings: There is a significant good correlation found between cognition, mobility, and functional performance to number of falls in recovering stroke patients. Conclusion: Cognition, mobility and functional performance might contribute to fall risk and fall related injuries in recovering stroke patients. Keywords: Stroke, Fall Incidence, Cognition, Mobility, Functional Performance.
INTRODUCTION Stroke is an acute onset of neurological dysfunction due to an abnormality in cerebral circulation with resultant sign and symptoms that correspond to involvement of focal areas of the brain. The term cerebrovascular accidents (CVA) are used interchangeably with stroke to refer to the cerebrovascular conditions that accompany either ischemic or hemorrhagic lesions.1 Stroke is the most common cause of chronic disability.2 People with stroke are at risk of falls.3,4 The majority of individuals with stroke will have some degree of residual impairment, but will regain walking ability and will be discharged home following hospitalization. Although impairment is common, most people with stroke will regain walking ability; however poor balance and impaired gait can persist. 5 Studies reported that patients with stroke three quarters fell in the first six months after discharge from hospital. Stroke patients in acute care and rehabilitation are at high risk of falling and remain a high-risk group
of the first few months after they are discharged to home. 6-10 Apart from age, osteoporosis, previous fractures, and falls are independent risk for hip fractures.10 Side of the fracture is positively correlated with the side of hemi paresis. 11 Patients with stroke have up to a 4 fold increased risk of hip facture because of their high incidence of falls.12 It has been shown that stroke patients in addition have reduced bone mass in their paretic extremities, that this development of hemi osteoporosis is extensive and pronounced, and that begins early after stroke onset.13 Furthermore, stroke has proved to be a factor for hip fracture among women in case control study14, and subjects with previous strokes have been over represented in a sample of femoral neck fracture patients.15 Stroke has a relative high risk for falling. Increased knowledge of incremental risk factors for falling and the assumption that some of the identified risk factors
can be modified may lead to development of intervention to reduce number of falls.16,17 Fall incidence rates between 23% and 50% have been reported in studies of people with chronic stroke (> 6 months post stroke). 18-21 This rate is much higher than rates reported for older community dwelling adults without stroke (11%-30%). 22-24 but lower than rates for people with sub acute stroke (1-6 months post stroke) (25%).25 Injury is a frequent consequences of falls in people with chronic stroke, with up to 28% reporting an injury.19 Studies shown that cognitive deficit 18,21,26 functional impairments26 and impaired balance 7,26 are related to fall history in people with acute stroke. 25 And cognition 18 , balance impairment 18 and ADL 19,21 increased fall risk in people with chronic stroke. The identification of fall- prone stroke patients is of great importance. The issue has already been studied to some extent, and a number of risk factors have been suggested.27 Postural sway8, increased motor response time to visual stimuli28, and right ward orienting bias among right hemisphere stroke patients29 have been associated with an increased fall risk. A multi factorial case control study concluded that a history of falls, impaired decision making ability, perceptual impairment, restlessness, generalized weakness and abnormal hemocritic level were independent fall risk factors among stroke patients in acute care.29,30 Studies shown that 37% stroke survivors reported at least one fall during the first six months after their stroke. Among whom those fell, 37 percent suffered an injury that require medical treatment, and 8 percent suffered a fracture. Among those who fell, about half fell only once, but 12 percent fell more than five times. The study also found that 77 percent of patients fell at home.31 Study showed that cognition, mobility and functional daily activity tend to decline after stroke. 31 The purpose of this study is to correlate the cognition, mobility and functional performance to fall incidence in recovering stroke patients. OBJECTIVES OF THE STUDY To explore the relationship between cognition, mobility and functional performance with respect to fall incidence in recovering stroke patients. HYPOTHESIS Null hypothesis (H0): There will be no significant
relationship existing between cognition, mobility, functional performance with respect to fall incidence among recovering stroke patients. Alternate hypothesis (H 1 ): There will be a significant relationship existing between cognition, mobility, functional performance with respect to fall incidence among recovering stroke patients. MATERIALS AND METHOD A Prospective observational study was used with purposive heterogeneous sampling technique. One hundred and eighteen people with stroke were recruited on a voluntary basis from vadodara city and surrounding villages between oct 2009 to may 2011 A written consent was sought from subjects participating in the study. Selected one hundred and eighteen subjects met the established criteria and one hundred and ten (77 male and 33 female) out them completed the study. Five subjects got an addition stroke and three of them were died. Subjects who were already diagnosed as stroke by physician participated in the study. Subjects of both sexes and either side of paresis, fulfilling the criteria were taken for the study. Inclusion Criteria 1. Above 50 years of age. 2. With ability to walk 8m (with assistive device, if required). 3. Deemed to be fit for the study and mentally stable. Exclusion Criteria 1. Major musculoskeletal problems (e.g. amputation or recent joint replacement surgery). 2. Neurological disorder in addition to stroke. 3. More than one attack of stroke during study period. 4. Perceptual disorders. 5. Sever communication problem. EXAMINATION Patients were assessed on the basis of cognition, functional performance and mobility during 4th week after stroke incidence. Cognition, Mobility and Functional performance were assessed by Mini Mental Status Examination (MMSE), Performance Oriented Mobility Assessment (POMA) and Barthel Index respectively.
Patients and caretakers were asked to maintain the chart for recording the number of falls, side of fall and injury if any during the study period. Patients were informed that a fall was defined as coming to rest on the floor or another lower level but was not due to seizures, stroke or myocardial infraction, or an overwhelming displacing force (e.g. earthquake.) Number of falls recorded between one month post stroke to six month post stroke (20 weeks). Information regarding number of falls and characteristic of falls were gained during a screening interview with the patient, six month after stroke. Assessment for the baseline score and interview for the number and characteristics of falls were done by different individuals.
Numbers of falls were correlated with the baseline scores FINDINGS

Table 1. Gender distribution
Males Females 77 33
Subjects participated in the study with mean age of 66.917.14. Pearsons correlation coefficient was used to determine the relationship among cognition, mobility and functional performance in relation to occurrence of falls. P value was kept at 0.01 for statistical significance. SPSS software was used for the statistical significance.
Table 2. Variable analysis

Variable Number of Falls MMSE POMA BI N 110 110 110 110 Mean 3.0 23.57 21.73 74.25 Standard Deviation 2.19 2.47 4.33 8.15 Pearsons Correlation Coefficient -0.76 -0.75 -0.64 Level of significance SS at 0.01 statistically significant SS at 0.01 statistically significant SS at 0.01 statistically significant
Table 3. Characteristics of subjects participated in the study

Right Side Hemiparesis, 45% Using walking devices, 65% Fallers, 67% Fall on hemiplegic side, 60% Reported serious injuries which required medical treatment, 17% Reported Fracture because of fall, 11% 1 Fall during study period, 45% Left side hemiparesis, 55% Independent Walking, 35% Non fallers, 33% Fall on non hemiplegic side, 7% Injuries required no medical intervention, 50% Fall without fracture, 56% More than 1 fall, 22%
DISCUSSION Most of the patients with stroke are prone to fall incidence during recovery stage. The purpose of this study was to determine whether cognition, mobility and functional performance could explain falls in individual with recovering stroke. It has been found that falls were common occurrence in recovering stroke patients. Most of the patients reported at least one fall during study period. Subjects who experienced fall, most of them fell on the paretic side. In addition, fall related injuries were common, although serious injury was less frequently reported. It
has been found that most of the falls occurred in home during walking activities. In this study measure of cognition, functional performance and mobility were clearly able to explain falls in this population or to discriminate between those who had fallen and had not fallen. It has been hypothesized that MMSE, POMA and Barthel Index score would be associated with fall incidence and be a risk factor for falls in recovering stroke patients, and result supported the hypothesis. Some authors32 have suggested that the recall method of information gathering can produce recall bias but to avoid that patients were asked to maintain chart in terms
of calendar and similar explanation was given to the caregivers. Comparing age as a risk factor for fall, studies showed that fall incidence rate is much lower in older community dwelling adults without stroke (11%-30%) than rates for people with subacute stroke (25%)4. Reason behind that is pathophysiology of stroke that changes the mental state dramatically.2 The scales which have been used for the study are easily applicable to the patients within short time span, having good reliability33-35 and found useful tool to identify the subject who has more chances to fall following hospitalization in this study. However cognition, mobility and functional performance are not the only factors responsible for fall incidence, other factors needed to be rule out. LIMITATIONS The clinical information (cognition, mobility and functional status) collected at the time of discharge may have been different at the time of fall. But the study outcome gave the predictive information about the future fall incidence (i.e. six month) with these measures. During the 20 weeks time frame used for fall history, participants could have experienced on illness (e.g. flu, cold) or an exacerbation or worsening of an existing condition (e.g. arthritis, dementia) that could have negatively influenced their functional status at the time of fall(s). In contrast, participants might have been in worse physical or mental condition at the time of examination that at the time of the fall(s). Fallers who had fractures (11%) must have had reduce mobility and affected the mobility component and functional performance (our baseline scores) With increasing age the cognition, functional status and mobility level tend to decline, however stroke can worsen the mental status dramatically. Factors such as vestibular function, sensation, perception and home environment have not been assessed in this population in relation to fall risk. Clinical implication Cognition, mobility and functional status level are able to explain the number of falls. MMSE, POMA I and Barthel Index are easily applicable tools and can be applied within minutes. Patients with relative low scores can be advised to be careful or to take further inpatient rehabilitation. Hip protectors can be given to the patients in order to avoid the fall related injuries.
Further recommendation 1. Factors such as sensation, perception and home environment can be included in this population. 2. Combination of multiple risk factors can be checked in relation to fall incidence. 3. Correlation of the variables studied can be done in stroke subjects with and without physiotherapy interventions. CONCLUSION MMSE, POMA and Barthel index are able to explain the fall incidence in recovering stroke patients. There is a significant relationship between cognition, mobility and functional performance to fall incidence. Cognition, Mobility and functional performance are some of the factors responsible for falls in recovering stroke patients, and might contribute to fall and fall related injuries. ACKNOWLEDGEMENT Sincere thanks to Dr Praful Bamrotia for helping us in data collection. REFERENCES 1. Susan B. O Sullivan, Thomas Schmitz. Physical Rehabilitation: 5th Edition. 2. Wolf, C: The impact of stroke. Br Med Bul. 2000; 56: 275. 3. Post stroke Rehabilitation Guideline panel: Post stroke Rehabilitation clinical practice Guideline. Aspen, Gaitherburg, MD, 1996. 4. Jocelyn E Harris et al. Relationship of balance and mobility to fall incidence in people with chronic stroke, Physical therapy. 2005; 85: 150-158. 5. Jorgense HS et al. Stroke. Neurologic and functional recovery- the cogenhagen stroke study. Phy med rehabil clin N Am. 1999; 10: 887-906 6. Anne Forster, John young. Incidence and consequences of falls due to stroke, a systemic inquiry, BMJ. 1995; 311: 83-86. 7. Nyberg L, Gustafon Y. Patients falls in stroke rehabilitation: A challenge to rehabilitation strategies. Stroke. 1995; 26: 838-842. 8. Sackely CM. Falls, sway and symmetry of weight bearing after stroke. Int. Disabil Stud. 1991; 13: 1-4. 9. Byers V et al. Predictive risk factors associated with stroke patients falls in acute care settings. J Neurosci Nurs. 1990; 22: 147-154. 10. Tutuarima JA, Van der Mevlen Jhet al. Risk factors for falls of hospitalized stroke patients. Stroke. 1997; 28: 297- 301.
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H.C. White: Archives of orthopeadic and Trauma surgery. 1998; 107: 345- 387. Anna Ramnemark, Mikael Nilson et al. Stroke, a major and increasing risk factor for femoral neck fracture. Stroke. 2003; 31: 157- 168. Hamdy R C, Moore SW et al. Long term effects of stroke on bone mass. Am J Phys Med Rehabil. 1995; 74: 351-356. Grisso JA, Kelsey JL et al. Risk factors for falls as a cause of hip fracture in women. N Engli Med. 1991; 324: 1326- 1331. Gustasfron Y, Brannstrom B et al. A geriatric anesthesiologic program to reduce acute conghesional state in elderly patients treated for femoral neck fractures. J Am Geriatic Soc. 1991; 39: 655- 662. Ramnemark A, Nyberg L et al. Progressive hemiosteoporosis on paretic side and increased bone mineral density in non paretic arm the first year after sever stroke. Osteoporos Int. 1999; 9: 269- 275. Cahit Ugur, Demet Gucuyener et al. Chracteristics of falling in patients with storke. J Neurology Neuro surgery Psychiatry. 2000; 69: 649- 651. Jorgensen L, Engstad Tet al. Higher incidences of falls in long term stroke survivors than in population controls. Depressive symptoms predict falls after stroke. 2002; 33: 542- 547. Lamb SE, Ferrucci L et al. Risk factors for falling in home dwelling older women with stroke. The womens health and aging study. Stroke. 2003; 34: 494- 501. Hyndman D, Ashburn A, Stack E. Fall events among people with stroke living in the community. Circumstances of falls and characteristics of fallers. Arch Phys Med. Rehabil. 2002; 83: 165- 170. Hyndman D, Ashburn A. People with stroke living in the community: attention deficits, balance, ADL ability, and falls. Disabil Rehabil. 2003; 25: 817- 822. Graafmans WC, Ooms Me et al. Falls in the eldery. A prospective study of risk factors and risk profiles. Am J Epidemial 1996; 143: 1129- 1136.
23. Bogle Thorbahn LD et al. Use of the Berg balance test to predict falls in eldery persons. Phy. Ther. 1996; 76: 576- 586. 24. Tinnetti ME, Speechley M, Ginter SF. Risk factors for falls among eldery persons living in the community. N Engl J M ed 1998; 319: 1701- 1707. 25. Stalpheton T, Ashburn A, Stack E. A pilot study of attention deficits, balance control and falls in subacute stage following stroke. Clini Rehab. 2001; 15: 437- 444. 26. Tea sall R, MC Rac M et al. The incidence and consequences of falls in stroke patients during inpatient rehabilitation. Factors associated with high risk. Arch Phys Med Rehabil. 2002; 83: 329- 333. 27. Lars Nysberg, Yngve Gustafson. Fall prediction index for patient in stroke rehabilitation. 1997; 28: 716- 721. 28. Mayo NE, Lorner Bitensky N, Kaizer F. Relationship between response time and falls among stroke patients undergoing physical rehabilitation. Int J Rehabil Res. 1990; 13: 47- 55. 29. Webster JS et al. Rightward orienting bias, wheel chair maneuring, and fall risk. Archy Phy Med Rehabil. 1995; 76: 924- 928. 30. Rapport LJ et al. Predictors of falls among right hemisphere stroke patients in the rehabilitation setting. Arch Phys Med Rehabil. 1993; 74: 621- 626 31. Medline Plus. A service of the U. S. National library of medicine and the national institute of Health. 15th may 2008. 32. Peeel N. Validating recall of falls by older people. Accidental Analysis and Prevention. 2000; 32: 371-372. 33. Marjan J Faber, et al: Clinimetric properties of the POMA, physical therapy 2006; 86: 944-954. 34. Hsuch I P, Lee M, Hsieh C L. Psychometric characteristics of the barthel activities of daily living index in stroke patients. J formas Med assoc. 2001; 100 (80): 526-532. 35. Folstein MF et al. Mini mental state. A practical method for grading cognitive state of patients for the clinician, J psychiatr Res 1975; 12: 189
Reliability of Modified Modified Ashworth Scale in Spastic Cerebral Palsy

Divya Gupta1, Pooja Sharma2 Post Graduate student, Amity Institute of Physiotherapy, Amity University Uttar Pradesh, 2Assistant professor, Amity Institute of Physiotherapy, Amity University, Noida, Uttar Pradesh, ABSTRACT Background & Objectives: In assessment of spasticity in the pediatric population, methods used in practice are ordinal scales that lack reliability. Being a recent scale, Modified Modified Ashworth Scale has not been used in pediatric population as yet. This study aimed to assess inter- and intra-rater reliability of MMAS in assessing children with spastic cerebral palsy and also compare results with those of AS and MAS. Methods & Materials: The study included 40 children with spastic CP with mean age 7.75 yrs .Functional levels of children were classified according to the Gross Motor Function Classification System. Spasticity in wrist, elbow and knee flexors was assessed according to the AS, MAS, and MMAS. Results: Interrater reliability and intrarater reliability of MMAS varied from moderate to good. Conclusions & Interpretations: The MMAS is a reliable tool in assessing children with spastic CP and so are AS and MAS. Keywords: Spasticity, Cerebral Palsy, Ashworth Scale
INTRODUCTION Cerebral Palsy is defined as a non-progressive group of disorders of movement and posture due to a defect or lesion of the immature brain.1 It can be further defined as a group of disorders of development of movement, posture and coordination with varied etiological associations and much phenotypic differences in the clinical presentation.2 Of the many types and subtypes of CP, none of them has a known medical cure and treatment is mainly symptomatic .3,4 One of the major manifestations of a sufficient intra-partum compromise of fetal cerebral perfusion include abnormal tone. However a study on the Indian population concluded that spastic quadriplegia constituted the predominant group ( 61%), followed by spastic diplegia (22%).5, 6, 7 Spasticity may be defined as velocity-dependent increase in muscle tone with exaggerated stretch reflexes.8,9 The nature of spasticity has prompted in a Corresponding author: Pooja sharma Assistant professor Amity institute of physiotherapy, Amity university, Noida E mail: psharma1@amity.edu
range of assessment and management techniques. Different methods of spasticity assessment include electrophysiological tests, electromyography, dynamic flex meter, myometer, plasticity measurement system, and pendulum test and is kinetic dynamometer. However, they have limited clinical use. Methods most commonly used in clinical practice are the Ashworth Scale, the Modified Ashworth Scale, the Tardieu Scale and the Modified Tardieu Scale.10 When using clinical measures to assess spasticity, one assesses the resistance to imposed passive movement when the limb is briskly stretched through the full range of available movement about a joint.10 The Ashworth scale was created in the mid-1960s by Dr Bryan Ashworth as a way of judging the effectiveness of anti-spastic drugs.11 It is a 5-point ordinal scale and has been used extensively since then to assess increase in muscle tone in a range of neurological disorders. The Modified Ashworth Scale was created in 1987 by Bohannon and Smith who introduced a 1+ grade to increase the sensitivity of the original scale thus making it a 6-point nominal scale.12 With the MAS grades of 1, 1+ and 2 having been questioned as hierarchical levels of spasticity, recently the Modified Modified Ashworth
Scale (MMAS) was created where grade 1+ was omitted and the grade 2 redefined in the MAS.13 Valid and reliable assessment tools are a pre-requisite in establishing baseline functions and monitoring developmental gains and also to contributing to an increasing body of evidence-based recommendations for CP. 14 Reliability of AS and MAS have been found to be poor to good as assessed in patients with various conditions.15,16, 17 18, 19 with values of MAS being slightly higher. The existing data suggests that the reliability of MMAS in patients with lower-limb muscle spasticity is very good, and it can be used as a measure of spasticity over time.20 21 . Although there are studies that conclude both AS and MAS are not reliable for the assessment of muscle spasticity, however experience and training may improve agreement between the raters.22,23,24 There is a need to standardize methods to apply these scales in clinical practice and research.25, 26, 27 Being a recent scale, the Modified Modified Ashworth Scale has not been used in the pediatric population as yet. It provides clearly defined and distinct grades to rate spasticity. Also, the other two scales i.e. AS and MAS give arguable results over their reliabilities in the same population. The present study aims to assess and the inter- and intra-rater reliability of the MMAS in three different muscle groups i.e. the wrist flexors, elbow flexors and knee flexors of children with spastic CP and also compare the results with those of the AS and the MAS which have already been used in the population under consideration. METHODOLOGY Subjects with spastic cerebral palsy belonging to age group 4 to 14 years were recruited from Special schools in Delhi and NCR whose informed consent had been attained. All subjects with history of any orthopedic surgery , botulinum toxin injection or those on oral or intrathecal myorelaxant drugs , mentally retarded were excluded. The procedure was explained to the subjects and their parents. The functional level of participants was classified according to the expanded and revised Gross Motor Function Classification System ( GMFCS E & R ). Each subject was assessed by two raters in two different sessions randomly . Both the raters are physical therapists who are well-versed with the procedure of the assessment and blinded to the results of each other. For the inter-rater reliability component of the study, a 30-minute interval period is added between the assessments. For the intrarater reliability component of the study, one of the raters repeated the procedure the next day. The measurements were
performed in a quiet environment . Subjects wore loose and comfortable clothing which did not pose any hindrance to the passive movements. Testing commenced five minutes after the subjects had been positioned. One repetition was done per joint. The scores for AS, MAS and MMAS were determined according to the level of resistance during the passive movement of the antagonistic muscles. The muscle groups tested were wrist flexors, elbow flexors, and knee flexors in the same order. Each test movement was performed over a duration of 1 second ( by counting one thousand one). A separate recording sheet was used for each session of each subject. As passive stretching is considered to affect the measurement results, measurements were repeated once on two different days of the study. To minimize the disadvantage of stretching of the spastic muscle, fast stretching was avoided. The data obtained was later statistical analyzed using the SPSS software.
Fig. 1. Testing wrist flexors
Fig. 2. Testing elbow flexors
proximal to the ankle and applying a constant extensor rotational force about the knee. Movement is from 90 flexion to full extension over 1 second.26 RESULTS A total of 40 children were evaluated .AS, MAS, and MMAS scores were considered ordinal and a value of 1.5 for MAS were assigned to ratings of 1+ to maintain equal intervals.
TABLE 1 : Mean and standard deviation of age and GMFCS level
Age ( years ) GMFCS level Mean Standard Deviation 7.775 2.823 2.375 1.147
TABLE 2 : Interrater reliability of A s, MAS AND MMAS in wrist flexors, ELBOW FLEXORS AND KNEE FLEXORS
As Wrist Flexors (ICC) .750 .857 .397 .569 .336 .503 Elbow Flexors (ICC) .757 .861 .787 .881 .866 .928 Knee Flexors (ICC) .359 .528 .738 .849 .605 .754
Single Measures Average Measures Fig. 3. Testing Knee flexors MAS Single Measures Average Measures MMAS Single Measures Average Measures
Patient positioned supine on a padded mat table. The patients shoulder was in mid-rotation, forearm in mid-pronation and hand was in functional position with the distal limb held vertical. Passive movement was achieved by the rater grasping the hand just proximal to the MCP joints . Movement was from full flexion to full extension over one second.26 Patient positioned supine on a padded mat table. The patients shoulder was in mid-rotation, the forearm in mid-pronation and the hand was in functional position. The patients elbow was extended passively from a position of maximal possible flexion to maximal possible extension over a duration of about one second. The lateral aspect of the forearm was grasped distally while applying a constant extensor rotational force about the elbow. While the elbow was extended, the arm was also stabilized proximal to the elbow.26 The subject was in a seated position. The distal leg was suspended vertically with the foot off the floor. The trunk was stabilized by means of a padded strap drawn comfortably tight around the pelvis and the hip was stabilized by means of a padded strap comfortably tight across the proximal legs, half-way between the knees and the hips. Passive movement was achieved by the rater grasping the posterior aspect of the distal leg just
TABLE 3: Intrarater reliability of AS , MAS ,MMAs in wrist flexors, elbow flexors AND KNEE FLEXORS
As Wrist Flexors (ICC) .786 .880 .630 .773 .874 .933 ELBOW Flexors (ICC) .890 .942 .910 .953 .986 .993 Knee Flexors (ICC) .379 .550 .692 .818 .735 .847
Single Measures Average Measures MAS Single Measures Average Measures MMAS Single Measures Average Measures
DISCUSSION The results of the present study are in accordance with the existing literature which demonstrate good inter- and intra-rater reliability for AS, MAS has good intra- and moderate inter-rater reliability, and MMAS has good intra- and moderate inter-rater reliability in wrist flexors.22,23 For the elbow flexors, all the three scales AS, MAS, and MMAS have good inter-and intra-rater
reliability. AS is found to be moderately reliable with MAS and MMAS highly reliable in the knee flexors for lower limbs. Various factors may affect the measurement results of reliability. While investigating the reliability of scales, related joints, anatomical and biomechanical characteristics of muscle groups as well as interrater and intrarater change and biological change should be taken into consideration. Low reliability results of ordinal scales are related to problems which occur during the measurement of spasticity as well as the environment and general condition of the patient. To minimize this, the measurements were performed in a quiet environment and screened from other patients and therapists and one repetition was performed per joint. The error with repeated measurements taken on different days would be probably due to systematic changes in the participant status leading to change in the tone. However, we considered it was important to document test-retest variability of repeated measurements by inclusion of an intervening time period because in clinical practice, results from repeated measurements are rarely compared without an intervening time interval. This interval has contributed to an underestimation of intrarater reliability scores in this study because fluctuations of tone during a single day as well are well established. For this, grading on the second day was done at the same time of the day as on the first day. 24 Tone is not static and may change with time,17 this factor may contribute to low agreement between the raters. It is therefore essential that repeated movements are kept to a minimum.25 It is not surprising that the interrater reliability is higher than the intrarater reliability indicating that these scales should be interpreted with caution and even the same rater has possibility of making an error. One possible reason could be the clinical environment in the hospital. 26 Findings of this study are consistent with the previous studies showing very good inter- and intra-rater reliability scores in elbow flexors for all the three scales AS, MAS, and MMAS; scores for MMAS being the highest. The current study does not observe any association between the limbs, upper or lower, as well. This is probably due to the fact that only one muscle group i. e. knee flexors were investigated in the present study. Future studies should include more muscle groups to investigate the effect of limb, upper or lower, on the reliability scores. The results of the present study are little variant from the previous studies due to the age of the population included .Younger kids would be easier to move due to smaller limbs but would be harder to test due to reasons of adherence. Out of a total of 40, 10 subjects were in GMFCS level I, 14 in level II, 9 in level III, 5 in level IV,
and 2 in level V. MMAS shows moderate interrater reliability in level II for wrist flexors, and moderate interand intra-rater reliability in level III for knee flexors. Reliability of MMAS in levels I and II for all the muscle groups under study was good. It could not be assessed in groups IV and V owing to very small sample size. Hence future studies should assess the reliability with a large sample size of at least 40 in each level. The degree of training and preparation to use the scales probably exceeds the preparation of most clinicians using the scales. CONCLUSION MMAS is a reliable tool in assessing spasticity in elbow flexors, wrist flexors and knee flexors of children as compared to AS and MAS in spastic CP. Conflict of interest - Nil REFERENCES 1. P O D Pharaoh, T Cooke, L Rosenbloom. Acquired cerebral palsy. Arch Dis Child. 1989;64:1010310116. 2. Carr LJ, Reddy SK, Stevens S, Blair E, Love S. Definition & classification of cerebral palsy. Dev Med Child Neurol. 2005; 47: 508-510. 3. Reddihough DS, Collins KJ. The epidemiology and causes of cerebral palsy. Australian Journal of Physiotherapy. 2003;49:7-12. 4. Gad M, Bailik, Uri Givon. Cerebral palsy: Classification and etiology. Acta Orthopaedica et Traumatologica Turcica. 2009; 43: 77-80. 5. Bax M, Tydeman C, Flodmark O. Clinical and MRI correlates of cerebral palsy: The European Cerebral Palsy study. JAMA. 2006; 296:1602-1608. 6. Singhi PD, Ray M, Suri G. Clinical spectrum of cerebral palsy in north India- an analysis of 1,000 cases. J Trop Pediatr. 2002; 48:162-166. 7. Srivastava VK, Laisram N, Srivastava RK. Cerebral Palsy. Indian Pediatr. 1992; 29:993-996. 8. Karen W Krigger. Cerebral palsy : an overview. Am Fam Physician. 2006; 73:91-100. 9. Samuel R Pierce, Richard T Lauer, Patricia A Shewokis, Joseph A Rubertone, Margo N Orlin. Test-Retest reliability of isokinetic dynamometer for the assessment of the spasticity of the knee flexors and knee extensors in children with cerebral palsy. Arch Phys Med Rehabil. 2006; 87:697-702. 10. Mutlu A, Livanelioglu A, Gunel MK. Reliability of Ashworth and Modified Ashworth Scales in children with spastic cerebral palsy. BMC Musculoskeletal Disorders. 2008; 9:44. 11. Ashworth B. Preliminary trial of carisoprodol in
multiple sclerosis. Practitioner. 1964; 192:540-542. 12. Bohannon RW, Smith MB. Interrater reliability of modified ashworth scale for muscle spasticity. Phys Ther. 1987; 67:206-207. 13. Ansari NN, Naghdi S, Hasson S, Mousakhani A, Nouriyan A, Omidvar Z. Inter-rater reliability of the Modified Modified Ashworth Scale as a clinical tool in measurements of post-stroke elbow flexor spasticity. Neurorehabilitation. 2009; 24:225-229. 14. Kothari CR, Research Methodology; Methods and Techniques. New Age International Publishers, New Delhi, 2007. 15. Brashear A, Zafonte R, Corcoran M, Jimenez NG, Gracies JM, Williams M, Chia-Ho Lee, Turkel C. Inter- and intrarater reliability of the Ashworth Scale and the Disability Assessment Scale in patients upper-limb post-stroke spasticity. Arch Phys Med Rehabil. 2002; 83:1349-1354. 16. Damiano DL, Quinlivan JM, Qwen BF, Payne P, Nelson KC, Abel MF. What does the Ashworth Scale really measure and are instrumented measures more valid and precise? Dev Med Child Neurol. 2002; 44:112-118. 17. Gregson JM, Leathley M, Moore AP, Sharma AK, Smith TL, Watkins CL. Reliability of the Tone Assessment Scale and the Modified Ashworth Scale as clinical tools for assessing post stroke spasticity. Arch Phys Med Rehabil. 1999; 80: 1013-1016. 18. Fosang AL, Galea MP, McCoy AT, Reddihough DS, Story I. Measures of muscle and joint performance in the lower limb of children with cerebral palsy. Dev Med Child Neurol. 2003; 45:664-670. 19. Clopton N, Dutton J, Featherston T, Grigsby A, Mobley J, Melvin J. Interrater and intrarater
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reliability of the modified ashworth scale in children with hypertonic. Pediatr Phys Ther. 2005; 17:268-274. Ghotbi N, Ansari NN, Naghdi S, Hasson S. Measurement of lower-limb muscle spasticity: Intrarater reliability of Modified Modified Ashworth Scale. J Rehabil Res Dev. 2011; 48: 83-88. Fleuren JF, Voerman GE, Erren-Wolters CV, Snoek GJ, Rietman JS, Hermens HJ, Nene AV. Stop using the Ashworth scale for the assessment of spasticity. J Neurol Neurosurg Psychiatry. 2010; 81:46-52. Ansari NN, Naghdi S, Hasson S, Fakhari Z, Mashayekhi M, Herasi M. Assessing the reliability of the Modified Modified Ashworth Scale between two physiotherapists in adult patients with hemiplegia. Neurorehabilitation. 2009;25:235-240 Ansari NN, Naghdi S, Moammeri H, Jalaie S. A comparative study on the inter-rater reliability of the Ashworth scales in assessment of spasticity. Acta Medica Iranica. 2006; 44:246-250. Haas BM, Bergstrom E, Jamous A, Bennie A. The interrater reliability of the original and of the modified ashworth scale for the assessment of spasticity in patients with spinal cord injury. Spinal cord. 1996; 34:560-564. Pandyan AD, Johnson GR, Price CIM, Curless RH, Barnes MP, Rodgers S. A review of the properties of limitations of the Ashworth and modified Ashworth scales as measures of spasticity. Clin Rehabil. 1999; 13:373-83. Blackburn M, van Vliet P, Mockett SP. Reliability of measurements obtained with the modified Ashworth scale in the lower extremities of people with stroke. Phys Ther. 2002; 82:25-34.
Evaluation of Pulmonary Function Tests in Patients Undergoing Laparotomy

Nahar P S1, Shah S H2, Vaidya S M3, Kowale A N4 Assistant Professor, Department of Physiology, BJ Medical College, Pune, 2Assistant Professor, Department of Physiology, BJ Medical College, Pune, 3Professor and Head of the Department, BJ Medical College, Pune, 4Professor and Head of the Department, Government Medical College, Kolhapur
1
ABSTRACT Background: Postoperative pulmonary complications are the most common cause of postoperative mortality and morbidity. In this study we tried to identify patients at high risk of developing postoperative pulmonary complication. Objectives: 1. To compare and evaluate preoperative and postoperative values of pulmonary function tests parameters. 2. To study the effect of gender difference, site of surgery and body mass index on postoperative pulmonary function parameters. Methods: Pulmonary Function Parameters were recorded preoperatively one day prior to surgery and postoperatively on 5th day. PFTs were recorded using RMS Helios spirometer and all the tests were conducted according to ATS/ERS guidelines. Parameters recorded : TV,ERV,IRV,IC,VC,MVV,FVC,FEV1,FEV1/FVC,PEFR,PIFR Statistical analysis were carried out by using t test Results: We found statistically significant decrease in all the pulmonary function parameters in postoperative period except that of FEV1/FVC. When we did intergroup statistical analysis, we found more decrease in PFT parameters in Male patients, Patients undergoing Upper abdominal surgery and in Obese patients. Conclusion: Thus after laparotomy there are Restrictive type of ventilatory changes due to pain, altered pattern of ventilation and diphragmatic weakness. Male patients, patients undergoing upper abdominal surgeries & obese patients are high risk patients for pulmonary complications. Since these postoperative pulmonary changes can be easily diagnosed by spirometer, all patients undergoing laparotomy should undergo preoperative and postoperative spirometry. Also prophylactic preoperative physiotherapy and postoperative deep breathing exercises, incentive spirometry and chest physiotherapy can be beneficial in patients of laparotomy. Keywords: Laparotomy, Pulmonary Function Tests, Postoperative INTRODUCTION Nowadays, the scope of surgery has widened tremendously. But along with this, the increased toll of complications has also come into focus. Even in the face of good surgery, these post-operative complications can tilt the balance between success and failure, and Corresponding author: Nahar Pradeep Department of Physiology, B.J. Medical College, Pune Phone numbers - 08237010726 E-mail: pradeepnahar85@yahoo.com among these, post-operative pulmonary complications are especially notorious. Occurrence of these postoperative pulmonary complications can be easily diagnosed by spirometry. Also these complications can be prevented by simple pre-operative training and regular postoperative physiotherapy in high risk patients. In this study, we hypothesized that after laparotomy in post-operative period there will be decrease in Pulmonary function test (PFT) parameters. We also believed that this decrease in PFT parameters is the major culprit for post-operative pulmonary
complications. In order to indentify the high risk patients we also studied the effect of gender difference (Male, Female), site of surgery (Upper abdomen, Lower abdomen) and BMI (Obese, Non obese) on postoperative PFT parameters. Aims and objectives 1) To record various pulmonary function parameters (TV, ERV, IRV, VC, IC, MVV FVC, FEV1, FEV1/FVC, PEFR and PIFR) preoperatively and postoperatively in patients undergoing laparotomy. 2) To compare and evaluate alterations between preoperative and postoperative values of pulmonary function parameters. 3) To study the effect of gender difference, site of surgery and Body Mass Index on postoperative pulmonary function parameters as compared to their preoperative values. MATERIALS AND METHOD The study protocol was approved by the Institutional Ethics Committee. Patients were selected from those admitted to Surgery and Gynaecology ward of the Sassoon General hospital. 28 males and 22 females of the age group 30-60 years undergoing planned laparotomy were selected for the study. The study protocol was explained in detail to the selected patients. All the patients willing to participate in the study were asked to fill an informed consent form. Pulmonary function parameters were recorded preoperatively on one day prior to surgery and the postoperative readings were taken on fifth post-operative day. The PFTs were measured using a computerized portable RMS Helios 702(Chandigarh) spirometer (Photograph 1). This spirometer is automated and has a flow sensor which converts the airflow signals to digital signals. Values obtained were in litres and they were compared with the existing database for the normal healthy Indian population depending on age, sex, height and weight. Patients with history of cardiorespiratory diseases, diabetes mellitus or hypertension were excluded from the study. Also patients who had intra-operative complications, post-operative pulmonary, cardiac or surgical complications were excluded. The tests were conducted according to the American Thoracic Society/ European Respiratory Society (ATS/ ERS) task force guidelines. The pulmonary functions were recorded in the sitting position and before the subject had lunch. The subjects were instructed to wear loose clothes on the day of test. Name, age, sex, height
and weight were entered in the spirometer. The procedures of all maneuvers were demonstrated to the subject using disposable mouthpiece. The Slow Vital Capacity (SVC) maneuver was conducted in the following order: Subjects were instructed to breathe normally through the mouthpiece. After the three normal breaths, they were asked to take deep inspiration followed by forceful expiration. And again they were asked to take three normal breaths without removing the mouthpiece. Parameters recorded in this manoeuvre were Tidal volume (TV) in litres, Expiratory reserve volume (ERV) in litres, Inspiratory reserve volume (IRV) in litres, Inspiratory capacity (IC) in litres, Vital capacity (VC) in litres. The Forced Vital Capacity (FVC) maneuver was conducted in the following order: Subjects were instructed to take slow and deep inspiration. Then subjects were instructed to hold the mouthpiece in the mouth with lips pursed around it and asked to blow forcefully into the mouthpiece as long as possible without hesitation and coughing. Then without removing the mouthpiece from the mouth, they were instructed to inspire maximally through the mouthpiece. Parameters recorded in this maneuver were Forced vital capacity (FVC) in litres, Force expiratory volume in one second (FEV1) in litres, FEV1/ FVC in %, Peak expiratory flow rate (PEFR) in litre per second and Peak inspiratory flow rate (PIFR) in litre per second. The Maximum Voluntary Ventilation (MVV) maneuver was conducted in following order: Subjects were instructed to breathe in and out as rapidly and deeply as they can for a period of 15 seconds through the mouthpiece. All the recorded maneuver results were analyzed for acceptability and repeatability. Three acceptable readings were taken and their mean values were calculated and analyzed. Statistical analysis was carried out by Students t test SPSS software( version 11). FINDINGS We found that post-operatively there is decrease in TV by 21.87%, ERV by 22.01%, IRV by 23.64%, IC by 26.23%, VC by 25.54%, MVV by 26.28%, FVC by 26.32%, FEV1 by 28.97%, FEV1/FVC by 3.48%, PEFR by 32.31% and PIFR by 41.73%. All these differences were statistically significant except that in FEV1/FVC. (Table 1, Figure 1)
Intergroup statistical analysis between Male and Female patients showed that post-operative percentage decrease was more in Male patients as compared to that in Female patients. (Table 2, Figure 2) Intergroup statistical analysis between patients undergoing upper abdominal surgery and patients undergoing lower abdominal surgery showed that post-
operative percentage decrease was more in patients undergoing upper abdominal surgery. (Table 3, Figure 3) Intergroup statistical analysis between obese and non obese patients showed that post-operative percentage decrease was more in obese patients as compared to the non obese patients. (Table 4, Figure 4)
Table 1: Mean preoperative and postoperative values of pulmonary function parameters with postoperative percentage decrease
Parameter TV_PRE (in Lit.) TV_POST (in Lit.) ERV_PRE (in Lit.) ERV_POST (in Lit.) IRV_PRE (in Lit.) IRV_POST (in Lit.) IC_PRE (in Lit.) IC_POST (in Lit.) VC_PRE (in Lit.) VC_POST (in Lit.) MVV_PRE (Lit/min.) MVV_POST (Lit/min.) FVC_PRE (in Lit) FVC_POST (in Lit) FEV1_PRE (in Lit.) FEV 1_POST(in Lit.) FEV1/FVC_PRE (in %) FEV1/FVC_POST (in %) PEFR_PRE (Lit/sec.) PEFR_POST (Lit/sec.) PIFR_PRE (Lit/sec.) PIFR_POST (Lit/sec.) Pre: Preoperative Post: Postoperative *< .05: statistically significant Mean 0.352 0.275 0.763 0.595 2.580 1.970 2.893 2.134 3.640 2.710 91.320 67.320 3.230 2.380 2.830 2.010 86.700 83.680 6.072 4.110 6.072 3.538 SD 0.06 0.04 0.18 0.15 0.26 0.21 0.34 0.28 0.52 0.30 7.91 6.90 0.42 0.36 0.42 0.32 4.82 6.01 1.31 1.04 1.31 0.88 2.534 (41.73) < 0.05 * 1.962 (32.31) < 0.05 * 3.020 (3.48) > 0.05 0.820 (28.97) < 0.05 * 0.850 (26.32) < 0.05 * 24.000 (26.28) < 0.05 * 0.930 (25.54%) < 0.05* 0.759 (26.23%) < 0.05* 0.610 (23.64%) < 0.05* 0.168 (22.01%) < 0.05* Preoperative Postoperative mean difference (Percentage %) 0.077 (21.87%) p value < 0.05*
Table 2: Postoperative Percentage decrease in pulmonary function parameters in relation to the gender difference
Parameters TV ERV IRV IC VC MVV FVC FEV1 FEV1/FVC PEFR PIFR MALE, Postoperative percentage decrease 25.00 24.44 25.45 28.01 27.59 28.15 27.66 30.23 4.22 34.31 43.74 FEMALE ,Postoperative percentage decrease 20.00 18.64 21.85 23.30 22.76 23.61 24.57 27.41 2.56 29.44 38.60
Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 173 Table 3: Postoperative Percentage decrease in pulmonary function parameters in relation to the site of surgery
Parameters UPPER ABDOMAN, Postoperative percentage decrease 26.47 24.32 25.09 29.65 29.47 27.81 29.79 32.35 3.69 35.96 45.70 LOWER ABDOMAN, Postoperative percentage decrease 20.00 20.77 21.40 22.02 21.85 24.19 23.05 26.19 3.28 28.87 37.90
TV ERV IRV IC VC MVV FVC FEV1 FEV1/FVC PEFR PIFR
Table 4: Postoperative Percentage decrease in pulmonary function parameters in relation to the BMI
Parameters OBESE, Postoperative percentage decrease 23.52 22.97 24.80 28.32 26.40 27.98 28.52 30.85 4.50 35.57 43.80 NON OBESE, Postoperative percentage decrease 19.44 21.51 22.48 23.50 24.86 24.53 24.08 27.11 2.34 28.91 39.58
TV ERV IRV IC VC MVV FVC FEV1 FEV1/FVC PEFR PIFR
DISCUSSION To the best of our knowledge no one has studied all the PFT parameters as a whole in postoperative period as we did. Few authors have studied some parameters in laparotomy patients. Beecher HK [2] found a greater decrease in TV, ERV, IRV and VC as compare to our study. This may be due to the fact that their study measured PFT parameters on 2nd postoperative day while ours was on 5th postoperative day. Similar study conducted by Collins et al [3] on FVC, FEV1, FEV1/FVC and PEFR showed lower decrease in PFT parameters this may be due to they have studied it on 7 th postoperative day. Very few authors have studied effect of laparotomy on PIFR. We found that post-operatively there was statistically significant decrease in all PFT values except that of FEV1/FVC. Thus post-operatively there is restrictive type of ventilatory dysfunction which is responsible for various post-operative pulmonary complications. The various mechanisms responsible for
this post-operative pulmonary dysfunction are: Impaired ventilation in post-operative period due to diaphragmatic dysfunction which can be proved by: a) Decreased diaphragmatic excursions [4] b) Paradoxical motion of the diaphragm [5] c) Loss of the diaphragms normal inspiratory - expiratory phasic activity [6] d) Decrease in trans-diaphragmatic pressure by almost 70% [7] Adaptation of shallow breathing pattern without periodic deep breathing in post-operative period results in decreased surfactant secretion by type II alveolar epithelial cells. This decrease in surfactant secretion causes post-operative atelectasis, thus decreasing PFT values.[8] It has been proved that there is dysfunction of intercostal muscles in post-operative period. Intercostal muscles play an important role in forceful respiration. So their dysfunction results in decrease in PFT values.[8] The situation is further aggravated by certain
post-operative factors such as prolonged recumbency, supine position and tight dressing over abdomen.[9] Intergroup statistical analysis showed that male patients are more severely affected than female patients. Various reasons that can be put forward for this difference are 1) Type of breathing [10], Normally during quiet respiration males show abdomino-thoracic type of breathing, while females have thoraco-abdominal type of breathing. Thus abdominal component is predominant in males and this abdominal component is mainly affected during laparotomy. 2) Progesteron, the female sex hormone, has its own influence on chemoreceptor cells in medulla. Progesterone increases sensitivity of respiratory center to CO2. So whenever there are postoperative ventilation abnormalities in females, it causes stimulation of respiratory center due to progesterone and this may improve postoperative pulmonary function in them.[11] Patients undergoing upper abdominal surgery are more affected than that of lower abdominal surgeries This can be explained by the fact that the diaphragmatic weakness is the main cause of postoperative pulmonary dysfunction and this diaphragmatic dysfunction mainly depends upon proximity of operative site to diaphragm. The proximity of operative site is inversely related to diaphragmatic function. This finding has been supported by the decrease in maximum inspiratory pressure, transdiaphragmatic pressure and expiratory muscle pressure observed after upper abdominal surgery in several studies. [ 12 13,14,15] This decrease is sustained for 48 hours after surgery and may persist for a week. [16,17] Furthermore, upper abdominal surgeries cause predominantly rib cage breathing in post-operative period, as shown by an increase in the ratio of oesophageal to gastric pressure swings (Poes/Pga) and by decrease in the abdominal to rib cage excursions. This indicates that the intercostal inspiratory muscles are more active after upper abdominal surgery. [12,14] This is because the diaphragm is the muscle that is mainly affected during upper abdominal surgery. The mechanism that underlies the reduction in diaphragmatic strength and the shift to predominantly rib cage breathing is not fully understood, but anaesthesia and pain are definitely responsible for this dysfunction, some studies in animals and humans also showed that an inhibitory reflex generated during the
surgical procedure is the major mechanism. Manipulation of the splanchnic organs during laparotomy causes reflex inhibition of the phrenic nerve output decreasing diaphragmatic function. [15] Thus upper abdominal operations are associated with substantially worse diaphragmatic function postoperatively than are lower abdominal operations, and the risk of postoperative pulmonary complications is accordingly higher by a factor of 1.5. [18] CONCLUSION We found after laparotomy in postoperative period, there are restrictive type of ventilatory changes. All these postoperative PFT decrease are more in male patients, in patients undergoing upper abdominal surgeries and in obese patients. All these changes are favorable for producing postoperative pulmonary complications. These changes are mainly due to altered pattern of ventilation in postoperative period. Since these postoperative pulmonary changes can be easily diagnosed by spirometer, all patients undergoing laparotomy should undergo preoperative and postoperative spirometry. Also prophylactic preoperative physiotherapy and postoperative interventions such as deep breathing exercises, incentive spirometry and chest physiotherapy should be advised to all patients undergoing laparotomy. These simple and inexpensive procedures can make a significant difference in patients outcome after laparotomy. This will definitely reduce mortality and morbidity after laparotomy and will give very good results to surgeon who had used good surgical technique and alert mind for betterment of his patients. REFERENCES 1. Miller MR, Hankinson J, Brusasco V, Burgos F, Casaburi R, Coates A et al. Standardization of spirometry. Eur Respir J 2005;26:319-38 Beecher HK. Effect of laparotomy on lung volume: Demonstration of a new type of pulmonary collapse. J Clin Invest 1933;651:12. Collins CD, Darket MD, knowelden J. Chest complications after upper abdominal surgery: Their anticipation and prevention. Brit Med J 1968; 1: 401-06.
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Rehder K, Sessler AD, Marsh HM. General anesthesia and the lung. Am Rev Respir Dis 1975; 112:541-63. 5. Marsh HM, Rehder K, Sessler AD, Fowler WS. Effects of mechanical ventilation, muscle paralysis and posture on ventilation-perfusion relationships in anesthetized man. Anesthesiology 1973; 38(1): 59-67. 6. Russel WJ. Position of patient and respiratory function in immediate postoperative period.BMJ 1981;283:1079-80 7. Simonneau G, Vivien V, Saltine R. Diaphragmatic dysfunction induced by upper abdominal surgery: role of postoperative pain. Am Rev Respir Dis 1983; 128:899 8. Rehder K. Anesthesia and the respiratory system. Can Anesth Soc J 1979; 26(6):451-62. 9. Brook lord. Abdominal operations.1969.5th ed. New York. p 484-91 10. Guyton and Hall. Textbook of Medical Physiology. 11th ed. Elsevier Pvt. Ld.;2006: p 471-80. 11. Keele C, Neil E, Joels N. Samsung Wrights Applied Physiology. 13th ed. Oxford University Press;2000 p 584 12. Ford GT, Whitelaw WA, Rosenal TW, Cruse PJ, Guenter CA. Diaphragm function after upper
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abdominal surgery in humans. Am Rev Resp Dis 1983; 127: 431-36. Celli BR, Rodriguez KS, Snider GL. A controlled trial of intermittent positive pressure breathing, incentive spirometry, and deep breathing exercises in preventing pulmonary complications after abdominal surgery. Am Rev Resp Dis 1984; 130: 12-15. Ford GT, Rosenal TW, Clergue F. Respiratory physiology in upper abdominal surgery. Clin Chest Med 1993;14:23752. Watters JM, Clancey SM, Moulton SB. Impaired recovery of strength in older patients after major abdominal surgery. Ann Surg 1993; 218:38090. Putensen-Himmer G, Putensen C, Lammer H. Comparison of postoperative respiratory function after laparoscopy or open laparotomy for cholecystectomy. Anesthesiology 1992; 77:67580. Siafakas NM, Stoubou A, Stathopoulou M. Effect of aminophylline on respiratory muscle strength after upper abdominal surgery: a double blind study. Thorax 1993; 48:6937. Mitchell C, Garrahy P, Peake P. Postoperative respiratory morbidity: identification and risk factors. Aust N Z J Surg 1982; 52:2039.
Evaluation of Standardized Backpack weight and its Effect on Shoulder & Neck Posture
Pardeep Pahwa Lect. in Physical Therapy, Composite Regional Centre for Persons with Disabilities (Ministry of Social Justice & Empowerment , Govt of India) Sundernagar (HP) ABSTRACT The Backpack is one of several forms of manual load carriage that provides versality and is often used by hikers, backpackers, and soldiers as well as school student. Students have emerged as another population of backpackers who carry their school supplies in book bags which are backpacks. As the students progress through the school grades the amount of homework and backpack loads of school age children increases. We all want our children to do well in school.16 To initiate an educational program regarding school backpack safety in our area, it is essential to know the 'weight' of backpack students are currently carrying. Keywords: Backpackpack, Craniohorizontal angle, Craniovertebral angle, Sagittal Shoulder posture, Anterior Head Alignment.
INTRODUCTION The Backpack is one of several forms of manual load carriage that provides versality and is often used by hikers, backpackers, and soldiers as well as school student. The Backpack is an appropriate way to load the spine closely and symmetrically, whilst maintaining the stability. However, musculoskeletal problems associated with backpack use have become an increasing concern with school children.1 Students have emerged as another population of backpackers who carry their school supplies in book bags which are backpacks. Carriage of backpack applies a substantial load to spine to school children.2 As the students progress through the school grades the amount of homework and backpack loads of school age children increases. As a result the students carry all their materials in book bags. This has lead to physical complaints in the form of muscle soreness (67.1%), back pain (50.8%), numbness (24.5%) and shoulder pain (14.7%). The most commonly reported medical problem is plexus or peripheral nerve injury. Physical examination can often reveal weakness, numbness and possible muscle atrophy. 3 The Backpack loading produce changes in standing posture when compared with unloaded standing posture which has been related to spinal pain.4 Although it is unclear whether backpacks can cause permanent damage, the healthcare costs associated
with strain and pain could be enormous.5 School bags are felt to be heavy by 79% of children, to cause fatigue by 65.7%10. We all want our children to do well in school.7 To initiate an educational program regarding school backpack safety in our area, it is essential to know the weight of backpack students are currently carrying. This information could be incorporated into school curriculum or distributed as a handout for children to take home to their parents. Many researches have been done on amount of load carried by student and their effect on shoulder and neck alignment is between 10% and 17% of students body weight.1 Chansirinukor et al6 suggested that a backpack load of 15% body weight is too heavy for adolescents to maintain a prolonged standing posture. Furjuouh el al5 reported that backpack carried by majority of school students, in the sample are no longer heavier than 10% of body weight which is associated with complaints of pain in back, shoulder, neck or other areas of body. Pascoe et al6 reported that mean weight of school bags was 17% of students mean body weight. The previous study done by Chansirinukor et al1 showed that carrying a load of less than 15% of body weight should be recommended, but none of study has shown the particular amount of backpack weight, from where the change in craniohorizontal and carniovertebral angle starts which leads to change in cervical and shoulder posture.
Aims and Objectives To determine the particular amount of backpack weight carried by students that does not change the students cervical and shoulder posture. To implement and recommend maximum weight of backpack that should be carried by students.
Study Design This study was an observational study design. PROCEDURE All the subjects were tested in DIBNS gymnasium To capture postural information on body segments, clothing was rearranged so that shoulder and upper half body exposed. With the subjects standing, adhesive markers (Bindis) were placed on anatomical points comprising :1. The External canthus of right eye.
Statement of Question How much percentage of backpack weight should be carried by students that does not change student posture? METHODOLOGY Sample A total of 10 school boys aged between 13 and 17 years old recruited as subjects. They were recruited from the G.N.D public school, Dehradun. This study was conducted at gymnasium of Dolphin Institute, Dehradun. Inclusion Criteria 1. Subjects with in age group of 13-17years. 2. Height of subjects 90-160 cms . 3. Weight of subjects 30-60 kg. Exclusion Criteria 1. Subjects with postural abnormality , LLD, cervical and shoulder pain 2. Balance disorder 3. Congenital abnormality such as spina bifida, cervical rib, deformity of spine. 4. Subjects with forward head posture, history of recent fracture. Instrumentation 1. Metter Digital Electronic Scale
2. Right tragus of the ear. 3. Inferior margins of both ears. 4. A midpoint between greater tuberosity of humerus and posterior aspect of acromion process of right shoulder; and 5. Spinous process of C7.
A small reflective ball was placed over the spinous process of C7 The lateral malleoli were placed between parallel lines, which are perpendicular to frontal Plane, 2 cm apart. The photographs were obtained using a digital kodak camera that was attached to tripod. The tripod was secured in correct position on floor by using masking tape for the sagittal view photography, the subject were placed 2.8 m from the camera and 1.8 m from the camera for frontal view photography. Then the subject were photographed from both lateral view and from anterior aspect at same time with 1. Unloaded 2. Carrying a backpack weighing 8% to 20% of body weight by adding 1% weight of body weight & so on. In order to evaluate posture of cervical and shoulder region, motion analysis software (protrainer 6.1 sports motion) was employed to calculate the angles from each anatomical landmark from the photographs. The angles in the lateral and frontal view thus calculated and readings taken for the data analysis. The four angles of measurement are Craniohorizontal Angle1 The angle formed at intersection of a horizontal line through tragus of ear and a line joining the tragus of ear and external canthus of eye. It is believed to provide an estimation of head on neck angle or position of upper cervical spine
2. Digital Video Camera 3. Height Statuometer 4. Adhesive Markers 5. Book Bags 6. Educational Material 7. Motion Analysis Software
Craniovertebral Angle1 It is angle formed at the intersection of a horizontal line through the spinous process of C7 and a line to the tragus of ear. This is believed to provide an estimation of neck on upper trunk position. Sagittal Shoulder Posture1 The angle formed by intersection of horizontal line through C7 and a line between the mid point of greater tuberosity of humerus and posterior aspect of acromion. This angle provides a measurement of forward shoulder position Anterior Head Alignment1 A line drawn between the inferior tip of left and right ears, and the angle of this line to horizontal. This measurement described how level the head was when viewed from the frontal.
DATA ANALYSIS The significance of postural changes from where the change starts in data were estimated by using paired t-test on each postural angle within which planned contrast were made of unloaded condition with loaded backpack weight from pair 1 to pair 13 including 8% upto 20% of body weight. The statistical significant level of this study was set at 0.025. RESULTS The mean and standard deviation for physical characteristics of all the 10 subjects were taken i.e. age (14.1 + 1.19) yrs, weight (44.3 + 7.84) kg and height (145.4 + 8.60) cms. The mean and standard deviation of both unloaded and loaded CHA, CVA, SSP and AHA from pair 1 to pair 13 were analysed by using paired t test.
Table: 1 Showing comparison of mean and standard deviation for each unloaded and loaded condition of Craniohorizontal angle at different percentages of body weight (8%-20%)
Variable Pair 1 ULCHA LCHA 8 Pair 2 ULCHA LCHA 9 Pair 3 ULCHA LCHA 10 Pair 4 ULCHA LCHA 11 Pair 5 ULCHA LCHA 12 Pair 6 ULCHA LCHA 13 Pair 7 ULCHA LCHA 14 16.42.5 25.03.0 7.20 .000 16.42.5 25.33.7 6.74 .000 16.42.5 24.14.9 4.81 .001 16.42.5 22.94.8 4.02 .003 16.42.5 21.34.3 3.86 .004 16.42.5 21.22.2 6.10 .000 16.42.5 19.03.9 2.53 .032 MeanSD t-value p-value Variable Pair 8 ULCHA LCHA 15 Pair 9 ULCHA LCHA 16 Pair 10 ULCHA LCHA 17 Pair 11 ULCHA LCHA 18 Pair 12 ULCHA LCHA 19 Pair 13 ULCHA LCHA 20 16.42.5 28.12.9 11.69 .000 16.42.5 28.02.1 12.75 .000 16.42.5 27.71.8 16.14 .000 16.42.5 27.42.3 15.73 .000 16.42.5 25.83.0 8.33 .000 16.42.5 24.21.98 8.29 .000 MeanSD t-value p-value
Graph: 1 Showing comparison of backpack load at different percentage of body weight with unloaded condition for Craniohorizontal Angle.
30 25 20
Degree
15 10 5 0 8 9 10 11 12 13 14 15 16 17 18 19 20 Percentage of body weight
Table: 2 Showing comparison of mean and standard deviation for each unloaded and loaded condition of Craniovertebral angle at different percentages of body weight (8%-20%)
Variable Pair 1 ULCVA LCVA 8 Pair 2 ULCVA LCVA 9 Pair 3 ULCVA LCVA 10 Pair 4 ULCVA LCVA 11 Pair 5 ULCVA LCVA 12 Pair 6 ULCVA LCVA 13 Pair 7 ULCVA LCVA 14 48.73.9 43.06.737 3.47 .007 48.73.9 43.37.14 2.90 .017 48.73.9 43.46.9 3.32 .009 48.73.9 45.45.8 2.74 .023 48.73.9 46.76.6 1.27 .235 48.73.9 47.26.4 .929 .377 48.73.9 47.94.4 .937 .373 MeanSD t-value p-value Variable Pair 8 ULCVA LCVA 15 Pair 9 ULCVA LCVA 16 Pair 10 ULCVA LCVA 17 Pair 11 ULCVA LCVA 18 Pair 12 ULCVA LCVA 19 Pair 13 ULCVA LCVA 20 48.73.9 41.17.6 4.451 .002 48.73.9 42.36.9 4.311 .002 48.73.9 41.86.4 4.89 .001 48.73.9 42.06.6 3.75 .006 48.73.9 42.86.2 4.65 .001 48.73.9 42.96.8 3.80 .004 MeanSD t-value p-value
Graph: 2 Showing comparison of backpack load at different percentage of body weight with unloaded condition for Craniovertebral Angle
51 49 47 45
Degree
43 41 39 37 35 8 9 10 11 12 13 14 15 16 17 18 19 20 Percentage of body weight
Table: 3 Showing comparison of mean and standard deviation for each unloaded and loaded condition of Sagittal shoulder posture at different percentages of body weight (8%-20%)
Variable
Pair 1 ULSSP LSSP 8 Pair 2 ULSSP LSSP 9 Pair 3 ULSSP LSSP 10 Pair 4 ULSSP LSSP 11 Pair 5 ULSSP LSSP 12 Pair 6 ULSSP LSSP 13 Pair 7 ULSSP LSSP 14
MeanSD
59.1 6.2 56.9 6.1 59.1 6.2 56.9 5.08 59.1 6.2 57.8 5.5 59.1 6.2 59.8 5.9 59.1 6.2 59.3 7.1 59.1 6.2 58.2 7.1 59.1 6.2 59.2 6.4
t-value
1.66
p-value
0.131
Variable MeanSD t-value

Pair 8 ULSSP LSSP 15 Pair 9 59.1 6.2 58.6 6.3 59.1 6.2 59.7 7.04 59.1 6.2 59.2 6.3 59.1 6.2 58.8 6.3 59.1 6.2 60.0 7.2 59.1 6.2 59.0 6.6 .082 .635 .209 .073 .599 .478
p-value
0.644
.246
0.811
ULSSP LSSP 16 Pair 10
0.564
.969
0.358
0.944
.793
0.448
0.839
.194
0.850
0.541
.588
0.571
ULSSP LSSP 20
0.936
.085
0.934
Graph: 3 Showing comparison of backpack load at different percentage of body weight with unloaded condition for Sagittal shoulder posture.
60 50
Degree
40 30 20 10 0 8 9 10 11 12 13 14 15 16 17 18 19 20 Percentage of body weight
Table: 4 Showing comparison of mean and standard deviation for each unloaded and loaded condition of Anterior head alignment at different percentages of body weight (8%-20%)
Variable Pair 1 ULAHA LAHA 8 Pair 2 ULAHA LAHA 9 Pair 3 ULAHA LAHA 10 Pair 4 ULAHA LAHA 11 Pair 5 ULAHA LAHA 12 Pair 6 ULAHA LAHA 13 Pair 7 ULAHA LAHA 14 1.0 .66 2.0 .94 3.3 0.008 1.0 .66 1.8 .78 3.2 0.011 1.0 .66 1.6 .57 2.2 0.051 1.0 .66 1.5 .70 1.8 0.096 1.0 .66 1.4 .51 1.8 0.104 1.0 .66 1.3 .48 1.9 0.081 1.0 .66 1.2 .42 1.0 0.34 MeanSD t-value p-value Variable Pair 8 ULAHA LAHA 15 Pair 9 ULAHA LAHA 16 Pair 10 ULAHA LAHA 17 Pair 11 ULAHA LAHA 18 Pair 12 ULAHA LAHA 19 Pair 13 ULAHA LAHA 20 1.0 .66 2.8 .42 7.2 0.000 1.0 .66 2.6 .51 9.7 0.000 1.0 .66 2.3 .67 8.5 0.000 1.0 .66 2.6 1.07 4.7 0.001 1.0 .66 2.2 .63 4.8 0.001 1.0 .66 2.3 .82 4.9 0.001 MeanSD t-value p-value
182 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 Graph: 4 Showing comparison of backpack load at different percentage of body weight with Unloaded condition for Anterior Head Alignment
3.0 2.5 2.0

Degree
1.5 1.0 0.5 0.0 8 9 10 11 12 13 14 15 16 17 18 19 20 Percentage of body weight

DISCUSSION of C7 remains fixed. But study done by Chansirinukor et al.,1 shows that sagittal plane shoulder posture increases under load, when a marker was placed in between greater tuberosity of humerus and posterior aspect of acromion. Braun and Amundson 8 in their study pointed bicipital tendon groove as acromion angle for assessing shoulder position in sagittal plane. There might be reason that different position adopted for measurement might have contributed to contrasting outcome. So further studies using a 3dimensional approach is required to identify the relationship between body landmark and their correct placement for sagittal shoulder posture. FUTURE RESEARCH Future research is needed to investigate the effect of backpack carriage on Unilateral side in dynamic conditions on cervical and shoulder posture changes. Girls students were not included in the study, because of exposure. As the spine is maturing, there may be gender based difference which can affect the results of the study.
For all three angles i.e craniohorizantal angle, carniovertebral angle and anterior head alignment, the change starts at 9%,11% and 13% respectively, which is less than 15% of body weight. According to Chansirinukor et al (2001), who recommended that 15% of body weight represent an overload to this age of young children support the present study. According to National Back Pain Association (1997) and Voll & Klimt11 (1997) who recommended that school children should carry no more than 10% of their body weight, supporting this study. But change in anterior head alignment in present study starts at 13% of body weight which is against the study done by Voll and Klimt. For sagittal shoulder position, the result of present study shows insignificant difference from 8% to 20% of body weight and so does not show any change in sagittal posture at any percentage of body weight. There is lot of controversy about the accurate anatomical landmarks of this angle according to different authors. Based on Rainey and Twomeys study (1994)1,12, a more rounded shoulder is represented by a smaller sagittal shoulder angle; provided the position
Relevance to Clinical Practice The carriage of heavy school bag coupled with long carriage duration and lack of access of lockers in Indian schools may represent an daily physical stress for school students and could lead to musculoskeltal symptoms. Therefore, if preventive measures can be introduced with regard to safe load carriage in school students. It will not only help to protect students while they are still developing but it will also ensure that the principles they learn now are carried through to workplace as adults. RECOMMENDATIONS
CONCLUSION Previous studies suggest that postural response in high school students are sensitive to load carriage equivalent to 15% of body weight. The amount of weight that does not change the students head and neck posture, that can be recommended lies between 9-10% of body weight. So, up to 10% of body weight, there is safeguard limit for adolescents. According to these results, teachers, children and families should be equally involved in safe carrying of backpack load. As a part of physiotherapy intervention, students were often advised about their habitual posture in relation to carrying backpack load. REFERENCES 1. Wunpen Chansirinukor, Dianne Wilson, Karen Grimmer and Brenton Dansie., Effects of Backpacks on students: Measurement of cervical and shoulder posture. Australian Journal of physiotherapy, 47, 110-116. 2001. Yong Tai wang, D.D. Pascoe, W. Weimar. , Evaluation of Book Back pack load during walking Ergonomics , 44 (9), 858 869, 2001 David D. Pascoe, Donna E. Pascoe, Yong Tai Wang, Dong-Ming-Shim and Chang K. Kim., Influence of carrying book bags on gait cycle and posture of youths. Ergonomics, 40, (6 ),631-641, 1997. Karen Grimmer, brenton dansie, S. Milanese, U. Pirunson and Patricia trott., Adolescent standing postural response to backpack loads: a randomized controlled experimental study.BMC Musculoskeltal Disorders, 3, 1-10, 2002 Forjuoh SN, Lane BL, Schuchmann J., Percentage of Body weight carried by students in their school backpacks.Am. J Phys. Med. Rehabil , 82, 261 266, 2003. Youlian Hong, Chi-kin Cheung., Gait and posture responses to backpack load during level walking in children. Gait and posture, 17,28-33, 2003. Richard- Pistolese., Backpacks- Your childs spine at risk. International chiropractic pediatric associationICPA, 3,1-2, 2000 Barbara lafferty brawn, Louis R. Amundson., Quantitative assessment of head and shoulder posture. Arch. Phys. Med. Rehabil, 70, 322-329, 1998.
2.
3.
4.
1. Wear padded, wide shoulder straps both sides. 2. Backpack should not too heavy than 10% of student body weight. 3. Advice the students to keep the load close to the body. Limitations of Study 1. If the number of subjects had been more, results would have been better enhanced. 2. The study was limited to only one school and particular age group. So, results may not be generalized to the source population.
5.
6.
7.
8.
9.
Daniel H.K. Chow, Monica L.Y Kwok, Alexander C.K., A.V. Yang, Andrew D. Holmes, Jack Y Cheng, Y.D. YAO. M.S Wong., The Effect of backpack load on the gait of normal adoloscent girls. Ergonomics, 48 (6) , 642 656, 2005. 10. Stefano Negrini, Roberta carabalona., Back packs on ! School Childrens Perception of Load, Associations with Backpain
and factors determining the load. Spine, 27, 187-195, 2002 11. J.K. Whittfield, S.J. Legg, DI Hedderley., The weight and use of school bags in Newzealand Secondary Schools. Ergononics , 44 (9) , 819- 824, 2001 12. Raine S, Twomey Lt .,Posture of Head Shoulders and thoracic spine in comfortable erect standing. Australlian J. Physiotherapy , 40 (1) , 25-32, 1994.
Effect of Abductor Muscle Strengthening in Osteoarthritis Patients: A Randomized Control Trial

Nishant H Nar Consultant Physiotherapist Wockhardt Hospital, Rajkot ABSTRACT Background: Osteoarthritis is a chronic, localized joint disease affecting approximately one-third of adults, with the disease prevalence increasing with advancing age. OA affects many joints including the large, weight bearing joints of the hips and knees and also the spine, hands, feet and shoulders. The knee is the most common weight bearing joint affected by OA, with the disease predominantly affecting the medial compartment of the tibio-femoral joint. Patients with knee OA frequently report symptoms of knee pain and stiffness as well as difficulty with activities of daily living such as walking, stairclimbing and house keeping. Objectives: To compare the effectiveness of hip abductor muscle strengthening exercises and conventional physiotherapy treatment with conventional physiotherapy treatment alone in people with unilateral medial compartment knee osteoarthritis. Materials and Methodology: Study included 30 (Thirty) subjects with unilateral medial compartment knee OA, aged 45 years or above. The subjects were randomly divided into 2 groups: Group -A and Group -B. The subjects were treated for a period of 6 weeks, 6 days a week, once daily. Pain was assessed by VAS score and physical function was assessed by WOMAC Index of Osteoarthritis. Results: The results were analyzed by Wilcoxon Signed Rank Test. Group A showed significant improvement in pain (T=120, p<0.05) and physical function (T=120, p<0.05). In Group B, results showed significant improvement in pain (T=91, p<0.05) and physical function (T=120, p<0.05). Comparison of Group A and Group B was done with Wilcoxon Sum Rank Test (Mann Whitney U Test), Group A showed significant improvement in pain (z = -2.82, p<0.0052) and physical function (z = 3.56, p<0.0004). Conclusion: Hip abductor muscle strengthening exercises showed over all improvement in pain and physical function and is a useful adjunct exercise therapy in treating patients with unilateral medial compartment knee osteoarthritis. Keywords: Shortwave Diathermy (SWD), Visual Analoge Scale (V AS), WOMAC
INTRODUCTION The term arthritis literally means inflammation of a joint, but is generally used to describe any condition in which there is damage to the cartilage. The cartilage coats the joint surfaces to absorb stress, and allow smooth joint movement. The proportion of cartilage damage and synovial inflammation (the lining and fluid in the joint capsule) varies with the type and stage of arthritis. Usually the early pain is due to inflammation. Later in the disease, pain is from the irritation of the worn joint structures and inability of the joint to move properly. Osteoarthritis (OA) is a chronic, localized joint disease affecting approximately one-third of adults, with
the disease prevalence increasing with advancing age[1]. Concomitant with this high prevalence is a large economic cost, with direct and indirect costs estimated to be $23.9 billion in Australia in 2007[2]. Indeed, given the changing demographics of the adult population[3], expectations are for the prevalence of disease and its burden on the health care system to increase in coming decades[4]. The knee is the most common weight bearing joint affected by OA, with the disease predominantly affecting the medial compartment of the tibio-femoral joint[5,6]. Patients with knee OA frequently report symptoms of knee pain and stiffness as well as difficulty with activities of daily living such as walking, stairclimbing and house-keeping[7].
To date, most knee OA research examining treatment for knee OA has focused on surgical or pharmacological strategies. Although effective, these types of interventions have many potential side effects and are expensive[8]. Thus, recent knee OA clinical guidelines reinforce the importance of non-pharmacological strategies in the management of the condition[9,10]. However, there is an absence of high quality evidence to support the use of such therapies[9]. There are several reasons for the development of OA including age, being overweight, heredity factors, and joint damage from a previous injury or during early development of a joint. Increased loading across the joint has been implicated in the progression of knee OA severity [11]. In knee OA, the medial tibiofemoral compartment is the most common site of disease. The susceptibility of the medial compartment to OA development may relate to greater load distribution (i.e., 6080%) to the medial than the lateral compartment, even in healthy knees, during gait. Excessive medial compartment loading is widely believed to contribute to medial OA progression. Because direct measurement of knee load is invasive, external knee adduction moment during gait, a correlate of medial load, has been used in knee OA studies[12]. The role of gait analysis in the quantification of dynamic joint load has received much attention in the literature in light of the difficulty in performing in vivo measurement of joint loading during movement[13, 14, 15]. From the research, the external knee adduction moment, an indirect measure of load in the medial compartment of the tibio-femoral joint[16], has emerged as an important and widely accepted biomechanical marker of knee load. Cross-sectional studies demonstrate that patients with knee OA have a higher peak knee adduction moment during walking when compared to healthy agematched controls[17, 18]. It is also likely that the higher prevalence of medial compared with lateral tibiofemoral joint OA is the result of differences in the relative loading within the tibiofemoral joint. The external knee adduction moment determines load distribution across the medial and lateral tibial plateaus[12, 19, 20], with force across the medial compartment almost 2.5 times that of the lateral[16]. It has also been reported that for patients with knee OA, the magnitude of the adduction moment is predictive of clinical outcomes such as severity of knee pain and radiographic disease[21, 22]. A variety of exercise programs for knee OA have been described in the literature. These have included general aerobic exercise programs such as walking or cycling
as well as more specific programs involving strengthening of particular muscle groups and/or flexibility exercises. The primary aim of this study is to determine whether strengthening of the hip abductor muscles in people with medial compartment knee OA can reduce knee pain and improve physical function. It is hypothesized that a 6-week programme of strengthening the hip abductor muscles will improve pain and physical function in people with medial compartment knee OA. AIMS AND OBJECTIVE 1) To determine the effectiveness of hip abductor muscle strengthening in people with medial compartment knee osteoarthritis. 2) To compare the effectiveness of hip abductor muscle strengthening and conventional treatment with conventional treatment in people with medial compartment knee osteoarthritis. STUDY DESIGN AND MATERIALS Study Design An Experimental study was conducted to study the effects of hip abductor muscle strengthening exercises in patients with osteoarthritic knee joints. Study Setting All patients were referred from Orthopaedic Outpatient Department, Civil Hospital, Ahmedabad to B1 ward, Physiotherapy Department, Civil Hospital, Ahmedabad where they all were treated during study period. Sample Selection The sample size consisted of 30 (thirty) patients, who were diagnosed with unilateral medial compartment tibiofemoral OA, as per the Inclusion Criteria and the Exclusion Criteria. Study Duration The total duration of the study was 6 months. The subjects were treated for a period of 6 weeks, 6 days a week, one session daily. Sample Size The sample size of 30 (thirty) patients was divided in to two groups.
Group A: 15 patients. Group B: 15 patients. Age Group 45 years or older. Gender: Male: 14 Female: 16 SELECTION CRITERIA Inclusion Criteria 1. Age greater than or equal to 45 years. 2. Unilateral medial compartment tibiofemoral OA without involvement of any other compartment of knee joint. 3. Duration of symptoms: Chronic according to IASP classification. 4. At least some difficulty in daily function due to knee OA. 5. Both genders are included. 6. Kellgren-Lawrence radiographic grade I, II and III. 7. Patients who are able to comprehend commands. 8. Willingness to participate in the study. Exclusion Criteria Both sexes
Description of the Tools Visual Analog Scale (VAS) WOMAC Index of Osteoarthritis METHODOLOGY Ethical clearance was obtained from the Ethical Clearance Committee of wockhardt hospitals,rajkot prior to the study. Those who fulfilled the inclusion criteria were taken up for the study. The whole procedure of the study was explained to all the subjects. A written informed consent of all the subjects was taken prior to the study. All the subjects were assessed as per the assessment form. 30 (thirty) subjects were taken for the study with diagnosis of unilateral medial compartment knee OA; 14 male and 16 female. They were randomly divided in to two groups for the study. Each subject of the study was treated for a period of 6 weeks, 6 days a week, one session daily. An assessment was done prior to starting of treatment and weekly assessment was taken for these subjects. EXERCISE PROTOCOL All the subjects were informed in detail about the type and nature of the study. The subjects were divided in to two groups; Group A and Group B, 15 patients in each group. All the subjects were randomly selected and assigned in to each group. Group A
1. History of trauma within one year to affected knee joint. 2. Associated with any other pathological condition such as neoplasm, osteomyelitis, vascular problem etc. 3. Low back pain radiating to knee joint. 4. Knee surgery or intra articular corticosteroid injection within 6 months to affected knee joint. MATERIALS USED IN THE STUDY Consent form, universal goniometer, vas scale, weight cuffs, WOMAC Index of Osteoarthritis, Examination Table, Thera-bands, Short-wave Diathermy Machine, Kodak C875 Zoom Digital Camera, Paper, Pencil, Scale, Pins.
The subjects in Group A were given hip abductor muscle strengthening exercises and conventional physiotherapy treatment. Group B The subjects in Group B were given conventional physiotherapy treatment. Conventional Physioterapy Treatment for Both Group -a & Group -b: - (Ref) A. Short wave Diathermy B. Stretching Exercises 1) Standing Calf Stretch 2) Supine Hamstring Stretch 3) Prone Quadriceps Stretch
C. Range of Motion Exercises 1) In long sitting position, knee mid-flexion to end range extension 2) In long sitting position, knee mid-flexion to end range flexion 3) Stationary bicycle D. Strengthening Exercise 1) Static quadriceps sets in knee extension 2) In high sitting position knee mid-flexion to end range extension with weight cuff 3) In prone position knee end range extension to midflexion with weight cuff Hip Abductor Muscle Strengthening Exercises for Group -a Subjects in Group A were given a series of three exercises designed to strength the hip abductor muscles, 6 days a week for 6 weeks. Type of exercise 1) Abduction in side lying 2) Abduction in standing Unilateral hip abduction performed in standing at moderate resistance With the use of resistance band. 3) Standing wall isometric hip abduction: Performed in unipedal stance with the opposite limb in 90 degrees of hip and knee flexion. The whole study was extended for a period of 6 months. The duration of treatment programme for each subject was 6 weeks. All the thirty (30) subjects completed the whole treatment programme of 6 weeks with out any discomfort. RESULTS Table 1 show the gender distribution of the 30 subjects who participated in the study. In the Group A where the subjects underwent hip abductor muscle strengthening exercises and conventional physiotherapy treatment had 8 males and 7 females and in the Group B where the subjects underwent conventional physiotherapy treatment alone had 6 males and 9 females. There was no significant predominance of sex.
Table 1 Gender Distribution of the Subjects:

Gender Male count% Female count% Total Group A 853.33% 746.66% 15 Group B 640% 960% 15
Table 2 displays the statistics of age distribution of the 30 subjects. Among the 30 subjects, the mean age of 15 subjects in Group A was 51.33 with a standard deviation (SD) of 5.2326, and the mean age of 15 subjects in Group B was 52 with a standard deviation of 5.0142. No significant age difference was seen across the two groups.
Table 2 Age Distribution of the Subjects:
Group Group A Group B N 15 15 Mean 51.33 52 SD 5.2326 5.0142
Wilcoxon Signed Rank Test (1,2) was applied in Group A and in Group B for with-in group analysis and it is as follows: In Group A, results showed significant improvement on VAS score (T = 120 > 95, p < 0.05). In Group A, results showed significant improvement on WOMAC score (T = 120 > 95, p < 0.05). In Group B, results showed significant improvement on VAS score (T = 91 > 74, p < 0.05). In Group B, results showed significant improvement on WOMAC score (T = 120 > 95, p < 0.05). Wilcoxon Sum Rank Test (Mann Whitney U Test) (1,2) was applied for between-group comparison of Group A and Group B, and it is as follows: On comparing Group A and Group B for posttreatment VAS score, results showed significant difference in improvement (z = -2.82, p = 0.0052). On comparing Group A and Group B for posttreatment WOMAC score, results showed significant difference in improvement (z = -3.56, p = 0.0004). For Group A
Score VAS WOMAC For Group B: Score VAS WOMAC PreMean + SD 6.93 + 1.387 67.13 + 6.577 PostMean + SD 4.066 + 1.907 37.46 + 6.356 T 91 120 p< 0.05 0.05 PreMean + SD 7 + 1.690 66.66 + 6.986 PostMean + SD 2 + 1.463 27.66 + 4.237 T 120 120 p< 0.05 0.05
On comparing Group A and Group B: Score VAS WOMAC z Value -2.82 -3.56 p Value 0.0052 0.0004
9.
The z values (corresponding to p) are highly significant which suggest that hip abductor muscle strengthening exercises are effective in reduction of pain and improvement of physical function along with conventional physiotherapy treatment. Hence, Null Hypothesis of no significant effect of hip abductor muscle strengthening exercises can be rejected and Alternative Hypothesis of , there is an additive effect of hip abductor muscle strengthening exercises on reduction of pain and improvement of physical function can be accepted. REFERENCES 1. Felson DT, Naimark A, Anderson J, Kazis L, Castelli W, Meenan RF: The prevalence of knee osteoarthritis in the elderly. The Framingham Osteoarthritis Study. Arthritis and Rheumatism 1987, 30:914-918. Australia A: Painful Realities: The economic impact of arthritis in Australia in 2007. 2007. Hamerman D: Clinical implications of osteoarthritis and aging. Annals of the Rheumatic Diseases 1995, 54:82-85. Badley E, Wang P: Arthritis and the aging population: projections of arthritis prevalence in Canada 1991 to 2031. Journal of Rheumatology 1998, 25(1):138-144. Ledingham J, Regan M, Jones A, Doherty M: Radiographic patterns and associations of osteoarthritis of the knee in patients referred to hospital. Ann Rheum Dis 1993, 52(7):520-526. Iorio R, Healy WL: Unicompartmental arthritis of the knee. J Bone Joint Surg Am 2003, 85-A (7): 1351-1364. Guccione AA, Felson DT, Anderson JJ, Anthony JM, Zhang Y, Wilson PWF, Kelly-Hayes M, Wolf PA, Kreger BE, Kannel WB: The effects of specific medical conditions on the functional limitations of elders in the Framingham study. American Journal of Public Health 1994, 84:351-358. Dieppe PA, Ebrahim S, Martin RM, Juni P: Lessons from the withdrawal of rofecoxib. Bmj 2004, 329(7471):867-868.
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19. Jackson B, Teichtahl A, Morris M, Wluka A, Davis S, FM C: The effect of the knee adduction moment on tibial cartilage volume and bone size in healthy women. Rheumatology 2004, 43:311-314. 20. Wada M, Maezawa Y, Baba H, Shimada S, Sasaki S, Nose Y: Relationships among bone mineral densities, static alignment and dynamic load in patients with medial compartment knee osteoarthritis. Rheumatology 2001, 40:499-505. 21. Shrader M, Draganich L, Pottenger L, Piotrowski
G: Effects of knee pain relief in osteoarthritis on gait and stair-stepping. Clinical Orthopaedics and Related Research 2004, 421:188-193. 22. Sharma L, Hurwitz DE, Thonar E, Sum JA, Lenz ME, Dunlop DD, Schnitzer TJ, Kirwanmellis G, Andriacchi TP: Knee Adduction Moment, Serum Hyaluronan Level, and Disease Severity in Medial Tibiofemoral Osteoarthritis. Arthritis & Rheumatism 1998, 41(7):1233-1240.
Effects of Scapular Stabilization Exercises and Taping in Improving Shoulder Pain & Disability Index in Patients with Subacromial Impingement Syndrome due to Scapular Dyskinesis
Bhavesh Patel1, Praful Bamrotia2, Vishal Kharod3, Jagruti Trambadia4 Physiotherapist, Mahavir Physiotherapy Clinic, Mumbai, 2Tutor, Parul Institute of Physiotherapy, Vadodara, 3Junior Lecturer, Shri K K Sheth Physiotherapy College, Rajkot, Gujarat, 4Physiotherapist, Shri Sai Physiotherapy and Rehabilitation Center, Vadodara ABSTRACT Background & purpose: Shoulder disorders are among the most common of all peripheral joint complaints1,2, with Subacromial Impingement Syndrome considered to be one of the most common forms of shoulder pathology3, accounting for 44% to 60% of all complaints of shoulder pain during arm elevation or overhead activities4. Researches for Subacromial Impingement Syndrome due to Scapular Dyskinesis show that scapular stabilization exercises provide good results39. On the other hand one of the study shows that effect of changing posture by taping will reduce the symptoms of Subacromial Impingement Syndrome41. So the study is to compare the effectiveness of Scapular Stabilization Exercises and Taping in improving shoulder pain & disability index in patients with Subacromial Impingement Syndrome due to Scapular Dyskinesis. Objective: To check the effect of Scapular Stabilization Exercises and Taping in improving shoulder pain & disability index in patients with Subacromial Impingement Syndrome due to Scapular dyskinesis. Method: A total of 60 patients were taken for the study. All subjects were diagnosed with Subacromial Impingement Syndrome due to Scapular Dyskinesis. The purpose of the study was explained to all the subjects and informed consent was taken from each subject. All subjects were randomly assigned to either Scapular Stabilization Exercises group (Group A) and Taping group (Group B). The base line data of SPADI was obtained to check for the pain functional outcome. SPADI was later taken at the end of the treatment after 6 weeks on follow up. Study design: Experimental design Sampling technique: Purposive sampling technique Outcome measure: Spadi Score Measurement Result: Results show that Scapular Stabilization Exercises showed a significant improvement Shoulder Pain and Disability Index (SPADI sub scores and total scores), when compared to Taping in individuals with Subacromial Impingement Syndrome. Conclusion: Scapular Stabilization Exercises showed a significant improvement Shoulder Pain and Disability Index (SPADI sub scores and total scores), when compared to Taping in individuals with Subacromial Impingement Syndrome. Keywords: Subacromial Impingement Syndrome, Adhesive Tapes, Shoulder Pain and Disability Index.
INTRODUCTION Shoulder disorders are among the most common of all peripheral joint complaints1, 2, with Subacromial Impingement Syndrome considered to be one of the most common forms of shoulder pathology3, accounting for 44% to 60% of all complaints of shoulder pain during arm elevation or overhead activities4.
The disorder was first recognized by Jarjavay in 1867, and the term Impingement Syndrome was popularized by Neer in the 1970s5. Subacromial Impingement Syndrome refers to encroachment of the coraco-acromial arch on the underlying mechanism of the rotator cuff 5. The Impingement Syndrome can be diagnosed by certain
impingement tests, that is, Neer test, Kennedy Hawkins test and the Cross Over Impingement (Horizontal adduction) test6. Shoulder impingement disorders are currently classified as primary or secondary7. Primary shoulder impingement occurs when the rotator cuff tendons, long head of the biceps tendon, glenohumeral joint capsule, and/or subacromial bursa become impinged between the humeral head and anterior acromion8. Secondary shoulder impingement is defined as a relative decrease in the subacromial space due to glenohumeral joint instability or abnormal scapulothoracic kinematics8. Some evidence exists that; Scapular dysfunction is associated with Shoulder Impingement9. Scapular Dyskinesis is the alteration in the normal static or dynamic position or motion of the scapula during coupled scapula-humeral movements. Other names given to this catch-all phrase include: Floating Scapula and Lateral Scapular Slide10. The scapular muscles facilitate upper extremity movement via the scapular motions of protraction, retraction, upward (lateral) rotation, and downward (medial) rotation. The main muscles providing scapular stabilization are the rhomboids, trapezius, and serratus anterior17. Researches for Subacromial Impingement Syndrome due to Scapular Dyskinesis show that scapular stabilization exercises provide good results39. One of the study shows that effect of changing posture by taping will reduce the symptoms of Subacromial Impingement Syndrome12. Taping is particularly useful in addressing movement faults at the scapula-thoracic, gleno-humeral and acromio-clavicular joints13. The basic rationale for taping is to provide protection and support for a joint while permitting optimal functional movement. It is assumed that external support increases joint stability by reinforcing the ligaments and restricting motions14. OBJECTIVES 1. To study the effectiveness of Scapular Stabilization Exercises in improving Shoulder pain and disability index in patients with Subacromial Impingement Syndrome due to Scapular Dyskinesis. 2. To study the effectiveness of Taping in improving Shoulder pain & disability index in patients with Subacromial Impingement Syndrome due to Scapular Dyskinesis.
3. To compare the effectiveness of Scapular Stabilization Exercises and Taping in improving Shoulder pain & disability index in patients with Subacromial Impingement Syndrome due to Scapular Dyskinesis. HYPOTHESIS Null hypothesis (H0) There is no significant difference between the effectiveness of Scapular Stabilization Exercises and Taping in improving Shoulder pain and disability index in patients with Subacromial Impingement Syndrome due to Scapular Dyskinesis. Alternative hypothesis (H1) There is a significant difference between the effectiveness of Scapular Stabilization Exercises and Taping in improving Shoulder pain and disability index in patients with Subacromial Impingement Syndrome due to Scapular Dyskinesis. Study Design Experimental design Sampling Technique Purposive sampling technique Samples 60 patients were taken for the study that were diagonesed as having subarcromail impingement syndrome and were randomly devided into two groups of 30 each Age Group 35 to 60 years. Inclusion Criteria Pain produced or increased during flexion and / or abduction of the symptomatic shoulder. And at least 4 of the following : Positive Neer Impingement Sign. Positive Hawkins Sign. Pain produced during Supraspinatous Empty-Can test. Painful Arc of movement between 60 and 120 degrees. Pain with palpation on greater tuberosity of the humerus
Exclusion Criteria Patient suffering with any shoulder fracture. Patient suffering with Frozen Shoulder or Adhesive Capsulitis.
Patient suffering with any neurological condition. Pregnancy. Known allergies to taping. Presence of a Positive Sulcus Sign METHOLOGY
3. Shoulder Pain And Disability Index. Assessment of Pain and Disability Evaluation. SPADI SCORE MEASUREMENT Pain and disability is evaluated by using SPADI. It consists of 2 self report sub scales of pain and disability. The items of both scales are VAS (Visual Analogue Scale) and the 5 items pain subscales asks people about their pain during ADLs (Activities of Daily Livings) and each item is anchored by the descriptions no pain (left anchor) and worst pain imaginable (right anchor). The 8 disability items ask people about their difficulty in performing ADL. Higher scores on the sub scale indicate greater pain and greater disability. To obtain the total score of SPADI both the pain and disability subscales are averaged. Study Duration: 6 weeks. Procedures of Scapular Stabilization Exercises For Upper Trapezius It is done by Prone Row Exercise, where the patient lies prone over the edge of the bed with the affected limb out of the bed, and performs rowing movement. For Lower Trapezius It is done by, patient lying prone at the edge of the bed, with the affected limb out of the bed and then performs overhead arm raise in line with lower trapezius For Middle Trapezius and Rhomboids It is done by, patient lying prone at the edge of the bed, with the affected limb out of the bed and then performs horizontal abduction neutrally. One of the functional exercise for Serratus Anterior : The patient performs stepping alternating punch exercise, with a resisted Thera tube. Procedure of Taping target muscles Taping for Upper Trapezius From anterior aspect of upper trapezius just above the clavicle over the muscle belly to approximately the level of rib seven in a vertical line. Once partially attached, a firm downward pull is applied and the tail of the tape attached. Taping for Middle Trapezius and Rhomboids From the anterior aspect of the shoulder, 2 cm medial
A total of 60 patients were taken. The purpose of the study was explained to all the subjects and informed consent was taken from each subject. All subjects were randomly assigned to either Scapular Stabilization Exercises group (Group A) and Taping group (Group B). PROCEDURES The patients were informed about the whole procedure, the treatment merits and demerits and a return consent were obtained from them for voluntary participation in the study. They were randomly divided into Group A and Group B of 30 subjects each. The base line data of SPADI was obtained to check for the pain functional outcome. SPADI was later taken at the end of the treatment after 6 weeks on follow up. Techniques of application Group A Scapular Stabilization Exercises along. The Scapular Stabilization Exercises are given for the muscles that include Upper Trapezius, Middle Trapezius, Lower Trapezius, Rhomboids, Serratus Anterior. Duration of Exercises : the scapular stabilization exercises are given for six weeks. Group B Taping Taping is given for the muscles that include Upper Trapezius, Middle Trapezius, Rhomboids, Serratus Anterior Duration of Taping : Taping is given for two times a week for six weeks. Ultrasound was given to both the groups once daily 5 times a week for six weeks. Pulsed mode was given at a frequency of 1Mhz for 10 minutes. Tools used for the study 1. Ultrasound Therapy Unit 2. Adhesive Tapes
to the joint line, around deltoid muscle just below acromial level to T6 area without crossing midline. Tape pull is into retraction. Taping for Serratus Anterior From 2 cm medial to the scapula border, following the line of the ribs down to the mid-axillary line. Four one-third overlapping strips are applied with the origin and insertion pulled together and bunching the skin. RESULTS
Table1: Average improvement in pain, disability and total SPADI score in group A
SPADI Pain Disability Total Average improvement 54 60 56.93 Z-value 4.813 4.813 4.800 p-value 0.000 0.000 0.000 Result p<0.05 significant p<0.05 significant p<0.05 significant
Therapeutic exercises have previously been determined to have long-term benefits for patients with shoulder impingement syndrome8. The therapeutic exercise stretches the anterior and posterior shoulder girdle, relaxes the muscle, helps in motor learning to normalize dysfunctional patterns of motion, and strengthening the rotator cuff and scapular muscles, which leads to improvements in pain, levels of disability and functional loss, strength, shoulder range of motion, pain with subacromial compression4. A potential mechanism by which proprioceptive shoulder taping may be effective is via augmented cutaneous input. Tape is applied in such a way that there is little or no tension while the body part is held or moved in the desired position or plane. It will therefore develop more tension when movement occurs outside of these parameters. This tension will be sensed consciously thus giving a stimulus to the patient to correct the movement pattern. Over time and with enough repetition and feedback, these patterns can become learned components of the motor engrams for given movements. It also causes increase in length and decrease in tension thereby producing greater force development in the inner range through optimised actinmyosin overlap during the cross-bridge cycle13. One of the study demonstrated that taping was effective in decreasing Upper Trapezius and increasing Lower Trapezius activity in individuals with shoulder impingement during overhead reaching tasks, thus improving scapular dyskinesis15. Here, both the groups had received Ultrasound therapy as a modality in the treatment, as it is effective in healing process, helps in decreasing inflammation and swelling. In present study, the results shows that Scapular Stabilization Exercises is more effective than Taping in patients with Subacromial Impingement Syndrome due to Scapula Dyskinesis. LIMITATIONS 1. In present study only SPADI is taken in outcome measures. 2. In this study there is no control group is present.
Table2:- Average improvement in pain, disability and total SPADI score in group B
SPADI Pain Disability Total Average improvement 40 53.75 48.46 Z-value 4.832 4.808 4.807 p-value 0.000 0.000 0.000 Result P<0.05 significant P<0.05 significant P<0.05 significant
Table 3:- Comparison of Pain, Disability and Total SPADI before and after the treatment within Group-A and Group-B using Mann-Whitney U test:SPADI Pain Disability Total Average Averag improvement(A) improvement(B) 54 60 56.93 40 53.75 48.46 U-value 263.50 254.00 239.00 p-value 0.005 0.003 0.002 Result P<0.05 significant P<0.05 significant P<0.05 significant
DISCUSSION Subacromial impingement syndrome is caused by narrowing of the subacromial space with secondary impingement of the bursal surface of the rotator cuff on the undersurface of the acromion16. Some evidence exists that, Scapular dysfunction is associated with Shoulder Impingement9. Clinical authorities have suggested that poor upper body posture and muscle imbalance may cause or perpetuate Subacromial impingement syndrome. The aim of many conservative rehabilitation programs is to correct posture and muscle imbalance using muscle strengthening, muscle stretching, and joint mobilization techniques. The evidence to support the efficacy of these clinical practices is limited12.
3. Its a short duration study as study duration is 6 weeks. CONCLUSION Scapular Stabilization Exercises and Taping
produced significant improvement in Shoulder Pain and Disability (SPADI Sub scores and Total scores) values in patients with Subacromial Impingement Syndrome due to Scapula Dyskinesis, when applied individually. However Scapular Stabilization Exercises showed a significant improvement Shoulder Pain and Disability Index (SPADI sub scores and total scores), when compared to Taping in individuals with Subacromial Impingement Syndrome. REFERENCES 1. Chard MD, Hazleman BL, King RH, Reiss BB. Shoulder disorders in the elderly : a community survey. Arthritis Rheum. 34:766-769.1991. Herberts P, Kadefors R, Andersson G, Petersen I. Shoulder pain in industry : an epidemiological study on welders. Acta Orthop Scand. 52:299306.1981. Ashim Bakshi. A combination approach using Manual Therapy and Supervised Exercises. Management of Subacromial Impingement Syndrome. Journal of Exploring Hand Therapy. 7(2):1-5.2007. Lori A Michener, Matthew K. Walsworth, Evin Burnet. Effectiveness of Rehabilitation for patients with Subacromial Impingement Syndrome : A systemic review. Journal of Hand Therapy. 17:152164.2004. David Morrison, Anthony.D.Frogameni and Paul Woodworth. Non-Operative Treatment Of Subacromial Impingement Syndrome. Journal of Bone Joint Surgery Am. 79:732-737.1997. Palmer LM and Epler ME : Fundamentals of Musculoskeletal Assessment techniques 2nd ed. Lippincott, Williams and Wilkins. 106-124.1998. Fu FH, Harner CD, Klein AH. Shoulder Impingement : a critical review. Clin Orthop. 269:162-173.1991. Neer CS. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: A preliminary report. J Bone Joint Surg Am. 54:41 50.1972.
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Philip W McClure, Jason Bialker, Nancy Neff, Gerald Williams, Andrew Karduna. Shoulder Function and 3-dimensional kinematics in people with Shoulder Impingement Syndrome before and after a 6-week Exercise Program. Physical Therapy. 84(9):832-848.2004. W. Ben Kibler, John McMullen. Scapular Dyskinesis And its Relation to Shoulder Pain. Journal Of American Academy Of Orthopaedic Surgery. 11:142-151.2003. Farhad O Moola. Orthopaedic Surgery Department. Scapular Stabilizing Muscles : Rehabilitation Protocol. New West Orthopedic and Sports Medicine Center. University Of British Columbia. Jeremy S. Lewis, Christine Wright, Ann Green. Subacromial Impingement Syndrome : The effect of changing posture on shoulder range of movement. Journal Of Orthopaedic and Sports Physical Therapy. 35:72-87.2005 Dylan Morrissey. Proprioceptive shoulder taping. Journal of Bodywork and Movement Therapies. 4(3),189-194.2000. A.M.Cools, E.E. Witvrouw, L.A. Danneels, D.C.Cambier. Does Taping influence electromyographic muscle activity in the Scapular rotatorsin healthy shoulders?. Manual Therapy. 7(3)154-162.2002. Selkowitz DM, Chaney C, Stuckey SJ, et al. The effects of scapular taping on the surface of electromyographic signal amplitude of shoulder girdle muscles during upper extremity elevation in individuals with suspected shoulder impingement syndrome. J Orthop Sports Phys THer. 37:694-702.2007. Benjamin Blair, Andrew S. Rokito, Frances Cuomo, Kenneth Jarolem and Joseph D. Zuckerman. Efficacy of Injections of Corticosteroids for Subacromial Impingement. J Bone Joint Surg Am. 78:1685-9.1996. Jason Brumitt, Erika Meira. Scapula Stabilization Rehab Exercise Prescription. Strength and Conditioning Journal. 28(3):62-65.2006.
Effects of Osteopathic Manipulative Treatment in Patients with Chronic Obstructive Pulmonary Disease
Praniti P. Bhilpawar1, Rachna Arora2 M. P. Th. from T.N. Medical College and B.Y.L. Nair Hospital, Mumbai, 2Asst. Professor in T.N. Medical College and B.Y.L. Nair Hospital, Mumbai ABSTRACT Background: The study was carried out to assess the effects of osteopathic manipulative treatment in patients with chronic obstructive pulmonary disease. Subjects: 30 patients with chronic obstructive pulmonary disease were selected for the study. Method: Patients were selected from the respiratory OPD at a tertiary care centre using convenience sampling technique. The patients were recruited after signing the ethics approved consent forms. Outcome measures: chest expansion, peak expiratory flow rate and respiratory rate were assessed and documented prior to and following the intervention. The subjects were given seven osteopathic manipulative techniques. The entire duration for osteopathic manipulative treatment session was approximately 20 minutes for each subject. Results: Significant improvements were found in chest expansion at axillary and xiphisternal level, peak expiratory flow rate and significant decrease in respiratory rate after single session of osteopathic manipulative treatment. Conclusion: Osteopathic manipulative treatment increases chest expansion at both axillary and xiphisternal level and peak expiratory flow rate and leads to reduction in respiratory rate in patients with COPD. Keywords: Chronic Obstructive Pulmonary Disease (COPD), Osteopathic Manipulative Treatment, PEFR
INTRODUCTION Chronic obstructive pulmonary disease (COPD) refers to a group of disorders characterized by chronic airflow obstruction/limitation. It includes two distinct patho-physiological processeschronic bronchitis and emphysema1, 2, 3, 4. It is associated with an abnormal inflammatory response of the lungs to noxious particles or gases, especially tobacco smoke and air pollution both indoor and outdoor. The term COPD was accepted in the British Thoracic Society (BTS) guidelines on management of this disease5. Chronic obstructive pulmonary disease (COPD) is currently the fourth leading cause of death worldwide. The male to female ratio varied from 1.32:1 to 2.6:1 with median ratio of 1.6:11. The disadvantages of bio mechanical alterations of hyperinflation are compounded by the increased demand for ventilation in COPD. More work is required of a less effective system. The energy cost of ventilation,
or the work of breathing, in COPD is markedly increased. Conventional management of COPD includes smoking cessation, pharmacological therapy, long-term oxygen therapy, and pulmonary rehabilitation. COPD have been shown to decrease compliance of the chest wall, force-generating capacity of the diaphragm, residual volume (RV) increases, and forced vital capacity (FVC). Therefore, the therapeutic intervention commonly done for chest wall and related structures are respiratory muscle stretching exercises. They have been reported to improve chest wall mobility, improve vital capacity, and decrease dyspnea6. However, COPD is an important disease whose incidence is rising worldwide and that there is a need to develop new treatments to prevent the progression of the disease7. The osteopathic medical profession has developed a variety of techniques for the specific purpose of improving chest expansion, quality of life and pulmonary function. These techniques are well
described and target various aspects of the musculoskeletal, neuronal and lymphatic components of the pulmonary system. The efficacy of osteopathic manipulative treatment (OMT) is thought to be enhanced by using techniques in combination, where one technique works synergistically with another to achieve an overall therapeutic effect8. Masarsky CS, Weber M, Virginia Chiropractic Association Research Committee, Vienna 22180, studied Chiropractic management of chronic obstructive pulmonary disease. They noted that a patient with a history of chronic obstructive pulmonary disease going back more than 20 years was treated with a combination of chiropractic manipulation, nutritional advice, therapeutic exercises, and intersegmental traction. Improvements were noted in forced vital capacity, forced expiratory volume in one second, coughing, fatigue, and ease of breathing9. The study was thus designed in order to determine if one session of OMT treatment could produce immediate changes on chest expansion, respiratory rate and PEFR in patients with COPD. MATERIAL AND METHOD Study design: An Experimental hospital based study Place of study: Physiotherapy OPD of Topiwala National Medical College & Nair Hospital Mumbai. Type of Sampling: convenience non-random sampling Operational definitions were provided. Inclusion criteria Patients with Chronic Obstructive Pulmonary Disease with FEV1/FVC < 70%. Exclusion criteria Unstable medical condition. Acute bronchitis. Pneumonia. Acute Exacerbation within 1 month of data collection. Chest wall deformity.
Measurement tool Measuring tape. Peak flow meter. Watch with seconds hand. Outcome measures Chest expansion at axillary, xiphisternal level (using measuring tape). Peak expiratory flow rate (using peak flow meter). Respiratory rate (for 1 minute) Thirty patients with COPD were selected and included in the study after signing ethics approved consent forms. The patients were evaluated prior to treatment and data was documented. The subjects were given seven osteopathic manipulative techniques. The duration of entire osteopathic manipulative treatment session was approximately 20 minutes for each subject. The outcome measures were documented post treatment. The patient was instructed to inform the therapist immediately any discomfort during treatment session. All the subjects in the study were able to tolerate the manipulative techniques with no sign of any discomfort. Techniques of Osteopathic manipulation 1. Soft tissue kneading (paraspinal muscles in lower cervical and thoracic region bilaterally) 2. Rib raising 3. Redoming the abdominal diaphragm (indirect myofascial release) 4. Suboccipital decompression 5. Thoracic inlet myofascial release 6. Pectoral traction 7. Thoracic lymphatic pump with activation DATA ANALYSIS Data analysis was performed by using Paired t-test and Wilcoxon Sign rank test.
Table No 1: Distribution of study group as per sex shows the distribution of sex in the study group. Study group consists of 7% female and 93% male.
Sex Female Male Total Count 2 28 30 Percent 7% 93% 100%
198 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 Table No 2: Comparison of Chest expansion (axillary) before and after treatment: shows that there is statistically significant improvement in chest expansion (axillary level) after single session of osteopathic manipulative treatment, p value=1.17E-05 (<0.05)
Chest Expansion (Axillary) Pre treatment Post treatment N 30 30 Mean 1.13 1.43 SD 0.46 0.50 Median 1 1.4 IQR 0.6 0.65 Wilcoxon Signed Rank Test -4.383 Difference is significant p value 1.17E05
Table No 3: Comparison of Chest expansion (Xiphisternal) before and after treatment: shows that there is statistically significant improvement in chest expansion (xiphisternal level) after single session of osteopathic manipulative treatment, p value= 3.06E-05 (<0.05)
Chest Expansion (Xiphisternal) Pre treatment Post treatment N 30 30 Mean 1.19 1.48 SD 0.45 0.51 Median 1.2 1.6 IQR 0.6 0.8 Wilcoxon Signed Rank Test -4.169 Difference is significant p value 3.06E-05
Table No 4: Comparison of PEFR l/min before and after treatment: shows there is statistically significant improvement in peak expiratory flow rate after single session of osteopathic manipulative treatment, p value= 2.84E-04 (<0.05)
PEFR l/min Pre treatment Post treatment N 30 30 Mean 159.74 171.47 SD 54.65 60.45 Median 150 160 IQR 64 82.5 Wilcoxon Signed Rank Test -3.629 Difference is significant p value 2.84E-04
Table No 5: Comparison of RR/min before and after treatment: shows that there is statistically significant decrease in respiratory rate after single session of osteopathic manipulative treatment, p value= 4.50E-03 (<0.05)
Respiratory Rate (per min) Pre treatment Post treatment N 30 30 Mean 25.37 23.23 SD 7.50 5.56 Median 24 23 IQR 9 8 Paired T test 3.08 Difference is significant p value 4.50E-03
DISCUSSION The results of the present study indicate that there is statistically significant increase in chest expansion at axillary and xiphisternal level. Also an increase is seen in peak expiratory flow rate and decrease in respiratory rate after osteopathic manipulative treatment, thereby supporting the experimental hypothesis. In this study, the mean age of the patients ranged from 37-81 years of age. The distribution of patients, according to sex is 93% male and 7% female. The ventilation depends on the rib motion, diaphragm function, muscles of respiration and mechanical properties of the airways10. In COPD there is hyperinflation of lungs and therefore chest wall is fixed in inspiration (barrel shaped chest) 11. This results in shortening of soft tissue of upper chest. COPD patients generally have a kyphotic posture with rounded shoulders (pectoral tightness) and elevated shoulder girdle (trapezius tightness) to effectively use accessory muscle of respiration. When the muscles are in a shortened position, the fascia overlying the muscle also gets shortened. Due to the barrel shaped chest, the ribs are horizontally oriented. This further reduces the
excursion of ribs during inspiration. There by reducing chest expansion. According to handbook of osteopathic technique by Laurie Hartman, kneading of paraspinal muscles relax them by reducing fluid congestion and tonic irritability. The underlying mechanism is thought to be due to reflex balancing or from fluid interchange and lymphatic drainage within the tissues12. Luce Helen and Robinson Mark stated that soft tissue kneading decreases muscle spasm, stretches and improves elasticity of soft tissues, improves circulation, improves venous and lymphatic drainage and promotes relaxation13. Principles and practices of therapeutic massage by Sinha states that kneading produces a local increase in the flow of blood due to pumping action, liberation of H substance and elicitation of axon reflex. This also decreases the stagnation of fluid and oedema as well as improves the nutrition of the area. It stretches the tight fascia and helps in restoration of mobility of skin and subcutaneous fascia. The intermittent pressure may also stimulate tension dependent mechanoreceptor, i.e. Golgi tendon organ, etc. and decreases the excitability of motoneuronal pool in neurologically healthy
individuals. This helps in decreasing the tension of muscles.14 Pectoral traction technique, a Myofascial release technique, also helps in increasing chest expansion by lengthening the tight structures12.The combination of traction and respiratory motion releases the upper anterior thoracic muscle tension15. In COPD there is increase in sympathetic nervous system activity leads to release of catecholamines into the blood stream and there is narrowing of airways which leads to reduction in peak expiratory flow rate.7 Paraspinal muscle kneading and rib raising probably stimulate Chapmans reflexes. Suboccipital decompression probably improves parasympathetic function by releasesing restricted tissues around vagus nerves. 13, 16 This may lead to normalization of sympathetic tone and which in turn may increase PEFR and reduce RR. The American Academy of Osteopathy states that the rib raising technique improves movement of ribs and thoracic cage by mechanical stimulation of sympathetic chain ganglia and related structures. This results in improved sympathetic tone in lung. This is supported by the study done by Aaron T. Henderson which shows that sympathetic nervous system activity may decrease immediately after rib raising17. Effective lymphatic drainage of the lungs is normally achieved by contraction of the diaphragm and thoracic cage movement during respiration. However, in patients with COPD, both of these mechanisms may be compromised, leading to impaired lymphatic drainage. There are several OMT techniques which address the problem of lymphatics such as rib raising, diaphragm release, and lymphatic pumps18. Numerous techniques are given in osteopathic texts for controlling circulation and drainage. Chapmans reflexes are one example that has already been mentioned. Kuchera also gives ideas for detailed treatment of lymphatic system dysfunction. The three basic goals are: a. To promote the free flow of lymph through its lymphatic vessels and fascial pathways. b. To improve function of the abdominal diaphragm, the extrinsic pump for the lymphatic system. c. To reduce sympathetic outflow19.
and Kuchera have this to say regarding lymphatic drainage and the lungs. Myofascial release techniques such as diaphragm release and thoracic inlet release also contributes to increase in chest expansion and improves motion of diaphragm. It releases connective tissue tension within structures of thorax. It helps in removing restriction to lymphatic flow. It releases tissue restriction, improves lymphatic drainage and improves mechanics of respiration.11, 14 According to handbook of osteopathic technique by Laurie Hartman, myofascial release techniques attempts to normalize these areas by allowing improved circulation and re-setting of the neural control of tendons and muscles. Its main action is on connective tissues, fascia and muscle attachments10. The reduction in RR could be attributed to normalization of sympathetic tone through Chapmans reflexes. The increase in chest expansion probably suggests that the patients tidal breathing has increased and therefore reflected as reduced RR. Donald R. Noll studied the Efficacy of Osteopathic Manipulation in Chronic Obstructive Pulmonary Disease. He stated that OMT sessions are designed to improve chest wall compliance and diaphragmatic function which produce an immediate positive change in pulmonary function parameters and chest wall mobility20. As this study supported our experimental hypothesis OMT can be used as an adjunct treatment in COPD along with pulmonary rehabilitation. Conclusion: Osteopathic manipulative treatment increases chest expansion at both axillary and xiphisternal level in patients with COPD. There is increase in peak expiratory flow rate following osteopathic manipulative treatment in patients with COPD. Osteopathic manipulative treatment leads to reduction in respiratory rate in patients with COPD. Limitations of the study Small sample size Patients are not divided according to GOLD classification Occupational background and socioeconomic status were not considered
Treatment techniques include manipulation of the thoracic inlet, stretching the abdominal diaphragm, fascial releases and thoracic lymphatic pump. Kuchera
SUMMARY In order to investigate the effects of osteopathic manipulative treatment in patients with chronic obstructive pulmonary disease, 30 patients were enrolled in this study. The patients were given single session of Osteopathic manipulation techniques such as soft tissue kneading, rib raising, Redoming the abdominal diaphragm, suboccipital decompression, thoracic inlet myofascial release, pectoral traction and thoracic lymphatic pump with activation. The outcome measures of chest expansion at axillary and xiphisternal levels, peak expiratory flow rate and respiratory rate were measured pre and post treatment. The mean pre treatment and post treatment score of chest expansion at axillary level were analysed using the Wilcoxon signed ranks test and the improvement in chest expansion was found to be significant, p value=1.17E-05 (< 0.05). The mean pre treatment and post treatment score of chest expansion at xiphisternal level were analysed using the Wilcoxon signed ranks test and the improvement in chest expansion was found to be significant, p value= 3.06E-05 (< 0.05). The mean pre treatment and post treatment score of peak expiratory flow rate were analysed using the Wilcoxon signed ranks test and increase in PEFR was found to be significant, p value= 2.84E-04 (< 0.05). The mean pre treatment and post treatment score of respiratory rate were analysed using paired t-test and reduction in RR was found to be significant, p value= 4.50E-03 (< 0.05). Therefore these results support the hypothesis of the study that Osteopathic manipulative treatment shows improvement in Chest Expansion, Peak Expiratory Flow Rate and reduction in Respiratory Rate. Conflict of Interest Statement I, Dr. Praniti P. Bhilpawar (PT) the primary investigator hereby declare that there are no conflicts of interest and the present study is an original work. REFERENCES 1. Murthy KJR, Sastry JG. Economic burden of chronic obstructive pulmonary disease. NCMH Background Papers Burden of Disease in India; 2005.
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Seaton Anthony, Seaton Douglas, Leith Gordon. Crofton And Douglass Respiratory Disease 1. 5th ed. London: Blackwell Science; 2000. p. 616-679. Fishman Alfred, Elias Jack. Fishmans Pulmonary Disease And Disorders. 3rd ed. US: McGraw-Hill; 1998. p. 645-681. Boon Nicholas A, College Nicki R, Walker Brian R, Hunter John. Davidsons Principles And Practice Of Medicine. 20 th ed. Philadelphia: Churchill Livingstone; 2006. p. 678-684. British Thoracic Society. Guidelines For The Management Of Chronic Obstructive Pulmonary Disease. Thorax 1997; 52. Celli BR, MacNee W. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J 2004; 23: 932946. Barnes Peter J. Chronic Obstructive Pulmonary Disease. NEJM 2007 Jul 27;343(4):269-280. Noll Donald R, Brian F Degenhardt, Jane C Johnson, Selina A. Burt. Immediate Effects of Osteopathic Manipulative Treatment in Elderly Patients with Chronic Obstructive Pulmonary Disease. JAOA 2008 May;108(5):259. Masarsky CS, Weber M. Chiropractic management of chronic obstructive pulmonary disease. J Manipulative Physiol Ther. 1988 Dec;11(6):505-10. Halma Kelly D. The Osteopathic Approach to the Chest Pain Patient. Rosenow Edward C. Barrel chest. MFMER. 2010 Aug 7. Hartman Laurie. Handbook of Osteopathic Technique. 3rd ed. UK: Chapman & Hall; 1997. Luce Helen, Robinson Mark. Integrating Osteopathic Manipulative Treatment into Clinical Care. University of Wisconsin Department of Family Medicine STFM Annual Meeting Denver, CO;April 29, 2009. Sinha Akhoury. Principles and practices of therapeutic massage. 1st ed. New Delhi: Jaypee; 2001. p. 57. Hruby Raymond J, Hoffman Keasha N. Avian influenza: an osteopathic component to treatment. Osteopath Med Prim Care 2007;1. American Academy of Osteopathy. An Overview of Osteopathic Manipulation Techniques.3500 DePauw Boulevard, Suite 1080 Indianapolis, Indiana 46268-1136(317) 879-1881. Henderson Aaron T et al. Effects of Rib Raising on the Autonomic Nervous System: A Pilot Study
Using Noninvasive Biomarkers. JAOA 2010 Jun;110(6):324-330. 18. Sutphin Dean, Chair Kerry Redican, David Harden, Billie Lepczyk. The Use of Osteopathic Manipulation in a Clinic and Home Setting to Address Pulmonary Distress as Related to Asthma in Southwest Virginia: 2009 Jan. 19. Mein Eric A. Physiological Regulation Through
Manual Therapy. Philadelphia: Physical Medicine and Rehabilitation; 2000. 20. Noll Donald R et al. Efficacy of osteopathic manipulation as an adjunctive treatment for hospitalized patients with pneumonia: a randomized controlled trial. Osteopath Med Prim Care. 2010;4:2.
Comparison of Stretch Glides on External Rotation Range of Motion in patients with Primary Adhesive Capsulitis
Paras Joshi, Bhavesh Jagad Lecturer, Shree K K Sheth Physiotherapy College, Rajkot ABSTRACT Back ground: Adhesive capsulitis, most commonly referred to as frozen shoulder (FS), is an idiopathic disease with 2 principal characteristics: pain and contracture, affecting the external rotation most. In contrast to traditional mobilization technique andrea et al found posterior glide more effective in improving external rotation ROM and pain. Objective: To find out the effective stretch glide for external rotation ROM and pain in patients with primary adhesive capsulitis. Methods: 30 subjects were divided into two groups called Anterior stretch glide (ASG) and Posterior stretch glide (PSG). Each group received ultrasound, same exercise protocol along with their designated glides for 2 weeks. Outcome measures were External Rotation ROM and VAS. Data was analyzed by using the SPSS software. Wilcoxon signed rank and rank sum tests were used to measure the differences in VAS and Paired and unpaired t tests were used for ROM evaluation. Findings: There was a significant difference in External Rotation ROM and VAS in both the groups after the intervention, even there is a significant difference between the groups. Conclusion: anterior stretch glide is very effective in reducing pain or unpleasantness intensity and increasing external rotation range of motion at shoulder in patients with primary adhesive capsulitis. Keywords: Primary Adhesive Capsulitis, Stretch Glides, External Rotation
INTRODUCTION Frozen shoulder, or idiopathic adhesive capsulitis is a condition of uncertain etiology characterized by substantial restriction of both active and passive shoulder motion that occurs in the absence of a known intrinsic shoulder disorder1 Although adhesive capsulitis is generally considered to be a self-limiting condition that can be treated with physical therapy, the best treatment has been the subject of extensive investigation2 The types of treatment have included benign neglect, chiropractic manipulation, oral corticosteroids, injection of corticosteroids, physical therapy exercises and modalities, manipulation under anesthesia, mobilization and arthroscopic and open releases of the contracture2-6 Adhesive capsulitis is caused by inflammation of the joint capsule and synovium that eventually results in the formation of capsular contractures. The capsule
does not become adhered to the humerus, as the term adhesive implied, but the contracted capsule holds the humeral head tightly against the glenoid fossa. Clinically, there is global loss of both passive and active ROM of the glenohumeral joint, with external rotation usually being the most restricted physiologic movement.2,7,8 In physiotherapy exercises, massage and modalities have been shown effective to improve ROM at shoulder joint, except rotational components. 9 Traditionally anterior glide of GH joint is used to improve External Rotation ROM based on convex concave concept.10 Where as Roubal11 and Andrea J12 et al have found posterior glide more effective based on capsular constrain mechanism.13 Purpose of this study was to find out the direction of movement for GH joint glide that would result in significant improvement in shoulder External rotation ROM in individual with primary adhesive capsulitis.
OBJECTIVES 1. To check the effectiveness of anterior stretch glide on External Rotation ROM and pain or unpleasantness in patients with primary adhesive capsulitis. 2. To check the effectiveness of posterior stretch glide on External Rotation ROM and pain or unpleasantness in patients with primary adhesive capsulitis. 3. To compare the effectiveness of anterior and posterior stretch glide on External Rotation ROM and pain or unpleasantness in patients with primary adhesive capsulitis. HYPOTHESIS Null Hypothesis: There will be no significant difference between Anterior Stretch Glide and Posterior Stretch glide on External Rotation ROM and pain or unpleasantness in patients with primary adhesive capsulitis. Alternate Hypothesis: There will be significant difference between Anterior Stretch Glide and Posterior Stretch glide on External Rotation ROM and pain or unpleasantness in patients with primary adhesive capsulitis. MATERIALS AND METHOD Total 55 Subjects with primary adhesive capsulitis, fulfilling the criteria of the study were selected between march 2011 to February 2012 from Shree K K Sheth Physiotherapy Center, Rajkot. 30 Subjects have completed the study and taken for final analysis. Study design: Experimental study. Inclusion criteria 1. Idiopathic or Primary Adhesive Capsulitis (insidious onset, no history of trauma) 2. Age between 30 to 55 years 3. Unilateral condition Exclusion Criteria 1. Any previous history of surgery to affected side 2. Cervical radiculopathy affecting the study 3. History of neurological conditions affecting the study (i.e stroke, Parkinsons)
4. History of steroid injection 5. Muscular tightness affecting the study (i.e subscapularis) Consent forms were signed by the Subjects before participation in the study. Subjects were randomly (by using the random number, i.e. 1, 2) assigned to one of the two treatment groups: Group 1: Anterior Stretch Glide (ASG), (6 male, 9 female =15) Group 2: Posterior Stretch Glide (PSG), (5 male, 10 female =15) 3 subjects have reported having diabetes and taking medications for the same (2 from ASG and 1 from PSG) Subjects were advised not to do exercises at home nor were any written guidelines given. MEASURES Subjects were exclusively evaluated for only External Rotation ROM and unpleasantness on VAS. External Rotation ROM External Rotation ROM was assessed at the baseline and at the end of the 6th treatment session by Hjelms protocol.15 All Measurements were taken in supine position. Baseline: Humerus was placed in full available Abduction passively, and active External Rotation ROM was measured. Available abduction at baseline was recorded for each subject. At the end of 6th session: Passively the humerus is abducted to baseline abduction and active External Rotation ROM was measured again. All measurements were taken by therapists having more than 5 years of clinical experience by standard goniometer. Therapists were kept blind about the groups and to avoid subjective bias Subjects were instructed to look opposite side during measurements. VAS Subjects were asked to mark VAS before the 1st treatment and after the last treatment; we asked the subjects to mark on 10cms vertical line the relative unpleasantness.16
Targeted capsule (anterior or posterior) was preheated before glide by 1 MHz 19Ultrasound, in order get the maximum effect of stretch glide.17 Ultrasound were applied at 1.5 w/cm2 in continuous mode for 10 minutes (Electroson 608, 35mm diameter of head, 12 acoustic watts max). Capsule region was effectively covered and subjects were asked to report discomfort if any. However no such reports were found during the study. In this study we used Kaltenborn grade III technique, applying the force to stretch tissues crossing the joints.18 We used stretch glide like Andrea J and al; no oscillatory motions were performed, only end range stretch position was held for 1minute at least. During each treatment session total 15 repetitions were given. Each subject was treated for 6 sessions on alternate days, in 2 weeks. Group 1: ASG group Subjects were positioned in prone; with maintained lateral humeral distraction (mid range position), while anterior stretch glides was performed to end range, at the end range of abduction and external rotation. Group 2: PSG group Subjects were positioned in supine; with maintained lateral humeral distraction (mid range position), while posterior stretch glide was performed to end range, at the end range of abduction and external rotation. Followed by the stretch glides subjects were participated in traditional ROM exercises which include rope and pulley, finger ladder, wand exercises, pendular exercises 20 repetitions for each exercise.
DATA ANALYSIS For each subject, the number corresponding to the subjects mark on the visual analogue scale was recorded. Raw score means and standard deviations of the visual analogue scale score and external rotation range of motion were calculated. In order to determine whether there was a significant difference within the two groups between the pre-treatment visual analogue scale scores and the post treatment visual analogue scale scores, Wilcoxon Signed Rank Test was performed. The difference between pretreatment visual analogue scale scores and post treatment visual analogue scale scores in ASG group was compared with that of PSG group using Wilcoxon Rank Sum Test. This analysis was done to determine whether the difference in the scores between the two groups is significant or not. The pretreatment external rotation range of motion was compared with the post treatment external rotation range of motion within two groups using two tailed Students paired t-test. Between groups comparison of difference in external rotation range of motion was done by performing two tailed students unpaired t-test. The paired and unpaired t-tests were performed using spss statistics 14.0. RESULTS
Table 1. Gender distributions of 30 subjects who participated in the study
Gender Male Female Total Mean age with SD ASG GROUP 6 (40%) 9 (60%) 15 43.09511.38 PSG GROUP 5 (33%) 10 (67%) 15 44.29510.6
Table 2. MeanSD for External Rotation ROM and VAS.

PRETREATMENT MEAN ER ROM ASG PSG VAS ASG PSG 5.66 5.53 1.71 1.50 3.80 4.93 1.82 1.22 1.86 0.60 -0.11 0.28 39.33 45.66 14.98 13.34 60.33 50.00 12.16 12.39 -21 -4.34 2.82 0.95 SD POSTTREATMENT MEAN SD DIFFERENCE MEAN SD
Table 3. T values for the External Rotation ROM.

Calculated ASG Group (t14) PSG Group (t14) Between groups ASG & PSG 5.37 2.54 2.86 Observed 2.14 2.14 2.05 P<0.005Highly significant P<0.05 P<0.01 Significant Significant
Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 205 Table 4. T value and z value calculated by Wilcoxon Signed Rank Test and Rank sum test respectively for VAS
VA S ASG Group(within group) PSG Group (within group) T value 110 60 Probability (P) <0.01 S <0.05 S <0.001 HS
Hence, the null hypothesis of no difference within and between groups is rejected and alternative hypothesis is accepted. DISCUSSION Study was done to investigate the effectiveness of anterior versus posterior stretch glide on External Rotation ROM and pain or unpleasantness in patients with adhesive capsulitis. We found that anterior stretch glide combined with ultrasound and exercises were superior in treating External Rotation ROM deficits commonly found in patients with adhesive capsulitis. We have excluded the patients who have muscular tightness affecting the study. i.e. subscapularis. Glenohumeral external rotation ROM deficit was attributed to muscle flexibil-ity deficit (eg, subscapularis flexibility deficits) if the glenohumeral external rotation ROM deficit became less as the shoulder was abducted.12 These findings are against of Roubal11 et al and Andrea12 et al, who found marked increase in External Rotation ROM with posterior glide. Our findings support the traditional convex concave rule.13, 18 Andrea et al have chosen flexion as additional component to increase effectiveness for mobilization using posterior stretch glide which could have affected their outcome; where as we have not added the flexion in posterior glide no matter whatever the progression is. Present study includes only those patients who have finished the protocol despite having vigorous stretch protocol for 1 min at least without compromising the intensity of stretching; where as Andrea et al have used the vigorous protocol in a minimal number of patients only. Novotny et al7 studied the gleno-humeral joint in vitro using techniques in which only the capsule and articular surface contact controlled the motion of the humerus. They found that at low mo-ments the humeral head initially trans-lates across the glenoid surface in the direction opposite to the motion, due to the joint surface geometry, as consistent with the concave-convex rule. Then, with increasing moment and angle of rota-tion, the humeral head changes direc-tion as the capsule tightens, pushing the humeral head back along the glenoid surface. Thus, it is thought that the tension in the capsular tissues rather than joint surface geometry controls the translatory movements of the humeral head. Asymmetrical capsular tight-ness has the potential to impact humeral head motion, especially
Between groups ASG & PSG 3.21 (z value)
Table 1 shows the gender distributions and mean age with standard deviations respectively. ASG group contained 6 (40%) male and 9 (60%) female with mean age of 43.09511.38 years, where as PSG group contained 5 (33%) male and 10 (67%) female with mean age of 44.29510.6 years. There was no significant age difference seen across two groups. Table 2 and Table 3 Shows pre treatment, post treatment and difference means and standard deviations of visual analogue scale score for pain or unpleasantness intensity and the external rotation range of motion values of each group. Scores reflect greater improvement for ASG group than for PSG group on all variables. The two tailed paired t-test has showed significant difference between pre and post-treatment external rotation range of motion in ASG and PSG group at 5% significant limit. Comparison showed significant difference between these groups. Calculated t values for the difference of External rotation ROM within ASG & PSG groups at 5% significance limit and t values for comparison of difference between two groups and value of probability of occurance by chance. Table 4 Wilcoxon signed rank test was applied in ASG and PSG group for within group comparison of visual analogue scale score and the result showed significant improvement in visual analogue scale scores in ASG (T=110>105, P<0.01) and PSG (T=60, P<0.05) Wilcoxon Rank Sum Test (Mann Whitney U Test) was applied for comparison between ASG and PSG for post treatment visual analogue scale scores. The result reflects significant difference in the improvement between ASG and PSG Groups Above results suggests that anterior stretch glide is more effective in improving shoulder external rotation and pain or unpleasantness as compared to posterior stretch glide.
when tension in the capsule increases as the arm is tak-en further into elevation, which supports the andrea et al results however we dint get such results and not able to clearly explain the why this mechanism has not been taken place in our patients. We found anterior stretch glide more effective based on traditional covex concave rule and naturally elongated anterior capsule provide more space for head of humerus when subject actively externally rotate the arm in contrast to capsular constrain mechanism.13 Moreover in adhesive capsulitis fibrous adhesion takes place surrounding the joint capsule, we believe that anterior stretch glide may be more effective in breaking those adhesion and allow normal kinetics when patient attempts active external rotation.7 Joint mobilization techniques are assumed to induce various beneficial effects. The neurophysiologic effect is based on the stimulation of peripheral mechanoreceptors and the inhibition of nociceptors. In addition obermann et al found high grade traditional mobilization found effective to treat the patients with primary adhesive capsulitis.20 Our results supports it in terms of pain and ROM. LIMITATIONS Dominance of hand is of much importance in adhesive capsulitis, we have not considered it in our study. Abduction and Internal Rotation could have included in this study as outcome measures. Functional outcome measure was not included in this study. Further recommendations Multi angle glides should be checked in larger population. Effects of glides can be checked with thickness of capsule and movement pattern in further studies. CONCLUSION The ASG group showed significant improvement in the External Rotation ROM as well as VAS score compare to PSG group. The results of this study indicate that anterior stretch glide is very effective in reducing pain or unpleasantness intensity and increasing external rotation range of motion at shoulder in patients with primary adhesive capsulitis.
ACKNOWLEDGEMENTS We would like to thank management of Shree K K Sheth trust and Dr. Sarala bhatt for their support and guidance. REFERENCES 1. Zuckerman, J. D., and Cuomo, F.: Frozen shoulder. In The Shoulder: A Balance of Mobility and Stability, pp. 253-267. Edited by F. A. Matsen, III, F. H. Fu, and R. J. Hawkins. Rosemont, Illinois, American Academy of Orthopaedic Surgeons, 1993. Roy, S., and Oldham, R.: Management of painful shoulder. Lancet, 1: 1322-1324, 1976. Ekelund, A. L., and Rydell, N.: Combination treatment for adhesive capsulitis of the shoulder. Clin. Orthop., 282: 105-109, 1992.
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Neviaser, R. J., and Neviaser, T. J.: The frozen shoulder. Diagnosis and management. Clin. Orthop., 223: 59-64, 1987. 5. Ozaki, J.; Nakagawa, Y.; Sakurai, G.; and Tamai, S.: Recalcitrant chronic adhesive capsulitis of the shoulder. Role of contracture of the coracohumeral ligament and rotator interval in pathogenesis and treatment. J. Bone and Joint Surg., 71-A: 1511-1515, Dec. 1989. 6. Matsen, F. A., III; Lippitt, S. B.; Sidles, J. A.; and Harryman, D. T., II: Evaluating the shoulder. In Practical Evaluation and Management of the Shoulder, pp. 1-17. Philadelphia, W. B. Saunders, 1994. 7. Novotny JE, Nicholoas CE. Normal kinematics of uncontrained glenohumeral joint under coupled moments loads. J shoulder elbow surg. 1998;62939. 8. Wamer et al. Adhesive capsulitis of shoulder. J bone joint surgery AM. 1996; 78:1808-16 9. Jurgel J, Rannama L, et al. Shoulder functions in Subjects with frozen shoulder before and after 4 week rehabilitation. Medicina 2005;41:30-38 10. Curl LA, Warren RF. Glenohumeral joint stability. Selective cutting studies on static capsular restraings 11. Roubal PJ et al. Glenohumeral gliding manipulation following interscalene brachial plexus block in Subjects with adhesive capsulitis. 12. Andrea J, Joseph J et al. The effect of anterior versus posterior glide joint mobilization on external rotation range of motion in Subjects with adhesive capsulitis. JOSPT 2007;37;3.
13. Donatelli RA, Wooden MJ. Orthopaedics physical thera. 2nd edi. :Churchill Liningstone; 1994 14. Harryman DT et al. translation of the humeral head on the glenoid with passive glenohumeral motion. J Bone joint Surg Am. 1990;72:1334-43 15. Hjelm, Draper C et al. anterior inferior capsular length sufficiency in the painful shoulder. J ortho Sport Phys Ther. 1996;23:216-22 16. Price DD, Mc Grath PA et al. the validation of visual analogue scales as ratio scale measures for chronic and experimental pain. Pain. 1983;17: 45-56
17. Reed B, Ashikaga T. The effects of heating with ultrasound on knee joint displacement. J Ortho Sports ther. 1997;26:131-7 18. Kaltenborn FM. Manual Therapy of the Extremity joints. Oslo, Norway: Olaf Norlis, Bokhandel;1973. 19. Gann N. Ultrasound: current concepts. Clin Manage1991;11:649. 20. Obermann et al. Comparison of High-Grade and Low-Grade Mobilization Techniques in the Management of Adhesive Capsulitisof the Shoulder: RandomizedControlled Trial. Phys thera. 2006; 86:355-368.
A Study of Electromyographic Activity of Masseter Muscle After Gum Chewing in Young Adults
Preeti Baghel1, Nidhi Kalra2, Sumit Kalra2 BPT Student, Assistant Professor, Banarsidas Chandiwala Institute of Physiotherapy (Maa Anandmai marg, Chandiwala estate, Kalkaji, New Delhi
2
ABSTRACT Background: Habitual gum chewing is considered as one of the causes which can lead to the development of Temporomandibular disorder (TMD). Previous studies have compared the effect of chewing induced masticatory muscle pain in females and males using different methods but this study compares the electromyographic behaviour of masseter muscle in females with males who do gum chewing. Aims and Objective: To compare the effect of gum chewing on masseter muscle in females with males by analyzing its electromyographic behaviour. Subjects: 60 young adults (30 females and 30 males) who do gum chewing took part in this study which was allotted to two groups: Group A- Females and Group B- Males. Research Design: Comparative study Methodology: The device used in this study is a single channel EMG. The subjects were given chewing gum and asked to chew gum at least one hour before coming for the study. All monitoring was performed with the patients in a sitting position. Two self-adhesive surface electrodes were utilized and placed on the midsubstance of muscle belly of right masseter muscle in line with muscle fibers. The EMG recording of masseter muscle was done at most comfortable position of jaw i.e., at rest position and the EMG activity was recorded after 30 seconds. Data Analysis: Data are expressed as mean, standard deviation and 95% confidence interval. The independent t- test or Levene's test for equality of variances was used to determine the normal distribution of the variance (P < 0.05). Results: The independent t-test indicates a significant increase in the motor activity of the masseter muscle in females than in males as t-test reveal statistically reliable difference between the mean number of POST TEST - A has (M = 2.171, s = 101.76) and that the POST TEST - B has (M = 1.62, s = 75.57), t(58) = 2.367, P = .05. Conclusion: Electromyographic behaviour of the masseter muscle in individuals who do gum chewing is found to be significantly increased in females than in males. This can result in the development of the signs and symptoms of the temporomandibular disorders. Therefore, it can be concluded from the present study that one should avoid gum chewing especially females on the regular basis so as to prevent their jaw from the risk of developing TMD at an early age. Keywords: Electromyography, Mastication, Muscle fatigue, Chewing.
INTRODUCTION Chewing is an oral function that is of vital importance for the biological and social life of human beings. As a pre-requisite for this function, a healthy masticatory system characterized by the absence of pain at rest and during functional movements of the mandible is required.1, 2 The Masseter muscle is an integral part of the oral facial complex and one of the major muscles of mastication. It functions with other masticatory muscles
in moving and posturing the mandible. When a patient has temporomandibular dysfunction (TMD) or a myogenic disorder, the integrity of the masseter muscle can be compromised resulting in pain, malfunction, inflammation and swelling. TMJ syndrome occurs in younger patients mostly women, typically between the ages of 20 and 40. A careful evaluation of the masseter muscle is necessary in facial pain patients since the pain can originate from a distant site and be referred to this area.3, 4, 5, 6
Gum Chewing like any product has positive and negative effects. Surprisingly, the positive effects of gum chewing are many; however excessive use can present problems. The type and duration of chewing are what determine how healthy or unhealthy gum chewing will be for an individual.6 Women are more likely to experience disability due to TMDs, and they represent over 80% of the patients who receive treatment of TMDs.9, 10 In 2003; H. Karibel, G. Goddard and R. W. Gear11 studied the sex differences in masticatory muscle pain after chewing. They tested the hypothesis that physiologically relevant exercise (i.e., chewing bubble gum for 6 min) increases masticatory muscle pain in patients, but not in asymptomatic control subjects, and that female patients experience a significantly greater increase than males. These results suggested greater susceptibility in women. Obviously, further research must be done on these possible negative side effects of constant gum chewing. But for now, the idea of research is to study the longterm effects of gum chewing on motor activity of the masseter muscle by comparing its electromyographic behaviour in females with males who do gum chewing. AIMS AND OBJECTIVE To compare the effect of gum chewing on masseter muscle in females with males by analyzing its electromyographic behaviour. NULL HYPOTHESIS (H0): Effect of gum chewing on masseter muscle in males is same as that of females as EMG indicates almost similar motor activity in both the males and females. EXPERIMENTAL HYPOTHESIS (H1): Effect of gum chewing on masseter muscle in females is more than that of males as EMG indicates greater motor activity in females. ALTERNATE HYPOTHESIS (H2): Effect of gum chewing on masseter muscle in males is more than that of females as EMG indicates greater motor activity in males. METHODOLOGY The subjects for the present study were selected from various colleges of Delhi. 60 young adults (Group A30 females and Group B- 30 males) took part in this study on the basis of following criteria:
Inclusion criteria (4, 12, 13) Age group of 20 to 25 years. Free of dental pathologies. Individuals who chew gum regularly. (3-5 sticks of gum a day)
Exclusion criteria(1, 14, 15, 16) TMJ Dysfunction. Sleep rated or waking bruxism. Medical systemic problems that could affect muscular function such as myalgia, myositis and fibromyalgia of masseter muscle. History of severe head and neck trauma (fractures or whiplash injury). History of orthognatic surgery. Using any medication that could interfere in muscle activity such as antihistamines, sedatives etc. Receiving any kind of treatment during the course of study that could directly or indirectly interfere in muscle activity such as speech therapy and otorhinolaryngology treatment. Subjects having any neurological, psychological or psychiatric disorder.
Instrumentation Electromyography machine -NeuroTrac TM MyoPlus4 attached with an desktop display. Two Self-adhesive surface electrodes, round shaped with a diameter of approximately 30mm. A chair (Adjustable in height).
Research design Comparative Design.
Variables Dependent variable: EMG activity. Independent variable: Gum chewing. PROCEDURE Subjects fulfilling the inclusion criteria were taken into consideration. The procedure was explained to the subjects and a written consent was taken after explaining the benefits and clearing the doubts of the subjects regarding study.
EMG RECORDING The device used in this study is a single channel EMG. The subjects of both the groups were given chewing gum and asked to chew gum at least one hour before coming for the study. All monitoring was performed with the patients in a sitting position. The subjects were seated comfortably upright in a chair of adjustable height at a desk of 30-inch height on which the EMG attached to an desktop display is placed.17 Back of their heads were supported and their feet was insulated from the floor.18 The subjects were asked to make no head or body movements during the recordings.19 Position of the head was kept vertical and no movement was allowed as jaw muscles respond to change in head position 20, 21 and facial muscles should be relaxed, keeping lips closed. Questions were answered after the instructions were given to be certain that the instructions were understood. Two selfadhesive surface electrodes were utilized and placed on the midsubstance of muscle belly of right masseter muscle in line with muscle fibers. 22, 23 One electrode was at the level of the lower border of the mandible, and the other 25 mm above this, close to the motor point. Preliminary experiments showed that with this placement, the waveform obtained by triggering an average of the surface EMG on the spikes of a single masseter motor unit was biphasic and approximately symmetrical. 23 The EMG recording of masseter muscle was done at most comfortable position of jaw (i.e., at rest position which is the habitual postural position of the mandible when at rest is in the upright position and the condyles are in a neutral unstrained position in the mandibular fossae). It was made sure that proper electrode placement is done and then EMG activity was recorded. The recording time for each analysis was 30 seconds. DATA ANALYSIS Data are expressed as mean, standard deviation and 95% confidence interval. The independent t- test or Levenes test for equality of variances was used to determine the normal distribution of the variance (P < 0.05). RESULTS All the subjects who took part in this study were analyzed. A t-test reveal statistically reliable difference between the mean number of POST TEST A has (M =
2.171, s = 101.76) and that the POST TEST B has (M = 1.62, s = 75.57),t(58) = 2.367, P = .05. The independent t-test indicates a significant increase in the motor activity of the masseter muscle in females than in males.
Graph 1: Right masseter muscle mean and standard deviation
CONCLUSION Electromyographic behaviour of the masseter muscle in individuals who do gum chewing is found to be significantly increased in females than in males. The independent t-test indicates that females show higher electromyographic activity of masseter muscle than males which means masseter muscle functions at a higher pace in females who chew gum continuously which may lead to the wear and tear of the temporomandibular joint. This can result in the development of the signs and symptoms of the temporomandibular disorders.1 Therefore, it can be concluded from the present study that one should avoid gum chewing especially females on the regular basis so as to prevent their jaw from the risk of developing TMD at an early age. DISCUSSION In this study, the effect of gum chewing on motor activity of the masseter muscle which is considered as the primary chewing muscle was compared in females with males who do gum chewing using EMG since it is well known that the amplitude of EMG is related to certain extent to the force a muscle may generate.15, 24 The temporomandibular joint is used throughout the day to move the jaw, especially in biting, chewing, talking and yawning. Slow and painful failure of jaw joint function is termed as temporomandibular syndrome/disorder. Habitual gum chewing is considered as one of the causes which can lead to the development of TMJ disorders.25 In this study we found
significant increase in the activity of masseter muscle in females who do gum chewing for prolonged time. For most people, pain in the area of the jaw joint or muscles does not signal a serious problem. Generally, discomfort from these conditions is occasional and temporary, often occurring in cycles. The pain eventually goes away with little or no treatment. Some people, however, develop significant, long-term symptoms.4,9 Many studies have also shown that women show a tendency to report significantly elevated levels of muscle pain after a heavy chewing exercise, while men do not.11 But, still neither the etiology of muscle related temporomandibular disorders nor the reason for the disproportionate number of women suffering from these disorders is well established. Further research is of course required but the present study suggests that one should avoid gum chewing on the regular basis especially females as continuous chewing has a harmful effect on the masseter muscle activity. In individuals who do continuous chewing, masseter muscle continues to function at a higher pace getting no time to recover between the meals. Thus, gradually it can lead to the development of signs and symptoms of temporomandibular disorders. CLINICAL RELEVANCE Many other conditions can cause similar symptoms to TMD including a toothache, sinus problems, arthritis, or gum disease. Therefore, health professional needs to conduct a careful patient history and clinical examination to determine the cause of the symptoms.9 Researchers throughout the health sciences are working together not only to gain a better understanding of the temporomandibular joint and muscle disease process, but also to improve the quality of life for people affected by these disorders. Simple self-care activities are often effective in maintaining oral health and also preventing jaw from the risk of developing TMDs. Nowadays, gum chewing is considered as the major culprit as it leads to the over usage of the jaw therefore it should be avoided. REFERENCES 1. M. Koutris et al: Effects of intense chewing exercises on the masticatory sensory-motor system. JDR 2009; vol.88 (7), pg.658-662. Paul Ingraham: Massage therapy for Bruxism, jaw clenching and TMJ syndrome, 2010.
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John S.Dupont, Christopher E. Brown: Masseter tenomyositis, The J. cranio. Prac.2009/July. Temporomandibular joint syndrome: chew on this: your jaw joint can be a source of painful arthritis. Arthritis today 2007/july-aug. Renata Cunha Matheus Rodriques Garcia: Influence of female hormonal fluctuation on maximum bite force and masticatory efficiencycomparison between subjects with and without temporomandibular disorder. Virtual library 2008/july 08/03106-6, 01. Robert P Sheon, MD: Temporomandibular joint dysfunction syndrome. Uptodate 2012/Jan. http://www.ehow.com/list_6457095_effectsexcessive-gum-chewing.html (Gail Sessons: The effects of excessive gum chewing). http://www.askmen.com/sports/foodcourt/ foodcourt11.html (Health and sports: Lose weight by chewing gum). National Institute of Dental and Craniofacial research: TMJ & Muscle disorders 2010/March, pub no. 10-3487. De Rossi SS, Stoopler ET, Sollecito TP: Temporomandiblar disorders and migraine headaches: co-morbid conditions? The internet journal of dental sciences 2005; vol.2, no.1. H. Karibel, G. Goddard, R.W Gear (2003): Sex differences in masticatory muscle pain after chewing. JDR 2003/Feb, vol.82, no. 2112-116. A. Gavish, M. Halachmi, E. Winocur and E. Gazit: Oral habits and their association with the signs and symptoms of temporomandibular disorders in adolescent girls. J. oral rehab. 2010; vol.27, 22-32. Regiane Cristina Mendonca et al: Electromyographic assessment of chewing induced fatigue in TMD patients- a pilot study. Braz. J.oral sci. 2005/oct-dec, vol.4, no.15. Macarena Venegas et al: Clenching and grinding: Effect on masseter and sternocleidomastoid electromyographic activity in healthy subjects. J. Cranio. Prac.2009/july. Dahlstrom L: Electromyographic studies of cranimandibular disorders- a review of the literature. J. oral rehabil 1989/Jan, vol.16 (1), pg.1-20. Selma Seissere et al: Electromyographic activity of masticatory muscles in women with osteoporosis. Braz Dent. J. 2009; vol.20, no.3.
17. Robert H. Jebsen, Neal Taylor et al: An objective and standardized test of hand position. Archives of physical medicine & rehab 1969/June. 18. Marie- Agnes Peyron et al: Influence of age on adaptability of human mastication. J. neurophysio. 2004/Aug; vol.92 (2), pg.773-779. 19. Simona Tocco, Stefano Teta and Felice Festa : Electromyographic evaluation of masticatory, neck & trunk muscle activity in patients with posterior crossbites. European J. orthodontics, vol.32, issue.6, pg.747-752. 20. HD Adhikari et al: Electromyographic pattern of masticatory muscles in altered dentition-part II. J. conserv. dent. 2011; vol.14, issue.2, pg. 120-127. 21. Ray La Touche et al: The influence of craniomandibular posture on maximal mouth opening and pressure pain threshold in patients
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with myofascial temporomandibular pain disorders. Clinical journal of pain 2011/Jan, vol.27, no.1. Paul Canavan and Jessica Capurso: Protocol for use of EMG and tactile biofeedback in treatment of temporomandibular disorders and orofacial pain. Timothy S. Miles, Andrew V. Poliakov and Michael A. Nordstrom: Responses of human masseter motor unit to stretch. The journal of physiology 1995/Feb, vol.483, pg.251-264. Claudia Maria de felicio et al: Reliability of masticatory efficiency with beads and correlational with the muscle activity. Pro-Fono R. Atual. Cient 2008; vol.20, no.4, 225-30, oct/dec. William C. Sheil Jr. MD, FACP, FACR: Temporomandibular joint disorder.
A Study to Evaluate the effect of Fatigue on Knee Joint Proprioception and Balance in Healthy Individuals
Purvi K. Changela1, K. Selvamani2, Ramaprabhu3 Lecturer, Shri K K Sheth Physiotherapy College, Rajkot, 2Assoc. Prof., Srinivas College of Physiotherapy, Mangalore, 3 Assoc. Prof., Srinivas College of Physiotherapy ABSTRACT Introduction: Balance and proprioceptive testing is more commonly used in clinical settings to evaluate injured athletes to return to activity. Muscle fatigue produces neuromuscular deficiency within the muscle , thus predispose a joint to injury and decrease the athletic performance. A finding of previous studies shows contradictory findings of effect of muscle fatigue on proprioception and balance. Aims & Objectives: A study to investigate the effect of fatigue on knee joint proprioception and balance in healthy individuals. Materials & Methods: An observational study was conducted on 30 healthy subjects ( age 18-30 years) from Srinivas college of physiotherapy, Mangalore. Subjects was selected by simple random sampling techniques. Fatigue was induced in the subjects by cycling upto level of exceeding 60% of predicted HRmax (14-17 PRE). Subjects were tested to estimate reproduction error by using weight bearing joint position sense test at 30 0 of knee flexion , by goniometric evaluation accompanied by photographic method and the balance assessment was done on force platform with the measurement of anteroposterior, lateral CoP excursion and stability score in single limb stance, before and after fatigue protocol. Results: After inducing fatigue,significant reproduction error was found for perception of joint position sense (t=-4.103) with significant changes were found in AP (t=3.997), lat CoP excursion (t=10.949) and stability score (t=11.785) at p>0.05. Conclusion: A study revealed that moderate exercises can reduce proprioception which affects the neuromuscular control of joint making individual more suspectible to injury. Keywords: Fatigue, Proprioception, Balance, Dynamic Stability.
INTRODUCTION Muscular fatigue is most often defined as an exercise induced reduction in the ability of a muscle to generate force. 1 It is caused by a combination of different physiological mechanisms occurring at both the central through the impairment of central drive and peripheral level through the impairment of muscle function.2 The high incidence of injuries occur during later session of sports suggest that fatigue may predispose a joint to injury and decrease the athletic performance.3 The study of fatigue relative to performance of different skills in the sports has long been a subject of practical interest.4 Since sports activities are strongly promoted, the risk of sport injuries is likely to increase. It is reported that knee joint injuries are the common injuries among all sports injury, 39.8% of all sports injuries involve the knee.5 It has been suggested that a higher incidence of injuries at the last third of match could be related to alteration of the lower limb neuromuscular control and
altered ability to dynamically stabilize the knee joint but exactly how this impairment comes about is less clear. 6 It is possible that one factor is reduced proprioceptive acuity.7 In 1906, Sherrington defined Proprioception as the perception of positions and movements of the body segments in relation to each other, without the aid of vision, touch or the organs of equilibrium. 7 The importance of the proprioception in knee function, stability, injury prevention has been studied extensively in literatures. The current consensus is that the sense of proprioception originates in the simultaneous activity of a range of different types of receptors located in muscles, joints, and skin.8 Some of these receptors have been shown in animal studies to be affected by muscle fatigue 9 and/or by increased intramuscular concentrations of substances (Arachnoid acid, KCL, 5HT, Bradykinin) released during muscle contractions10 which have a direct impact on the discharge pattern of muscle spindles that represent the peripheral
component of fatigue and efferent as well as afferent neuromuscular pathways are modulated with excessive fatigue via reflexes originating from smalldiameter muscle afferents (group III and IV afferents) could modify the central processing of proprioception.11. Although it is reasonable to assume that these receptors are affected in a similar way in humans, comparably little is known about the fatigue effects on human proprioception.12 The perception of movement or joint position in clinical measurements reflects the status of the whole system, or that measured proprioceptive defects are connected to functional disability.13 It is believed that the Central Nervous System (CNS) links together afferent proprioceptive feedback from multiple joints of a limb segment and redundancy of the afferent information can be used as an error check to improve proprioceptive feedback in order to maintain function.8 Reproduction ability is decreased; possibly due to increased sensitivity of capsular receptors from muscle fatigue-induced laxity.3 The assessment of potential injury risk before sports participation followed by intervention may decrease the relative injury incidence in athletes.14 The integrity and control of the proprioceptive acuity is essential for the maintenance of balance.15 Balance is defined as persons ability to maintain an appropriate relationship between the body segments and between the body and the environment and to keep the bodys center of mass over the base of support when performing a task.16 It is assumed that some form of muscle spindle desensitization or perhaps ligament relaxation and Golgi tendon desensitization occurs with excessive fatigue which leads to decreased efferent muscle response and poorer ability to maintain balance.17 Balance testing is more commonly used in the clinical setting to establish gains in the proprioceptive capacity of injured limbs and helps to evaluate injured athlete to return to activity.15 Measures of postural control such as center of pressure (CoP) excursion which may be a more sensitive measure of postural control that incorporates proprioception have been used clinicaly.18 In humans, the effect of fatigue on proprioception has been investigated at various joints. Findings of disturbed proprioception and balance are frequent in the literatures, but together they are not conclusive. So the purpose of this study is to investigate the effect of muscular fatigue on proprioception and balance in healthy individuals.
METHODOLOGY Study design: Observational study design Sampling Technique: Simple Random Sampling Sample collection: 30 healthy subjects in age group of 18-30 yrs of both sex were taken for the study from Srinivas College of Physiotherapy, Mangalore. Inclusion Criteria 1. 2. Age group: 18-30 years Both male and female were included.
Exclusion Criteria 1. Knee joint pathology 2. Musculoskeletal disease of lower limb 3. Neurological condition 4. Respiratory and heart problem Materials used Static cycle Reference markers Universal Goniometer Video camera HR assessment apparatus (cardio-vigil) Two dimensional digitizing software of the peak measurement system (UTHSCSA Image Tool version 3) Force Platform (BERTEC, Columbus, OH 43229, U.S.A.) TESTING PROCEDURE The proposed title and procedure was being approved by ethical committee members , written consent was taken from subjects who fulfilled the inclusion and exclusion criteria and they were randomly selected. Subjects age, sex, height, weight, body mass index (BMI), resting heart rate was recorded prior to the test. Borg scale of perceived rate of exertion (PRE) was clearly explained to all the subjects before cycling. Right lower limb was used for measurement of proprioception and balance test. Fatigue was induced by asking the subject to perform cycling on a static cycle as fast as possible, the level of
fatigue was indicated and measured by using Borgs Rate of Perceived Exertion (RPE) scale and HR was monitored using cardio-vigil. Fatigue was induced in the subjects by cycling. When subjects reached upto level of exceeding 60% of predicted HRmax and a level of exertion of 14-17 on the RPE scale, immediately the subjects were asked to discontinue cycling.19 Proprioception and balance tests were performed before and after fatigue protocol and scores were recorded. Subjects were tested to estimate reproduction error by using weight bearing joint position sense test at 30 0 of knee flexion , by goniometric evaluation accompanied by photographic method.The subject was given three trials to identify and reproduce knee joint position (300 knee flexion) initially with eyes open followed by eyes closed. After trials of test positions, reference markers were placed along the lateral aspect of the lower limb for photographic evalution: a) over the greater trochanter, b) over the iliotibial tract proximal to the superior border of the patella and c) over the neck of fibula.20 The balance assessment was done on force platform while the leg was flexed to 90at the hip and knee joints, with both arms hanging relaxed at the sides in singlelimb stance with the measurement of AP, Lat CoP
excursion and Stability score in single-limb stance on the force platform after the JPS test following fatigue protocol.21 DATA ANALYSIS The demographic data were analyzed using paired t-test for comparison of pre and post fatigue measurement.The data analysis was done using SPSS softwear package version 14.level of significance was set at d 0.05 with Cl of 95% RESULTS
Table 1: Distribution of age groups
Age 19 20 21 22 23 Total Frequency 3 5 13 6 3 30 Percent 10.0 16.7 43.3 20.0 10.0 100.0 Valid Percent 10.0 16.7 43.3 20.0 10.0 100.0
Table 2: Gender Proposition

Frequency male female Total 21 9 30 Percent 70.0 30.0 100.0
Table 3: Comparison of pre and post fatigue joint position sense (JPS) test score, AP CoP excursion, Lateral CoP excursion and stability score.
Mean Pre fatigue JPS test score Post fatigue JPS test score Pre fatigue AP CoP excursion Post fatigue AP CoP excursion Pre fatigue LAT CoP excursion Post fatigue LAT C oP excursion Pre fatigue stability score Post fatigue stability score VHS=very highly significant 6.7370 8.7197 1.2777 1.7620 .4590 .6820 86.6090 81.7803 Std. Deviation 3.04761 3.04767 .27712 .32318 .32341 .44055 2.84795 2.75167 Std. Error Mean .55641 .55643 .05060 .05900 .05905 .08043 .51996 .50238 11.785 29 .000VHS -3.997 29 .000VHS -10.949 29 0.000VHS t -4.103 df 29 p .000VHS
The above table shows the mean of pre JPS test score i.e. 6.7370 3.04761 (SD) and post JPS test score i.e. 8.71973.04767 which shows significant differences (t = -4.103, p<0.05) (figure 1), mean of pre AP CoP excursion i.e. 1.2777 0.27712 (SD) and post AP excursion i.e. 1.76200.32318 which shows significant difference (t = -10.949, p < 0.05) (figure 2), mean of pre Lat Cop excursion i.e. 0.4590 0.32341 (SD) and post Lat excursion i.e.0.6820 0.44055 (SD) which shows significant difference (t = -3.997, p < 0.05) ( figure 3),
mean of pre stability score i.e. 86.6090 2.84795 (SD) and post stability score i.e. 81.7803 2.75167 (SD) which shows significant difference for pre and post stability score (t = 11.785, p < 0.05) (figure 4) for the present study. DISCUSSION The results of the present study indicated that fatigue reduces knee joint proprioception i.e. higher reproduction error was found for perception of joint
position sense (t = -4.103, p < 0.05) thereby supporting the experimental hypothesis. The findings of David Roberts et al. (2003) on healthy young persons, to estimate threshold for perception of movement before and after fatigue shows statically significant difference in threshold value, after inducing fatigue which support the results of our study.22 However, Marks and Quinney (1993) provided contradictory findings suggested that muscle fatigue had a negligible effect on knee JPS. However, they induced fatigue by having the subject contract the quadriceps muscle 20 times, which likely was less fatiguing and that mainly affected the anterior structures of the thigh. Therefore, the posterior structures, which are of afferent importance during extension, were probably less affected by fatigue.23 An important issue here in this present study is, whether the effects of fatigue on position sense of knee can be attributed to central fatigue or to muscle fatigue. Central fatigue may have accompanied peripherally elicited effects, but there is a chain of evidence indicating that alterations in the proprioceptive inflow from peripheral muscle receptors have contributed considerably to the central fatigue effects. 10 Djupsjobacka M. et al. (1995) suggested that muscle spindles are strongly affected by metabolic products , such as bradykinin, 5-HT, and lactic acid, the proprioceptive inflow from spindle afferents during the JPS test is likely to have been affected by fatigue.24 Different methods have been used to assess proprioceptive acuity in various studies. Amongst them, Goniometric evaluation for measuring the angle accompanied by video films is an adequately accurate method of measuring the joint angle. Berry C. Stillman et al. (2001) explained that WB assessments of proprioception which is more functional might have greatest relevance in the area of sports medicine . Theoretically, fatigue may increase the time of reaction, which, in the present study, would be seen as higher reproduction error scores. 20 The results of the present study also indicated that fatigue reduces balance performance (t= 11.785; p < 0.05). There are several possible reasons why muscular fatigue affects balance performance. It seems plausible that some form of muscle spindle desensitization or perhaps ligament relaxation and Golgi tendon desensitization occurs with excessive fatigue. The increased AP and Lat CoP excursion observed after cycling in the present study may be explained by a
decrease in muscle response and a delay in muscle reaction and poorer ability to maintain balance.17 Eva Ageberg et al. (2003) found that short-term cycling decrease ability to maintain balance in single limb stance in healthy subjects 30 support the result of present study . 21 We found that a short period of moderate exercise can reduce proprioception, which may affect the neuromuscular control of the knee joint and significantly affects the ability of an individual to maintain balance on force platform device, thus, may make it more susceptible to injury. CLINICAL IMPLICATION Balance and Proprioceptive testing can be used in the clinical setting to evaluate injured athlete to return to activity. CONCLUSION The knee joint proprioception and balance are affected after fatigue in healthy individuals. ACKNOWLEDGEMENT I wish to express my thanks to respectable Principal Ramprasad M. Srinivas College of Physiotherapy, Mangalore , to my respected Guide Assoc. Prof. K. Selvamani and all my respected teachers for their help and valuable suggestions.We gratefully acknowledge our respected principal Dr. Sarla Bhatt for their kind support and guide in the journal publication. REFERENCES Vollestad NK. Measurement of human muscle fatigue. J Neurosci Methods June 1997; 74 (2): 219-227. Noakes TD. Physiological models to understand exercise fatigue and the adaptations that predict or enhance athletic performance. Scand J Med Sci Sports June 2000; 10 (3): 123-145. Hiemstra LA., Lo IK., Fowler PJ. Effect of fatigue on knee proprioception: implications for dynamic stabilization. J Orthop Sports Phys Ther Oct 2001; 31(10): 598-605. Mark Lyons, Yahya Al-Nakeeb, Alan Nevill. The impact of moderate and high intensity total body fatigue on passing accuracy in expert and novice basketball players. J of Sports Sci and Med June 2006; 5: 215-227. Majewski M., Susanne H., Klaus S. Epidemiology
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of athletic knee injuries: A 10-year study. J Knee June 2006; 13(3): 184-188. Ribeiro Fernando1, Santos Fernando2, Oliveira Jose. Effects of a volleyball match induced fatigue on knee joint position sense. 12th Annual Congress of the ECSS, 1114 July 2007, Jyvaskyla, Finland. Martin B. Jorklund. Effects of repetitive work on proprioception and of stretching on sensory mechanisms. Umea university medical dissertation, new series no. 877 91. 2004; 90: 7305-604. Grigg P. Peripheral neural mechanisms in proprioception. J. Sport Rehab Feb 1994; 3 (1): 2-17. L. Hayward, U. Wesselmann and WZ. Rymer. Effects of muscle fatigue on mechanically sensitive afferents of slow conduction velocity in the cat triceps surae. J Neurophysiol 1991; 65 (2): 36070. Pedersen, Jonas, Lonn, Johan, Hellstorme, Fredric, Djupsjobacka, Mats, Johansson, Hakan. Localized muscle fatigue decreases the acuity of the movement sense in the human shoulder. Williams and Wilkins July 1999; 31(7): 1047-52. Solomonow M., R. Baratta, BH. Zhou. The synergistic action of the anterior cruciate ligament and thigh muscles in maintaining joint stability. Am J Sports Med May-June 1987; 15 (3): 207-13. Meral Bayramoglu, Reyhan Toprak and Seyhan Sozay. Effects of osteoarthritis and fatigue on proprioception of the knee joint. Arch of Phys Med and Rehab Mar 2007; 88(3): 346-50. Ashton Miller JA., Wojtys EM., Huston LJ., FryWelch D. Can proprioception really be improved by exercises? Knee Surg Sports Traumatol Arthrosc May 2001; 9 (3): 128-136. Chandy TA. and Grana WA. Secondary school athletic injury in boys and girls: A three-year comparison. Phys Sports Med 1985; 13: 10611. Peggy A. Houglum and David H. Perrin. Therapeutic exercises for athletic injuries.United
States. First edition. Human Kinetics 2001: 272-3. 16. Shumway Cook A. and Woollacott M. Control of posture and balance. Motor control. Theory and practical application. Second edition. Baltimore, Williams and Wilkins 1995; 120-121. 17. Johnston, Richard B., Howard, Mark E., Cawley, Patrick W., Losse, Gary M. Effect of lower extremity muscular fatigue on motor control performance. Med Sci Sports Exerc Dec 1998; 30 (12): 1703-1707. 18. Gandevia SC. Spinal and supraspinal factors in human muscle fatigue. Physiol Rev Oct 2001; 81 (4): 1725-1789. 19. J.E. Bullock Saxton, WJ. Wong, N. Hogan. The influence of age on weight-bearing joint reposition sense of the knee. Exp Brain Res Jan 2001; 136(3): 400-406. 20. Barry C. Stillman and Joan M. McMeeken. The role of WB in the clinical assessment of knee joint position sense. Austr J of Physiotherapy 2001; 47: 247-253. 21. Eva Ageberg, David Roberts, Eva Holmstrom, Thomas Friden. Balance in single-limb stance in healthy subjects - Reliability of testing procedure and the effect of short-duration Sub-maximal Cycling. BMC Musculoskeletal Disorders June 2003; 4: 14. 22. David Roberts, Eva Ageberg, Gert Andersson, Thomas Friden. Effects of short-term cycling on knee joint proprioception in healthy young persons. Am J of Sports Med 2003; 31: 990-994. 23. Marks R., Quinney HA. Effect of fatiguing maximal isokinetic quadriceps contractions on ability to estimate knee-position. Percept Mot Skills Dec 1993; 77 (3 pt 2):1195-202. 24. M. Djupsjobacka, H. Johansson and M. Bergenheim. Influences on the -muscle spindle system from muscle afferents stimulated by increased intramuscular concentrations of arachidonic acid. Brain Res Nov 1994; 663 (2): 293302.
Effect of Core Stabilization and Balance-Training Program on Dynamic Balance

Rabindra Basnet1, Nalina Gupta2 BPT Student, HOD Department of Physiotherapy, College of Applied Education and Health Sciences, Meerut, Uttar Pradesh
2
ABSTRACT Introduction: Over the years, injury rehabilitation has changed from strengthening the body using strength training to achieve functional kinetic chain movements using neuromuscular training, which includes balance and proprioception. Neuromuscular control is the motor response to the sensory input of the muscles, whereas balance is a state of bodily equilibrium. The purpose of this study was to find out the effect of core stabilization and balance training on dynamic balance. Method: subjects were randomly assigned to one of the two groups: Group A-core stabilization group and Group B-Balance training group. Both groups were given exercise program for six days per weeks for two weeks. Pre and post analysis was done by using Star Excursion Balance Test. Result: Paired T-test was used within the group and p value was found to be less than .05 in both the groups and independent sample T-test was used between the groups where p value was found to be more than .05. Conclusion: Our study concluded that there was no statistical significant difference between core stabilization group and balance training group. Keywords: Core-Stability Training, Balance Training, Neuromuscular Control
INTRODUCTION Balance is a key component of normal daily activities. In the simplest terms, balance can be defined as the ability to maintain the bodys centre of gravity within the limits of stability as determined by the base of support. Balance, or postural control, can be described as either dynamic or static. Static postural control is attempting to maintain a base of support while minimizing movement of body segments and the centre of mass; while dynamic postural control involves the completion of a functional task with purposeful movements without compromising an established base of support.1 To maintain balance, it is necessary to have a functional awareness of the base of support to better accommodate the changing centre of gravity. The goal of balance training is to improve balance through perturbation of the musculoskeletal system that will facilitate neuromuscular capability, readiness, and reaction.2
Panjabi describes clinical instability as the loss of the spines ability to maintain its patterns of displacement under physiologic loads so there is no initial or additional neurologic deficit, no major deformity, and no incapacitating pain. The spine stability system consists of the following interacting elements Neuromuscular control (neural elements), Passive subsystem (osseous and ligamentous elements) & Active subsystem (muscular elements).3 The human core is described as the human low backpelvic-hip complex with its governing musculature. The core is important because it is the anatomical location in the body where the centre of gravity is located, thus where movement stems. The core functions to maintain postural alignment and dynamic postural equilibrium during functional activities, which helps to avoid serial distortion patterns. Core stability is the motor control and muscular capacity of the lumbopelvic-hip complex.4 The core is split into two different regions, the local and global musculature. The multifidus, transverse
abdominus, internal oblique and quadrates luborum constitute the local stabilizing system. The longissimus thoracis, rectus abdominus and external oblique make up the global system. The local system is responsible for segmental spine stability while the global system is responsible for isometric and isotonic contraction in the spine. Both of these regions play a role not only in daily and athletic movement but also potentially in injury prevention.6 A useful method of measuring dynamic balance is the Star Excursion Balance Test.1 The test provides a quantifiable way to measure dynamic balance. This single leg standing and contralateral reaching test can be used to determine the dynamic stability of an individual as they perform a functional movement task. SEBT requires a participant to maintain a base of support with one leg while maximally reaching in different directions with the opposite leg without losing balance or significantly altering the base of support in the stance leg.6 According to Kibler et al, core stability and strength is an important component to maximize efficient balance and athletic function in upper and lower extremity movements. The same authors suggest that the core acts as a base for motion of the distal segments, or proximal stability for distal mobility.7 Logically, strengthening core muscles will improve stability of the lumbar spine. What has been researched in much less detail is the effect core strengthening will have on tasks that encompass whole body movement and dynamic postural control.7 Thus, the aim of this study was to find out the effect of core stability and balance training on dynamic balance. MATERIALS AND METHOD It was an experimental study. Thirty normal healthy subjects of CAEHS, Meerut of both the gender with age 18 to 25 years were included in the study. Subjects
having injury and pathology of Hip, Knee and Ankle, deformities such as Genu valgum & varum etc, Sharp acute pain, recent hematoma of knee, hip & ankle and any acute inflammatory condition, history of LBP with sciatica and subject with neurological impairments were excluded from the study. All the subjects were explained about the procedure and were made to fill the consent form. Subjects were divided into two groups: Group A (n=15) - Core stabilization group and Group B (n=15) - Balance training group. Pre evaluation was done by using Star Excursion Balance Test. Group A received core stability exercises of 3 sets for 30 seconds/session once a day 6 days a week for 2 weeks. Exercises given to this group were Plank Jao, Side Plank, Bridge, Superman, Sideline Hip Abduction, Oblique Crunch, Straight Leg Rise and Lying Windscreen Wipers Wipers. Group B received Balance Training exercise of 3 sets for 30 seconds/session once a day 6 days a week for 2 weeks, exercises are Tandem Standing, One Limb Balance, Hip Rise, Knee Band, Standing Kick, Side Kick, Standing On Foam, One Leg Standing On Foam, Back Kick with Band and Side Kick With Band Band. After two weeks, both the groups were evaluated again using SEBT. DATA ANALYSIS AND RESULT Data analysis was done by using SPSS software. Paired T-test was used within the group and p value was found to be less than 0.05 in both the groups. There was significant difference within the groups as seen in Table 1 & 2. Independent sample T- test was used between the groups where p value was found to be more than 0.05. There was no statistical significant difference between the groups as seen in table 3.
220 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 Table 1 Mean and Pre-Post analysis of Group A
Mean Pair 1 Pair 2 Pair 3 Pair 4 Pair 5 Pair 6 Pair 7 Pair 8 Pair 9 Pair 10 Pair 11 Pair 12 Pair 13 Pair 14 Pair 15 Pair 16 RtANTpreA RtANTpostA RtALpreA RtALpostA RtLATpreA RtLATpostA RtPLpreA RtPLpostA RtPOSTpreA RtPOSTpostA RtPMpreA RtPMpostA RtMEDpreA RtMEDpostA RtAMpreA RtAMpostA LtANTpreA LtANTpostA LtALpreA LtALpostA LtLATpreA LtLATpostA LtPLpreA LtPLpostA LtPOSTpreA LtPOSTpostA LtPMpreA LtPMpostA LtMEDpreA LtMEDpostA LtAMpreA LtAMpostA 58.9333 80.8667 60.2667 80.0667 61.5333 77.5333 60.3333 75.8667 54.2667 70.7333 49.0000 70.0667 48.2000 66.8667 55.6000 74.8000 58.5333 85.0000 55.8000 75.2000 47.6000 65.6000 50.6000 70.8000 52.9333 71.5333 58.6000 73.6000 60.8000 76.7333 61.6000 78.8667 .000 Pair 16 .000 Pair 15 .001 Pair 14 .000 Pair 13 .000 Pair 12 .000 Pair 11 .000 Pair 10 .000 Pair 9 .000 Pair 8 .000 Pair 7 .000 Pair 6 .000 Pair 5 .000 Pair 4 .000 Pair 3 .000 Pair 2 Sig. .000 Pair 1 RtANTpreB RtANTpostB RtALpreB RtALpostB RtLATpreB RtLATpostB RtPLpreB RtPLpostB RtPOSTpreB RtPOSTpostB RtPMpreB RtPMpostB RtMEDpreB RtMEDpostB RtAMpreB RtAMpostB LtANTpreB LtANTpostB LtALpreB LtALpostB LtLATpreB LtLATpostB LtPLpreB LtPLpostB LtPOSTpreB LtPOSTpostB LtPMpreB LtPMpostB LtMEDpreB LtMEDpostB LtAMpreB LtAMpostB
Table 2 Mean and Pre-Post analysis of Group B

Mean 56.0000 73.7333 54.4000 74.1333 53.8000 69.8667 51.2667 66.0667 49.3333 64.6667 48.2000 61.4667 46.1333 58.0667 54.5333 71.5333 57.0000 71.6667 52.1333 69.2000 47.6667 64.0667 47.0667 62.6667 52.4667 64.4667 54.9333 66.3333 53.7333 67.2000 53.2667 71.6000 .005 .003 .000 .000 .000 .000 .000 .000 .000 .000 .000 .000 .001 .001 .000 Sig. .000
Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 221 Table 3 Independent T-Test between the Groups
Sig.(2-tailed) RtANTpre RtANTpost RtALpre RtALpost RtLATpre RtLATpost RtPLpre RtPLpost RtPOSTpre RtPOSTpost RtPMpre RtPMpost RtMEDpre RtMEDpost RtAMpre RtAMpost LtANTpre LtANTpost LtALpre LtALpost LtLATpre LtLATpost LtPLpre LtPLpost LtPOSTpre LtPOSTpost LtPMpre LtPMpost LtMEDpre LtMEDpost LtAMpre LtAMpost .482 .105 .188 .215 .082 .133 .034 .033 .132 .157 .818 .075 .632 .086 .767 .555 .733 .008 .443 .204 .988 .745 .460 .052 .892 .092 .458 .069 .108 .103 .048 .151
By just training the core, overall dynamic stability can be positively affected with strong magnitude of change. There is also evidence that a 4 week intervention might be enough to cause a significant training effect, with a strong magnitude of change in core global muscular endurance.6 When the transverse abdominus contracts, the intraabdominal pressure increases and tenses the thoracolumbar fascia. These contractions occur before initiation of limb movement allowing the limbs to have a stable base for motion and muscle activation. The rectus abdominus and oblique abdominals are activated in specific patterns with respect to limb movement that also provide postural support.9 Piegaro et al in 2003 stated in their study that there is a trend towards improving dynamic balance with core stability exercises and balance training exercises.8 Zech A, et al in 2010 concluded that Balance training is effective at improving static postural sway and dynamic balance in both athletes and non-athletes. But balance training exercises should be given for longer duration for finding it to be effective.21 Limitation of the study: Sample size was small and study was done in a shorter duration. Future research: In future, combined effect of core stability and balance training exercises on dynamic balance can be done. Study can be done on geriatric population. Bio feedback can also be incorporated in the study. Study can be done for longer duration. CONCLUSION Our study concluded that there was no statistical significant difference between core stabilization and balance training program. REFERENCES 1. Kahle N. The Effects of Core Stability Training on Balance Testing in Young, Healthy Adults.2009. Available at [http://etd.ohiolink.edu] Yaggie, JA, and Campbell BM. Effects of balance training on selected skills. J. Strength Cond. Res. 2006;20(2):422-428. Akuthota V, Ferreiro A, Moore T, and Fredericson M. Core stability exercise principles. Curr. Sports Med.Rep., 2008;7(1)39-44. Samson KM, BS, ATC, PES. The Effects of a FiveWeek Core Stabilization-Training Program on
DISCUSSION This study was an attempt to find out the effect of core stabilization and balance training on dynamic balance. In our study we found significant difference within the group and we did not find any significance between the groups. This is in agreement with the study done by Kimberly et al. in 2005. They also specified in their study that, although the results of study between groups were not significant, enhancement of dynamic balance may result if the core stabilization training program is applied in the clinical settin.4 Core stability improves static and dynamic balance and could be beneficial for improving balance by strengthening those muscles most often associated with lumbar spine control.
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5. 6.
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Dynamic Balance in Tennis Athletes.2005 Available at [http://wvuscholar.wvu.edu.] Akuthota V, Nadler SF. Core strengthening. Arch Phys Med Rehabil 2004;85(3 Suppl 1):S86-92. McCaskey A,The Effects of Core Stability Training on Star Excursion Balance Test and Global Core Muscular Endurance,2011 Available at [http:// etd.ohiolink.edu] Bashiri J, Hadi H, Razavi SD, Bashiri M. Effect of Resistance-Balance training on dynamic balance in active elderly males. Annals of Biological Research, 2011; 2(5):689-695. Piegaro AB, JR., BS, ATC. The comparative effects of four-week core stabilization & balance-training programs on semi dynamic & dynamic
balance,2003 Available at [http:// www.portalsaudebrasil.com] 9. Robinson R, Gribble P. Support for a reduction in the number of trials needed for the Star Excursion Balance Test. Arch Phys Med Rehabil. 2008; 89(2):364-370. 10. Hessari FF, Norasteh AA, Daneshmandi H, Ortakand SM . T he effect of 8 weeks core stabilization training program on balance in deaf students. Medicina Sportiva, 2011;15 (2): 56-61. 11. Zech A. Balance training for neuromuscular control and performance enhancement: a systematic review. J Athl Train, 2010 JulAug:45(4):392-403.
A Retrospective Analysis of Disability-Related Data on Disabled Children and their Families in Turkey
Rasmi Muammer Assistant Professor, Yeditepe University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation TR-34755, Istanbul, Turkey ABSTRACT Purpose: The aim of this study was to investigate and analysis the data and records of disabled children and their families. Materials and Methods: Records and data of 116 patients with different neurological conditions seen at the Physiotherapy Department at a special education centre between August 2004 and August 2008 were investigated. Obtained data and records included: age, gender, mode of delivery, diseases distribution , types of cerebral palsy and related factors, education level and job status of the parents, intermarriage, therapy interest rate. Results: The most prevelant mode of delivery was as a vaginal delivery in 68 (59%) cases while a caesarean section seen in 47 (41%) cases in addition to one adoption case with unknown delivery type. 29 (25%) of this deliveries were as a premature while 2 (2%) deliveries were as late deliveries. Cerebral palsy was the most prevalent (61%) cause of physiotherapy attendance. The spastic type also represented the most type of cerebral palsies with prevelant of 57%. The most prevelant parents educational level included the primary school (mothers-fathers, 56%-47%). There was also intermarriage betweeen 33 pairs with cousin relation in 28 pairs and 5 pairs with distant relation. Most of the mothers were housewifes (%97) and attendance to therapy realized by 91% of the mothers. Conclusion: Many factors are related to physiotherapy attendance of the paediatric neurological conditions. Parents low educational level, intermarriage, high percentage of housewifes, free- worker position of fathers and high percentage of mothers who attend to children care may reflect socioeconomic level of this population. Keywords: Cerebral Palsy; Parents INTRODUCTION A wide spectrum of motor impairments affect function in children and adolescents which may be congenital and acquired conditions such as cerebral palsy, traumatic brain injury, myelomeningocele, spinal cord injury, Down Syndrome, and neuromuscular disease. Many of these disorders result from dysgenesis or injury to developing motor pathways in the cortex, basal ganglia, thalamus, cerebellum, brainstem, central white matter, or spinal cord. These conditions are associated with motor impairments including muscle weakness, abnormal muscle tone, decreased joint range of motion, and decreased balance and coordination. There are variations in severity within each of these conditions. Many children with impairments attributable to these conditions will have some degree of disability that may limit their normal development and functions and should benefit from physical, occupational, and/or speech-language therapy services.1,2 The amount of the physiotherapy may be intensive or routine amounts with long or short term therapy3 and a specific and measurable goals of the therapy are essenetial for evaluation of improvement in motor function.4,5 Also the goal of treatment of children with motor disorders mirrors the management of other forms of chronic disease and disability 2. Establishing such goals are related to many factors and to each condition of the wide spectrum of the diseaes in which cerebral palsy is the most frequent diagnosis of children who receive physiotherapy.6 However having a sufficient knowledge about rare cases related to pediatric physiotherapy has a key role of setting the objective goals. MATERIALS AND METHOD This retrospective study was conducted at a special
education centre, Istanbul, Turkey. The centre provides physiotherapeutic services as well as a special education according to the patients needs who were reffered from guidance and research centers with a diagnosis from an official institution. Records and data of 116 infant, children and young with different neurological conditions seen at the physiotherapy department between August 2004 and August 2008 were investigated. Obtained data and records included: age, gender, mode of delivery, diseases distribution , types of cerebral palsy and related factors, education level and job status of the parents, intermarriage, therapy interest rate. Physical therapy a patient received was based on the evaluation of the physical therapist and the severity of the problems including classic physiotherapy in addition to neurodevelopmental therapy. Data were analyzed using descriptive statistics of mean and standard deviation. Range and percentages, and the frequency distributions of the various data were calculated and presented in tables and figures. RESULTS One hundred and sixteen paediatric patients were managed at the physiotherapy department of a special education centre between August 2004 and August 2008. 44% of the cases were females while the males represented 56% with mean age of 22.3529.95 months for females and and 24.3533.56 months for males at the entry. The most prevelant mode of delivery was as a vaginal delivery in 68 (59%) cases while a caesarean section seen in 47 (41%) cases in addition to one case adoption with unknown delivery type. 29 (25%) of these deliveries were as a premature while 2 (2%) deliveries were as late deliveries (Table 1a,1b).
Table 1a: Mode of Delivery
Mode of Delivery Vaginal Delivery Caesarean Section Unknown(Adoption) N 68 47 1 % 59% 41% < 1%
Table 2: Diseases distribution (CP: Cerebral Palsy, DS: Down Syndrome, SB: Spina Bifid, Myopathy: Myopathy, Polio: Poliomyelitis
Diseases CP DS SB Myopathy Polio N 71 14 18 12 1 % 61% 12% 16% 10% 1%
The spastic type also represent the most type of cerebral palsies with prevelant of 57%, hypotonic type prevalent 21%, mixed type 7%, athethoid type 6%, ataxic type 6% and unknown 3% (Table 3).
Table 3: Types of Cerebral Palsies
Type Spastic Hypotonic Mixed Athethoid Ataxic Unknown N 41 15 5 4 4 2 % 57% 21% 7% 6% 6% 3%
Result of factors related to cerebral palsy showed that the widespread prenatal, perinatal and postnatal factors as causes of cerebral palsy showed a rate of 41% were seen in 29 cases, Kernicterus (6%) was seen in 4 cases, Rett Syndrome (1%) was seen in 1 case, Mapple Syrup Urine disease (3%) was seen in 2 cases, Cytomegalovirus infection (3%) was seen in 2 cases, Pelizaeus-Merzbacher (1%) was seen in 1 case, trauma (6%) was seen in 4 cases, West syndrome (8%) was seen in 6 cases and others related to genetic factors, chromosome anomalies or unknown factors (31%) seen in 22 cases (Table 4).
Table 4: Result of factors related to cerebral palsy
N Pre, peri, post natal Factors Kernicterus Rett Syndrome Mapple Syrup Urine disease Cytomegalovirus Infection Pelizaeus-Merzbacher Trauma West syndrome Others 29 4 1 2 2 1 4 6 22 % 41% 6% 1% 3% 3% 1% 6% 8% 31%
Table 1b: Mode of Delivery

Premature Late Delivery 29 2 25% 2%
Diseases distribution is presented in Table 2. Cerebral palsy was the most prevalent (61%) cause of physiotherapy attendance, Down Syndrome prevalent 12%, spina bifida 16%, myopathies 10%, while Poliomyelitis comprised the least frequent (1%).
The parents educational level is seen in (Figure 1) and the most prevelant included the primary school.
Figure 1: The figure shows the parents educational level and the most prevelant included the primary school for both mothers (56%) and fathers (47%). The other levels respectively are: None-education (4%, 3%), Secondary School (22%,22%), High School (13%, 24%) and Collage (5%, 4%).
Figure 3: Most of the fathers were workers (%94), the rate of the state officers is 3% and fathers of none-job is 3%.
There was also intermarriage betweeen 33 (28%) pairs with cousin relation in 28 pairs and 5 pairs with distant relation (Table 5).
Table 5: Intermarriage betweeen pairs
N Non- intermarriage intermarriage 83 33 (28 pairs cousin, 5 pairs distant relation) % 72% 28% (85% cousin, 15% distant relation)
Attendance to therapy realized by 105 (91%) mothers, 7 fathers (6%) and 4 others (3%) (Figure 4). Figure 4: Attendance to therapy realized by 105 (91%) mothers, 7 fathers (6%) and 4 others (3%).
Most of the mothers were house wifes (%97), while most of the fathers were workers (%94) (Figure 2, 3). Figure 2: Most of the mothers were house wifes (97%), the rate of the state officers is 2% and mothers of free job is 1%.
DISCUSSION Paediatric Neurological diseases affect the mental motor development of the patients resulting in various impairments of the ability to co-ordinate muscle action to maintain normal posture and movement.7 Muscle weakness, abnormal muscle tone, restricted joint range, and decreased balance and coordination are associated with motor impairments. Cerebral palsy, Down syndrome and central nervous system infections are some of the pediatric neurological condition. Cerebral palsy is the most common condition responsible for physiotherapy attendance8 and affects as estimated
500,000 Americans.9 Furthermore spastic type was found to be the most common type.8,10 In this study we found that cerebral palsy was the most prevalent cause of physiotherapy attendance. The spastic type also represents the most type of cerebral palsies. These findings correlated with findings in the literature. Brain damage causing cerebral palsy may develop during the prenatal, perinatal or postnatal periods. Prenatal factors have a significant role in the cases. Prenatal factors lead to premature birth and/or intrauterine retardation of the infant.11 This research showed that 29 (25%) of these deliveries were as a premature while 2 (2%) deliveries were as late deliveries. It is also found that factors related to central nervous system infection, metabolic, storage disorders, congenital, developmental disorders, hereditary, familial genetic and chromosome anomalies disorders included a several conditions with different rates that caused brain damage and retardation such as Kernicterus, Rett Syndrome, Mapple Syrup Urine disease, Cytomegalovirus infection, and PelizaeusMerzbacher. Trauma, West syndrome and others unknown factors was recorded. In addition to the previous factrors of course the widespread prenatal, perinatal and postnatal factors such as pregnancy rsik factors, delivery risk factors, asphyxia, infections and injuries are common causes.12 Down Syndrome, spina bifida, and miopathies accounted for 12%, 16%,10% respectively of cases reviewed. Although these children experience postural and movement abnormalities which benefit from physiotherapy and rehabilitation 13,14,15 , the low prevalence seen in this study may be due however to the low prevalence of the condition in general population.8.Poliomiyalitis has the least percentage between the conditions which reflects its termination in the public. The negative impact of socioeconomic deprivation has been shown for many aspects of child mortality and morbidity but the relation between socioeconomic status and the risk of cerebral palsy is not clear. Low birth weight and prematurity are the strongest risk factors for cerebral palsy. Given the observed association between these factors and socioeconomic status, an increased prevalence of cerebral palsy with low socioeconomic status is expected. A strong association was observed between socioeconomic status and the risk of cerebral palsy.16 Other factors in child disability include poverty, lack of exercise, bad housing and poor diet are being
important.17 Marrying within family; genetic risks increase the chance of children being born with disabilities. Parents low educational level, intermarriage betweeen the family, high percentage of housewifes, free- worker position of fathers and high percentage of mothers who attends to children care may reflect a low socioeconomic level. ACKNOWLEDGEMENT The auther appreciate the cooperation of Prof. Dr. Erturul KILI at Yeditepe University-stanbul, and M.Yldrm Special Education centre and all physiotherapists at department of physiotherapy, stanbul, Turkey. REFERENCES 1. Michaud LD Prescribing Therapy Services for Children with Motor Disabilities, Pediatrics 2004; 113 (6): 1836-1838. Sanger T D, Delgado M R, Spira D G , Hallett M, Mink J W Classification and Definition of Disorders Causing Hypertonia in Childhood, Pediatrics 2003; 111 (1): 89-97. Bower E, Michell D, Burnett M, Campbell MJ, McLellan DL Randomized Controlled Trial of Physiotherapy in 56 Children with Cerebral Palsy Followed for 18 Months, Dev Med Child Neurol 2001;43 (1): 415. Kolobe H A, Palisano R J, Stratford PW Comparison of Two Outcome Measures for Infants With Cerebral Palsy and Infants with Motor Delays, Physical Therapy 1998; 78 (10): 1062-1072. Bower E, McLellan DL, Arney J, Campbell MJ A randomised Controlled Trial of Different Intensities of Physiotherapy and Different Goal-Setting Procedures in 44 Children with Cerebral palsy, Dev Med Child Neurol 1996; 38 (3): 226237. Hayes M S, Mc Ewen I R, Lovett D Next step: Survey of Pediatric Physical Therapists Educational Needs and Perceptions of Motor Control, Motor Development and Motor Learning as They Relate to Services for Children with Developmental Disabilities, Pediatric Physical Therapy 1999; 11(4): 164 182. Hurand J, Cochrane R Academic Performance of Children with Cerebral Palsy: A Comarative Study of Conductive Education and British Special Education Programmes, The British Journal of Developmental Disabilities 1995; 41 (80): 33-41.
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Peters G.O., Adetola A.,Fatudimu M.B Review of Paediatric Neurological Conditions Seen in the Physiotherapy Department of a Childrens Hospital in Ibadan, Nigeria, African Journal of Biomedical Research 2008; 11 (3): 281 284. 9. Nelson K B, Grether J K Causes of Cerebral palsy, Current Opinion in Pediatrics 1999; 11 (6): 487-491. 10. Kerem M M, Livanelolu A, Aysun S Importance of Eearly Diagnosis and Rehabilitation of Cerebral Palsy, Turkiye Klinikleri J Pediatr 2000; 9 (1): 23-7. 11. EL , Peker , Bozan , Berk H, Koay C General Features of Cerebral Palsied Patients, DE Tp Fakltesi Dergisi 2007; 21 (2): 75 80. 12. Reddihough D S, Collins K J The epidemiology and causes of cerebral palsy, Australian Journal of Physiotherapy 2003; 49 (1): 7-12. 13. Boureau F, Eymard B., Laforet P, Cottrel F Clinical
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Study of Chronic Pain in Hereditary Myopathies, Eur J Pain 2004; 8 (1): 55-61. McDonnell G V, McCann J P Issues of Medical Management in Adults with Spina bifida, Childs Nerv Syst 2000 16 (4): 222227. Lauteglager PEM, Vermeer A, Helders PSM Disturbances in the Motor Behavior of Children with Downs syndrome: The Need for a Theoretical Framework, Physiotherapy 1998; 84 (1): 5-13. Sundrum R, Logan S, Wallace A, Spencer N Cerebral palsy and socioeconomic status: a retrospective cohort study, Arch Dis Child 2005; 90 (1):1518 doi:10.1136/adc.2002.018937 Gyan S, Peter C, Subesinghe D, Wild J, Levene M I Prevalence and Type of Cerebral Palsy in a British Ethnic Community: The Sole of Consanguinity, Developmental Medicine & Child Neurology 1997; 39 (4): 259-262.
Effect of Postural Brace for Correcting Forward Shoulder Posture and Kyphosis in Patients with Chronic Obstructive Pulmonary Disease: A Pilot Study
Ravi Savadatti1, Gajanan. S. Gaude2, Prashant Mukkannava3 Principal, SDM College of Physiotherapy, Dharwad, 2HOD Respiratory Medicine, JNMedical College Belgaum, KLE University, 3Assistant professor, SDM College of Physiotherapy, Dharwad ABSTRACT Objectives: 1.To evaluate the effect of postural brace in correcting forward shoulder posture and kyphosis in patients with chronic obstructive pulmonary disease.( COPD) 2. To evaluate the effect of postural correction on inspiratory muscle strength in COPD patients. Design: A Pilot study comparing baseline values with post-test values. Subjects: A total of 30 subjects between age group of 45-60 years of either gender, diagnosed to have COPD with forward shoulder posture and Kyphosis were studied. Methods: Daily inspiratory muscle training(IMT) sessions of 30 minutes' duration and weekly training load increments of -2 to -4cmH2O over a 8-week period with the training device at loads of >30% of baseline maximal inspiratory pressure (PImax) was given. Posture was corrected by a brace and patients were asked to wear it throughout the day for 8 weeks. Outcome measures: Posture was assessed by Plumbline (PL), intra scapular distance(ISD) and percentage of kyphotic index(KI). Inspiratory muscle strength was measured by deriving maximal inspiratory pressure (PIMax) Results: All subjects tolerated the training load, improved their inspiratory muscle strength, and reported correction of posture. Conclusion: A combination of posture correction by a brace and inspiratory muscle training using TIMT is beneficial in improving posture and the strength of inspiratory muscles of COPD patients. Keywords: COPD, Posture, Kyphosis, Forward Shoulder Posture, Maximal Inspiratory Pressure forward shoulder posture (FSP) affects the respiratory values in COPD.1,11 There is excessive thoracic flexion in kyphosis and thoracic supportive device such as postural brace can be used to prevent excessive thoracic flexion, thus correcting posture. 14 Taking into consideration, the beneficial effects of IMT on strength of inspiratory muscles and the ill effects of bad posture in the form of dorsal Kyphosis and FSP on respiratory values in COPD, It is legitimate to question whether addition of postural correction with IMT has any beneficial effects in rehabilitation patients with COPD. Till date to our knowledge, none of the studies have reported weather IMT along with upper thoracic posture correction by a brace can have an additional effect on the strength of the inspiratory muscles in COPD. Hence the aim of this study was to evaluate the
INTRODUCTION There is decreased strength and endurance of diaphragm in COPD.1,2 The inspiratory muscles are placed at a suboptimal length for generation of muscle tension due to overinflation.3 Hence the diaphragm is susceptible to fatigue as a result of increased loading and diminished capacity to produce inspiratory force.3,5,6 Inspiratory muscle strength and endurance have been shown to be reduced in COPD.4,7 Patients experiencing dyspnea in COPD benefit from IMT, as strong inspiratory muscles help decrease dyspnea.8 However the efficacy of IMT is controversial and its use in a clinical setting is limited in patients with COPD. Patients with COPD will attend forward head, rounded and elevated shoulders. Posture such as Kyphosis, and
effect of adding postural correction to IMT in patients with COPD. METHODOLOGY Subjects: 30 subjects between age group of 45-60 years of either gender, diagnosed to have COPD with FSP and Kyphosis, from Physiotherapy OPD of S.D.M. Hospital, were studied and taken as per their inclusion and exclusion criteria. Inclusion and exclusion criteria: Inclusion criteria: Subjects having mild to moderate COPD (as per GOLD standards)9with FSP and Kyphosis. Subjects were excluded if they had any respiratory conditions other then COPD, cardiovascular, neuromuscular, or orthopedic diseases. All the individuals with fixed deformities of shoulder girdle and upper quadrant were also excluded from the study. Procedure: A routine method of evaluation and collecting data on COPD with FSP and kyphosis was done. Outcome measures such as Plumb line (PL), ISD (inter scapular distance) was assessed to know FSP. Kyphotic index(KI) was derived to know the percentage of kyposis and maximal inspiratory pressure (PI Max) was measured to know the strength of the inspiratory muscles. After briefing the subjects about the study, their written consent was taken and ethical clearance was obtained prior to the study. A plumb line was hung 3 feet in front of a wall with the plumb bob approximately a quarter inch off the floor anterior to the lateral mellolus. This point was considered as a reference point for assessing posture in lateral view. The subjects were in bare feet, wearing clothing that allowed for visual observation of body landmarks and standing between the wall and the plumb line. Subjects were asked to expose the external auditory meatus. The tip of the acromian process was marked with a skin marker. The distance from the tip of the shoulder (acromion processes and is termed as landmark) and the plumb line was measured with a scale. For the purpose of analysis, FSP was graded as normal or mild that is considered to be within normal limits(WNL) or grade 1 and was measured from center of landmark in line with or up to 1cm anterior to the plumb line, moderate deviations or grade 2 was measured from posterior border of landmark in line with or displaced up to 1 cm anterior to the plumb line , and severe or grade 3 was measured from posterior border of bony landmark displaced more than 1 cm beyond the plumbline.13,15 For measuring ISD the subject was made to stand in his or her relaxed posture with back exposed.The horizontal distance
between T3 spinous process and the vertebral border of both the scapulae was measured by an cloth inch tape. The distance was calculated in inches.15,16 Measurement of kyphotic index was done using a flex curve ruler of 60 cms. Initially, the subjects were asked to expose their spine and adopt their normal posture. C7 spinous process and posterior superior iliac spine(PSIS) level were marked.17 The flexicurve ruler was pressed against their back with the top end placed against the C7 spinous process in the midline. The ruler was molded into the shape of the subjects spine in the midline to the level of the PSIS. The flexicurve ruler was removed and the shape of the spine was then traced on a paper consisting of the horizontal line.The cervical end of the flexi curve was placed on the line and the distal end of the ruler was made to coincide with the other end of the horizontal line .The curvatures were then traced on the paper. Thoracic height (H) and thoracic length (L) was measured. The KI (%) was calculated as18 KI (%)= Thoracic height X 100 Thoracic length The larger the KI, the more marked is the Kyphosis. Inspiratory muscle strength was derived as PI Max which was measured with a Magnehelic pressure gauge(No. 2000-200cm) at residual volume (RV) with the highest pressure generated in five trials taken as PIMax. Initially the subject was made to sit and asked to exhale slowly and completely (to RV). Then he/she was asked to seal the lips firmly around the mouthpiece (to prevent air leak), and then inhale forcefully through the mouthpiece (as if he/she is trying to pull in hard, like you are trying to suck up a thick milkshake). The largest negative pressure sustained for 1 second on the pressure gauge was recorded. The participant was allowed to rest for about 1 minute, and then repeated the maneuver 5 times. The highest value recorded, was taken for the study. The mechanical pressure gauge has minor tick marks at 5cmH2O increments, so results were rounded to the nearest 5cmH2O19,20 Intervention: Threshold inspiratory muscle training device (TIMT) was used to training the inspiratory muscles. Subjects inhaled through the spring-loaded TIMT device that provides resistance to inspiratory muscles. The pressure settings are adjustable in 2cmH2O increments (range, -7cmH2O to-41cmH2O).The subjects were asked to inspire hard enough through the mouth piece to open the valve in the device and permit inspiration against that force. Nose clip were used to occlude nasal air flows. The initial training load
(resistance) was attempted at 30% of the patients baseline PI Max. As the strength improved to the point where subject were exercising for continuous of 30 minutes, then the pressure load was increased by2cmH2O. The advance in the pressure was up to, -40 cm H2O. TIMT was given with an intensity of 30% of PIMax for 30 min/ day for 8 weeks10 Posture was corrected with subject standing in upright posture and was asked to wear the brace (Vissco posture brace) that fitted best in upper thoracic region for a whole day (except while lying down) for 8 weeks. The outcome measures were measured at baseline (before intervention)and at the end of 8 weeks and 3 months of intervention. Data analysis: All analyses were done using SPSS Ver-sion 16. Descriptive statistics are reported as means and SD (standard deviation). A repeated measures analysis of variance for each individual outcome measure time was performed to determine if there was any change in scores at three time periods. The repeated measures of time were baseline, 8 weeks post intervention and 3 months post intervention. The data sphericity was tested using the Mauchly test. When the test results were statistically significant, the data were corrected using the Greenhouse-Geisser correction to determine if significant differences existed between conditions. For significant main effects, pairwise comparisons were performed between levels using t tests with a modified Bonferroni procedure. Significance was set at p < 0.05. To determine inter-rater reliability, the measurements from all the outcome parameters obtained by rater 1 and rater 2 at baseline, 8weeks and 3 months were sub-jected to statistical analysis using Intraclass Correlation Coe-fficient type 3,1 (ICC3,1)21. To determine
intra-rater reliability, the measurements from all the outcome parameters obtained in the first evaluation of rater 1 and in the second evaluation of the same rater at baseline, 8weeks and 3 months were analyzed using (ICC1,1)21. Utilizing data from SPSS, Standard Error of Measurement (SEM)22 as a measurement of the within subject re-test variation ( )23 were obtained.
Table 1: Discrpitive analysis and baseline characterstics:
Mean SD n Age in years Sex M/F ISD in inches Plumb line in grades Kyphotic index (%) PI Max in cm H2O 30 52.87 5.04 20 (67%)/10(33%) 5.35 0.71 1.97 0.76 11.20 0.90 60.33 12.79
For values ranged from 1.0 to 0.81, the reliability was conside-red excellent; from 0.80 to 0.61, very good; from 0.60 to 0.41, good; from 0.40 to 0.21, reasonable and, finally, from 0.20 to 0.00, poor1 RESULTS Descriptive statistics of all subjects is given in Table 1.The means and standard deviations for all outcome measures at baseline, 8 weeks and 3 months are shown in Table 2. The Repeated measures ANOVA for the ISD scores revealed a significant difference((F1.03,30.01)= 71.08,p<0.000) among three time periods. A post hoc pair-wise t test showed means of ISD scores for all three time periods(at baseline, 8 weeks post intervention and 3 months post intervention) were significantly different from one another (Table 2).
Table 2 Descriptive statistics [mean & SD] for the outcome measures for forward shoulder posture, kyphosis and inspiratory muscle strength between three time periods
1 Outcome Measures ISD (Inches) PL Scores(Grade) KI Scores(%) PIMax Scores(Cm H2o) Baseline Mean 5.35 1.97 11.20 60.33 SD (0.71) (0.76) (0.90) (12.79) Mean 4.73 1.27 10.38 90.67 2 8WeeksPost intervention SD (0.54) (0.64) (1.11) (19.82) Mean 5.08 1.53 10.85 81.17 3 3 MonthsPost intervention SD (0.61) (0.63) (0.98) (18.41) 0.000 0.000 0.090
(1-2, 1-3,2-3) (1-2, 1-3) (2-3) (1-2, 1-3,2-3) (1-2, 1-3,2-3)
p-value*
0.000 0.000
*Repeated measures analysis of variance .Post-hoc t tests with a modified Bonferroni procedure p < 0.05 statistically significant. ISD=Intrascapular Distance; PL= Plumbline; KI=Khyphotic index; PiMax=Maximal Inspiratory pressure There was 11.5% significant reduction (p<.000) of ISD scores after 8 weeks post intervention. The Repeated measures ANOVA for the PL scores revealed a significant difference ((F 2,58)= 22.06,p<0.000) among three time periods. A post hoc test showed means of PL scores differed at all three time periods (Table2).There was a statistical significant reduction(p<.000)of plumbline measurement after 8weeks of intervention
with improvement scores of 35.53%. The Repeated measures ANOVA for the KI scores revealed a significant difference ((F1.56,45.39)= 62.05,p<0.000) among three time periods. A post hoc pair-wise t test showed means of KI scores for all three time periods were significantly different from one another (Table 2). Kyphotic index scores reduced 7.3% significantly (p<0.000) following 8 weeks of post intervention. The Repeated measures ANOVA for the PIMax scores revealed a significant difference ((F 1.21,35.22 )= 195.78,p<0.000) among three time periods. A post hoc pair-wise t test showed means of PIMax scores for all three time periods were significantly different from one another.
Table 3 Inter-Rater Reliability (ICC 3,1) for all OutcomeMeasures

Outcome Measures ISD (Inches) Baseline 8th week 3months PL Scores (Grades) KI (%) PIMax (Cm H2O) Baseline 8th week 3months Baseline 8th week 3months Baseline 8th week 3months Rater 1 Mean 5.34 4.73 5.08 1.96 1.26 1.53 11.2 10.37 10.85 60.3 90.66 81.16 SD 0.71 0.54 0.61 0.76 0.63 0.62 0.89 1.11 0.97 12.7 19.8 18.41 Rater 2 Mean 5.48 4.72 5.18 1.96 1.36 1.63 11.5 10.3 10.77 61.5 88.16 79.16 SD 0.69 0.49 0.68 0.76 0.61 0.66 0.81 1.05 0.96 10.5 18.21 15.09 ICC 3,1 0.946 0.942 0.929 0.943 0.933 0.937 0.835 0.944 0.993 0.923 0.927 0.914 95%CI (.873; .976) (.878; .972) (.850; .966) (.938; .986) (.857; .968) (.867; .970) (.678; .966) (.883; .973) (.981; .997) (.840; .963) (.847; .965) (.821; .959) SEM 0.16 0.12 0.18 0.18 0.16 0.17 0.33 0.26 0.09 3.3 5.38 5.05
ISD=Intrascapular Distance; PL= Plumbline; KI=Khyphotic Index; PiMax=Maximal Inspiratory Pressure;SEM= Standard Error of Measurement
(Table 2).The maximal inspiratory pressure increased significantly by 50.29% following 8 weeks (p<0.000).The improvement was carried over till 3 months of followup in all variables except for PL scores(table 2).Inter-rater and intra-rater reliability estimates of all outcome measures at baseline, 8weeks and 3 months are shown in Table 3 and Table 4 respectively. Interrater ICC scores were Excellent, ranging from 0.83 to 0.94 for all measures with SEM ranging from 0.09 to 5.38 (table 3).Similarly Intra rarter ICC scores were Excellent, ranging from 0.956 to 0.999 for all measures with SEM ranging from 0.02 to 1.84 (table 4). Discussion: COPD is the leading cause of morbidity and mortality worldwide.12 Patients with COPD tend to develop FSP and Kyphosis.1,11, 24 these postural deviations affect the respiratory values1. This study demonstrates an 8-week intervention program with a 3
month follow up. Following intervention, both posture and inspiratory muscle strength improved in adult COPD patients after 8 weeks and the improvement was retained till 3 months of followup. Posture was corrected by a brace and correction of posture was associated with decrease in the intra scapular distance, kyphotic index and plumb line. IMT was given by a TIMT device and improvement in the inspiratory muscle strength was associated with increase in the maximal inspiratory pressure. Previous report 10 have demonstrated the use of TIMT device for training inspiratory muscles. IMT of 5 to 30 minutes for 6 weeks at loads of >30% of baseline PIMax improved patients inspiratory muscle strength, similar effects were found with 8 weeks of intervention and 3 months of follow up in this study (table 2).Poor posture along with weak back muscles, causes inability to straighten the upper back, which in turn limits the ability to raise and expand the chest and maximize the lung capacity.13
232 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 Table 4 Intrarater Reliability (ICC 1,1) for all Outcome Measures
Outcome Measures ISD (inches) Baseline 8th week 3months PL (grades) KI (%) PiMax (Cm H2O) Baseline 8th week 3months Baseline 8th week 3months Baseline 8th week 3months Rater1 (day1) Mean 5.34 4.73 5.08 1.96 1.26 1.53 11.2 10.37 10.85 60.3 90.66 81.16 SD 0.71 0.54 0.61 0.76 0.63 0.62 0.89 1.11 0.97 12.7 19.8 18.41 Rater1 (day2) Mean 5.35 4.73 5.11 1.93 1.26 15.3 11.2 10.38 10.88 60.5 90.83 81.5 SD 0.7 0.54 0.61 0.78 0.63 0.62 0.89 1.1 0.97 12.6 20.3 18.38 ICC 3,1 0.999 0.997 0.998 0.957 0.956 0.956 0.999 0.999 0.999 0.999 0.997 0.999 95%CI (.997; .999) (.995; .999) (.996; .999) (.909; .979) (.907; .979) (.908; .979) (.997; .999) (.998; 1.00) (.998; .999) (.997; .999) (.995; .999) (.997; .999) SEM 0.07 0.02 0.02 0.17 0.13 0.14 0.08 0.11 0.09 1.27 1.09 1.84
ISD=Intrascapular Distance; PL= Plumbline; KI=Khyphotic Index; PiMax=Maximal Inspiratory Pressure;SEM= Standard Error of Measurement
We assume that correction of posture with brace, would have aided in straightening the upper back and expanding the chest, thus having an additional beneficial effect on inspiratory muscle force generated by the inspiratory muscles. Hence postural correction might have influenced the increase in the PIMax values along with inspiratory muscle training. In this study we found a high inter rater(ICC 3,1)and intra rater (ICC 1,1) reliability ( table 3,4) for all measurements to evaluate posture and strength of the inspiratory muscles in COPD patients. CONCLUSION The results of this pilot study suggest that, TIMT device can be used to improve the strength of the inspiratory muscles. With addition of postural correction by a brace, not only improved posture but also aided in increasing the inspiratory muscle strength. Hence, posture correction needs to be given adequate importance in pulmonary rehabilitation of patients with COPD, however, despite the lack of a control group and the small size of the sample studied, we suggest that further study is warranted. REFERENCE 1. Hillegass and Sadowsky. Essentials of cardio pulmonary physiotherapy, 2nd ed. WB Saunders company,2001.p. 742. Verheul AJ, Dekhuizen PN.Diaphragm dysfunction in patients with COPD. Ned Tijdschr Geneeskd.2003;147(18): 855-60.
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18. Bembalgi V. A cross sectional study of skeletal deformities in post menopausal women in urban and rural areas.Indian journal of physiotherapy and occupational therapy,2010 june; 4(2): 87-88. 19. Sachs CM, Enright LP ,Hinckley Stukovsky KD, Rui Jiang and R Graham B, for the Multhi-Ethnic Study of Atherosclerosis Lung Study. Performance of Maximal Inspiratory Pressure Tests and Maximal Inspiratory Pressure Reference Equations For 4 Race/Ethnic Groups. Respiratory Care 2009;54(10):1321-1328, 20. Wen AS, Woo MS, Keens TG. How many maneuvers are required to measure maximal respiratory pressure accurately? Chest 1997; 111:802-807. 21. Weir JP. Quantifying test-retest reliability using the intraclass correlation coefficient and the SEM. J Strength Cond Res. 2005;19(1):231-40. 22. Peat JK, Mellis C, Williams K, Xuan W. Health science research: a handbook of quantative methods. London: SAGE Publications; 2002. 23. Harvill L. Standard error of measurement. Educ Meas. 1991;10:33-41. 24. OSullivan BS, Schmitz JT. Physical rehabilitation assessment and treatment. 4th ed. Philadelphia: FA Davis Company. publ; 2001:445-465.
Effect of Neck Extensor Muscles Fatigue on Postural Control Using Balance Master
Reshma S.Gurav1, Rajashree V.Naik2 Lecturer, MGM College of Physiotherapy, Kamothe, Navi Mumbai, 2HOD and Professor, L.T.M.C. and Sion Hospital, Sion, Mumbai ABSTRACT Background: Poor postural performance is observed in patients suffering from neck pain and following Whiplash injuries. Fatigued muscles following the neck pathology are unable to transmit somatosensory information to the central nervous system, and hence upright postural control may be compromised. Hence there is need to investigate neck muscles fatigue and balance. Objectives: 1.To assess the dynamic endurance of neck extensors till fatigue sets in. 2. To study the postural control pre and post fatigue in neck extensors. Methods: 50 healthy students participated in the study. Balance assessment was done on balance master with modified clinical test of sensory interaction and balance. Fatigue was induced in neck extensor muscles using pressure biofeedback apparatus in supine position. The posturographic data of sway velocity was obtained pre and post fatigue & analyzed with paired't' test. Results: Postural sway velocities in mCTSIB test showed significant difference after inducing fatigue in neck extensors (mean 0.14+0.22, P<0.001) Conclusion: It is speculated that from the fatigued neck muscles, altered sensory input leading to abnormal central processing may compromise balance, thereby reflecting a notable change in postural sway. Keywords: Fatigues, Postural Control, Sway Velocity. INTRODUCTION Balance, both literally and figuratively, is one of the most important concepts and functions in life. Historically balance has not been considered a critical factor in rehabilitation of orthopedic patients or perhaps the impact of these deficits on high-level functional outcomes had not been sufficiently documented. Yet balance deficits in orthopedic patients exist are often persistent, impede the return of normal function and increase the risk of re-injury.1 The crucial role of the sensory systems and the brain in producing skilled, co-ordinated movement is recognized by orthopedic physical therapist as evidenced by closed chain testing and training.1, 2 Neuromuscular re-education is necessary for efficient co-ordinated movement, which in turn is necessary for skilled function on the job or on the playing field.1,2,3 Balance a highly integrative process involving multiple afferent pathways, depends on somatosensory, visual and vestibular inputs for the reception of intrinsic (body) and extrinsic (environment) information. The brain for the integration of this information and the formation of a motor plan and musculoskeletal system for the production of adequate movements to execute the plan. Problems in any of these areas can lead to the imbalance. The known presence of proprioceptive deficits and musculoskeletal impairments in orthopedic patients should arouse the suspicion that balance problem may exist in these patients and research confirms these suspicions.1,2,3,4 Poor postural performance is observed in patients suffering from neck pain and following whiplash injury in which there is hyperextension injury and too much rotation at the cervical spine.Especially those who have had injuries or disruption of joint surface in the peripheral joints or spine such as whiplash injuries to the neck. The small intrinsic, deep dorsal and suboccipital cervical muscles show a high density of muscle spindles that are likely to provide a main contribution to neck proprioception.
If fatigued muscles are unable to transmit somatosensory information to the CNS, then upright postural control may be compromised. Therefore there is need to use a specific testing method to determine the correlation between the neck extensors fatigue and balance1, 5 In the erect standing posture, the body undergoes a constant swaying motion called postural sway or sway envelope. Physiological postural sway is defined as the continuous corrective movements around the center of gravity of a body designed to maintain postural control in the upright position while stand still.6, 7 Shumway- cook and Horak in 1986 suggested a method for clinically assessing the influence of sensory interaction on postural stability in the standing position. The purpose of the test is to identify abnormalities in the three sensory system contributing to postural control- somatosensory, visual and vestibular. In mCTSIB (Modified Clinical Test of Sensory Interaction of Balance) the level of challenge is increased by altering the support surface from the firm level forceplate to a complaint foam pad. Mean COG sway velocity assessed under four conditions: - In all conditions, low sway scores are good and high sway scores are worse.8 Eyes open, firm surface. Eyes closed, firm surface. Eyes open, foam surface. Eyes closed, foam surface. It was hypothesized that the balance would be significantly changed when the fatigue sets in neck extensors muscles. AIMS AND OBJECTIVES AIM To study the effect of neck extensor muscles fatigue on postural control using balance master. OBJECTIVES To assess the dynamic endurance of neck extensor muscles till fatigue sets in. To study the postural control on stable and unstable surfaces pre and post fatigue in neck extensor muscles.
MATERIAL AND METHODOLOGY Study Design: -Experimental within subject design. Selection Criteria -The study was carried out on subjects selected from physiotherapy department, K.E.M Hospital. The study was approved by the ethical committee, Seth G. S. Medical College and K.E.M Hospital and subjects gave informed consent to the work. 50 Normal healthy students volunteered for the study. Subjects of either sex within the age group of 20-25 years were included. There were no dropouts during the course of study. EXCLUSION CRITERIA Any history of cervical spine trauma. Neck pain or any type of musculoskeletal treatment taken for neck complaints in the past three months. Any balance disorders. Visual impairments not corrected by glasses. H/o ankle sprains / knee ligament injuries. STUDY MATERIAL Pressure biofeedback apparatus. Blood pressure apparatus (sphygmomanometer) and stethoscope. Balance master and foam Personal computer. Pentium 3, 128 MB, Neurocom software STUDY PROCEDURE Balance Assessment Balance master was connected to the personal computer for obtaining digital recording of postural sway. The subject was asked to stand still on the force plate as per the foot placement displayed on the computer screen. The four test conditions of modified CTSIB (m CTSIB) test administered each test for 10 seconds duration.
The four test conditions were always administered in chronological order Eyes open, firm surface (FIRM-EO) Eyes closed, firm surface (FIRM-EC) Eyes open, foam surface (FOAM-EO) Eyes closed, foam surface (FOAM EC) Posturographic data of sway velocity obtained for each test. Procedure for inducing fatigue in neck extensor muscles. The subject assumed a supine position on the plinth with head and neck placed in neutral position such that tragus of the ear and tip of the shoulder are in the same horizontal plane. Layers of towels were placed under the head to achieve the neutral position as needed. The air bag of the stabilizer was folded into three and placed behind the neck suboccipitally. The airbag was inflated to 20 mmHg as baseline. The subject was asked to perform the static neck extension over the inflated cuff. The maximal neck
extension contraction was noted on biofeedback apparatus. 60% of maximal voluntary isometric contraction was calculated and subject was asked to repeat that submaximal contraction as many times as possible and no. of contractions were counted. The biofeedback was held such that the performer and subject both can see the fluctuations on the pointer. When the subject was unable to exert the pressure at given sub maximal pressure values against the cuff he or she was allowed to stop and made to stand. The blood pressure was measured to rule out the effect of postural hypotension on balance. Again the subject was taken on the balance master and posturographic data obtained as earlier. The collected posturographic data was analyzed statistically with paired t test. Results and Graphical Representation Every condition of test and composite of all conditions of the test were analyzed witht test in which pre and post posturographic recordings were compared.
TABLE -1 - Comparison of Postural sway velocities in four test conditions of mCTSIB pre and post neck extensors fatigue
Sway Velocity (in degrees/sec) PRE POST DIFFERENCE P Value *statistically significant Mean Mean Mean Firm EO 0.23 0.32 0.11* P<0.001 Firm EC 0.27 0.34 0.07* P<0.1 Foam EO 0.60 0.68 0.08* P<0.01 Foam EC 1.50 1.56 0.06* P<0.05 Composite 0.61 0.73 0.12* P<0.001
Observation Postural sway velocities before and after neck extensors fatigue were compared using the pairedt test. There was significant difference between the Postural sway velocities demonstrated by subjects. In eyes open on firm surface the difference was highly significant (p value <0.001) whereas even though the postural sway velocities were high in eyes closed on foam surface the difference was significant. (p value <0.05). The difference between the postural sway velocities in composite of all test conditions was highly significant at p value <0.001. DISCUSSION As observed in this study, there was maximum increased postural sway in Eyes open, firm surface test condition, in spite of all the three sensory inputs were
available, which can be explained as because of neck muscles fatigue, the proprioceptors could not provide the accurate somatosensory inputs to the CNS, required for maintaining postural control and hence there was increase in postural sway. It can also be said that as this test was done immediately after the fatigue was induced hence the postural sway was maximum in this particular test condition as seen in graph 2. In Eyes closed on firm surface, when the visual information was unavailable, the postural sway was increased and the difference between pre and post sway velocity was statistically significant as in this condition subjects relied more on somatosensory and vestibular inputs. In test conditions on foam surface, there was additional challenge to musculoskeletal systems
because of inaccurate somatosensory information. As shown in table 3, the postural sway velocity was increased definitely and the difference pre and post fatigue was statistically significant. So it can be inferred that mechanoreceptors of the synovial facet joints and surrounding soft tissues of the cervical spine if affected by a spinal injury such as whiplash injury or chronic neck pain due to cervical spondylosis can alter postural control. Stampley et al (2006) in their study, Neck muscles fatigue and postural control in patients with whiplash injury showed that patients with whiplash injury show identifiable increase in neck muscle fatigability and associated increase in postural sway after contractions of dorsal neck muscles and physiotherapy treatment reduces these effects9. CONCLUSION The submaximal isometric contraction of the neck extensor muscles for maximal no. of repetitions produced changes in displacement of center of gravity and velocity of postural sway in young healthy subjects. Therefore this study accepts the hypothesis that the neck extensor muscles fatigue significantly affects the balance, which was confirmed by mCTSIB test. Abnormal central processing of sensory input may compromise balance in the setting of postural perturbations to a greater degree in patients with neck muscles weakness as in case of chronic neck patients and whiplash injuries. Ultimately, this may help us in developing objective evaluation procedure and the priority treatment goal for subjects suffering from neck complaints, thus taking care of all aspects of functional rehabilitation of the patients with neck complaints. ACKNOWLEDGEMENT This is to acknowledge the help and support extended to me by Head of the Physiotherapy
Department, my Guide, the Bio statistician, the Departmental Staff and to all my subjects. I wish to express my heartfelt gratitude to Mr. Vivek Nadkarni and Mrs. Tanuja Nadkarni and whole team of Neurocom international Ltd. I thank them for providing me balance master equipment and their valuable guidance and technical expertise in analyzing data. Their special interest and assistance has been guiding force in every step during the preparation of my study. I thank Dr.Yesha Pandya (PT) for technical help. REFERENCES 1. Kauffman, Nashner Lewis. Balance is critical parameter in orthopedic rehabilitation. Orthopadic Physical Therapy Clinics of North America.New Technologies in Physical Therapy. March 1997;(6-1) Lewis Nashner. The anatomic basis of balance in orthopedics. Orthopedic physical therapy clinics of North America. March 2002;(11-1) Blackburn TML, Voight , A matter of balance. Rehabilitation Therapies. June 2001. Guyton C, Hall JE. Textbook of medical physiology. Chapter 49, 50, 51, 52, 55, 9th Edition Mark Morningstar. Reflex control of the spine and posture, a review of literature from a chiropractic perspective. Chiropractic Osteopathy journal 2005; (13-16). Sharon Thomas. Functional Efficiency of the vestibular system in the performance of standing balance Sept. 2004. Shumway Cook, Motor control: Theory of practical Application, 2nd edition, 1995. Neurocom Internantional The clinical test for the sensory interaction of balance Description and definations. Stapley D.J. Neck muscle fatigue & postural control in patients which whiplash injury. Clinical Neurophysiology March 2006, (117-3): 610-622.
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Aerobic Capacity in Regular Physical Exercise Group and Indian Classical Dancers: A Comparative Study
Rupali B. Gaikwad1, Vijay Kumar R. waghmare2, D.N. Shenvi3 Assistant Professor, Dept. of Physiology, Govt. Medical College, Miraj Dist. Sangli, Maharashtra, 2Assistant Professor, Dept. of Anatomy, Govt. Medical College, Miraj Dist. Sangli, Maharashtra, 3Associate professor, Dept. of Physiology, Seth.G.S.M.C. & K.E.M.H., Parel, Mumbai, Maharashtra ABSTRACT Introduction: Dance in its many forms has recently received much attention in medical literature and considerable promotion in the lay press. This has been in keeping with current awareness of physical fitness, which has been the result of increasing evidence linking cardiovascular disease to physical inactivity, lack of cardiopulmonary fitness and obesity. One such program is aerobic or cardiovascular training program. Cardiovascular fitness is one of the most important health component required for performing more physical work with many health benefits. It is common notion that, only physical exercise provides fitness and is beneficial to health. Attempts have been made in the past to correlate other physical activities like ballet (western dance) with established physical exercise routines in gymnasium.1, 2. Indian classical dance is one of the physical activities as it is performed regularly. Material and Methods: The study group consists of 30 female subjects aged 17-30 yrs from each group who had received training in their respective physical exercise/ activity for a minimum duration of 6 months. Aerobic power was determined by simple exercise step test (Queen's College step test). Grading of aerobic capacity was done by using indirect estimation of VO2 Max. Results: Comparison in the given study groups showed that; not only conventional aerobic exercises but also any physical activity (Indian classical dance) performed regularly improved cardiovascular endurance of an individual. This improvement in endurance was statistically proved. Discussion: Comparison in the given study groups showed that; not only conventional aerobic exercises but also any physical activity (Indian classical dance) performed regularly improved cardiovascular endurance of an individual. This improvement in endurance was statistically proved. Conclusion: The mean value of the vo2 max in ml/kg/min was found to be higher in Indian classical dancers than females engaged in gymnasium. The number and percentage of females falling into good and average category was more in Indian classical dancers than females engaged in gymnasium. The percentage of Indian classical dancers from Bharatnatyam type falling into good category was more than Indian classical dancers from Kathak type. This concludes that the vo2 max in ml/kg/ml and aerobic capacity under grading into "good" and "average" category was more in Indian classical dancers than females engaged in gymnasium. Keywords: VO2 Max (Aerobic Power), Aerobic Capacity, Indian Classical Dance, Physical Exercise Group.
INTRODUCTION Less physical activity with relative sedentary life style habits leads to gradual deteriorations of physical wellbeing or even disability. Sports, exercise or everyday chores will help us to live longer. Today people are more aware of the fact that physical exercise will not only decrease the incidence of health problems but also lead to an improved quality of life and longevity. Subsequently a new fitness trend has
gradually developed over the last two decades which has led to a tremendous increase in the number of individuals who participates in fitness and wellness programmers. One such program is aerobic or cardiovascular training program. Cardiovascular fitness is one of the most important health component required for performing more physical work with many health benefits. It is common notion that, only physical exercise provides fitness and is beneficial to health.
Attempts have been made in the past to correlate other physical activities like ballet (western dance) with established physical exercise routines in gymnasium.1, 2 . Indian classical dance is one of the physical activities as it is performed regularly. There are very few studies 3, 4, 5,6,7,8 showing that Indian classical dance (BharatNatayam, Kathak) can provide health related fitness and endurance. MATERIALS AND METHOD Study was done in 2 groups First study group (engaged in physical exercise in gymnasium): comprising of 30 female subjects of age group 17 to 30 years. Second study group (Indian classical dancers): comprising of 30 female subjects of age group of 17 to 30 years. Inclusion criteria 1) Subjects ages 17-30 years. 2) Minimum regular six months training (with at least one session of one & half to two hours duration & minimum three days in a week.) Exclusion criteria 1) Subjects without regular 6 months training. 2) Subjects having any type of cardiopulmonary diseases like myocardial infraction, unstable angina, aortic stenosis, cardiac arrhythmia, acute endocarditis, myocarditis and pericarditis. Such subjects are excluded by history, general & systemic examination. METHODOLOGY Cardiovascular endurance assessment by Queens college step test: The equipments used: Stepping bench of height 16.25 inches, Metronome set at 88 beats / min or 22 steps ups / min for women. Stop watch, Scale for measuring height, weighing scale. Prior to testing, required pretest instructions will be given & test was properly explained & demonstrated to each subject. Calculations were done to obtain the results. Observations & results The Table No. I and the Fig.1 shows the Comparison
of VO2 max/ aerobic power in ml/kg/ min between Indian classical dancers & females engaged in gymnasium. The VO2 Max/ aerobic power in ml/kg/ min was to be higher in Indian classical dancers than females engaged in gymnasium. The difference was found to be highly significant with the p value of 0. The Table No. II show Comparison of actual & predicted VO2 Max/ aerobic power (ml/kg/min) in Indian classical dancers. There was difference in means of actual VO2 Max & predicted VO2 Max. The difference was found to be significant with the p value of 0.05. The Table No. III show Comparison of actual & predicted vo2 max / aerobic power VO2 Max (ml/kg/ min) in females engaged in gymnasium. There was no difference in means of actual VO2 Max and predicted VO 2 Max. The difference was found to be nonsignificant with p value of 0.05. The Table No. IV show comparison of aerobic capacity/fitness in both study groups; Indian classical dancers and females engaged in gymnasium. The total number and percentage of females from both study groups falling into average category was more compared to good and fair category. The total number and percentage of females falling into good and fair category was more in Indian classical dancers compared to females engaged in gymnasium. The total number and percentage of females falling into fair category was more which was from study group of females engaged in gymnasium only. DISCUSSION It is common notion that only physical exercise provides physical fitness & is beneficial to health. But it is found that any type of physical activity done regularly can improve cardiovascular endurance. Indian classical dance is one of the physical activities as it is done regularly. The VO2 max in ml/kg/ml and aerobic capacity under grading into good and average category was more in Indian classical dancers than females engaged in gymnasium. Following are the reasons. a) Muscle group involved The total muscle mass involved in Indian classical dance was much more and variable, moment to moment, in the entire duration of the activity in
comparison to females engaged in gymnasium. Predominantly the lower extremity is involved in the exercises performed by the females engaged in gymnasium. Thus higher the VO 2 Max in Indian classical dancers. The organism (inclusive heart) could tolerate a prolongation of the exercise period when larger mass of skeletal muscle were activated. The subjective feeling of strain was more related to metabolism. Therefore a training of the oxygen transporting system was more efficient and psychologically less strenuous, the larger the muscular mass involved in dynamic activities. 9 b) Duration Indian classical dancers were practicing for an average duration of 45-60min daily. In addition, they were also learning the skills for 3-4 days in a week. This might be classified as intermittent type of training method. (Teacher teaches dance step for 5 min then student dances for learning that step for 5 to 10 min.) Compared to Indian classical dancers, females engaged in gymnasium did the exercise for an average duration of 60 min. (15 to 20 minutes- treadmill, cross cycling, stepper; 30 min strength and flexibility exercise.) females did this training for 5-6 days on an average in a week. No threshold duration per workout exists for optimal aerobic improvement. If threshold exists, it probably depends on the interaction of total work accomplished (duration or training volume), exercise intensity, training frequency and initial fitness level. Generally, the more frequent and longer the endurance training programme is, the greater will be the fitness benefits10. c) Effect of Nritta, specific position, Natya, Nritya and music in Bharatnatyam. Bharatnatyam comprises three aspects, Nritta, Nritya and Natya. Nritta are rhythmical and repetitive elements, i.e. it is dance proper. Natya (Abhinaya) is the dramatic art, and is a language of gestures, poses and mime. Nritya is a combination of Nritta and Natya. Nritta in Bharatnatyam type includes complex steps in different postures with expressions which involve each and every part of the body of the dancer. In Nritta the whole body was made the instrument to produce
action. The solar plexus at the naval forms the centre from which all movements originate and are controlled by breath. The vibrations generated by Nritta lead to correction of energy imbalance in the body by acting upon nervous flexes or chakras a result of biochemical changes. Natya, Nritya and music were helpful in reducing the stress and increasing the functions of limbic system, reticular activating system, probably by releasing the neurotransmitters. This might help to elevate the mood and to keep the mind calm and alert. d) Effect of Kathak In Kathak physical activity is based on bhav (mood), raga (melody) and tala (rhythmic beat) mainly. Kathak dance is an art which has mainly vigor of dynamic foot work and pin point spins the subtle movements of the face and blended with miming of stories of all kinds. In Kathak workload was by bells around the ankles, leg exercise by tapping of feet in a high speed rhythm called Tatkar. Kathak dance improves and maintains cardiovascular endurance and respiratory fitness. Females engaged in gymnasium were performing exercises on treadmill, cross cycling and stepper with strength and flexibility exercises. Females engaged in gymnasium had speed, inclination variation while they were performing exercises on treadmill. e) Training period Training period varies among dancers & among females engaged in gymnasium. f) Goal
The goal of most of the Indian classical dancers is to attain expertise in a dance form, some of them wanted to make career in dance and few of them were dancing as a hobby. But the goal of the females engaged in gymnasium was to reduce weight to maintain figure, while some of them wanted to achieve for physical fitness. CONCLUSION .This concludes that the VO2 max in ml/kg/ml and aerobic capacity under grading into good and average category was more in Indian classical dancers than females engaged in gymnasium. Thus physical activity like Indian classical dance done regularly improved aerobic capacity/ cardiovascular endurance in dancers.
Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 241 Table I. Comparison of VO2 max/ aerobic power in ml/kg/ min between Indian Classical dancers & females engaged in gymnasium.
Samplesize VO2 max in ml/kg/ min mean S.D. S.E. of mean 0.4162 0.4584 Indian classical dancers vs. females engaged in gymnasium. t value Indian classical dancers Females engaged in gymnasium S.D. = standard deviation, 30 30 38.5975 33.7707 2.2798 2.5108 7.7952 p value P< o.oo1Highly significant
S.E. of mean = standard error of mean the unpairedt test was used for the test of significance.
Table II. Comparison of actual & predicted VO2 Max/ aerobic power (ml/kg/min) in Indian classical dancers.
Sample size Actual VO2 Max (Mean) Predicted VO2 Max (Mean) d S.D. Actual vs. predicted VO2 Max t' value IndianClassical dancers 30 38.5975 42.6068 4.0093 4.5042 4.875 p' value <0.05 significant t
d= mean difference, S.D. = standard deviation. The pairedt test was used for the test of significance. Table III. Comparison of actual & predicted vo2 max / aerobic power (ml/kg/min) in females engaged in gymnasium.
Sample size Actual VO2 Max (Mean) Predicted VO2 Max (Mean) d S.D. Actual vs. predicted VO2 Max t' value Females engaged in gymnasium. 30 33.7707 33.2747 0.4959 2.5188 1.0784 p' value <0.05Nonsignificant t
d= mean difference, S.D. = standard deviation the pairedt test was used for the test of significance. Table IV. Comparison of aerobic capacity/fitness in both study groups; Indian classical dancers and females engaged in gymnasium. Aerobic capacity based on age, gender and maximal oxygen consumption (VO2 Max) in ml/kg/min Good (%) Indian classical dance- Kathak Indian classical dance-Bharatnatyam Females engaged in gymnasium Total (%) 06(9.99%) 06(9.99%) 01(1.66%) 13(21.64%) Average (%) 11(18.33%) 07(11.67%) 09(15%) 27(45%) Fair (%) 0 0 20(33.33%) 20(33.33%)
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REFERENCES COHEN JL, S EGAL KR, Witrol I, et al., Cardio respiratory responses to ballet exercise and VO2 Max. of elite ballet dancers. Med Sci Sports Exerc. 1982; 14: 212-217. ROBIN D. CHEMELAR, BARRY B. SCHULTZ, ROBERt O. RUHLING, TERRY A. SHEPHERD, MICHAEL F. ZUPAN, SALLY S. FITT., A physiologic profile comparing levels and styles of female dancers. The Physician and Sports Medicine. July 1988; Vol.16, No. 7: 87-97.
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GABER C. E., MCKINNEY J. S. and CARTETON R. A., Is aerobic dance an effective alternative to walk jog exercise training? Indian Journal of Medical Research. 1968; 56, No.6, June: 845-849. HANNA J.L., the power of dance: health and healing. J Altern Complement Med. 1995; winter, 1(4): 323-331. MILLBURN S., BUTTS N. K., A comparison of the training responses to aerobic dance and jogging
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in college females, Med Sci Sports Exerc. 1983; 15(6): 510-513. N OVAC L. P., M AGILL L. A. and S CHUTTE J. E., Maximal oxygen intake and body composition of female dancers. Eur J Appl Physiol Occup Physiol. 1978; Oct 20, 39(4):277-282. PEPPER M. S., Dance a suitable form of exercise? A Physiological appraisal. S Afr Med J. 1984; Des 8, 66(23):883-888. Changes in selected cardio respiratory responses
to exercise and in body composition, following 12 week aerobic dance programme. Jr Sports Sci; winter, 4(3): 189-199. 9. ASTRAND P.O. and RODAHL K., Textbook of Work Physiology. 1988; Third edition, (London: MacGraw Hill), pp. 311,356,361. 10. Merle L. Foss.,Steven J Keteyian , Foxs Physiological basis for exercise & sports. 1998; Sixth edition, (MacGraw Hill), pp. 301-303.
Comparative Study to Determine the Hand Grip Strength in Type-II Diabetes Versus Non-Diabetic Individuals - A Cross Sectional Study
Jayaraj C. Sindhur1, Parmar Sanjay2 Associate Professor, Dept. of Medicine, 2Assistant Professor, Dept. of Physiotherapy, S.D.M. College of Medical Sciences & Hospital, Dharwad ABSTRACT Abstract: Background and objective: The diabeties is increasing in developing countries, many complication have been studied hand getting affected is one of them. As hand is major in human function. So objective of this study was to evaluate the grip strength in diabetic group and compare with non-diabetic individuals. Materials & Method: After obtaining ethical clearance, a pilot study was conducted and total 274 subjects 137 in each group that is diabetic and non-diabetic were assessed for hand grip strength and compared with each other. The standard method of assessment by using hand dynamometer and Body Mass Index was assessed by using stadiometer and weaning machine. After obtaining of the data analysis was done. Results: The mean age of diabetic group was 57.63 + 6.76 year, non diabetic mean age was 57.70 + 6.48. The mean Body Mass Index was 22.81 +2.04 kg/m2 and 24.62+3.06 in non-diabetic and diabetic group was respectively. The mean grip strength for the diabetic left hand was 13 kgs while non-diabetic it was 15kgs while right hand was 14kgs in diabetics and 16kgs was in non-diabetic individuals. Conclusions: We concluded that there is significant reduction in grip strength in diabetic group. It was increased as the duration of diabeties was increased. There fore incorporating grip strength evaluation and treatment at the earlier stages may help in preventing complication, which will also reduce the impact on functional disability in diabetic population. Keywords: Diabetes Mellitus, Grip Strength, Hand Dynamometer
INTRODUCTION As per word health organization (WHO), diabetes mellitus is a heterogeneous metabolic disorder characterized by common feature of chronic hyperglycemia with disturbance of carbohydrate, fat and protein metabolism is a leading cause of morbidity and mortality1. India leads the world with largest number of diabetic subjects earning dubious distinction of being termed the diabetic capital of world according to diabetes atlas 2006 published by the international diabetes federation, number of people with diabetes in India currently around 40.9 million is expected to rise to 69.9 million by 2025 unless urgent preventive steps are taken.2
Diabetes causes various system dysfunction and which leads to disabling function which include musculoskeletal disorder although other complication of diabetes are better recognized as cause of the morbidity and mortality. The musculoskeletal syndromes associated it with it may be very debilitating.3 The prevalence of connective tissue disorder in these patient has increased in the recent years affecting significantly their quality of life. Approximately 82.6% of individual with diabetes have been found to exhibit musculoskeletal abnormalities, mainly of the degenerative, non-inflammatory type musculoskeletal disorder are the common finding among patient with type II diabetes. It causes connective tissue in many ways which leads to different alteration in periarticular and skelectur system.4
The hand of human is remarkable instrument, capable of performing countless actions owing to its function as prehension and precision. The functional view point of the hand is the effectar organ of the upperlimb which supports it mechanically and allows it adopt the optimal position for any given action. However hand is not only motor organ but also a very sensitive and accurate sensory receptor, which feeds back information essential for its own performance.5 Grip strength is one of the many components to be considered in the examination of the hand function. The grip strength measurement can provide objective the quantifiable information regarding hand function.6 Less importance has been given to hand in diabetes mellitus, though hand function is crucial for productivity and quality of life.7 OBJECTIVE OF STUDY To study the hand grip strength in type II diabetes mellitus as compare to non-diabetes age matched individuals. HYPOTHESIS Null Hypothesis: There will not be difference in Hand grip strength in non-diabetic to diabetic individuals. Alternative Hypothesis: There will be difference in Hand grip strength in non-diabetic to diabetic individuals MATERIAL AND METHODOLOGY Department of medicine S.D.M. College Medical Science & Hospital Dharwad. MATERIAL 1. Data collection sheet including conset form 2. Hand dynamometer (IMI-1417) 3. Straight backed chair without armrest 4. Sphygmomanomenter (Diamond) 5. Steltho Scope (Littman) 6. Weighing machine (Koups) 7. Stadiomeler 8. Goniometer (IMR: 1432)
Inclusion Criteria Subjects of either gender of any age with type-II diabetics as diagnosed according to American Diabetic Association Criteria.8 Exclusion Criteria 1. Any musculoskeletal, Neurological, Disorder/ Injury 2. Subjects unwilling and not comfortable during procedure or before. Sampling: Convenient Sampling as all included. Earlier as diabetic group which were diagnosed. The sample derived from pilot study which came upto 274 individuals divided as 137 diabetic individuals and than age matched and gender, BMI matched individuals were taken for the study. PROCEDURE The study was approved by the SDM College of Medical Science & Hospital Ethical committee. Subjects with diabetics mellitus were screened by doing routine blood test and previous record which followed to the Principal Investigator. Grip strength was collected using Hand Dynamometer9,10. Inter- rater and intra rater reliability were assessed by a pilot study and r values were found to be 0.95 and 0.94 respectively. Before testing vitals were noted and the procedure was explained and demonstrated in local language. The position prescribed by the American Society of Hand Therapist was used. The dynamometer reading taken was mean was three trials for each hand. The dynamometer was reset to zero prior to each reading and was read to be nearest increment of the 2 scale division. 60 second rest was given between each trial. Each contraction was held for 3 seconds. 11 RESULTS
Table I . Distribution of Study Subject according to study groups and gender
Groups Diabetic Non-Diabetic Total Male 64 64 128 % 46.72 46.72 46.35 Female 73 73 146 % 53.28 53.28 53.65 Total 137 137 274
Table 2. Mean and standard Deviation or study samples according to groups

Groups Diabetic Non-Diabetic Total Mean age (Years) 57.63 57.70 57.66 Standard Deviation 6.76 6.48 6.61
Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 245 Table 3.Comparison of diabetic and non-diabetic groups with respect to grip strength (Kg) by unpairedt test.
Variables Grip strength kgs in left hand Grip strength in Kgs on right hand Groups Diabetic Non diabetic Diabetic Non diabetic Mean 12.820 15.006 13.868 15.960 SD 3.93 3.21 4.06 3.22 t value -5.034 -4.71 P-value 0.000
FUTURE SCOPE To study correlation between duration of diabetic and grip strength as a longitudinal study CONCLUSION
0.000
Significant at 5% level of significance (P<0.05)
DISCUSSION Hand is an important target for diabetic musculoskeletal complication. Much less attention has been given to the hand. Hand function is crucical for productivity and quality of life.12,13 The mean BMI was 25.18 kg/m2 in diabetic and 25.69 kg/m2 in non diabetic thus no significant difference was found. As BMI (Body Mass Index) said to influence grip strength. That is individual with higher BMI has higher grip strength. The Systolic Blood Pressure (SBP) & Diastolic Blood Pressure (DBP) was changed significantly this was true for both group. The recommended 3 second duration of hold and repetition of three times was used in study so as to register maximum reading. However isometric muscle contraction can cause in blood pressure and heart rate which was monitered by physician. The blood pressure values came to normal in 3 minutes.11 Hand grip values were significantly lower in diabetic group compared with control non diabetic group. This finding is in accordance with studies by Cetinus et al and Sayer et al, in there study evaluated muscle strength and physical function in 1391 diabetic subjects it was found that mean grip strength in diabetic was 41.8 kgs while as in normal non- diabetic it was 44.7 kgs. (P=0.002).14 Also reduction in grip strength is associated with power glycemic control with increased systemic inflammatory cytokines such as Tumor Necrosis Factor (TNF-) and interleukin-6(IL-6) have detrimental effects on muscle function. Distal symmetrical neuropathy which may present sebclinically is also responsible for distal muscle weakness and therefore attributes to low grip strength15. LIMITATIONS Work profile /level of physical activity were not taken into considerations
The objective of this study was to determine grip strength between diabetic and non- diabetic population. Thus we conclude that be grip strength gets reduction and early medical and physical therapy intervention may show better out come in hand function REFERENCES Mohan H. Textbook of pathology 5th ed New Delh: Jaypee Brothers Medical publisher 2005. P 842-48 2. Mohan V. Sandeep S.; Epidemiology of Type -2 Diabetes: Indian scenario Indian J. Med Res (serial online) 2007 March (cited 2008 Oct. 23); 25: 217-230 3. Joslin E. Joslins diabetes mellitus 14th ed Boston: Lippincott Williams and Wilkins: 2004, P. 1061-1121. 4. Browne D, Mc care F. Musculoskeletal disease in diabetes 18 (2); 62-64; 2009 5. Magee D. Orthopedic physical Assessment 4th edition penny sylovania Elsevier science; 2002, p 355-418 6. Kuzala EA, Vargo MC. The Relationship between elbow position and grip strength. Am J occup Ther 1992; 46 (6): 509-512 7. Cosanova JE, Young MS, Hand function in patient with diabetic mellitus, southern medical journal (serial online) 1991 September (citied 2008 September 10); 84 (9): 1111-1113 8. Stewart P. Diagnosis and classification of Diabetes mellitus. Diabetes care (serial online) 2008 Jan (cited 2008 Sept. 4); 31 suppl 1:55-60 9. McAradle WD, frank IK, victor L. Exercise physiology Energy, Nutrition and Human performance 6th ed Baltimore: Lippincott Williams and Wilkins: 2007 P 774-775. 10. Brown SC, Millor WC, JC ME: Exercise Physiology: Basis of Human Movement in health disease 6th ed London Lippincott Williams and Wilkins; 2007 P 529-530 11. Innes E. Hand grip strength testing: A review of the literature. Australian occupational therapy Journal (serial online) 1999 (cited 2008 August 2011); 46 ; 120-140 1.
12. Casanopva JS, Young MJ. Hand function in patient with diabetes mellitus. Southern medial Journal (serial online) 1991 Sept. 2008; 84 (9) ; 1111-1113 13. Savas, Hakanc, et al: The effects of the diabeties related soft tissue hand legion and the reduced hand strength on function disability of hand in type 2 diabetic patient. Diabetic Research and clinical practice 2007; 77: 77-83 14. Sayers, Dennison E- Type 2 diabetes, muscle
strength and impaired physical function. Diabetes care (serial online) 2005 (cited 2008 August 2011); 28 (10): 2541-2. 15. Goodpaster BH, Decreased muscle strength and quality in older adults with type 2 diabetes: The Health ageing and body composition study diabetes (serial online) 2006 Jun (cited 2008 October 2008); 55:1813-1818
Study of Correlation between Hypermobility and Body Mass Index in Children aged 6-12 Years
Parmar Sanjay1, Praveen. S. Bagalkoti2, Rajlaxmi Kubasadgoudar2 Assistant Professor, Department of Physiotherapy, 2Associate Professor, Department of Pediatrics, SDM College of Medical Sciences And Hospital, Dharwad, 2Consultant Pediatric Physiotherapist, Regional Neuroscience Centre, Hubli, Karnataka
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ABSTRACT Objectives: Joint hypermobility indicates an increase in the range of joint movement among normal individuals. Joint hypermobility commonly occurs in school age children (8-39%). Weight gain may precipitate the onset of symptoms of hypermobility syndrome. This study was done to assess the correlation between hypermobility and body mass index in children aged 6-12 years. Design: Cross sectional study Methods: Beighton score was used to evaluate 420 healthy children. One point was scored for each positive result (maximum: 9). Scores >4 were considered to be generalised hypermobility. Body mass index was calculated using height and weight of the children. Then, the data was evaluated statistically using SPSS 16.0 version statistical software and results were obtained. Results: The result showed that 57.14% of hypermobile children were under weight, 35.93% of hypermobile children had normal weight, 19.15% of hypermobile children were at risk of being overweight where as 16.67% of hypermobile children were overweight. A negative correlation (-0.0008) between hyper mobility and BMI was found. Conclusion: Hypermobility was more prevalent (57.14%) among under weight children aged 6-12 years. Keywords: Hypermobility, Beighton Score, 6-12 Years Aged Children, Body Mass Index
INTRODUCTION Generalised joint hypermobility indicates an increased range of motion in general compared with the mean range of motion. Generalised joint hypermobility is claimed to be present in 515% of general population.1 There is clear evidence that factors such as gender, age group, ethnic group, certain physical activities and their intensity, and the presence of certain pathological conditions, may be associated with joint mobility.2 Greater range of motion is inherently present in children than adults.3 The most widely used scale for hypermobility is the Beighton hypermobility score. It can be conducted easily and requires less time. A study done by van der Giessen LJ showed that Beighton score is valid in healthy children aged between 4 to 12 years.4 It is a practical and reliable method for defining hypermobility in children.
Ancedontal evidence suggests that sudden and substantial weight gain may precipitate the onset of symptoms, notably arthralgia, in previously asyptomatic hypermobile individuals. Despite the fact that no study has yet demonstrated an improvement in symptoms following weight loss, it would seem advisable to recommend such a measure to obese adults or children with the symptoms.5 There is no study done on correlation between hypermobility and body mass index in children aged 6-12 years. There is need for identifying body mass index in hypermobile children who are at risk of developing musculoskeletal complications. Education and therapeutic interventions can be targeted to this specific group of children before they become symptomatic and prevent further sequelae. In this study we assessed the correlation between hypermobility and body mass index in children aged 612 years.
METHOD Before commencement of the study, an ethical clearance from Shri Dharmastala Manjunatheshwara Institutional Ethical Committee, Dharwad was taken. Children from various schools of Dharwad were included in the study. Prior to the commencement of the study, a written consent letter was obtained from all parents. SUBJECTS 420 children aged 612 years were included, of which there were 252 boys and 168 girls. At first, all the children were screened by a paediatrician and children with skeletal problems such as fracture, neuromuscular disorder like cerebral palsy, rheumatic disorders, metabolic dysfunctions or disorders such as homocystinuria, developmental delay and genetic disorders such as downs syndrome were excluded. PROCEDURE Joint hypermobility was measured in five body areas
using Beighton score. One point was scored for each positive result (for each side), and scores of 4 or more points were considered to be generalised hypermobility. The children were categorized according to the scoring. Along with scoring the hypermobility, even height and weight of the children were taken. Body mass index (kg/mt2) was calculated using these height and weight measurements. According to CDC growth charts, the children were categorized as underweight, normal weight, at risk of being overweight and overweight groups. Statistical Analysis SPSS 16.0 version statistical software was used for statistical analysis. The investigator used Chi square test to evaluate the descriptive statistics that is distribution of study subjects by BMI and generalised hypermobility. Then, the Correlation between hyper mobility scores (i.e. only scores are greater than or equal to 4) with BMI scores was found out using Karl Pearsons correlation method.
RESULTS
Table1. Distribution of study subjects by BMI and hyper mobility.
BMI Underweight Normal weight At risk of being overweight Overweight Total Chi-square=12.5291 Normal mobility 9 214 38 15 276 df=3 p=0.0057, S % 42.86 64.07 80.85 83.33 65.71 Hyper mobility 12 120 9 3 144 % 57.14 35.93 19.15 16.67 34.29 Total 21 334 47 18 420 % 5.00 79.52 11.19 4.29 100.00
Table1 shows the distribution of study subjects with respect to BMI and hyper mobility. This table shows that 57.14% of hypermobile children were under weight, 35.93% of hypermobile children had normal weight,
19.15% of hypermobile children were at risk of being overweight where as 16.67% of hypermobile children were overweight.
Table 2. Correlation between hyper mobility scores with BMI scores by Karl Pearsons correlation method
Correlation between Hyper mobility scores (i.e. only scores are greater than or equal to 4) with Correlation coefficient BMI scores -0.0008 t-value -0.0099 p-value 0.9921
Table 2 shows correlation between hyper mobility scores (i.e. only scores are greater than or equal to 4)
with BMI scores. There was negative correlation coefficient of -0.0008 between hypermobility and BMI.
DISCUSSION The purpose of this study was to assess the correlation between hypermobility and body mass index in children aged 612 years. A study was done to know the prevalence of joint hypermobility in children from Mumbai, India and its association with malnutrition. 829 children of the lower urban socio-economic strata, between 3 and 19 years of age were evaluated independently by two observers for hypermobility using the Beighton 9-point scoring system. Their nutritional status was stratified using standard Indian growth charts and hypermobility was quantified in various nutritional groups. Musculoskeletal symptoms were assessed by a questionnaire given to parents. They found hypermobility in 58.7% of population. Near equal sex incidence was noted. A higher incidence of finger signs was noted in comparison to elbow hyperextension, knee hyperextension and hands to floor. 26% of the hypermobile population had musculoskeletal symptoms as compared with 17.2% of the non hypermobile population. A positive Beighton score was found in children with grade 3 and 4 malnutrition and 26.1% of those hypermobile had musculoskeletal to symptoms in comparison 17.7% of their non hypermobile counterparts.6 A population-based evaluation of generalized joint laxity (Hypermobility) in fourteen-year-old children from the UK was studied. Among the 6,022 children evaluated, the prevalence of hypermobility (defined as a Beighton score of >4 [i.e., >4 joints affected]) in girls and boys age 13.8 years was 27.5% and 10.6%, respectively. 45% of girls and 29% of boys had hypermobile fingers. There was a suggestion of a positive association between hypermobility in girls and variables including physical activity, body mass index, and maternal education. Girls who were obese were 2.7 times more likely to be hypermobile (adjusted OR 2.70 [95% CI 1.245.88]) compared to girls who were underweight.7 Our study showed that 57.14% of hypermobile children were under weight, 35.93% of hypermobile children had normal weight, 19.15% of hypermobile children were at risk of being overweight where as 16.67% of hypermobile children were overweight.
The limitations to our study was that further follow up regarding any complication secondary to generalised hypermobility was not carried out. Moreover, hypermobile children were screened subjectively and individual hypermobility were not documented (example, elbow hyperextension). No correlation between socioeconomic factor and hypermobility was studied. Future scope of this study will be long term follow up of any secondary problem in hypermobile group of various body mass index. CONCLUSION From this study, we can conclude that hypermobility is more prevalent (57.14%) among under weight children aged 6-12 years. REFERENCES 1. 2. Russek LN. Hypermobility syndrome. Phys Ther 1999 Jun;79(6):591-599. Lamari NM, Chueire AG, Cordeiro JA. Analysis of joint mobility patterns among preschool children. Sao Paulo Med J 2005 May 2;123(3): 119-123. Juul Kristensen B, Rogind H, Jensen DV, Remvig L. Inter-examiner reproducibility of tests and criteria for generalized joint hypermobility and benign joint hypermobility. Rheumatology (Oxford) 2007 Dec;46(12):1835-1841. van der Giessen LJ, Liekens D, Rutgers KJ, Hartman A, Mulder PG, Oranje AP. Validation of Beighton score and prevalence of connective tissue signs in 773 Dutch children. J Rheumatol 2001 Dec;28(12):2726-2730. Peter Beighton, Rodney Grahame, Howard Bird. Hypermobility of joints. 4th ed. Springer Verlag London Limited; 2012. p. 82. Hasija RP, Khubchandani RP, Shenoi S. Joint hypermobility in Indian children. Clin Exp Rheumatol 2008 Jan-Feb;26(1):146-150. Clinch J, Deere K, Sayers A, Palmer S, Riddoch C, Tobias JH, Clark EM. Epidemiology of generalised joint laxity (hypermobility) in fourteen year old children from the UK. Arthritis Rheum. 2011 Sep;63(9):2819-2827.
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Comparison of Reaction Time in Older Versus Middle-aged Type II Diabetic Patients - An observational Study
Shruti Bhat1, Sanjiv Kumar2 MPT, Dept of Neuro Physiotherapy, 2PhD Principal and Professor, Institute of Physiotherapy, KLE University, Belgaum ABSTRACT Introduction: Diabetes mellitus affects the various systems of the body like the somatosensory, auditory system and slows psychomotor and cognitive responses all of which together may affect the reaction time. Reaction time is the time taken by the individual to react or respond to a applied stimuli. Slowing of these reaction times affects the everyday tasks such as balance, increasing probability of a slip or a fall. Objective: The objective of the study was to evaluate and compare the reaction time of the middle aged and old age individuals with type II diabetes mellitus. Methodology: Thirty individuals having diabetes mellitus of age 40 to 60 were randomly allotted in two groups. The individuals between 40 to 60 years were allotted to Group A and those between 60 to 80 years were allotted to Group B. The reaction time of both the groups were evaluated by using Drop Ruler Test and compared. Results: Results showed that the reaction time in Group A was 0.19 seconds (0.01) and in group B it was 0.21 seconds (0.01). The reaction time was more in group B compared to group A but was not statistically significant. The co-relation co-efficient between age and reaction time of the two groups combined was r=0.605 Keywords: Diabetes Mellitus, Reaction time, Drop Ruler Test, Middle aged, Old age.
INTRODUCTION Diabetes mellitus a metabolic disorder of multiple aetiology. It is characterized by chronic hyperglycaemia associated with disturbances of carbohydrate, fat and protein metabolism. This may result due to defect in the production of insulin or its action or due to both the mechanism.1 India ranks first in the list of top 10 countries estimated to have the highest numbers of people with diabetes in 2000 and 2030. 2 The International Diabetes Federation (IDF) estimates the total number of people in India with diabetes to be around 50.8 million in 2010, rising to 87.0 million by 2030.3 Diabetes mellitus may present with characteristic symptoms such as thirst, increased frequency of urination, visual disturbances, and decrease in body mass. The condition is symptomless in initial stages but may give rise to various complications affecting various organs of the body like eyes, kidneys, nerves giving rise to conditions like retinopathy, nephropathy, and neuropathies respectively. Diabetes also affects the
central nervous system and Type 2 diabetes has been associated with cognitive impairments4 Reaction time is the time taken by an individual to react or respond to an applied stimulus. It is the time lapse between the stimuli and response shown by the individual. Reaction time is considered to be a putative component of higher cognitive functions 5 this reaction time is found to be increased in individuals with type II diabetes6. The reaction time depends on both the peripheral and central components of the nervous system. Impaired peripheral sensations and declined cognitive function, due to affection of central nervous system are the important factors for increased reaction times in diabetic individuals. One of the largest implications of increased reaction time is in the area of slips and falls. Falls are incurred by most of the diabetic population and are a common source of morbidity and mortality. Hence the assessment and improvement of reaction time constitutes an important part of management of individuals with type II diabetes.
Various studies are done to assess the reaction time in diabetic individuals by comparing with the healthy individuals but no study is done on comparison of these reaction times between patients with diabetes mellitus of different age group. Hence objective of this study was to compare the reaction time in middle age and old age type II diabetic patients. PARTICIPANTS 30 subjects diagnosed with type II diabetes from KLEs Dr. Prabhakar Kore Hospital And Medical Reasearch Centre, Belgaum and Vrudhashram were recruited in this study and divided in to two groups according to their age. Those between age 40 to 60 were allotted to group A and those between age 60 to 80 were allotted to group B. Group A had 15 patients (9 females and 6 males with mean age 50.4 yrs +/- 6.16 yrs) and Group B also had 15 patients (7 females and 8 males with mean age 70.2 +/- 4.73 yrs). PROCEDURE The participants were explained about the test to be performed and written consent was obtained from each participant. After obtaining the consent the patient was allotted to one of the groups according to his/her age. The reaction time in all subjects was tested using the Drop Ruler Test.7 A 30cm wooden ruler was used to perform the test. The subject was made to sit on a chair or stool with elbow supported on a table with wrist outside the table. The forearm was placed in midprone position. The ruler was then placed between the thumb and the index finger such that the finger and thumb are close but not touching the ruler. The 0cm mark on the ruler coincided with the borders of the fingers. The ruler was then dropped between two fingers without prior intimation and the subjects were asked to grasp it at their earliest. The distance at which the ruler was grasped was noted down and reaction time was calculated. The standard equation for freely falling bodies is Sf=1/2at2+vot+So.8 Where Sf is the average distance that the ruler fell, a is the acceleration of gravity (980 cm/sec2),t is the time that it takes the ruler to fall (the reaction time), vo is the initial velocity (zero) and
So is the initial distance (zero). Substituting in zero for vo and So simplifies the equation as Sf=1/2at2. Solving this equation for t yields dt=(2Sf/a) As the intra subject variability is high in this method 10 trials were conducted for each subject and the mean reaction time was taken for statistical analysis. Statistical analysis Mean baseline demographic values were calculated for the continuous variables and analysis was done to find the co-relation between age and the reaction time. The data was analysed in SPSS 16 using independent t-test to estimate the difference between groups in each outcome. The significance level was set at p<0.05. RESULT The data were collected from group A and group B which was analysed and assessed for the significance. (Table-1) The gender distributions among the groups were as follows; in group A there were 6 males and 9 females with mean age 50.4 (+/-6.16) years and in group B 8 males and 7 females with mean age 70.2 years (+/4.73) were included. The mean height of group A was 1.65 meter (+/-0.14) and group B the mean height was 1.61 meters (+/-0.13). Hence there were no significant difference between the groups and within the group as far as height was concerned. The weight of participants of group A was 65.21kg (+/- 4.17) whereas in group B it was 65 kg (+/- 11.02). Within the group there were moderate difference whereas inter group comparison does not show any significant difference hence it may be concluded that the group was homogenous. BMI was assessed and for group A mean BMI were 23.62 (+/2.38) thus signifies that there were hardly any overweight individuals included in group A. In group B mean BMI was 25.03(+/- 1.98) suggestive of presence of overweight individuals in this group. The reaction time was calculated in group A and found that mean reaction time was 0.19 seconds (+/- 0.01) and in group B 0.21 seconds (+/- 0.01). The reaction time of groups might be related to the BMI of the groups. The co-relation co-efficient between age and reaction time of the two groups combined is r=0.605
Table 1. Demographic details and outcome result

Gender A B T DF P<0.05 6 males9 females 8 males7 females Age 50.46.16 70.24.73 Height(m) 1.650.14 1.610.13 0.970 28 0.340 Weight(kg) 65.214.17 6511.02 0.058 28 0.955 BMI 23.62 2.38 25.03 1.98 1.574 28 0.127 Reaction time(s) 0.19 0.01 0.21 0.01 2.872 28 0.008
DISCUSSION A reaction time measurement includes the latency in the sensory neural code traversing peripheral and central pathways; perceptive, cognitive and volitional processing; a motor signal again traversing both central and peripheral neuronal structures; and finally, the latency in end effector (e.g., muscle) activation5. Many studies have been done to evaluate the reaction times in healthy individuals. A study on human reaction times found that in almost every age group, males have faster reaction times than females and also that while men were faster than women at aiming at a target, the women were more accurate.9 Here in the present study the difference of reaction times in females and males with diabetes was not calculated. A longitudinal study was done on 1,265 community-dwelling volunteers (833 males and 432 females) who ranged in age from 17 to 96 and cross-sectional analyses revealed slowing of simple reaction (SRT) and relatively greater slowing of disjunctive reaction time (DRT) across decades for both males and females. Repeated testing within participants over eight years showed consistent slowing and increased variability with age 10. In our study similar results were shown with group B having more reaction time compared to group A. Holmes et al. reported significant slowing of visual reaction time during a hospital clamp study at a blood glucose level of 16.7 mmol/l but were unable to replicate this subsequently using an auditory reaction-time task.11 The present study showed that hyperglycaemia is associated with increase in reaction time in diabetic individuals. There is increasing evidence that hypoglycaemic episodes are also critical factor in type 2 diabetes and older subjects aged more than 65 years, who represent the majority of type 2 diabetic patients, appear at a particularly high risk of experiencing severe hypoglycaemia. Hypoglycaemia unawareness in the presence of pronounced hypoglycaemia, induced reaction time prolongation in older type 2 diabetic patients 12. Earlier study on diabetic individuals concluded that middle-aged individuals with type 2 diabetes showed a greater decline in cognitive function than middle-aged individuals without diabetes 3. Another study on the effect of metabolic syndrome on cognitive function showed that subjects with metabolic syndrome showed poorer cognitive performance than subjects without metabolic syndrome, especially those with high levels of inflammation and hyperglycaemia was the main contributor of the association of metabolic
syndrome with cognition 13 . Study done on 20 individuals with type 2 diabetes with mean age 61.5 years concluded that during acute hyperglycaemia, cognitive function was impaired and mood state also deteriorated.14 These evidences show that the delay in the reaction time may be the consequence of somatosensory affection, cognitive decline and hypoglycaemic unawareness. In the present study there is increase in the reaction time in the second group but is not statistically significant. This increase may be due to age factor or episodes of severe hyperglycaemia. Another reason may be the increased BMI in the second group i.e group B. study on middle aged individuals concluded that increased BMI was associated with poor cognitive functions15. Comparison of type 2 diabetic subjects with normal individuals concluded that patients with long standing diabetes showed improved cognitive capacity with restoration of glycaemic control16. Hence it can be said that the decline in cognitive function in diabetes mellitus is rapid in the first few years after diagnosis and with progression of the condition the process of this decline is slowed down. This might be a reason why there was no significant difference in the reaction times between the middle aged and old aged diabetic individuals. The reaction time in Group B did not show statistical increase because the increased reaction time in them may be attributed to the old age more than presence of the condition. The further scope of this study is to evaluate large population of diabetic individuals and to take into account the duration of the condition which was not considered in the present study. CONCLUSION Our present study concludes that the slowing of reaction time in individuals with type II diabetes is more pronounced in the early stages of the condition and does not significantly worsen with the progression of the disease. REFERENCES 1. Definition, Diagnosis and Classification of Diabetes Mellitus and its Complications, Report of a WHO Consultation. World Health Organization Department of Noncommunicable Disease Surveillance Geneva 1999.
2.
A Ramachandran, AK Das, SR Joshi, CS Yajnik, S Shah, KM Prasanna Kumar. Current Status of Diabetes in India and Need for Novel Therapeutic Agents. Supplement To JAPI. 2010 June; 58: 7-9. 3. Astrid C.J. Nooyens, Caroline A. Baan, Annemieke M.W. Spijkerman, W.M. Monique Verschuren. Type 2 Diabetes and Cognitive Decline in MiddleAged Men and Women. Diabetes Care 2010, 33(9):19641969. 4. Christopher M. Ryan and Michelle O. Geckle. Circumscribed Cognitive Dysfunction in MiddleAged Adults With Type 2 Diabetes. Diabetes Care 2000, October, 23(10):14861493. 5. Ian J. Deary and Geoff Der. Reaction Time, Age, and Cognitive Ability: Longitudinal Findings from Age 16 to 63 Years in Representative Population Samples. Aging, Neuropsychology and Cognition,2005, 12:187215. 6. Samantha J Richerson, Charles J Robinson and Judy Shum. A comparative study of reaction times between type II diabetics and non-diabetics. 7. Ziaee Vahid, Kordi Ramin, Halabchi Farzin, Ghebleh Zadeh Mohammad and Kestidar Mohammad. Can We Promote Physical Fitness Among Medical Students By Education Program? J.Med.Sci, (4):300-306. 8. Reaction Time. Roy Coleman, Morgan Park High School Retired. 9. Tapani N. Liukkonen. Human Reaction Times as a Response to Delays in Control Systems. Kajaani Unit of Department of Information Processing Science, University of Oulu. 10. James L. Fozard, Max Vercruyssen, Sara L. Reynolds, P. A. Hancock and Reginald E. Quilter.
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Age Differences and Changes in Reaction Time: The Baltimore Longitudinal Study of Aging. The Gerontological Society of America, 1994. Daniel J. Cox, Boris P. Kovatchev, Linda A. GonderFrederick, Kent H. Summers, Anthony Mccall, Kevin J. Grimm,William L. Clarke. Relationships Between Hyperglycemia and Cognitive Performance Among Adults With Type 1 and Type 2 Diabetes. Diabetes Care 2005, january 28(1): 7177. Jan P. Bremer, Kamila Jauch-Chara, Manfred Hallschmid, Sebastian Schmid, Bernd Schultes. Hypoglycemia Unawareness in Older Compared With Middle-Aged Patients With Type 2 Diabetes. Diabetes Care 2009, 32(8):15131517. Miranda G. Dik, Cees Jonker, Hannie C. Comijs, Dorly J.H. Deeg, Astrid Kok, Kristine Yaffe, Brenda W. Penninx. Contribution of Metabolic Syndrome Components to Cognition in Older Individuals. Diabetes Care 2007 October, 30:26552660. Andrew J. Sommerfield, Ian J. Deary, Brian M. Frier. Acute Hyperglycemia Alters Mood State and Impairs Cognitive Performance in People With Type 2 Diabetes. Diabetes Care 2004, 27:2335 2340. M. Cournot, J. C. Marqui, D. Ansiau, C. Martinaud, H. Fonds, J. Ferrires, J. B. Ruidavets. Relation between body mass index and cognitive function in healthy middle-aged men and women. W. Hewera, M. Mussella, F. Ristb, B. Kulzerc and K. Bergis. Short-Term Effects of Improved Glycemic Control on Cognitive Function in Patients with Type 2 Diabetes. Gerontology 2003;49:8692.
Effect of Rehearsal Digit-Span Working Memory Intervention on Sensory Processing Disorder in children with Autism: A Pilot Study
Smily Jesu Priya V1, Jayachandran V1, Noratiqah S2, Vikram M3, Mohamad Ghazali M1, Ganapathy Sankar U4 Lecture, Department of Occupational Therapy, 2Student, Department of Occupational Therapy, 3Lecturer, Department of Physiotherapy, Universiti Teknologi MARA (UiTM), Malaysia, 4Associate professor, SRM University, Kattankulathur ABSTRACT This pilot study investigated the effect of rehearsal digit span WM training on Sensory processing disorder (SPD). Twenty children's with autism (6-9 years) were participated. The experimental group received combination modalities of rehearsal digit span WM training to SPD, while the control group did not receive. The duration of training was one hour, twice per day for ten sessions. The finding indicate that rehearsal digit Span WM intervention has significant changes in the auditory filtering and no changes in tactile sensitivity, movement sensitivity, low energy, visual/auditory sensitivity taste/smell sensitivity, seeks sensation and total score, since training was not conducted with controls. The study discusses consideration for future WM intervention on SPD for children with ASD. Keywords: Autism; Working Memory; Digit Span; Sensory Processing Disorder
INTRODUCTION Sensory processing disorder (SPD) is quite common among children with autism; literature reports a range of occurrence from 42% to 80% 1. Children with evidence of sensory processing dysfunction, such as those with autism, often have difficulty regulating their response to sensation and specific stimuli and may use selfstimulation to compensate for their limited sensory input or to avoid overstimulation2. These atypical sensory reactions suggest poor sensory integration in the central nervous system and could explain impairments in attention and arousal1. One area of executive function (EF) is which is frequently discussed in autism is working memory (WM). Among the many potential areas of deficit in autism is related with executive function3. The clinical presentation of sensory processing disorder in autism has been linked to deficits in executive functioning5. Executive function is an umbrella term for a set of subfunctions that are integrated throughout cortical and subcortical areas of the brain and used to carry out higher order cognitive tasks. Overall the evidence is mixed about the relationship between sensory processing disorder and executive deficits in autism, and it is unlikely that executive dysfunction is the primary explanatory model of these behaviors4. Still it is important to examine if executive function (working
memory) intervention also could account for the improvement of sensory issues in autism. This will allow researchers to determine whether working memory intervention will solve the sensory processing disorder in children with ASD. Despite the documented deficits in working memory (WM) in autism, relatively little research has been published on procedures for remediating these deficits. A small number of studies have evaluated approaches to improving working memory, often focusing on children with attention deficit hyperactive disorder (ADHD), fetal alcohol spectrum disorder (FASD) or Down syndrome. The rehearsal training program effectively improved the mnemonic performance of a child with down syndrome7. This finding was later replicated with typically developing peers. For example, authors found that WM span scores increased as a result of using a rehearsal strategy and positive reinforcement improves the WM in autism8. Sensory symptoms in autism also are impacted by cognitive maturation, at least in preschool-aged children. Researchers have found that lower mental ages are predictive of aberrant sensory features in young children with autism or other developmental disabilities9. Based on the previous studies there was a relationship between executive functions and sensory processing disorder in individuals with ASD, virtually
no research has been published in cognitive intervention to sensory issue problems. Therefore, the purpose of this was to examine the rehearsal digit span working memory intervention on sensory processing disorder in children with ASD. METHOD Research design We used a pretestposttest, control group design. This study was approved by the ethics committee as required (Institutional Review Board), and all parents provided consent for their childrens participation. Participants and setting Participants in the study were a convenience sample of children diagnosed with autism (n=20) on the basis of the Diagnostic and Statistical Manual of Mental Disorders criteria10. All participants were between ages 6 and 9 (mean [M] age = 7.4) (See Table 1). All participants with autism were selected from the Occupational Therapy Department and they were assigned to an experimental (n=10) and control (n=10) group. Inclusion criteria for this study included: Nonverbal intelligence scores within the average range on the Wechsler Intelligence Test11, language scores below the average range on the Clinical Evaluation of Language Fundamentals-Fourth Edition (CELF-4) 12, and no known auditory, neurological, or physiological basis for their difficulties. Exclusionary criterion included: A significant history of hearing problems or speech/ language difficulties, a diagnosis of dyspraxia, a core language standard score outside the range of 85 to 115 on the CELF-412, and for all participants, an inability to
recognize the numbers 1 to 9 in English.

Table 1. Distribution of Demographic Characteristics
Variables Group Gender Diagnosis Age (year) Experimental Control Male Female Autism MeanSD Range Respondents 10 10 13 7 20 7.401.155 69
INSTRUMENTATION Short Sensory Profile (SSP): This study used the SSP to assessed SPD (according to parent observation). The SSP, which is based on the Sensory Profile13,14, is a 38item caregiver questionnaire that was specifically designed to be used as a research instrument and screening tool to identify children with SPD (age 3 -10). The 7 sections of the SSP found in a normative sample are Tactile Sensitivity, Taste/Smell Sensitivity, Movement Sensitivity, Under-responsive/Seeks Sensation, Auditory Filtering, Low Energy/Weak, and Visual/Auditory Sensitivity. TASK DESIGN The four digit recall tasks were designed using the different combinations of visual and auditory modalities for both the input presentation and the childs response (output), as described in Table 2. All four tasks used digit sequences, which ranged from two to seven digits. In order to minimize the use of a chunking strategy, sequences did not include repeated or consecutive numbers. The four task types were used for both the DF and DB recall conditions. The digit recall tasks are available on the journals website at (http:// www.informaworld.com/ijslp).
Table 2. Outline of task designs used for digits forwards (DF) and backwards (DB) conditions
Task 1 Input Auditory Visual Support Output Verbal Visual Support Abbreviation Aud/Verb Description Participant listens to a digit sequence says the numbers aloud. No visual information is available. Participant listens to a digit sequence and says the numbers aloud while pointing to them on a full digit grid. Participant listens to a digit sequence while watching it on the screen and says the numbers aloud. Participant listens to a digit sequence while watching it on the screen and says the numbers aloud while pointing to them on a full digit grid.
Auditory
Verbal and motor
Aud/Verb-Mot
Auditory and visual
Verbal
Aud-Vis/Verb
Auditory and visual
Verbal and motor
Aud-Vis/ Verb-Mot
PROCEDURE Control group was not received training and experimental group received rehearsal training of four digit recall tasks using different combinations of auditory and visual input and output for a DF and DB recall. The duration of intervention was one hour, twice per day and total ten sessions. Prior to each task, the participants were given a short explanation outlining what they were required to do and some reminders. The tasks that used visual input or required gestural output included a 3-second presentation of the full digit grid before the task began, to familiarize the participants with the designated locations of the numbers. Each task began with four training items (two trials at a length of two digits and two trials at a length of three digits). This allowed the participants to become familiar with the demands of the task and receive feedback if they were a difficulty. The test sequences began at a length of two digits and progressed to a length of seven digits, with two trials at each length. The participant was required to score at least one of the two trials correct at each digit length to progress to a longer sequence. This design was adapted from Pickering.15. For each digit sequence, the tester controlled when it was presented and said go after its completion. The participants then gave a response and the tester recorded this online. A 3-second animation reward was then revealed on the screen.
The tasks for both the DF and DB conditions were presented in the following order: Task 1 (Aud/Verb), 2 (Aud/Verb-Mot), 4 (Aud-Vis/Verb-Mot), 3 (Aud- Vis/ Verb). Tasks with auditory only input were presented first, followed by those with mixed modality input. The DF and DB tasks were completed in separate sessions, with the DF tasks first and the DB tasks in the last session. Before starting the DF condition, each child was shown a full digit grid and asked to name the numbers. The tester pointed to each number in a random order to ensure automatic speech patterns were not used. If the child unable to recognize and name one or more of the numbers, they were excluded from further testing. Production of a correct sequence was given a score of 1, and a sequence where any number was incorrect was scored 0. If there was a discrepancy between the number the child pointed to and the number said aloud (regardless of whether one of these was correct), a score of zero was given for that sequence. RESULT Table 3 shows the pre- and post-test score for all participants for the SSP. The Wilcoxon Signed Rank test was to determine whether any differences in pre and post test for experimental and control group on SSP in children with ASD. The result showed that there was no significant changes were found in both experimental and control group (P > 0.05).
Table 3. Pre and post test scores for all participants on the SSP for both groups
Group Experimental Variable Tactile sensitivity Taste/smell sensitivity Movement sensitivity Seeks sensation Auditory filtering Low energy Visual/auditory sensitivity Total Control Tactile sensitivity Taste/smell sensitivity Movement sensitivity Seeks sensation Auditory filtering Low energy Visual/auditory sensitivity Total Pre test Median (IQR) 27.50 (9.00) 15.00 (3.00) 12.00 (2.00) 24.50 (7.00) 18.50 (5.00) 28.50 (3.00) 20.50 (8.00) 149.00 (17.00) 24.50 (14.00) 16.00 (9.00) 11.00 (2.00) 27.00 (14.00) 21.50 (9.00) 25.00 (5.00) 17.00 (2.00) 143.00 (34.00) Post test Median (IQR) 30.50 (4.00) 15.50 (5.00) 13.00 (4.00) 28.50 (7.00) 24.00 (4.00) 28.50 (2.00) 22.50 (4.00) 162.00 (15.00) 30.00 (11.00) 14.50 (9.00) 11.50 (5.00) 29.00 (12.00) 17.00 (5.00) 25.50 (7.00) 17.00 (9.00) 146 .00 (35.00) Z-statistic -1.604 -1.342 -1.414 -1.826 -1.826 -1.00 -1.604 -1.826 -1.342 -0.184 -0.816 -0.552 -1.105 -0.447 -0.365 -1.826 P-value 0.109 0.180 0.157 0.068 0.068 0.317 0.109 0.068 0.180 0.854 0.414 0.581 0.269 -0.447 0.715 0.068
Table 4 present Mann Whitney test was used to analysis post test between experimental group and control group in children with ASD. The experimental group displayed significant changes in auditory filtering than the control group, as measured by a SSP (P < 0.05, Z = 0.041), indicating that rehearsal digit span
working memory interventions were having impact on ASD. No significant changes were found between the two groups on tactile sensitivity, taste/smell sensitivity, movement sensitivity, seeks sensation, low energy, visual/auditory sensitivity and total (p > 0.05).
Table 4. Comparison between experimental and control group on SSP

Variables Tactile sensitivity Taste/smell sensitivity Movement sensitivity Seeks sensation Auditory filtering Low energy Visual/auditory sensitivity Total Experimental (n=10)Median (IQR) 30.50 (4.00) 15.50 (5) 13.00 (4.00) 28.50 (7.00) 24.00 (4.00) 28.50 (2.00) 22.50 (4.00) 162.00 (15.00) Control (n=10)Median (IQR) 30.00 (11.00) 14.50 (9.00) 11.50 (5.00) 29.00 (12.00) 17.00 (5.00) 25.50 (7.00) 17.00 (9.00) 146.00 (35.00) Z-statistic 0.00 -0.577 -1.169 0.00 -2.045 -0.899 -1.162 -1.732 P-value 1.00 0.564 0.243 1.00 0.041 0.369 0.245 0.083
DISCUSSION Results identified significant post-intervention changes in auditory filtering (see Table 4) between the groups, as determined by SPP scores in the area of sensory processing. The findings of this study show that auditory short-term memory performance can be improved in children with ASD through rehearsal strategies. Previous study suggested that since shortterm memory skills are strongly related to language acquisition, it is very important to improve these skills in children with ASD17. The rehearsal working memory intervention improved auditory filtering in experimental group. In this study, an experimental group applied rehearsal training on working memory with animation reward in children with autism. A reward is one type of positive reinforcement. Positive reinforcement provided motivation to the respondent to perform the digit span tasks. Researcher suggested that basic intervention (positive reinforcement) may be successful in improving working memory in children with autism8. No significant changes in the experimental and control groups were found in the scores on the SSP or from pretest to posttest. Many reasons could exist for the non significant results, ranging from a lack of rehearsal working memory and sensory memory training. With regard to the effectiveness of intervention, it may not fully reflect common clinical sensory processing disorder because recommendations for rehearsal into other working memory span were not provided. A previous study supported digit forward task involving central executive of Baddeley model of
working memory16 and increase cognitive demand of digit backward recall. The study stated that rehearsal training improves working memory capacity18. Children who not receive some specific training they do not show any significant changes in their performance. In addition, the sensitivity of the measurement tools may have influenced their ability to detect the changes. LIMITATIONS To fully interpret and apply the results of this study, several limitations should be considered. As with pretestposttest control group designs, a small sample was used; we had only twenty participants. Conclusions from the study should be interpreted and applied in the context of the small number of participating individuals. To increase external validity and generalizability of results, future researchers should include a larger sample size. Second, this study involved digit span task only as intervention and duration of treatment was short. Working memory involved many tasks such as listening recall, counting recall, word list matching, word list recall, Non-word list recall and others. Future researches to need to be examined all the combined tasks of activities to WM skills on sensory processing disorder. Third, this study was not used sensitive of outcome measures for sensory processing disorder in ASD. CONCLUSION This study provides preliminary support for using rehearsal digit span working memory intervention in children with ASD, although further research is
necessary. Results identified significant progress towards auditory filtering after rehearsal digit span working memory interventions, although no significant changes were found on the other components. Results suggest implementing intervention, that are generalized to home and community setting, using interventions that allow for individualized improvement in further studies, and completing future studies with a large sample. Moreover, WM is an essential skill for everyday life, and is an important link to skills, such as word learning and mathematics. ACKNOWLEDGMENT
6.
7.
8.
9. The authors would like to thank all parents or care taker for their co-operation with data collection. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/ or publication of this article. REFERENCES 1. Baranek GT: Efficacy of sensory and motor interventions for children with autism. Journal of Autism and Developmental Disorders 2002; 32, 397422. Roberts JE, King-Thomas L, Boccia ML: Behavioral indexes of the efficacy of sensory integration therapy. American Journal of Occupational Therapy 2007; 61, 555562. Hughes,C: Executive dysfunctions in autism: Its nature and implications for the everyday problems experienced by individuals with autism. In: J. Burack and T. Charman, Editors, The development of autism: Perspectives from theory and research 2001; (pp. 255275). New York: Erlbaum. OHearn K, Asato M, Ordaz S, Luna B: Neurodevelopment and executive function in autism. Development and Psychopathology 2008, 20, 11031132. Lopez BR, Lincoln AJ, Ozonoff S, Lai Z: Examining the relationship between executive functions and restricted, repetitive symptoms of autistic disorder. Journal of Autism and Developmental Disorders 2005; 35(4), 445460. 12. 10.
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Evaluation of Inter-Rater Reliability to Measure Hand and Arm Function in Reaching Performance Scale for Stroke Patients
SureshKumar T.1, Leo Rathinaraj A.S.2, Jeganathan A.3, Vignesh waran Vellaichamy4 Assistant Professor, Maharashtra Institute of Physiotherapy, Latur, 2Professor, Maharashtra Institute of Physiotherapy, Latur, 3Professor, MAEER's Physiotherapy College, Talegaon, Pune, 4Lecturer, Santosh College of Physiotherapy, Ghaziabad ABSTRACT Objective: This study is to assess the inter-rater reliability of Reaching Performance Scale test in hand function evaluation. Introduction: Stroke is defined as a rapidly developing clinical sign of focal or global disturbance of cerebral function lasting for more than 24 hours or leading to death due to no other reason than vascular origin. As there is high incidence of middle cerebral artery stroke, upper limb is more affected than the lower extremity and about 20% of the individual fail to regain any functional use of affected upper extremity. When a stroke patient attempts to move and encounters all the deficits the natural reaction is to compensate with available motor strategies. The measurement of the performance of the affected arm and hand of the patient with hemiplegia is important for determining the goal of intervention as well as outcomes of rehabilitation. So there is a need to have a scale that measures the quality of motor performances specific to the task and identify which elements of the task are missing and how they are compensated. Reaching performance scale is for the identification and quantification of movement pattern and their compensation during reach to grasp task in patients with upper extremity involvement after a stroke. Materials & Methodology: 30 Hemiplegic patients between age group of 40-60 years who met the inclusion criteria were selected and explained about the study and procedure, and the consent for the study was taken. The Type of study is Inter-rater reliability study (correlation). The Materials used were card board cone, Table, inch tape and a chair. Procedure: The patients were examined by two Physiotherapists respectively. The patient was seated in a chair with backrest but no arm rest. Reaching performance scale evaluated six components. For all patients both close target [Task I] and Far target [Task II] were assessed and graded. Only reach to grasp component of task are taken into account. The inter-rater reliability to measure the hand and arm function in Reaching Performance scale was statistically analysed by the Mann-Whitney test with P<0.05. Result & Conclusion: In this study the reliability between the investigators is very highly significant correlation of closed target (0.951) and P <0.05, Far target (0.946) and P<0.05. So we can conclude that inter rater reliability of RPS scale in assessing arm and hand function is high and hence RPS can also be used to assess the compensatory strategies in stroke patients for an effective intervention. Keywords: CVA, Stroke, Arm and hand function, Reaching Performance scale, Inter-rater Reliability, Compensatory strategies. INTRODUCTION Stroke is the third leading killer on western countries after heart disease and cancer. Among all neurological disease of adult life, the cerebro-vascular disease ranks first in frequency and importance. 1 Stroke or cerebro-vascular accident CVA is defined as a rapidly developing clinical sign of focal or global disturbance of cerebral function lasting for more than 24 hours or leading to death due to no other reason than vascular origin.2 The term CVA is used interchangeably with stroke of either ischemic or hemorrhagic lesions and affects approximately 7,00,000 individual a year out of them 75% have weakness in the upper extremity.3 With an estimated number of 5, 00,000 stroke survivors and the incidence of stroke increases dramatically with age, doubling every decade after 55 years of age. In India, the prevalence range is 20 per 1, 00,000 population and
in south India, the incidence of stroke is 56.9 per 1, 00,000 population.4 The most common insult to the brain results from middle cerebral artery lesion. More than two third are within the distribution of middle cerebral artery5. Owing to high incidence of middle cerebral artery strokes, upper limb is more affected than the lower extremity, about 20% of the individual fail to regain any functional use of affected upper extremity. Typically distal muscles more affected than proximal muscles.6 Grip strength changes accordingly to the size of object being grasped. In hemiplegics commonly grasp an object and then initiate the movement from the shoulder which places the hand in a non functional position 7 . Recent movement analysis studies shows that the patient with hemiparesis due to stroke, use excessive trunk and shoulder girdle displacement, when pointing to targets or attempting to reach and grasp objects placed within and beyond the reach of the arm8. Such excessive displacement is thought to be compensatory behaviour emerging from the efforts of spared cortical and subcortical system to compensate for lost control over motor function such as elbow extension and shoulder elbow inter joint co-ordination.9 Studies of motor recovery following stroke have shown that improvement in outcome measures such as speed, precision and variability of arm movement may be accomplished by compensatory strategies. For example in patients with severe hemiparesis, compensatory trunk movements that are used to extends the reach of the arm may limit the recovery of shoulder adduction and elbow extension needed for independent arm movement.10 A compensatory strategy used by stroke patients is the fixation of body segments. This may decrease the number of motor elements (degree of freedom).11 A negative consequence may be the lack of girdle mobility, which may limit the normal kinematics of upper and lower limb movement.12 The measurement of the performance of the affected arm and hand of the patient with hemiplegia is important for determining the goal of intervention as well as outcomes of rehabilitation.13 Functional outcome scale access the performance of daily living at the activity level and quantify whether task is performed with in the constraint specified by the test, while little attention is paid how the movement performed. Impairment scales assess the underlying impairment such as decreased range of motion or muscle weakness or how well the specific movement performs. Thus test evaluate movement or movement pattern having no
functional goal. Impairment scales identify the factor that may affect the performance of the task.14 So there is a need to have a scale that measures the quality of motor performances specific to the task and identify which elements of the task are missing and how they are compensated.15 Reaching performance scale is for the identification and quantification of movement pattern and their compensation during reach to grasp task in patients with upper extremity involvement after a stroke. These scales particularly focus on the transport phase of reaching, defined as the beginning of the movement until the object is grasped. This scale also includes a measure of compensatory strategies used for grasping. METHODOLOGY The purpose of the study is to assess the inter-rater reliability of Reaching Performance Scale test in hand function evaluation. 30 Hemiplegic patients between age group of 40-60years who met the inclusion criterias were selected by simple random sampling from various hospitals and rehabilitation centers. They were explained about the study and procedure, and the consent for the study was taken. The Inclusion Criteria include patients who Sustained with single Cerebro vascular accident, aged between 40-60 years, with duration of one month to five years, having good cognitive function, both the right and left side involvement. The Exclusion criterias were Patients who are not able to follow simple instructions, having any musculoskeletal condition that prevent test procedure, Non co-operative patients, flaccid stage and Mental retardation. The Type of study is Interater reliability study (correlation). The Materials used were card board cone [7 cms base & 17.5 cms height] , Table [72 cm height], inch tape and a chair [seat height 42 cms] to evaluate hand and arm function by using Reaching Performance Scale. PROCEDURE As the test procedure is to find the inter-rater reliability, the patients are been examined by two Physiotherapists respectively. Prior to performance, the patient were been instructed briefly how to carry out the test procedure. The patient was seated in a chair with backrest but no arm rest. The chair kept facing the table. The table and chair placed one arm distance of patients arm, keeping wrist on the table. Patient seated without leaning on the back support and patient feet flat on the floor. A card board cone kept on the table. Reaching performance scale evaluates six components
namely Trunk dissplacement, Movement smoothness, Shoulder movements, Elbow movements, Prehension and Task accomplishments. This is an ordinal scale and graded according to the patient performance. For all patients both close target [Task I grasping the cone placed 1 cm far from the front edge of the table] and Far target [Task II - grasped the cone placed 30 cm far from the front edge of the table] were assessed and graded. Only reach to grasp component of task are taken into account. As a procedure is a double blind one time study, in order to prevent scoring error, 3 successive readings is noted and a separate recording sheet is used for the two examiners and examiners were unaware of each others results. The inter-rater reliability to measure the hand and arm function in Reaching Performance scale was statistically analysed by the Mann-Whitney test with P<0.0 RESULTS
Table 1. Median and Quartile deviation for Close target
Close target Median 11.5 Quartile deviation 1.25
Shows the correlation of grasp between the 2 investigators. Statistical analysis reveals that spearmans rank correlation co-efficient is r = 0.946 [Far target] and the level of significance p = 0.000. Since the correlation is between the values -5 and +5 and level of significance is < 0.05, the correlation between the raters is very highly significant. Graph 1:
SCATTER DIAGRAM FOR CLOSED TARGET

20 15 10 5 0 0 5 10 15 20 INVESTIGATOR A
Graph 2:
INVESTIGAT OR B
INVESTIGATO R B
Table 2. Median and Quartile deviation for Far target

Far target Median 12.0 Quartile deviation 1.50
SCATTER DIAGRAM FOR FAR TARGET

20 15 10 5 0 0 5 10 INVESTIGATOR A
DISCUSSION This study was aimed at determining the inter rater reliability of Reaching performance scale test in assessing the arm and hand functions of stroke patients. The data analysis and statistical inference has reinforced the reliability of Reaching performance scale test. This study indicates reaching performance scale test is extremely reliable for each of the subscales as well as the total score when performed by different raters. Different users of RPS test achieved consistent
Table 3. Correlation between Investigator I and investigator II

Close target r-value 0.951 P-value 0.000 Result P<0.05[Very highly significant]
15
20
Shows the correlation of grasp between the 2 investigators. Statistical analysis reveals that spearmans rank correlation co-efficient is r = 0.951 [Close target] and the level of significance p = 0.000. Since the correlation is between the values -5 and +5 and level of significance is < 0.05, the correlation between the raters is very highly significant.
Table 4. Correlation between Investigator I and investigator II
Far target r-value 0.946 P-value 0.000 Result P<0.05(Very highly significant)
result. Recent movement analysis studies have shown that patient with hemiparesis due to stroke use excessive trunk and shoulder girdle displacement when pointing targets or attempting to reach and grasp object placed within and beyond the reach of the arm. Such excessive displacement is thought to be compensatory behaviour emerging from the efforts of spared cortical and subcortical system to compensate for lost control over motor function such as elbow extension and shoulder-elbow interjoint coordination. In the flaccid extremity as a result of CVA there is insufficient muscle tone to hold the glenohumeral joint in proper alignment due to the force of gravity and weight of the arm. The scapula placed in a downwardly rotated and abducted position (Ryerson and Levitt 1997). In the extremity with the spasticity unbalanced muscle activation can contribute to downward depression and retraction of scapula (O Sullivan 2001). Difficulty with Reach, and grasp occurs often in the patient with CVA. The factors that may cause changes in upper extremity function are unbalanced muscle pull, paralysis, decrease in sensation, secondary joint changes, pain and odema. These factors restrict the reach and grasp due to increase tone of muscle, the pattern that develops include internal rotation and elevation of shoulder, elbow flexion, fore arm supination or pronation, wrist and finger flexion. If this position of fingers and wrist flexion continues for longer periods, flexor tendons shorten. This cause increased difficulty in active or passive opening of the hand.16 To mask the impairment the patient always compensate with the other movement to accomplish the task. For example a patient with severe hemiparesis, compensatory trunk movements are used to extend the reach of the arm. This may limit the recovery of shoulder adduction and elbow extension needed for independent arm movement. Compensatory strategies in reaching activities of stroke patients are adaptive one. It invariably lead to other problems by causing altered movement or joint glides. Hence it is important for then to be evaluated and corrected. This scale particularly focuses on transport phase of reaching i.e. the beginning of movement until the object is grasped. This scale also includes measure of compensatory strategies used for grasping. Reaching performance scale test is constructed for assessing upper limb functional recovery. Performance evaluated for close and far targets. A wide range varying from acute stroke to chronic strokes were included in this study. The duration of the samples
included ranged from a minimum of 1 month to 5 years of post stroke. Mindy F Levin concluded that the interrater reliability of reaching performance scale in assessing arm and hand function was significantly high.17 In this study the reliability between the investigators is very highly significant correlation of closed target (0.951) and P <0.05, Far target (0.946) and P<0.05. So we can conclude that inter rater reliability of RPS scale in assessing arm and hand function is high and hence RPS can also be used to assess the compensatory strategies in stroke patients for an effective intervention. CONCLUSION This study led to the inference that the Reaching performance scale test used in assessment of hand function in stroke patient has got very high significant inter-rater reliability. The current study being an evaluative study, have assessed the functional recovery of affected upper limb, and the inter-rater reliability, so that it can be used for clinical and research purpose. The inter-rater reliability is found to be high, the clinical implication of this study is that this scale can be used either when two therapists treat the same patient or when the clinical data is shared and they will be able to interpret each other score without assessing the patient again. Though the inter-rater reliability of Reaching performance scale test was already proved but it was less compared with that of intra rater reliability and further studies was recommended. To conclude, the inter-rater reliability of Reaching performance scale test was analyzed and found that it is highly reliable, with high level correlation and significance in measuring hand function of stroke patients. ACKNOWLEDGEMENTS The authors are thankful to, Prof Dr.Koti Reddy M.P.T, Principal, Maharashtra Institute of Physiotherapy for kindly providing laboratory facilities to carry out this work. A special thanks to my senior Dr.Lenin, for being source of inspiration. Conflict of Interest There is no conflict of interest between the authors SOURCE OF FUNDING Nil
ETHICAL CLEARANCE This research study is given clearance under Ethical committee headed by Prof Dr.Koti Reddy, Principal, Maharashtra Institute of Physiotherapy, Latur. REFERENCES 1. Berg K O, Maki B E, Williams J, Holliday P, WoodDauphiner S L. Clinical and laboratory measure of postural balance in an elderly population J Phy Med Rehab. 1992 Nov, 73(11):1073-80. Berg K, Wood- Dauphiner S L, Williams J. The balance scale: Reliability assessment with elderly residents in patients with stroke. J Phy Med Rehab. 27:27-36.1995 Lawrence ES, Coshall C, Dundas R. et al, Estimate of the prevalence of acute stroke impairments and disability in a multiethnic population. Stroke. 2001; 32: 1279-1284. Bergk o Makib e ,Williams j , Holliday PJ woodDauphnier s l, clinical and laboratory measure of postural balance in elderly population j phy med rehab 1992 nov ,73 11. 1073-80. Catherene M, Dean M, Robeta B Sheaperd ,Task related training improve performance of seated reaching task after stroke 1997 ,28 ,722-728. Susan O Sullivan, Thomas PJ, Schimitz Physical reahybilitation assessment and treatment IV edi Chapter17;532-para3. Horak HB: The effect of movement velocity, mass displaced, and mass certainty on associated postural adjustment made by normal and hemiplegic individuals, J Neurol Neurosurg psychiatry 47:1020,1984. Michaelsen SM, Luta A, Roby-Brami A, Levin MF. Effect of trunk restraint on the recovery of reaching 9.
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movements in hemiparetic patients. Stroke.2002; 32:18751883. Horak FB. Assumptions underlying motor control for neurologic rehabilitation. In Contemporary management of Motor control Problems Proceedings of the II step conference. Alexandria, Va: Foundation for Physical Therapy;1991 :1127. Cirstea CM, Ptito A, Forget R, Levin MF. Arm motor improvement in stroke patients may depend on type of training.Soc Neurosci Abtstir.2000; 26:162 Brunnstrm S. Motor testing procedures in hemiplegia: based on sequential recovery stages. Phys Ther.1966; 46:357375. Levin MF. Interjoint coordination during pointing movements is disrupted in spastic hemiparesis. Brain.1996; 119:281294. Fisher B. Effect of trunk control and alignment on limb function, J head trauma Rehabilitation 2:72,1987. Mindy F Levin, Johanne Desrosiers, Danielle Beauchemin, Nathalie Bergeron and Annie Rochette. Development & Validation of a scale for rating moto Compensation used for reading in patients with Hemiparesis: The Reaching Performance scale. Physio therp Vol 84, Number 1, Jan 2004. Roby-Brami A, Fuchs S, Mokhtari M, Bussel B. Reaching and grasping strategiein hemiparetic patients.Motor Control.1997; 1:7291 . Dolores B Bertoti. Functional Neuro rehabilitation through the life span. 316-3rd para. Mindy F Levin. Development and validation of a scale for rating motor compensations used for reaching in patients with hemiparesis.Reaching Performance scale. Phys Ther 2004;84;8-22.
8.
Effect of Incentive Spirometry on Cardiac Autonomic Functions in Normal Healthy Subjects

Trupti Ajudia1, Pravin Aaron2, Subin Solomen3 Lecturer, Professor, Assistant Professor, Padmashree Institute of Physiotherapy, Bangalore
2 3
ABSTRACT Objective: Objective of the study was to examine the effects of Incentive Spirometry on cardiac autonomic functions in normal healthy subjects in 18-25 years age group. Material & Method: 30 subjects (n=15 in Study group and n=15 in Control group) were included in this study. The duration of study was 3 months. Primary outcome measures included cardiac autonomic function tests. Outcome measures were recorded before and 3 months after the study. Result: 3 months practice of Incentive Spirometry resulted in statistically significant change (p < 0.05) in following parameters - Basal heart rate, Immediate maximum heart rate, Steady state heart rate, Steady State heart rate (time in seconds) during heart rate response to Standing test; Minimum heart rate and Deep Breathing Difference (DBD) during heart rate response to Deep Breathing test. Conclusion: 3 months practice of Incentive Spirometry changes autonomic function response. Keywords: Breathing Exercise, Pranayama, Incentive Spirometer, Autonomic Functions.
INTRODUCTION Breathing exercise is defined as the therapeutic intervention by which there is purposeful alteration of a given breathing pattern.1 Breathing exercises are fundamental interventions for prevention and comprehensive management of acute or chronic obstructive pulmonary disorders, for patients who have undergone thoracic and abdominal surgical procedures, for patients with central nervous system deficit, for psychological conditions or for patients who are bedridden for extended period of time.2,3 It is known that the regular practice of breathing exercise (Pranayama) increases parasympathetic tone, decreases sympathetic activity, improves cardiovascular and respiratory functions, decreases the effect of stress on the body and improves physical and mental health.4 Pranayama has been researched mostly for its beneficial application in treatment of cardiovascular diseases,
pulmonary disease, autonomic nervous system imbalances and psychological or stress related disorders.5-7 Different forms of pranayama activate different branches of the autonomic nervous system.5 Incentive Spirometry (IS), also referred as sustained maximal inspiration (SMI), is designed to mimic natural sighing or yawning by encouraging the patient to take long, slow, deep breaths by using a device that provides patients with visual or other positive feedback when they inhale at a predetermined flow-rate or volume and sustain the inflation for a minimum of 3 seconds.8,9 Studies have suggested that Incentive Spirometer is effective mean as prophylaxis and as part of intensive post-operative physiotherapy program following cardio-thoracic and abdominal surgeries, 10-13 for pulmonary hygiene with sickle cell disease and neuromuscular diseases, as well as a rehabilitation tool with COPD.14-16 Some of the proposed benefits of Incentive Spirometer are - subjects can assume responsibility for their own treatment without any harmful side effects, thus reducing the amount of direct patient contact time with therapist, 10 provision of prolonged phase of effective inspiration, more controlled flow and greater enthusiasm to practice, suitable to children and those with learning difficulties because it can be learnt by demonstration.17
Corresponding author: Trupti Ajudia Lecturer, Padmashree Institute Of Physiotherapy, #23 Gurukrupa Layout, 80 Feet Ring Road, Nagarbhavi, Bangalore - 560072, India Ph(cell): +91-9989824237 E-mail: Trupti_Patel_511@Yahoo.co.in
STATEMENT OF PURPOSE Studies have proven that practice of pranayamic type of breathing exercises can produce significant effects on autonomic functions. Since, which is a SMI, is also one type of slow breathing exercises, similar results in terms of changes in autonomic response can be expected with use of IS-training. Therefore, there exists the need of the study to find out the effect of IS on cardiac autonomic functions. Therefore, this study was designed to assess the effect of IS on cardiac autonomic functions in normal healthy subjects in the age group of 18-25 years. SUBJECTS AND METHOD The study was conducted at Padmashree Institute of Physiotherapy, Bangalore on 30 male and female undergraduate physiotherapy student volunteers. The inclusion criteria were: subject should be in the age group of 18-25 years, should be non-smoker and free from major health problems. Subjects who were unwilling or unable to complete the study or had cardiorespiratory problems or were practicing any form of regular breathing exercises were not included. Prior to participation, a written-informed consent was taken from all subjects and subjects were informed about study protocol. Ethical clearance for the study was obtained from the Institutional Ethical Committee, Padmashree Institute of Physiotherapy, Bangalore as per the ethical guidelines for Biomedical Research on Human subjects, 2001 ICMR, New Delhi. PROCEDURE The subjects were instructed not to practice any other physical exercise or yogic technique other than the prescribed one. Subjects were randomly assigned to Study group (n=15) and Control group (n=15). Autonomic function tests were performed before and 3 months after the study period for both groups. Study group: Study group subjects were given training to learn and perform IS. The subjects were instructed to perform Incentive Spirometry (MediciserTM Respiratory Exerciser) for 10 repetitions every waking hour for 3 months.17 The IS exercise was performed as below The subject was asked to sit relaxed on a chair. Incentive Spirometer was held with one hand; other hand supporting the tube with mouth-piece which was inserted inside mouth. The subject was asked to inhale inside the mouthpiece till he/she can raise two balls in the Incentive -
Spirometer (Third ball as a control) and sustain it for 3 seconds. Same procedure was repeated for 10 times per session.
Control group: Control group subjects were not allowed to perform IS. The autonomic function test recordings were performed in the afternoon (between 2 and 5 pm) at the Padmashree Diagnostic Centre, Bangalore. The subjects were instructed not to take tea, coffee or any drinks 1 hour before and any food 2 hours before the recordings in order to exclude the effects of food and water intake on the recordings. Before performing the test, subjects were given enough rest of 15-20 minutes. Altogether, 30 subjects completed the study and there was no dropout. The following cardiac autonomic function tests were performed following the procedures described by Banister and Mathias.4,18 Heart-rate response to Standing
The subjects were allowed to lie down for 5 min in supine position and ECG leads (GE Medical system MAC1200 ST) were connected. The basal heart rate was noted from the heart-rate counter in the polygraph. The subject was then asked to stand up immediately and changes in the heart-rate (HR) were recorded from the polygraph. The manoeuver was repeated 3 times at an interval of 5 min between each and the mean of three was taken for recording. Heart-rate response to Deep Breathing
This was done with subjects in sitting posture with ECG leads attached to polygraph. The subject was asked to take a deep breath (deep inhalation followed by deep exhalation) and HR changes during these respiratory phases were recorded from the polygraph. This procedure was repeated for 3 times at 5 min interval and best of three was taken for calculation. STATISTICAL ANALYSIS Statistical analysis was performed using SPSS software (version 17). Alpha value was set at 0.05. Descriptive statistics was used to find out mean and standard deviation (SD) for demographic and outcome variables. Chi-square test was used to test for gender difference among both groups. Paired t-test was used to measure the outcome variables before and after training within Study and Control group. Unpaired ttest was used to test the age, height and weight differences among both groups and also to measure outcome variables between Study and Control group.
RESULTS Baseline characteristics of 30 male and female volunteers of Study and Control groups are shown in Table 1. Control group didnt show significant change for both autonomic function tests. Test 1: HR response to Standing (Refer Table 2) In Study group, the post-score Basal HR was significantly more compared to pre-score value. Immediately on standing, Max HR attained in the Study group was significantly more in comparison to their pre-score values. Post-score Steady state HR of Study group was significantly more compare to post-score
data of Control group. Time for achieving the Steady State HR was significantly less following 3 months of IS-training compare to pre-score value in Study group as well as post-score Steady State HR (time in sec) in Control group. Test 2: HR response to Deep Breathing (Refer Table 3) Post-score Min HR of Study group was significantly more in comparison to their pre-score data as well as to post-score Min HR in Control group. Post-score DBD was significantly less in Study group compare to postscore DBD in Control group.
TABLES
Table 1: Baseline data for demographic variables
Variable/Group Age(years) Gender(Male/Female) Height(cm) Weight(kg) Study Group (n=15) 19.860.91 7/8 166.46.5 53.25.7 Control Group (n=15) 20.460.83 9/6 164.88.4 57.17.3
Data are mean SD; p-value < 0.05, Comparison of groups at baseline showed no significant difference.
Table 2: HR response to standing in Control Group and Study Group

Control Group Pre-score Basal HR Imm Max HR Mean Beat Steady state HR Steady state HR(time in sec) Data are mean SD 78.466.0 106.9312.3 28.468.9 859.3 32.220.9 Post-score 77.465.4 105.3310.6 27.868.9 836.6 32.241.0 Study Group Pre-score 77.468.45 103.210.9 25.808.09 8810.24 30.763.86 Post-score 82.538.9* 109.5312.0* 27.008.90 90.88.39 29.43.32*
*Statistically significant at p < 0.05, comparison made between Pre-score and Post-score data of Study group Statistically significant at p < 0.05, comparison made between Post-score data of Control and Study groups Basal HR: Mean basal HR in supine posture after 5 min of rest; Imm Max HR: Immediate mean maximum rise in HR after standing; Mean beat: the mean beat at which Imm Max HR was achieved; Steady state HR (time in sec): Mean HR in standing position after reaching a steady state (the time in seconds at which this was achieved)
Table 3: HR response to deep breathing in Control Group and Study Group

Control Group Pre-score Basal HR Max HR Min HR DBD Data are mean SD 80.335.2 100.0611.0 74.87.0 25.28.5 Post-score 79.265.0 98.810.3 74.16.5 24.667.8 Study Group Pre-score 79.666.8 9812.31 75.5312.63 22.467.91 Post-score 838.96 101.67.9 83.3310.36* 18.267.54
*Statistically significant at p < 0.05, comparison made between Pre-score and Post-score data of Study group Statistically significant at p < 0.05, comparison made between Post-score data of Control and Study groups
Basal HR: Mean HR in sitting posture after 5 min of rest; Max HR: Mean maximum HR recorded during deep inspiration; Min HR: Mean minimum HR recorded during deep expiration; DBD: Difference in HR between the maximum during inspiration and the minimum during the expiration DISCUSSION The baseline data of the demographic and outcome variables did not show any statistically significant difference between the subjects in the Study and Control groups. Test 1: HR response to Standing In normal resting subject, Basal HR is the function of parasympathetic system.4 In this study, significant increase in post-score Basal HR in Study group indicates that the practice of IS may be improving sympathetic activity. On immediate standing, HR increases and continues to rise for next several seconds.19,20 Following this, HR falls to minimum and then rises again to stabilize at Steady State HR.4 HR response to Standing assesses the integrity of parasympathetic cardiovagal function.19 In this study, post-score Imm Max HR was significantly more in Study group. However, it may be argued that the maximum increase in HR was more in Study group because their post-score Basal HR following 3 months of IS-training was more. Following standing from supine position, subsequent HR changes are baroreceptor mediated which enhance sympathetic tone. 19 Therefore, significant increase in Steady State HR in Study group indicates that there may be improvement in sympathetic activity. In this study, the stabilization of heart rate following the standing occurred in less time compare to its prestudy counterpart which indicates that there may be improvement in parasympathetic activity. Study done by G. K. Pal (2004) showed that Steady state HR (Time in sec) was reduced by more than 100 seconds to consider it as increased parasympathetic activity.4 However, in this study, reduction in Steady State HR (Time in sec) within Study group and in between Study and Control groups were 1.36 sec and 2.84 sec respectively, which were negligible changes. Therefore, 30:15 ratio could be considered as more appropriate measure of parasympathetic function.21
Test 2: HR-response to Deep Breathing Following HR-response to Deep Breathing, postscore Min HR was significantly more in Study group compare to post-score Min HR in control group. The variation of HR with respiration is known as Sinus Arrhythmia, which is generated by autonomic reflexes. Inspiration increases HR and expiration deceases HR i.e. during inspiration, vagal activity decreases and sympathetic activity increases. Opposite mechanism occurs during expiration.4,19 Thus, increase in Min HR during expiration in present study indicates that there may be predominance of sympathetic activity. Significant decrease in DBD following 3 months of IS-training in Study group indicates that there may be increase in sympathetic activity. Previous studies have suggested that wellperformed slow, yogic breathing decreases sympathetic activity. 4,21-24 However, in this study, most of the variables of cardiac autonomic function tests were indicating marked increase in sympathetic reactivity. Possible reasons for obtaining this result may be as following: In this study, IS, which is considered as slow and sustained maximal inspiration, is performed for 10 repetitions per session without focusing on expiration. Previous study has shown that stimulation of carotid chemo- or baroreceptors can evoke reflex bradycardia, but such reflex effects are wholly or partly blocked during inspiratory phase of breathing by central neural inspiratory mechanisms and by the central actions of sensory nerves from the lungs.25 Additionally, hyperventilation resulting from slow and sustained maximal inspiration through Incentive Spirometer without focusing on expiration phase could be one of the possible mechanisms for getting sympathetic predominance response because hyperventilation is a powerful physiological stimulus and induces tremendous sympathetic stimulation.26 Moreover, in this study, IS was performed via mouth. Some studies have suggested that because breathing mechanism (nerve innervation) is situated in the nose and not in the mouth; nose breathing becomes the function of parasympathetic nervous system.27 Studies done by Dr Douillard mentions that on a physiological level, nose breathing enhances deep breathing which contracts diaphragm and makes us breathe more efficiently by pulling more air into lower lobes of lungs. Chest breathing through mouth fill the middle and
upper lobes but tends not to engage lower lobes, which host many of parasympathetic nerve receptors.28 Limitations of the study were small sample size, data collection from one place which may limit the generalizability of the findings, not performing IStraining under closed supervision of the therapist and autonomic function tests recording in afternoon time which may have influence on autonomic function. Future recommendations are - conducting the study with larger sample size with inclusion of subjects from various sources under closed-supervised IS-training. There is further research scope to investigate effect of IS-training on pulmonary autonomic functions. Conclusion - Most of the variables of cardiac autonomic function tests were showing marked improvement in sympathetic activity and so 3 months practice of IS is showing considerable increase in sympathetic activity. Acknowledgement/Source of support/Conflicts of Interest: Nil REFERENCES 1. Claudia R. Breathing exercises: In Cynthia Coffin Zadai. Pulmonary Management in Physical Therapy. 1st ed. NY (USA):Churchill Livingstone Inc.,1992:135. Carolyn Kisner, Lynn Allen Colby. Therapeutic exercise - foundations and techniques. 4th ed. New Delhi:Jaypee Brothers Medical Publishers (P) Ltd.,2002:749. Donna L. Frownfelter. Chest Physical Therapy and Pulmonary Rehabilitation - An Interdisciplinary Approach. 2nd ed. St. Louis(USA):Mosby Year Book Medical Publisher,1987:233. GK Pal, S. Velkumary, Madanmohan. Effect of short term practice of breathing exercises on autonomic functions in normal human volunteers. Indian Journal of Medical Research 2004 August:115-21. Ravider J, John WE, Vernon A., Vandna J. Physiology of long pranayamic breathing: Neural reapiratory elements may provide a mechanism that explains how slow deep breathing shifts the autonomic nervous system. Med Hypotheses 2006;67(3):566-71. Carlos H, Renato A, Denise G, Maria J. Spontaneous respiratory modulation improves cardiovascular control in essential hypertension. Arq. Bras. Cardiol 2007 June;88(6):576-83.
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pranayama on blood pressure and heart rate. J Altern Complement Med. 2009 Mar;15(3):293-5. Bernardi L, Gabutti A, Porta C, Spicuzza L. Slow breathing reduces chemoreflex response to hypoxia and hypercapnia, and increases baroreflex sensitivity. J Hypertens. 2001 Dec;19(12):2221-9. R Bhargava, MG Gogate, JF Mascarenhas. Autonomic responses to breath holding and its variations following pranayama. Indian journal of physiology and pharmacology 1988;32(4): 257-64. Shirley Telles, T Desiraju. Oxygen consumption during pranayamic type of very slow-rate breathing. Indian J Med Res. 1991 Oct;94:357-63. SC Gandevia, DI McCloskey, Erica K. Reflex bradycardia occurring in response to Diving,
Nasopharyngeal stimulation and Occular pressure, & its modification by Respiration and Swallowing. J. Physiol. 1978;276:383-94. 26. Dr KK Deepak. The role of autonomic nervous system in rapid breathing practices. Department of Physiology, All India Institute of Medical Sciences, New Delhi(India): p.42-45. (Available at: http://aolresearch.org/pdf/other/Deepak.pdf) 27. Nose Breathing Research & Benefits NBM homepage. Available at http:// www.nosebreathe.com/benefits.html. (Accessible on date: 10/01/2011) 28. Susan Moran. Going the Distance - Yogic breathings can make any kind of workout easier and enjoyable. Yoga Journal (Health) 2007 February:39-41.
Concurrent Validity of Clinical Chronic Obstructive Pulmonary Disease (COPD) Questionnaire (CCQ) in South Indian Population
C.M. Herbert1, V.K. Nambiar2, M. Rao3, S. Ravindra4 Clanical Physiotherapist, Dubai Medical Centre, 2Associate Professor, Dept. of Physiotherapy, 3Professor & Head, Dept. of Chest Medicine, 4Professor & Head, Dept. of Physiotherapy, .M.S.Ramaiah Medical College & Teaching Hospital, Bangalore ABSTRACT Background: Chronic Obstructive Pulmonary Disease (COPD) is a progressive disease associated with a high level of disability, the treatment of which is aimed at reducing symptoms, increasing function and improving the quality of life of the patient with lot of emphasis been given to the development of a Health Related Quality Of Life (HRQOL) questionnaire. St. George's Respiratory Questionnaire (SGRQ) is a self administered validated questionnaire used in COPD. The Clinical COPD Questionnaire (CCQ) was developed as a simple tool to help clinicians identify the clinical status of airways in individuals with COPD. Hence there is a need to validate the CCQ to identify the health status of those with COPD in Indian population. Aims: To measure and compare the scores and time taken with SGRQ and CCQ respectively in COPD subjects. Methodology: A convenience sample of 35 COPD subjects, were asked to answer the SGRQ and CCQ. Results: Pearson correlation and Student's t-test were used for statistical analysis and it was found that the three individual components of CCQ correlated with those of the SGRQ (r =0.909, p<0.001). Conclusion: CCQ can be considered at par with SGRQ to assess the HRQOL in individuals with COPD in South Indian population. Keywords: St. George's Respiratory Questionnaire, Clinical COPD Questionnaire, Chronic Obstructive Pulmonary Disease. INTRODUCTION Chronic Obstructive Pulmonary Disease (COPD) is the major cause of morbidity and mortality throughout the world. It is currently the 4th major cause of death in the world. The death rate from the disease has increased in the recent decades in apparent association with increase in cigarette smoking and air pollution.1 Globally, by 2020, COPD is expected to rise to the 3rd position as a cause of death and at 5th position as the cause of loss of Disability Adjusted Life Years (DALYs) Corresponding author: V.K. Nambiar Associate Professor, Dept. of Physiotherapy, M.S. Ramaiah Medical Teaching Hospital, MSR Nagar, MSRIT Post, Bangalore - 560 054 E-mail ID: veenakiran_nambiar@yahoo.co.in according to the baseline projections made in the Global Burden of Disease Study (GBDS).2 In India, about 5% males and 2.7% females above 30 years of age have been estimated to be suffering from COPD. There is a significant burden of COPD as a disease in the Indian community with overall prevalence of 6.85% in South India; with the prevalence of males being 7.4% and females being 4.64%.3 It is known that in addition to the primary organ dysfunction, impaired skeletal muscle performance is a strong predictor of low exercise capacity in subjects with severe COPD.4 Progressive decrease in functional activity and exercise performance in subjects with severe COPD is found. 5 The perception of the dyspnoea worsens with the sudden onset of high intensity constant work rate exercise. Further such dyspnoea is found to affect the activities of daily living (ADL).6 According to GOLD (Global Obstructive Lung Diseases) guidelines, the goals of clinical control in patients with COPD include Health Related Quality of Life (improved
exercise and emotional function) and clinical goals (prevention of disease progression and minimization of symptoms).7 In recent years, a great deal of attention has been paid to developing and validating quality of life questionnaires for individuals with COPD, in order to identify and treat the functional as well as the emotional problems that are most important to those suffering from the disease.7Health Related Quality Of Life (HRQOL) has been defined as the functional effect of an illness and its consequent therapy, upon a patient, as perceived by the patient. HRQOL questionnaires allow the clinicians to measure directly the impact of the disease on an individuals Activities of Daily Life.8 St George Respiratory Questionnaire (SGRQ) is a supervised, self administered, reproducible, valid and responsive instrument chosen as the gold standard to assess the HRQOL in Indian individuals with COPD. Clinical COPD Questionnaire (CCQ) is a self administered questionnaire specially developed as a simple tool to help clinicians identify the clinical status of airways in the individuals with COPD. Since the CCQ, which is a shorter and easier questionnaire, has not been validated for the Indian environment, the aim of the present study is to validate the CCQ and establish its effectiveness in comparison to the SGRQ, in South Indian population MATERIALS AND METHOD An ethical clearance was issued from the institution prior to the study. A convenience sampling was done. It was a cross sectional study with 35 subjects inclusive of both males and females between 35 and 60 years of age, diagnosed with COPD(all stages according to GOLD standard) and having good English comprehension. Subjects with any neurological or orthopedic dysfunction, recent surgeries and other cardiopulmonary dysfunction were excluded from the study. The source of data collection was from M. S. Ramaiah Teaching Hospitals. On the day of the first session, the subject was handed out the SGRQ and asked to fill it up in the presence of the examiner. After two days, subjects were given the CCQ and asked to do the same. The scores of the individual components as well as the overall total were separately calculated for each of the questionnaires. Time taken by each patient for each of the questionnaires was also recorded using a stop watch. STATISTICS Data was analyzed by using SPSS 15.0, Stata 8.0, MedCalc 9.0.1 and Systat 11.0. Microsoft word and Excel were used to generate tables, graphs, etc. Statistical Method: Descriptive statistical analysis has been carried out in the present study. Results on continuous measurements are presented on Mean SD (Min-Max) and results on categorical measurements are presented
in Number (%).Significance is assessed at 5 % level of significance. Statistical Tests: Pearson correlation was performed to assess the correlation between the component scores and the total scores of CCQ and SGRQ. Students t-test has been used to find the significance of the correlation between the component scores and the total scores of CCQ and SGRQ. RESULTS Out of the 35 subjects, there were 29 males and 6 females. The scores of SGRQ Symptoms component was a mean of 55.59 24.93; Activity component was 66.32 15.94; Impact component was 49.93 18.39 and total scores were a mean of 53.69 16.29(Table 1). The scores of CCQ Symptoms domain was a mean of 3.11 1.40; Functional state domain was 3.75 1.08; Mental state domain was 2.91 1.18 and total scores were a mean of 3.32 0.99 (Table 2). The symptom component of CCQ had a good correlation with the symptom component of SGRQ (r=0.955, p<0.001); the functional state component of CCQ correlated well with activity component of SGRQ (r=0.821, p<0.001); the mental state component of CCQ correlated well with the impact component of SGRQ (r=0.886, p<0.001). The overall total score of 50 questions of SGRQ and the 10 questions of CCQ showed a very high correlation (r=0.909, p<0.001) (Table 3) and (Figure 3) .It takes a comparatively less duration of time to complete the CCQ as compared to SGRQ ( Table 4).
Table 1. Descriptive statistics of St. George respiratory Questionnaire (SGRQ).
SGRQ *SG-Symptoms SG-Activity SG-Impact SG-Total Min-Max 6.25-93.75 25.88-88.88 9.09-78.78 11.68-79.50 Mean SD 55.5924.93 66.3215.94 49.9318.39 53.6916.29
The table shows the mean scoring of each component of SGRQ i.e. symptoms, activity and impact; and the mean of the total scoring of SGRQ. *SGrepresents SGRQ.
Table 2: Descriptive statistics of Clinical COPD questionnaire (CCQ).
CCQ *C-Symptoms C-Functional C-Mental C-Total Min-Max 0.50-12.00 1.25-5.75 0.50-8.00 0.80-5.40 Mean SD 3.111.40 3.751.08 2.911.18 3.320.99
The table shows the mean scoring of each component of CCQ i.e. symptoms, functional state and mental state; and the mean of the total scoring of CCQ. *Crepresents CCQ
272 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 Table 3: Pearson Correlation of CCQ with SGRQ
Pearson correlation SG-Symptoms vs C-Symptoms SG-Activity vs C-Functional SG-Impact vs C-Mental SG-Total vs C-total r value 0.955 0.821 0.886 0.909 P value <0.001** <0.001** <0.001** <0.001**
Each of the components and the total of CCQ are significantly correlated with those of SGRQ .CCQ can predict the SG by 82.8% accuracy. Figure 3 : Correlation scatter plot between the total scoring of SGRQ and total scoring of CCQ;
SGRQ total
CCQ - total The total score of SGRQ (Y-axis) is showing a high correlation with the total score of CCQ (X-axis).
Table 4: Time taken to administer the SGRQ and CCQ
Questionnaire SGRQ CCQ Min-Max (minutes) 11.05-16.25 2.00-4.40 Mean SD (minutes) 13.500.96 2.990.71
It takes a comparatively less duration of time to complete the CCQ. DISCUSSION The (CCQ) has been deemed as a valid and reliable tool to measure the Health Related Quality Of Life (HRQOL) in individuals with COPD and has been considered to be at par with the (SGRQ) in Netherlands, Italy and Sweden.7,8,9 The validation of a questionnaire is linked to the place and population where it is administered. SGRQ has been validated in the Indian population, but the CCQ has not been validated. SGRQ has been chosen as the gold standard as it is well validated, frequently used in COPD trials, it is available in Hindi and it was used in the original validation of CCQ.10 The overall total score of 50 questions of SGRQ
and the 10 questions of CCQ showed a very high correlation (r=0.909, p<0.001) (table 3 and figure 3).The individual components of CCQ significantly correlated with each of the components of SGRQ (table 3). Thus the CCQ can be considered at par with the SGRQ. Any increase in any of the components or the total of SGRQ would mean an increase in the corresponding component or total of CCQ. Both questionnaires have three components each. SGRQ, which has a total of 50 questions, is divided into symptoms component (8 questions), activity component (9 questions) and impact component (33 questions). It includes all possible questions that are asked in order to assess the overall status of the patient and the impact COPD has on people suffering from the disease. On the other hand CCQ has a total of 10 questions and is divided into three similar components symptoms (4 questions), functional state (4 questions) and mental state (2 questions). CCQ has been developed by selection of potential questions that assess the quality of life of people suffering from COPD by experts in the field. Hence the 10 questions of CCQ include the important and relevant questions to be answered in order to assess the HRQOL in individuals suffering from COPD.8 From the present study, CCQ has shown a very high correlation with SGRQ. Hence it is apparent that CCQ can be used to assess the HRQOL in Indians who have COPD. Since this study has been done on a population of South Indians, it can be concluded that CCQ has a concurrent validity in South Indian population when compared to SGRQ. The CCQ takes a appreciably shorter duration of time to administer as there are only 10 questions to be answered as compared to the 50 questions of SGRQ. Thus CCQ has the added advantage of being easier and quicker to administer, thus can be used as a quick tool to assess the HRQOL of South Indians who have COPD. FUTURE STUDIES Validation of the CCQ could be done for a greater population covering larger geographical area in India. CONCLUSION There was a strong correlation between the St George Respiratory Questionnaire (SGRQ) and the Clinical COPD Questionnaire (CCQ); hence CCQ can be considered at par with the SGRQ in South Indian population. The CCQ is easy to score and allows data to be quickly collected. It is thus suitable for use in everyday practice for clinical trials or quality of care monitoring, of individuals with COPD, in South India.
ACKNOWLEDGEMENT The authors wish to thank Dr. S. Kumar, President of Medical Education at M.S. Ramaiah Medical College, Dr. Eva Wikstrom Jonsson, author, Karolinska University Hospital Solna, Stockholm, Sweden and referring Doctors and Physiotherapists, who provided the subjects for the study. REFERENCES 1. G. Viegi, F. Pistelli et al. Definition, epidemiology and natural history of COPD. Eur Respir J; 2007; 30: 9931013. Jindal, Surinder K et al. Emergence of chronic obstructive pulmonary disease as an epidemic in India. Indian Journal of Medical Research; Dec 2006. K.J.R. Murthy, J.G. Sastry et al. Economic burden of chronic obstructive pulmonary disease. NCMH Background Papers Burden of Disease in India, 2005. Harry R Gosker et al. Skeletal muscle dysfunction in chronic obstructive pulmonary disease and heart failure: underlying mechanisms and therapy perspectives. American Journal of Clinical Nutrition; 2000; 71(5); 1033-1047.
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Francois Maltais et al. Oxidative enzyme activities of the vastus lateralis muscle and the functional status in patients with COPD. Thorax; 2000; 55; 848 853. 6. Luis Puente Maestu et al. Dyspnea, Ventilatory Pattern, and Changes in the Dynamic Hyperinflation Related to the Intensity of Constant Work Rate Exercise in COPD. CHEST; 2005; 128; 651 656. 7. Salvatore Damato, Chiara Bonatti et al. Validation of the Clinical COPD questionnaire in Italian language. Health and Quality of Life Outcomes, 2005; 3:9. 8. Thys van der Molen et al. Development, validity and responsiveness of the Clinical COPD Questionnaire. Health and Quality of Life Outcomes, 2003; 1:13. 9. Bjorn Stallberg et al. Validation of clinical COPD questionnaire (CCQ) in primary care. Health and Quality of Life Outcomes, 2009; 7:26. 10. Ashutosh N. et al. Validation of Hindi Translation of St. Georges Respiratory Questionnaire in Indian Patients with Chronic Obstructive Pulmonary Disease. Indian J Chest Dis Allied Sci; 2007; 49: 87-92.
To Study the effect of Mental Practice on one Leg Standing Balance in Elderly Population
Vidya V Acharya1, Saraswati Iyer2 M.P.Th., Professor, Seth G.S.Medical College & K.E.M. Hospital, Parel, Mumbai
2
ABSTRACT Purpose of study is: to compare "effect of only physical practice" with " effect of physical practice and mental practice" in subjects, for activity of one leg standing. Materials used: table, chair, cassette and record player, stop-watch, newspaper. Methodology: 80 independently ambulatory subjects (age group 50-70yrs) were randomly selected and divided into 2 intervention groups of 40 each. Task was to stand on the preferred leg with arms by side and one legged balance time was measured. Two sessions (1st & 2nd) of the task, of 5 days each, were given to subjects at a periodic gap of 30 days. Baseline and final measurements of one legged balanced time were compared after a three days practice intervention period. Group I (n=40, 20 male s and 20 females) performed only physical practice in both sessions (1st & 2nd) and Group II, (n=40, 20 males and 20 females) performed only physical practice in 1st session and in 2nd session performed physical practice interspersed with mental practice. Mental Practice involved use of idealized visual and kinesthetic mental images provided to subjects through recorded tape. Results: Percentage improvement in balance time in both sessions was compared and statistical analysis was done by paired 't' test and 'z' test. All groups showed improvement, but Group II showed the most improvement in 2nd session, of 33.01% in males and 31% in female's resp. ('p' < 0.001). Comparison of percent improvement between Group I and II, showed an increment of 10% in balance time of group II in its 2nd session('p' < 0.001,HS).Thus showing that balance time increased significantly with physical practice interspersed with mental practice. Conclusion: Our study concludes that Mental Practice along with Physical Practice may hence be an important therapeutic tool to encourage rapid acquisition of a motor skill. Keywords: Mental Practice, Physical Practice, One Leg standing Balance
INTRODUCTION Major concern of physical therapist is movement its acquisition, quality and retention. Primary aim of physical therapist is to maximize patients movement potential. So focus is on physical techniques, for teaching new motor skills to patients.1 However it is not always possible to carry out task under guidance of therapist. Hence Mental practice, which is cognitive rehearsal of a physical skill in absence of any gross muscular movement, can be an utilized as a clinical tool in assisting patients, to rapidly learn a motor task. 1 A major concern of physical therapists with all patients, but especially with elderly, is balance. The increased postural sway seen with age is correlated
with loss of balance and increased incidence of falls in elderly2.Therefore, balance is selected as physical task to test the effect of mental practice on. MATERIAL AND METHOD Materials Table, chair, cassette and record player, stop-watch, newspaper. ii. Method a. Inclusion Criteria Age group: 50 to 70 years. All subjects are independently ambulatory without assistive device.
b. Exclusion Criteria Subjects with orthopaedic, neurological, uncontrolled diabetes, uncontrolled blood pressure problem, significant hearing and vision loss and psychological problems were excluded. c. Selection of Subjects
Subjects PP and ONLY PP PP and PP + MP Sex FM 2020 Number 2020 2020 Age (yrs) 50-70 50-70 Mean Age (yrs) 59.22 59.12
3. understood satisfactorily 4. understood properly 5. understood properly and completely. Group II subjects Likerts scale response was 4,5 after tape session. So on day 2, 3, 4 group II subjects took
PHYSICAL PRACTICE Tape Session PHYSICAL PRACTICE Tape Session PHYSICAL PRACTICE
Group I II
PP=PHYSICAL PRACTICE MP=MENTAL PRACTICE
FINDINGS Results And Observations Percent improvement in balance time in both sessions was compared and statistical analysis was done by pairedt test and z test. Group I (Males)
Day 1 P. P1st session P. P 2nd session 54 36.57 55.95 36.78 Day 5 62.15 37.13 67.60 38.56 % improvement t- value p- value 17.45 10.37 21.88 10.97 7.52 8.89 < 0.001 < 0.001
d. Study Procedure A short verbal health care history was taken. SESSION I Each subject from group I and group II stood on preferred leg and lifted other foot. Arms were held by side and time was measured using a stopwatch until lifted foot contacted ground. An average of three readings of measured time was taken to have a baseline value on day 1. Group I & II subjects carried out physical practice of activity for next three days. Final value of balance time was taken from an average of three readings on day 5. On day 2,3,4: reading task was given, which distracted attention from original activity. So on day 2,3,4 group I & II subjects took:
PHYSICAL PRACTICE Reading Session PHYSICAL PRACTICE Reading Session PHYSICAL PRACTICE
During 1st session,% improvement in response for balance time is 17.45.This increase is statistically highly significant at p<0.001,which indicates response on day 5 is likely to be much more as compared to day 1 due to physical practice. During 2nd session,% improvement in response for balance time is 21.88.This increase is statistically highly significant at p<0.001,which indicates response on day 5 is likely to be much more as compared to day 1 due to physical practice. Group I (Females)
Day 1 P. P1 session P. P 2nd session
st
SESSION II After a month Group I subjects took only physical practice same as they took in previous month. Group II took physical practice and mental practice of the activity. Baseline and final measurements of balance time of both groups were taken again on day 1 and day 5 respectively. Group II subjects listened to recorded speech through record player. Speech consisted of details regarding balance activity & relaxation. The capability of subjects to concentrate and perceive recorded speech was measured on Likerts scale. Likerts Scale 1. did not understand 2. understood little
Day 5 70.65 46.54 78.20 49.48
% improvement t- value p- value 19.25 10.62 23.99 12.30 7.52 8.89 < 0.001 < 0.001
59.85 44.70 62.30 45.96
During 1st session,% improvement in response for balance time is 19.25%.This increase is statistically highly significant at p<0.001,which indicates response on day 5 is likely to be much more as compared to the day 1 due to physical practice. During 2nd session,% improvement in response for the balance time is 23.99%.This increase is statistically highly significant at p<0.001,which indicates response on day 5 is likely to be much more as compared to day 1 due to physical practice.
Group II (Males)
Day 1 P. P1st session P. P + M.P2 nd session 50.30 29.30 52.7529.89 Day 5 61.65 34.97 77.20 40.57 % improvement t- value p- value 19.48 9.98 33.01 11.86 8.27 12.44 < 0.001 < 0.001
Group II (Females)
Day 1 P. P1st session P. P + M. P2nd session 52.60 39.51 55.60 38.46 Day 5 61.85 41.38 77.30 42.73 % improvement t- value p- value 19.00 10.001 31.79 12.86 8.48 11.04 < 0.001 < 0.001
During 1st session,% improvement in response for balance time is 19.48%.This increase is statistically highly significant at p<0.001,which indicates response on day 5 is likely to be much more as compared to day 1 due to physical practice. During the 2nd session,% improvement in response for balance time is 33.01%.This increase is statistically highly significant at p<0.001,which indicates response on day 5 is likely to be much more as compared to day 1 due to physical practice and mental practice.
During 1st session,% improvement in response for balance time is 19%.This increase is statistically highly significant at p<0.001,which indicates response on day 5 is likely to be much more as compared to the day 1 due to physical practice. During 2nd session,% improvement in response for balance time is 31.79%.This increase is statistically highly significant at p<0.001,which indicates response on day 5 is likely to be much more as compared to the day 1 due to physical practice and the mental practice.
Comparison of Average % Improvement Between 1st and 2nd Session in Males and Females.
Subjects Group I Group II Males PP FemalesPP MalesMP + PP FemalesMP + PP % Improvement I 17.45 19.25 19.48 19.00 % Improvement II 21.88 23.99 33.01 31.79 % Difference improvement 4.33 4.74 13.53 12.79 t- value 8.18 6.74 11.67 11.91 p- value P < 0.001 P < 0.001 P < 0.001 P < 0.001
From above table maximum improvement is seen with Group II carrying out physical practice and mental practice in second session. Comparison of Overall Average % Improvement Between Group I and Group II in the 1st and 2nd Session.
Group-I (M+F) % Improvement1st Session % Improvement2nd Session 18.35 + 10.49P.P 22.93 + 11.69P.P Group-II (M+F) 19.24 + 9.999P.P 32.4 + 12.37P.P z- value 0.3 3.53 p- value NS P < 0.001(HS)
From above table we can infer that Comparison between Group I and II is statistically not significant in first session, which indicates that overall improvement between both groups is the same. Difference between them is 0.89%, which is not up to the level of significance. Irrespective of sex of the subjects, physical practice is not enough to increase response in 2nd session for subjects in group I.But with supplement of mental practice response in 2nd session for subjects in group II increased by 10%.This increase is statistically highly significant p<0.001, which indicates that physical practice and mental practice is likely to yield much more
response in 2nd session as compared to only physical practice. Mental Practice interspersed with Physical practice significantly improved balance time in the study. The difference between comparative groups showed highly significant results: Within groups
All groups showed improvement, but the Group II showed the most improvement in 2nd session of 33.01% in males and 31% in females respectively.
Between both groups
The comparison of percent improvement in Group I and II, showed an increment of 10% in balance time of group II in its 2nd session. Thus showing that the balance time increased with physical practice and mental practice of the activity. Following could be the reasons for significant increase in balance time for Group II subjects. Strengthening of Engram Formation The plausibility that improvement in performance is a direct function of mental practice is related to engram formation. Program of engram formation3 includes i) Perception ii) Precision iii) Perceptual practice. PERCEPTION While carrying out, the act of standing on one leg, perception of sensory inputs are mainly from: proprioception, vision and auditory stimulus from tape session, which provides information about performance to cerebellum and automatic monitoring centre. Mental imaging during tape session and physical practice facilitate process of engram formation, thus enhancing motor learning. This is evident from response of Group II in 2nd session. For Group 1 subjects, it can be inferred that, engram process is not strengthened as those subjects carried out an activity, not related to one leg standing, during reading session. Imaging studies by Shadmer and Holcomb have shown cerebellum to be active during consolidation of a learned internal model of a task4. It acts as adaptive feed forward control system, which programs voluntary movement skills, based on memory of previous sensory inputs and motor outputs. PRECISION Precision of one leg activity is enhanced by mental practice, which entails picturing of standing on one leg, while imagining kinesthetic feel of act and trying to balance on one leg and at the same time correcting imagined mistakes. This occurs in addition to actual physical performance of activity. Perceptual practice Results into excitation of desired neuronal linkages and inhibition of those motor neurons, which should
not be performing in pattern of the one leg standing activity. This helps into minimizing leg muscle work & facilitating muscle work with appropriate force and direction5, thus developing a more efficient balance & co-ordination. So Mental Practice substitutes Physical Practice in process of engram formation. This image would then create a perception of motor act, that would activate automatic monitoring center and facilitate consolidation of engram formation. With engram development, volitional excitation4 takes place, which is strengthened during Physical Practice of the activity and this adds for improvement in performance in Group II. Effect of Auditory Stimulus Mental Practice given in form of auditory cue helped in facilitation of mental picture, by guiding activity of balancing on one leg. Use of background music induces relaxation response. Commands used during tape session affect tone regulation, attention, arousal. This in turn enhances performance by increasing focus to be achieved4. EFFECT OF PRACTICE During Physical Practice Subjects carry out Procedural learning6 i.e. repeated exposure of activity-hence strategies applicable to changing stimulus configuration, within task must be acquired through practice. Procedural Learning is supported by circuits involving Prefronto-caudate-striosmal topographic projections6 . Saint and Taylor propose that straitums role involved with mobilizing new procedures to select among known procedures by acting as procedural memory buffer7 . i. During Mental Practice Subjects carry out Perceptual learning & Declarative learning. Declarative learning results in ability to store and consciously recall tape session during actual practice session. Temporal-cortico-caudate projections are involved (neo striatum)6.
iii. Acquisition of procedural knowledge through repeated practice may eventually result into development of declarative knowledge of task. iv. Conversely development of declarative knowledge of task may hasten acquisition of procedural knowledge8. v. With repetitive information through mental and physical input, Group II showed significant improvement in average balance time during second session. This improvement in the task can be supported by the research: Neuro-imaging Studies In mental simulation of motor act, cerebral blood flow studies suggest that prefrontal cortex, supplementary motor area, basal ganglia, cerebellum, structures required for performance of actual movement, are active5. PET studies have shown changes in local cerebral blood flow associated with state of information processing i.e. activation when hearing words. (Stephan H Koslow, George V. Coelho)9
CONCLUSION In elderly population, Mental Practice coupled with Physical Practice has shown to improve one leg balance time more significantly than Physical Practice alone. This improvement in balance, which is fundamental component of human movement, suggests that Mental Practice has promising usefulness in health care. Because efficacy of mental practice increases with increasing task familiarity, it could be useful modality for rehabilitation. Therapeutic exercise could be supplemented with mental imaging during rest period. Patients confined to bed can use visualization techniques to prepare for future retraining in gait and activities of daily living. It could easily be incorporated into patients home program. Mental rehearsal encourages patients to assume responsibility for their recovery. Thus, Mental Practice may be an important therapeutic tool to encourage rapid acquisition of a motor skill. ACKNOWLEDGEMENT My heartfelt thanks to the Dean of Institute, Head of Physical Therapy Department, Bio-statistician, all my subjects, departmental staff and colleagues. Conflict of Interest - Nil. REFERENCES 1. Claudia, L.Fansler, Cathy L. Poff, Katherine F Shepard: Effects of mental practice on balance in elderly women. Physical Therapy, September 1985, Vol.65, No.9. Antonio Nardone, Rosella Siliotto: Influence of aging on keg muscle reflex response to stance perturbation. Arch Phys Med Rehabilitation, February 1995, Vol 76. Frederic J Kottke, Daniel Halpern: The training of co-ordination.Arch phys Med Rehabil, December 1978, Vol.59.
Effect on Memory Function Hippocampus 10 provides drive that causes translation of short term memory to long term i.e. it transmits signals which seems to make mind rehearse over & over new information. Consolidation of long term memory of verbal type takes place within hippocampi.
Effect of Motivation Motivation hypothesis postulates that Mental Practice increases the subjects motivation to improve1. Following structures are involved in motivation: prefrontal cortex, limbic structures, hypothalamus, thalamus, brainstem, motor cortex (structures are also active during mental practice)11.
Effect of Neurotransmitter Activity Noradrenergic, dopamine, serotonin systems influence operations of neural systems for decision making12. These systems have cognitive appraisals often without conscious awareness.
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4. 5.
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Darcy A Umphred: Interventions for Neurological Disability, Neurological Rehabilitation 4 th Ed. Janet Carr, Roberta Shepherd: Training motor control, increasing strength and fitness and promoting skill acquisition, Neurological Rehabilitation. Optimising Motor Performance. J.A.SaintCyr, Ann.E.Taylor, A.E.Lang: Procedural Learning and Neo-straital Dysfunctions in man, Brain 1988, 111,941-959. P.Soliveri, R.G.Brown, M.Jahanshahi: Learning manual pursuit tracking skills in patients with Parkinsonss Disease. Brain 1997, 120, 1325-1337. Pascual Leone, J Grafman, K.Clark, M.Stewart:Procedural learning in Parkinsons Disease and Cerebellar Degeneration.Annals of Neurology,July-Dec 1993,Vol.34,1-6.
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Stephan H.Koslow, George V.Coelho: Functional Mapping of the Human Brain.Decade of the Brain. 10. Guyton and Hall: Behavioral and Motivational Mechanisms of the Brain. Textbook of Medical physiology.9th Ed. 11. Paul D Cheney: Role of cerebral cortex in voluntary movements.A Review. Physical Therapy, May 1985, Vol65, No5. 12. R E OCaroll, B P Papps: Decision making in Humans: The Effects of manipulating the central noradrenergic systems.J Neurology Neurosurgery Psychiatry 2003:74:376-378.
Effect of Midprone Decubitus on Pulmonary Function Test Values in Young Adults with Undesirable Body Mass Indices (BMI)
Junaid Ahmed Fazili1, Ajith S2, A.M.Mirajkar3, Mohamed Faisal C K4, Ivor Peter D'Sa5 Physical Therapist, Dept. of Physiotherapy, 2Asst. Professor, Dept. of Physiotherapy, 3Professor and HOD, Dept. of Physiology, 4Professor and HOD, Dept. of Physiotherapy, 5Professor Dept of Medicine, NITTE University, Mangalore
1
ABSTRACT Background and purpose: Body positioning is prescribed by Physical Therapists to directly enhance oxygen transport and oxygenation, to minimize the risk of aspiration, and to drain pulmonary secretion in most of the intensive care units. The aim of this study is to assess pulmonary function in sitting, right mid-prone, left mid prone position in healthy young adult subjects and to compare the effect of Body Mass Index (BMI) on pulmonary function in sitting, right and left mid prone position. Materials and Methods: We recruited 60 healthy male volunteers by using convenience sampling with the mean age 20.5 ranges from 18-30 years. The subjects were divided into two groups based on their BMI (Group A BMI 18.5-24.9kg/m2and Group B BMI>25kg/m2 ). The spirometric test was done to measure Forced Vital Capacity (FVC), Forced expiratory volume in 1 second (FEV1), Slow Vital Capacity (SVC), Maximum Voluntary Ventilation (MVV) in sitting, right side lying and left side lying position, the values of three different positions were compared with in the groups and between the groups. Results: FVC and FEV1 values show significant changes in three different positions in normal and obese subjects. The MVV of normal and obese groups in sitting, right side lying and left side lying was significantly varied. There was no significant difference in other values. Conclusion: With right side and left side lying position the FVC and FEV1 values decreased significantly in compare to the sitting position, and there is no difference in lung volumes between normal and obese except MVV. MVV is significantly reduced in right and left side lying position. Upright sitting position will increase the lung volumes and capacities compared to the other positions. Keywords: Midprone Decubitus, Pulmonary Function Test, Body Mass Indices (BMI). INTRODUCTION Body Mass Index (BMI) is a widely accepted and used index to measure obesity in both adults as well as in adolescents. Obesity can cause various deleterious effects to respiratory function, such as alterations in respiratory mechanics, decrease in respiratory muscle strength and endurance, decrease in pulmonary gas exchange, lower control of breathing, and limitations in pulmonary function tests and exercise capacity. These changes in lung function are caused by extra adipose tissue in the chest wall and abdominal cavity, compressing the thoracic cage, diaphragm, and lungs15. Many studies have stated that there is a direct relationship between lung function and body mass index .Weight and body mass index as measures of overall abdominal adiposity are used as predictors of pulmonary function in many epidemiological studies. These measures are widely accepted as determinants of pulmonary function in many epidemiological studies6, 7. Abdominal adiposity may restrict the descent of diaphragm and limit lung expansion compared to overall adiposity, which may compress the overall chest wall.2Several previous studies have stated that increase in body weight decrease lung volume, but many studies have been small; they included subjects with coexisting morbidities8-10. Therefore, it is important to understand the relationship between body mass index (BMI) and lung
function to properly interpret Pulmonary Function Tests (PFTs). Different side lying body positioning is prescribed by Physical Therapists to directly enhance oxygen transport and oxygenation, to minimize the risk of aspiration, and to drain pulmonary secretion in most of the intensive care units.11Compared with the upright position, recumbent positions have well documented deleterious effects on lung volume of the dependent airways, reduced flow rates ,and reduced arterial saturation .These effects are accentuated with age ,smoking history, obesity, breathing at low lung volumes, sedation and direct effects of anaesthesia12. Although side lying (mid prone) positions are commonly used clinically, the differential effects of right and left side mid prone position on lung function compared with a reference position such as upright sitting have not been studied in detail. There have been a few reports of improved arterial oxygenation in left versus right side-lying in patients with unilateral lung disease and bilateral lung disease and in patients following coronary artery bypass surgery.13 In recumbent positions gas exchange is improved with the healthy lung down in patients with unilateral lung disease and in right side lying in patients with bilateral lung disease. In patients with unilateral lung disease, the role of the inferior lung as gas exchanger and diffusion capacity is enhanced because of the cephalad displacement of the hemi diaphragm placing it in greater mechanical advantage.14The Effect of mid prone position on pulmonary function test among young adults of altered BMI has not been studied with the importance it deserves. This study aims to understand the relationship between the side-lying position and BMI on lung function. METHOD Subjects This study was approved by the Central Ethical Committee of Nitte University; 60 healthy male volunteers were selected by using convenience sampling. We included healthy male volunteers of age range 18-30 years, and excluded the subjects with a history of cardio respiratory disease, BMI< 18.5, yoga and exercise practitioners, subjects with history of
smoking, subjects taking medication, which has effect on respiratory system. STUDY PROTOCOL The study was conducted at the Nitte Institute of Physiotherapy; the subjects were briefed about the protocol and the informed consent was obtained from them prior to the commencement of study. A detailed history regarding their habits, physical activity and history suggestive of any cardio respiratory or any systemic illness was elicited. The percentage of body fat was calculated by Quetelets Index15 BMI=weight (kg)/height2 (m2)) Body fat composition was measured was measured by the skin fold thickness method in the following manner, the skin fold thickness was measured at four different sites on the dominant side of the body by using skin fold callipers. Extremity skin folds were measured at the triceps, biceps, trunk, supra-iliac and sub scapular areas16, 17. The skin fold was picked up between the thumb and forefinger and the readings were taken 5 seconds after the calliper was applied. Three consecutive readings were taken and recorded at each site. The average of three readings at each site was calculated and sum of these values was entered into the table given by Durnin and Womersley18.to find out the body fat percentage. Body fat percentage and BMI of the subjects were compared to add weight age to the classification; high body fat percentage was seen to be associated with high BMI. The subjects were divided into 2 groups based on the BMI Group I 30 subjects with BMI 18.5-24.9kg/m2 Group II 30 subjects with BMI>25kg/m2 The lung function parameters which were assessed by computerized spirometers were Forced Vital Capacity (FVC), Forced expiratory volume in 1second (FEV1), Slow Vital Capacity (SVC), and Maximum Voluntary Ventilation (MVV) The sessions were conducted in ventilated room; the instrument used to measure respiratory parameters is SPIROMETER HELIOS 401. Session I - Sitting position (recordings taken after 15 minutes in sitting)
Session II- Right mid prone position (recordings taken after 15 minutes in side lying to the right). Session III - Left mid prone Position (recordings taken after 15 minutes in side lying to the left). A gap of 15 minutes was maintained in between the sessions to avoid bronchospasm or exhaustion, the sessions lasted for an hour and the study was divided into three sessions based upon the position For recording FVC and Fev1, the subject was instructed to keep the disposable mouth piece attached to the transducer halfway in the mouth above the tongue, the nose clip was applied and the subject was asked to look away from the monitor, after that he was asked to take a deep inspiration and then blow hard in the transducer up to 6secoonds followed by a deep inspiration19 For recording SVC the subjects with his nose clip was asked to breathe normally, after a minimum of 3 quiet breaths he was asked to take a deep inspiration followed by expiration and then breathe normally and to record MVV, the subject was instructed to breathe in and out rapidly through the transducer for at least 15 seconds. For each manoeuvre the subject performed thrice and the best of the 3 readings were selected. In each session the rest period was 15 minutes to accommodate the effects of position change on the pulmonary circulation, notably the pulmonary capillaries, which is time dependent. RESULTS 64subjects were selected for the study; the data collection of four subjects could not be completed. Statistical analysis was performed with SPSS software package. The mean age of the subjects who participated in the study was 20.5; range (18-30) .T-test compared the various positions in the two groups. Annova was used to compare the variables within the groups. FVC and FEV1 values showed significant changes in all three positions in normal and obese subjects (Table 1 & 2), (figure 1). But when we compared the values in between normal and obese groups in sitting position there was significant difference in MVV and no significant difference in other values (Table 3, figure 2).
In right side lying positionFev1/fvc and MVV shows significant difference (Table 4&figure3) In left side lying position the MVV values of obese group is at a lower level when compared to the normal group and this difference is very highly significant.( Table 5 &figure 4).
Table 1. (Normal subjects)
Normal Sitting Rt Sidelying FVC FEV1 FEV1/FVC SVC MVV 3.95 0.65 3.32.55 83.339.7 3.807.66 119.6727.240 3.583.61 3.0 .55 84.1308.7 3.756.68 Left Sidelying 3.484.83 2.9173.77 82.5810.7 15.92068.39 .p<.05(s) p<.05(s) .829 .393 .861 P-value
116.0733.909 119.4323.471
Table 2. (obese subjects)

Normal Sitting Rt Sidelying FVC FEV1 FEV1/FVC SVC MVV 3.95 0.65 3.32.55 83.339.7 3.807.66 119.6727.240 3.583.61 3.0 .55 84.1308.7 3.756.68 Left Sidelying 3.484.83 2.9173.77 82.5810.7 15.92068.39 p<.05(s) p<.05(s) .829 .393 .861 P-value
116.0733.909 119.4323.471
Fig. 1. Error bar graph with mean & SD in three positions
Table 3. Comparison of Pft Variable with Obese and Normal In Sitting

Group-1 (N=30) Sitting Fvc Fev1 Fev1/fvc Svc Mvv 3.9503.648 3.321.55 83.3189.79 3.905.65 119.6727.24 4.0227.547 3.32.50 82.236.26 3.759.71 104.7022.78 p>0.05(ns) p>0.05(ns) p>0.05(ns) p>0.05(ns) p<.05(s) Group-2 (N=30) p-value
Fig. 2
(1999)19 concluded that FVC and FEV1 were decreased equally in left and right side lying positions in older individuals without cardiopulmonary disorders. Therefore the present study aims to assess the PFT values in sitting and side lying positions in young healthy population of different BMIs. We studied 60 healthy young adults in two different groups with three different positions. Our study findings confirm that FVC and FEV1 value was decreased in right side lying and left side lying when compared to the sitting position. The results of our study conform to the result of the previous study done by Fiona Manning et al19 and Behrakis et al 20. The decrease in FVC in recumbency may reflect both increased thoracic blood volume due to the increased venous return and cephalad displacement of the diaphragm caused by abdominal encroachment. Other factors which may have caused this decrease include increased airway resistance and decreased lung compliance secondary to anatomical difference between the left and right lungs and shifting of mediastinal structures. When the value between normal and obese subjects was compared, there is significant reduction in MVV in obese population. MVV is a measurement of respiratory muscle endurance, is reduced by 20% in healthy obese individuals and by 45% in obese individuals with obesity hypoventilation syndrome (OHS) 21. This may result from diaphragm dysfunction due to increased abdominal and visceral adipose tissue deposition. While other studies conducted by earlier authors have shown reduction in the lung volumes especially FRC and ERV, many researches proved that obesity (BMI>30) has a direct restrictive effect on pulmonary function. Wafaa R. AlBader et al22 proved that BMI>30 is associated with a restrictive effect on pulmonary ventilation. We selected subjects with BMI> 25, and the number of subjects with BMI>30 was very much limited; this may be the reason the other values are not significant in both the groups. The major limitations of our study is we recruited normal subjects and we could have increased the number of subjects that would have given more statistical weightage, if we selected a diseased population that would have given more clinical validity of our study. The other components of pulmonary function tests could also have been done to further validate the study. The clinical importance of our study is that since optimal lung function is seen in upright position, it can be beneficial if ventilator dependent patients are nursed in the upright position as opposed to the traditionally
Table 4. Comparison Of Pft Variables With Obese And Normal In Right Sidelying
Group-1 (N=30) Right sidelying Fvc Fev1 Fev1/fvc Svc 3.5827.61 3.0400.55 3.6600.66 2.9227.58 p>0.05(ns) p>0.05(ns) p<.05(s) p>0.05(ns) Group-2 (N=30) p-value
84.1238.7145 79.7887.8893 3.7563.68422 3.8123.72779
Fig. 2
DISCUSSION Body position exerts a strong effect on pulmonary position, but its effect on the side lying position with undesirable Body Mass Indices (BMI) is still to be understood. This study investigated the interrelationships of PFT values in side lying positions between two different BMI groups. Studies previously done on this subject have shown marked improvement in patients who lay with the diseased or operated lung uppermost compared with the dependent position and many studies have concluded that obesity has a direct effect on pulmonary function. Fiona Manning et al
used supine position, the need of early mobilization after the major surgical procedure is also considered. Since Obesity will increase the demand for ventilation, elevated work of breathing, respiratory muscle inefficiency and diminished respiratory compliance, the result of our study will benefit the patients of cardiopulmonary disorders with high BMI. The physical therapist should know the physiological effects of positioning while administering chest physical therapy. CONCLUSION Authors concluded that with right side and left side lying position the FVC and FEV1 values decreased significantly in compare to the sitting position, and there is no difference in lung volumes between normal and obese except MVV. MVV is significantly reduced in right and left side lying position, authors also concluded that upright sitting position will increase the lung volumes capacities. ACKNOWLEDGEMENT Authors would like to thank the Nitte University, Dep. of Physiology K S Hegde Medical Academy and Dep. of Physiotherapy for their complete support to fulfil this study. Conflict of Interest Authors agree that there was no source of conflict of interest REFERENCES 1. Faintuch J, Souza SAF, Valexi AC, Santana AF, Gama-Rodrigues JJ. Pulmonary function and aerobic capacity in asymptomatic bariatric candidates with very severe morbid obesity. Rev Hosp Clin Fac Med S Paulo. 2004; 59:181-86. Koenig, SM. Pulmonary Complications of obesity. Am J Med Sci. 2001; 321:249-79. Ladosky W, Botelho MAM, Albuquerque JP. Chest mechanics in morbidly obese non-hypo ventilated patients. Respir Med. 2001; 95:281-6. Lotti P, Gigliotti F, Tesi F, Stendardi L, Grazzini M, Duranti R et al. Respiratory muscles and dyspnea in obese nonsmoking subjects. Lung. 2005; 183:311-23. Rasslan Z., Junior RS, Stirbulov R, Fabbri RMA, Lima CAC. Evaluation of Pulmonary Function in Class I and II Obesity. J Bras Pneumol. 2004; 30: 508-14. Heather M Ochs-Brydon Pulmonary Function and
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Comparison of Quality of Life in off-pump Versus on-pump Coronary Artery bypass Graft (CABG) Patients before and after Phase II Cardiac Rehabilitation
Nikhil Vishwanath1, Ajith S2, Ivor Peter D'Sa3, M.Gopalakrishnan4, Mohamed Faisal C K5 Physical therapist, Dep. of Physiotherapy, 2Asst. Professor, Dep. of Physiotherapy, 3Professor, Dep. of Medicine, 4HOD, Dep. of Cardio Thoracic Surgery, 5Professor and HOD, Dep. Of Physiotherapy, NITTE University, Mangalore ABSTRACT Background and purpose: Coronary artery Bypass Graft (CABG) is the commonly performed revascularization procedure after a major vessel block. Many studies have indicated that there is a reduction in Quality of Life after CABG. The aim of our study was to compare the Quality of Life (QOL) in off pump and on pump CABG patients before and after phaseII Cardiac rehabilitation and to find out the effectiveness of cardiac rehabilitation to improve the QOL. Materials and Methods: The QOL of 50 patients consisting of two groups were studied on two different occasions before phase II cardiac rehabilitation and after Phase II cardiac rehabilitation respectively by using SF-36v2 questionnaire. Results: 50 patients with the mean age 47.9 years, (range 40-58) completed the study. Following the cardiac rehabilitation there was a marked improvement in the QOL of both the groups, and the physical and mental components scores in the SF-36v2 questionnaire were increased. The difference between the scores of off pump and on pump CABG was significant before phase II cardiac rehabilitation. After phaseII cardiac rehabilitation, there were no significant changes between the scores except for those of general health (p=.005), emotional role functioning (p<.001) and mental component score (p=.01) Conclusion: The QOL was seen to increase significantly after 3 months of structured cardiac rehabilitation program(comprising of Phase I and Phase II cardiac rehabilitation) in both on pump and off pump CABG patients .There were significant changes in the all the 8 domains in the SF-36v2 questionnaire in both groups before and after Phase II cardiac rehabilitation, but there was no significant difference in QOL between on pump and off pump CABG subjects after Phase II cardiac rehabilitation program. Keywords: Quality of Life (QOL), off Pump CABG (OPCAB), on Pump CABG, Phase II Cardiac Rehabilitation.
INTRODUCTION Coronary artery bypass grafting (CABG) is the major coronary artery revascularization procedure after any major vessel block. It is one of the landmark operations in the history of cardiac surgery that saved the lives of millions of people afflicted with coronary artery disease.1, 2 Coronary Artery Bypass Graft is a commonly performed surgery worldwide. In India around 500,000 CABGs are performed annually. CABG is the most accepted coronary revascularization procedure performed after a major vessel block3-5. There are 2 different methods of doing CABG: the traditional way, which is called the on-pump CABG, and the newer way, which is called the off-pump CABG (OPCAB). The pulmonary function after CABG is severely reduced; the reasons for the restrictive
impairment and atelectasis are multiple and include, besides the effects of anesthesia, intra-operative events such as internal mammary artery harvesting, changes caused by mechanical alteration of the thoracic cavity, immobilization and pain6. Roentgenologial signs of atelectasis are common and various studies have documented reduced lung volumes and oxygenation in the post-operative period7. Many studies show that the pulmonary complications are more in patients with on pump coronary artery bypass graft8 The World Health Organization (WHO) classifies Cardiac Rehabilitation as The sum of activities required to influence favorably the underlying cause of the disease, as well as to ensure the patient the best possible physical, mental and social conditions, so that they may, by their own efforts, preserve or resume when lost,
as normal a place as possible in the life of the community9, 10 Cardiac rehabilitation is divided into four phases, progressing from the acute hospital admission stage to long-term maintenance of lifestyle changes. According to American College of Sports Medicine (ACSM) 11, the rehabilitation phase can be divided into Phase I in-patient period, duration 5- 7 days. Phase II early post-discharge, duration up to 3 months. Phase III supervised out-patient program including structured exercise. Phase IV long-term maintenance of exercise and other lifestyle changes.
STUDY PROTOCOL All the patients underwent pre-operative chest physiotherapy to clear secretions and to improve the lung function. After surgery, the patients were divided in to two groups based on the type of surgery. Group 1 On pump CABG patients (n= 25). Group 2 Off pump CABG patients (n= 25). No mortality was recorded in both the groups after extubation and all patients underwent phase I cardiac rehabilitation. The phase I cardiac rehabilitation included the physiotherapy techniques like incentive spirometry, coughing, huffing, chest manipulation, segmental expansion, thoracic mobilization and ambulation. Post operatively the exercises were started approximately 1 hr after extubation, and the patients were encouraged to perform all the exercises twice daily for the first 7 postoperative days. After the phase I program the SF36-v2 questionnaire was administered. It consists of 36 short questions mirroring health and Quality of Life (QOL) in eight different aspects: bodily pain (BP, 2 items); mental health (MH, 5); vitality (VT, 4); social functioning (SF, 2); general health (GH, 5); physical functioning (PF, 10); and role functioning, both emotional (RE, 3) and physical (RP, 4). Role functioning reflects the impact of emotional and physical disability on work and regular activity. All the patients were explained about the questionnaire and asked to fill according to the questions. Phase II cardiac rehabilitation was a home-based individualized tailored program of aerobic exercises; preferably brisk walking17, 18. The exercises were taught to the patient in the department under physiotherapist supervision, and then the program protocol was given to the patient to be done at home for 3months. Patients were also trained in palpating the pulse and calculating the heart rate, and to rate the Rating of Perceived Exertion (RPE) of 11 to 14.The exercise program consisted of warm up which included breathing exercise, stretching exercise and gentle active exercise to upper limb, lower limb and trunk muscles for a period of 10 minutes, followed by graded aerobic training and cool down. Aerobic training was brisk walking for 3-5 times a week with intensity of 40-70% of Heart Rate Reserve (HRR) achieved in exercise test by using Karvonen formula, and RPE of 11-14 for duration of 20 to 40 minutes (ACSM guidelines 2005)19. Patients were contacted by phone every two weeks to ensure their interest in the program and to monitor the
Even reports on health economic aspects show that cardiac rehabilitation is a justifiable use of the healthrelated budget. However, access to cardiac rehabilitation is often limited12, 13, 14 Cardiac rehabilitation ensures improvement in quality of life and makes it easier for patients to work, participate in social activities and exercise. Quality Metrics SF-36V2 Health Survey asks 36 questions to measure functional health and well-being from the patients point of view. Its called a generic health survey because it can be used across age (18 and older), disease, and treatment groups, as opposed to a disease-specific health surveys which focus on a particular condition or disease. The survey is meaningful to patients, clinicians, researchers, and administrators across the health care spectrum, and has various applications15. METHOD Subjects This study was approved by the Central Ethical Committee of Nitte University. The patients posted for Coronary Artery Bypass Graft (CABG) were randomly selected from the cardiothoracic unit of K S Hegde Medical College with the permission of the cardiothoracic surgeon. We included subjects with isolated CABG, aged between 40-65 years and with Ejection fraction > 35% and we excluded the subjects with other than isolated CABG ,Age > 65 years, Myocardial infarction after CABG, Ejection fraction <35% , Renal failure and high risk subjects .
progress. The exercise log was reviewed every 15 days .Subjects were also advised to contact the physiotherapist if any advice or help was needed. We provided a detailed booklet in the patients mother tongue which contained dos and donts after cardiac surgery and termination criteria while doing exercise. The progression of the exercise intensity was done every two weeks .As the RPE falls with improving fitness the intensity of exercise was increased by 5 to 10 percent of the maximum heart rate, and the RPE was maintained 11 to 14 throughout the 3 months duration. Subjects started to do the exercise for 15 to 20 minutes and by the end of 3rd month they gradually progressed to 30 to 40 minutes20. After the end of the phase II cardiac rehabilitation SF36V2 questionnaire was again administered to the
patients and asked to fill accordingly. Later the questionnaire scores were compared with the pre-phase II cardiac rehabilitation scores and scores were compared between on pump and off pump CABG. RESULT 58 subjects were selected for the study out of which the questionnaire was not completed for eight subjects. Statistical analysis was performed with SPSS software package. The mean age of the subjects who participated in the study was 47.9 years, range (40-58). 33 males and 17 females completed the study. In comparison with the pre and post values from the SF36 v2 administered to the patients of both the group of on-pump and off pump. There was significant difference when the scores of the questionnaire were compared after one week of surgery (before phase II) of both the groups. (Table- 1)
Table 1. Before phase II cardiac rehabilitation

GROUP PF Group I GroupII RP Group I GroupII BP Group I GroupII GH Group I GroupII VT Group I GroupII SF Group I GroupII RE Group I GroupII MH Group I GroupII PCS Group I GroupII MCS Group I GroupII PCS - physical component summary score, PCS = PF+RP+BP+GH MCS mental component summary score, MCS = VT+SF+RE+MH N 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 Mean 30.2360 33.7080 31.1360 33.7680 49.5280 54.9640 51.8080 54.8160 59.7200 62.8640 46.7960 49.2120 40.0960 43.6120 59.3120 63.9320 50.1800 53.6880 49.2160 53.0880 Std. Deviation 2.70086 4.20150 3.81744 3.50721 5.68718 2.16578 2.75550 4.25182 5.09220 2.70545 6.65014 3.41219 3.10145 3.34692 5.15871 2.65601 3.49327 2.76059 4.95468 3.24807 T 2.25000 p=0.005 hs 2.83400 p=0.04sig 4.92600 P<.001 vhs 2.53600 p=0.005 hs 2.44700 p=0.01 hs 2.48400 p=0.005 hs 2.20700 p=0.04sig 2.55900 p=0.01 hs 2.84700 p=0.04 sig 2.35700 p=0.005 hs
There were no significant changes in the score after Phase 2 cardiac rehabilitation in both the groups. There were changes in the PF (physical functioning) GH
(general health) RE (emotional role functioning) MCS (mental component summary score). (Table-2).
288 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 Table 2. After Phase II Cardiac Rehabilitation
GROUP PF Group I GroupII RP Group I GroupII BP Group I GroupII GH Group I GroupII VT Group I GroupII SF Group I GroupII RE Group I GroupII MH Group I GroupII PCS Group I GroupII MCS Group I GroupII N 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 25 Mean 40.8720 41.9720 32.8120 35.2120 54.9400 55.7080 61.5120 64.5280 62.5880 63.4520 51.8160 52.2600 49.0360 54.9640 62.1400 63.1680 52.2720 53.5440 59.7160 62.7120 Std. Deviation 3.96227 3.01407 5.25808 6.31667 5.55788 3.89657 2.17855 4.66329 5.26223 5.61503 3.48589 3.38674 5.43207 2.58697 3.30568 1.87143 3.63198 5.07092 5.04824 2.40387 T 2.10900 p=0.307 ns .45700 P=.654 ns .56600 p=0.574 ns 2.93000 P=0.005 hs .10700 P=0.916ns .45700 p=0.656 ns 4.92600 p<.001 vhs 1.35300 p=0.182 ns .58400 P=0.562 ns 2.67900 P=.01 hs
Paired sample test was done to compare pre and post values of both the groups, and there were significant difference between pre phase II and post
phase II of cardiac rehabilitation scores between on pump and off pump cardiac surgery.(Table-3 and 4)
Table 3. Paired Samples Test, Group-1

GROUP Paired Differences Mean Group I PF- PRE PF-POST RP-PRE RP-POST BP-PRE BP-POST GH-PRE GH-POST VT-PRE VT-POST SF-PRE SF-POST RE-PRE RE-POST MH-PREMH-POST PCS-PRE PCS-POST MCS-PRE MCS-POST -9.6360 -.6760 -9.4120 -3.7040 -9.8680 -5.0200 -16.9400 -9.8280 -3.0920 12.5000 Std. Deviation 10.08319 16.14273 11.40677 6.47447 12.44946 9.54799 15.05631 10.38775 8.27682 12.61266 -4.778 -.209 -4.126 -2.860 -3.963 -2.629 -5.626 -4.731 -1.868 -4.955 <.001 vhs .836 <.001 vhs 0.009 hs <.001 vhs 0.015 sig <.001 vhs <.001 vhs .074 <.001 vhs
Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 289 Table 4. Paired Samples Test, Group II
GROUP Paired Differences Mean GroupII PF-PRE PF-POST RP-PRE RP-POST BP-PRE BP-POST GH-PRE GH-POST VT-PRE VT-POST SF-PRE SF-POST RE-PRE RE-POST MH-PREMH-POST PCS-PRE PCS-POST MCS-PRE MCS-POST -12.2640 -3.4440 -12.7440 -7.7120 -13.5880 -10.0480 -18.3520 -15.2360 -5.8560 -16.6240 Std. Deviation 7.03526 19.16059 10.20139 8.90048 9.04366 14.03852 13.76787 11.24333 8.24768 12.54184 -8.716 -.899 -6.246 -4.332 -7.512 -3.579 -6.665 -6.776 -3.550 -6.627 <.001 vhs .378 <.001 vhs <.001 vhs <.001 vhs 0.002 hs <.001 vhs <.001 vhs 0.002 hs <.001 vhs
DISCUSSION Overall QOL after surgical myocardial revascularization was fairly well preserved in both groups and comparable with that of a standard population in most aspects. General and mental health, vitality, physical and social functioning, and bodily pain were not negatively affected by surgery irrespective of the procedure chosen. The quality of life before the phase II cardiac rehabilitation in off pump and on pump patients was significantly changed; the QOL rating was more in off pump patients than on pump group. This may be due to CABG performed with cardiopulmonary bypass (CPB), also known as on- pump CABG, which has been associated with significant pulmonary complication and functional changes. Many of these abnormalities are thought to be caused by CPB. Duration of hospital stay and extubation period was lesser in off-pump group compared with on-pump group. The incidence of atelectasis and pleural effusion and ventilator support was significantly higher in on pump group. Four of the on pump patients were re- intubated during the phase I cardiac rehabilitation period. Many studies suggest that quality of life is better in OPCAB patients in the initial 2 weeks after surgery; our study revealed that quality of life can improve in both types of surgery after structured cardiac rehabilitation. One limitation of the study may be the sample size, since the less number will not give more statistical weightage. The phase II cardiac rehabilitation program was an individually tailored exercise program, in which the exercise frequency, intensity and mode were prescribed and the patient was encouraged to perform the exercise at home. The disadvantage of this type of exercise program is that it is non- monitored and thus compliance with the program cannot be ensured.
CONCLUSION The authors concluded that 3 months of structured cardiac rehabilitation programs significantly improved QOL in on pump and off pump CABG patients; there were significant changes in the all the 8 domains in the SF36 questionnaire before and after Phase II cardiac rehabilitation. But there were no significant difference in QOL between on pump and off pump CABG subjects after a cardiac rehabilitation program. Conflict of Interest -nil REFERENCES 1. Kolesov VI. Mammary artery-coronary artery anastomosis as a method of treatment of angina pectoris. J Thorac Cardiovascular Surg. 1967; 54: 535544. Favaloro RG. Saphenous vein autograft replacement of severe segmental coronary artery occlusion: operative technique. Ann Thorac Surg. 1968; 5: 334339. H S Rissam, S Kishore, N Trehan Coronary Artery Disease in young Indians- The missing link. J Indian Academy of clinical Medicine. 2001Julyseptember; 2(3). Thomas A .Schwann.Effects of body size on operative, intermediate, and long-term outcomes after coronary artery bypass operation.Ann Thoracic Surg. 2001; 71:521-530. Reeves BC,Ascione R, Chamberlain MH,Angelini GD. Effect of body mass index on early outcomes in patients undergoing coronary artery bypass surgery. J Am Coll Cardiol. 2003; 42:668-676. D Johnson. Postoperative physical therapy after coronary artery bypasses surgery. Am. J. Respir. Crit. Care Med. Sep 1995; 152(3):953-958. Elisabeth Westerdahl. Chest physiotherapy after
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CABG surgery- A comparison of three different deep breathing techniques. Rehab Med. 2001; 33:79-84. 8. Ignacio J. Ferreira-Gonzalez, Aida Ribera, Purificacion Cascant and Gaieta PermanyerMiralda1. The ARCA study group Epidemiology Unit, Department of Cardiology, Vall dHebron Hospital, Paseo Vall dHebron. European Heart Journal. 2006; 27: 24732480. 9. Bo Hedback, Joep Perk, Mikael Hornblad and Ulf Ohlsson. Cardiac rehabilitation after coronary artery bypass surgery:10-year results on mortality, morbidity and readmissions tohospital. Journal of Cardiovascular Risk. 2001; 8:153158. 10. Yaacov Drory MD. Cardiac Rehabilitation after Coronary Artery Bypass GraftSurgery: Urgently Needed. IMAJ. 2001; 3:427-429. 11. Eagle KA, Guyton RA, Davidoff R, Ewy GA, Fonger, J, Gardner TJ, Gott JP, Herrmann HC, Marlow RA, Nugent WC, OConnor GT, Orszulak TA, Rieselbach RE, Winters WL, Yusuf S. ACC/ AHA guidelines for coronary artery bypass graft surgery: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines Committee. 12. Oldridge N, Furling W, Feeny D. Economic evaluation of cardiac rehabilitation soon after acute myocardial infarction. Am J Cardiol.1993; 72:154161. 13. Levin LA, Perk J, Hedb B. Cardiac rehabilitation a cost analysis. J Intern Med. 1991; 230:427434.
14. Ades PA, Pashkow F, Nestor JR. Cost-effectiveness of cardiac rehabilitation after myocardial infarction. J Cardiopulm Rehabil. 1997; 17: 222231. 15. Dempster M, Donnelly M. Measuring healthrelated quality of life among people with ischaemic heart disease. Heart. 2000; 83:641644. 16. John E. Ware, Jr., PhD, founder/CEO of Quality Metric Health Outcomes Solutions, releases the Users Manual for the SF 36v2 Health Survey Second Edition. Lincoln RI September 2007. 17. Morag K. Thow Dip PE, BSc, PhD, MCSP .Exercise Leadership in Cardiac Rehabilitation An evidence-based approach. Glasgow Caledonian University Glasgow, UK.page1 and page 9. 18. Machionni N, Fattirolli F, Fumagalli S. Improved exercise tolerance and quality of life with cardiac rehabilitation of older patients after myocardial infarction: results of a randomized controlled trail. Circulation.2003; 107: 2201-2206. 19. American College of Sports Medicine (ACSM) Guidelines for exercise testing and prescription. 7th Ed. Philadelphia: Lippincott, Williams and Wilkines.2006. 20. Mohammad H Haddadzadeh, Arun G Maiya, Bjan Shad, Fardin Mirbolouk, R Padmakumar, Vasudeva Guddattu .Effect ofcardiac rehabilitation on myocardial contractility in coronary artery disease patients: A trail from Iran.ijcrr.2011 september;03(09):149-158.
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Effectivness of PNF Stretching and Self Stretching in Patients With Adhesive Capsulitis - A Comparative Study Pag 53

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Volume 7

Sub Editor Kavita Behal Sharma MPT (Ortho)

Nishat Quddus, New Delhi

Devtech Publishers & Printers Pvt. Ltd., Faridabad

Indian Journal of Physiotherapy and Occupational Therapy

Table 2. Intra group mean difference

Table 3. Inter group comparison using Multiple Scheff test

12. 13. 14.

Table 2. Resting and Non-Dominant

Table 3. Dominant and Non-Dominant

Table 5. Resting and Non-Dominant

Table 6. Dominant and Non-Dominant

MALES AND FEMALES

Table 8. Resting and Non-Dominant

Table 10. Dominant (male & female)

Table 11. Non-Dominant (male & female)

B: Students paired t test

Evaluation of effects of Nebulization and Breathing Control in Asthmatic Patients

1) Evaluation of peak expiratory flow Rate (PEFR) in N+B and B group

3) Evaluation of Respiratory Rate (RR) in N+B and B group

4) Evaluation of perceived exertion (RPE) in N+B & B group

Mean S.D Pre value Post value 1.3330.408 2.530.833

Fig: 1 Tools Used

Outcome Measures Star Cancellation Test (SCT) to assess visual attention,

Fig. 4 Therapist Testing Berg Balance Scale

Fig. 2 Star Cancellation Test

RESULTS Graph 1: Age & Gender distribution of the subjects

Table 1: Descriptive statistics for Outcome measures

Star Cancelation test (Time of Discharge)

Berg Balance Scale (Time of Discharge) Barthel Index (Time of Discharge)

Table (1): Descriptive characteristics of patients in the three groups .

S= Significant, HS= Highly significant , NS= not significant

S= Significant, HS= Highly significant , NS= not significant

S= Significant, HS= Highly significant , NS= not significant

Mean -21.667 -31.733 -10.067 -14.400 -21.800 -7.400

Std. Error 2.065 1.850 .658 2.908 2.694 .466

p-value .000 .000 .000 .001 .000 .000

Periods 2nd wk 4 wk 4th wk 2nd wk 4th wk 4 wk

Mean -38.200 -48.533 -10.333 -23.000 -31.600 -8.600

Std. Error 3.151 2.862 .779 2.556 2.124 1.125

p-value .000 .000 .000 .000 .000 .000

Effect of Modified Hold-Relax and Active Warm-Up on Hamstring Flexibility

Fig.1: The Modified hold relax stretching technique.

Table.2: Between Group Comparison of Range of Motion using t and p values

Fig. 3. Superficial heat (Moist pack)

Fig. 4 Deep heat (Ultra sound)

Fig. 5. Static Stretching

Influence of different Types of Hand Splints on Flexor Spasticity in Stroke Patients

Table 1: Demographic and clinical characteristics

Percentage of improvement in acute neuralgia

Percentage of improvement in subacute neuralgia

Percentage of improvement in established neuralgia

**highly significant * significant

MWM 2/10 170 0 167 0 15%

Musculoskeletal Pain among Computer Users

Figure 1: Showing distribution of study sample according to nationality

Fig. 2. Ambulation at the time of discharge.

Table 2. Mean age of subjects in group l and group 2

Table 2: SAMP score of right upper limb in percentage.

Score Right Score Left

Total (N = 72) Total (N = 72) Total (72)

20.44 (SD 5.25) 18.49 (SD 4.49) 1.09 (SD 0.29)

0.619 0.53 0.03516

Figure 1 & 2 Delivery of Group Physiotherapy Sessions (GROUP A)