Indian Journal ofPhysiotherapy and Occupational TherapyAn International JournalISSN P - 0973-5666ISSN E - 0973-5674Volume ...
INDIAN JOURNAL OF PHYSIOTHERAPY ANDOCCUPATIONAL THERAPYEditorArchna Sharma (PT)Head, Dept. of Physiotherapy, G.M. Modi Hos...
iIndian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 201	 Case report of an ankylosing sp...
ii Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 280	 Effectiveness of nerve mobili...
1Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2Case report of an ankylosing spondy...
2 Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2approaches which enable the patien...
3Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2antigen HLA-B272,6.Subject selected...
4 Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2erosions, squaring of the vertebra...
5Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2Efficacy of enhancement forearm sup...
6 Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2using the nine hole peg test. All ...
7Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2and shoulder in sitting position de...
8 Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2periarticular connective tissue st...
9Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2A comparative study on effectivenes...
10 Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2between the gel sheet and the pre...
11Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2between ultrasound group and the l...
12 Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2laser therapy treatment both have...
13Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2Comparison of the effects of thera...
14 Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2of soft tissue injuries. Pain rel...
15Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2The number of females in group A w...
16 Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2was to compare the effects of US ...
17Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2Slow breathing training on cardio-...
18 Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2breathing technique appears to be...
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  1. 1. Indian Journal ofPhysiotherapy and Occupational TherapyAn International JournalISSN P - 0973-5666ISSN E - 0973-5674Volume 6 Number 2 April-June 2012website: www.ijpot.com
  2. 2. INDIAN JOURNAL OF PHYSIOTHERAPY ANDOCCUPATIONAL THERAPYEditorArchna Sharma (PT)Head, Dept. of Physiotherapy, G.M. Modi Hospital, Saket, New Delhi 110 017E-mail: editor.ijpot@gmail.comExecutive EditorDr. R.K. SharmaDean, Saraswathi Institute of Medical Sciences, Ghaziabad (UP)Formerly at All-India Institute of Medical Sciences, New DelhiNational Editorial Advisory BoardProf. U. Singh, New DelhiDr. Dayananda Kiran, IndoreDr. J.K. Maheshwari, New DelhiSuraj Kumar, New DelhiRenu Sharma, New DelhiVeena Krishnananda, MumbaiDr. Jag Mohan Singh, PatialaN. Padmapriya, ChennaiG. Arun Maiya, ManipalProf. Jasobanta Sethi, BangaloreProf. Shovan Saha, ManipalProf. Narasimman S., MangaloreKamal N. Arya, New DelhiNitesh Bansal, NoidaAparna Sarkar, NoidaAmit Chaudhary, FaridabadSubhash Khatri, BelgaumDr. S.L. Yadav, New DelhiSohrab A. Khan, Jamia Hamdard, New DelhiDheeraj Lamba, HaldwaniDr. Deepak Kumar, New DelhiKalpana Zutshi, New DelhiInternational Editorial Advisory BoardDr. Amita Salwan, USADr. Smiti, CanadaDr. T.A. Hun, USAHeidrun Becker, GermanyRosi Haarer Becker, Germany,Prof. Dra. Maria de Fatima Guerreiro Godoy, BrazilDr. Venetha J. Mailoo, U.K.Dr. Tahera Shafee, Saudi ArabiaDr. Emad Tawfik Ahmed, Saudi ArabiaDr. Yannis Dionyssiotis, GreeceDr. T.K. Hamzat, NigeriaProf. Kusum Kapila, KuwaitProf. B.K. Bhootra, South AfricaDr. S.J. Winser, MalaysiaDr. M.T. Ahmed, EgyptProf. Z.W. Sliwinski, PolandDr. G. Winter, AustriaDr. M. Nellutla, RwandaProf. GoAh Cheng, JapanDr. Sema Oglak, TurkeyDr. M. Naveed Babur, PakistanPrint-ISSN: 0973-5666 Electronic - ISSN: 0973-5674, Frequency: Quarterly (4 issues per volume).“Indian journal of physiotherapy and occupational therapy” An essential indexed double blind peer reviewed journal forall Physiotherapists & Occupational therapists provides professionals with a forum to discuss today’s challenges - identifyingthe philosophical and conceptual foundations of the practics; sharing innovative evaluation and tretment techniques; learningabout and assimilating new methodologies developing in related professions; and communicating information about newpractic settings. The journal serves as a valuable tool for helping therapists deal effectively with the challenges of the field. Itemphasizes articles and reports that are directly relevant to practice. The journal is now covered by INDEX COPERNICUS,POLAND. The journal is indexed with many international databases, like PEDro (Australia), EMBASE (Scopus) & EBSCO(USA) database. The journal is registered with Registrar on Newspapers for India vide registration DELENG/2007/20988.The Journal is part of UGC, DST and CSIR consortia.Website : www.ijpot.comAll right reserved. The views and opinione expressedare of the authors and not of the Indian journal ofphysiotherapy and occupational therapy. The Indianjournal of physiotherapy and occupational therapy doesnot guarantee directly or indirectly the quality or efficacy ofany product or service featured in the advertisement in thejournal, which are purely commercial.EditorArchna SharmaFirst Floor, Punjab National Bank BuildingMain Dadri Road, Bhangel, NOIDA - 201 304, UTTAR PRADESHPrinted, published and owned byArchna SharmaPrinted atProcess & SpotC-112/3, Naraina Industrial Area, Phase-INew Delhi-110 028Published atFirst Floor, Punjab National Bank BuildingMain Dadri Road, Bhangel, NOIDA - 201 304, UTTAR PRADESH
  3. 3. iIndian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 201 Case report of an ankylosing spondylitis patient & review Abha Sharma, Niti Khurana, Sukhmeet Singh Hanspal05 Efficacy of enhancement forearm supination on improvement of finger dexterity in hemiplegiccerebral palsy children Ahmed M. Azzam09 A comparative study on effectiveness of ultrasound therapy and low level laser therapy in themanagement of second stage pressure sores Anil Rachappa Muragod, Sreekumaran P, Danesh K U13 Comparison of the effects of therapeutic ultrasound v/s myofascial release technique in treatment ofplantar fasciitis Apeksha O. Yadav, R. Lakshmiprabha18 Slow breathing training on cardio-respiratory control and exercise capacity in persons with essentialhypertension – A randomized controlled trial Balasubramanian Sundaram, Purvesh J. Maniyar, Varghese John. P, Vijay Pratap Singh23 Postural stability during seven different standing tasks in persons with chronic low back pain – Across-sectional study Balasubramanian Sundaram, Meghna Doshi, Joseley Sunderraj Pandian29 Efficacy of lateral wedged insole with subtalar strapping on the functional status of medialcompartment 3rd grade osteoarthritis of the knee Bindya Sharma, L.Chandrasekar33 An examination of Cyriax’s passive motion tests as a diagnostic tool in patients having osteoarthritisof the knee joint Garg Chaya, Aggarwal Garima37 Abdominal versus pelvic floor muscles exercises in mild stress urinary incontinence in obeseEgyptian women Dalia M. Kamel, Ali A. Thabet, Sayed A. Tantawy, Mohamed M. Radwan42 A study to compare the effects of moist heat therapy with ultrasonic therapy and ultrasonic therapyalone in lateral epicondylitis Dheeraj Lamba, Swastika Verma, Kavita Basera, Meenakshi Taragi, Aditi Biswas46 The effect of neural mobilization with cervical traction in cervical radiculopathy patients Dheeraj Lamba, Deeksha Rani, Nupur Gaur, Rita Upadhyay, Neerja Bisht50 Effects of motor imagery in phantom pain management following amputation: A review of literature Hemakumar Devan, Parimala Suganthini K55 The beneficial effects of low intensity laser acupuncture therapy in chronic tonsillitis Marwa M. Eid, Intsar S. Waked, Amany R. Abdel Wahid60 Early clinical exposure as a teaching learning tool to teach neuroanatomy for first year occupationaland physical therapy students – our preliminary experience Ivan James Prithishkumar, Sunil J Holla64 A comparative study on the effects of incentive spirometry and deep breathing exercise onpulmonary functions after uncomplicated coronary artery bypass grafting surgery Mueenudheen TP, Jamal Ali Moiz, V.P. Gupta69 Sjogren’s Syndrome – A case report Kakkad Ashish71 Comparison of Brunnstrom hand manipulation and motor relearning program in hand rehabilitationof chronic stroke: A randomized Trial Shanta Pandian, Ebenezer Wilson Rajkumar D, Kamal Narayan Arya76 Effect of Bean pillow as an adjunct to exercises for neck pain in cervical spondylosis: A pilot study Krunal V Desai, Sheela A. RaoVolume 6, Number 2 April-June 2012
  4. 4. ii Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 280 Effectiveness of nerve mobilization in the management of sciatica Meena Gupta83 Effects of customized proprioceptive training and balance exercises among diabetic patients Nandini B. Kadabi, Sanjiv Kumar87 Extubation outcome after spontaneous breathing trials with T-tube or pressure support ventilation Neeraj Vats, Jaswant Singh, Seema Kalra91 Effectiveness of valgus insole on pain, gait parameters and physiological cost index of walking in flatfeet in 5-15 years Bharati Asgaonkar, Pradnya Kadam96 The effects of upper limb exercises on hand writing speed Nilukshika KVK, Nanayakkarawasam PP, Wickramasinghe VP101 Effect of spinal manipulation in primary dysmennorhoea Sidana Ruchi, Narkeesh106 Reliability of the six-minute walk test in individuals with transtibial amputation Sangeeta Lahiri, Pooja Ghosh Das110 Evaluation of thumb pain and lumbrical grip of post graduate physiotherapist practising Maitland’smoblisation Shweta Awasthi, Amit Purib115 Effect of different body positions on manual dexterity in clinical nurses Sonia Talreja, J. Andrews Milton, Dharam Pani Pandey119 Comparative study of spinal cord independence measure scale versus functional independencemeasure scale to assess functional capacity in patients with spinal cord injury Priya Makkad, S.S Ganvir, Sourya Acharya124 Prevalance of low back pain in geriatric population in and around Ludhiana, Punjab Supriya Sharma129 Correlation between ankle range of motion and balance in community - dwelling elderly population Tanushree Agarwal, Parul R Agarwal132 A pilot study to compare between effectiveness of functional mobility and strengthening exercisesand strengthening exercises alone in Guillian Barre Syndrome patients Venu V. Dombale, Sanjiv Kumar137 Mulidisciplinary Vm – Weight distribution analysis system: A diagnostic and evaluative tool foraltered weight distribution Vijay Batra, V. P. Sharma, Meenakshi Batra, Vineet Sharma140 Low back pain in pregnancy – incidence & risk factors Vijayan Gopalakrishna Kurup, V K Mohandas Kurup, T M Jayasree, A John William Felix145 Health related quality of life in chronic non specific low back pain individuals with type ii diabetes Wani S.K., Dongre A., Ramteke G. J.149 Effect of dorsal neck muscle fatigue on postural control Muniandy Yughdtheswari, Ravi Shankar Reddy
  5. 5. 1Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2Case report of an ankylosing spondylitis patient & reviewAbha Sharma1, Niti Khurana2, Sukhmeet Singh Hanspal21Asst. Professor, 2Clinical Demonstrator, Banarsidas Chandiwala Institute of Physiotherapy, Chandiwala Estate, MaaAnand Mai Marg, Kalkaji, New DelhiAbstractAnkylosing Spondylitis (AS) is a chronic inflammatory disorderof the musculoskeletal system with gradually increasing axialstiffness and restriction in movement. It leads to pain, reducedspinal & joint mobility and limitations in physical functioning. Timelyidentification of disease and a combination of pharmacotherapy aswell as rehabilitation helps combat the pain and disability. A casereport is presented of an AS patient with all characteristic features.Key WordsAnkylosing Spondylitis, peripheral arthritis, total hiparthroplasty, physical therapy.IntroductionAnkylosing Spondylitisis a chronic, immune-mediated inflammatory disease that is associatedwith inflammation in the sacroiliac joints, the axialskeleton, entheses, peripheral joints, uvea, and otherstructures1, of unknown aetiology;2predilection foraxial skeleton, affecting particularly SI and spinalfacet joints3; approximately 0.9% population affected4,found worldwide, more often in Caucasians than otherraces5. A strong family history & approximately 90-95%of patients have tissue antigen HLA-B272,6. Recentidentification of two new genes, ARTS1 and IL23R, andconfirmation of IL-1A association further substantiatethat AS is determined to a large extent by genes outsidethe major histocompatibility complex7. Onset age is 2ndor 3rd decade, with peak age of disease onset around15-35 years (mean 26years), males affected 2 to 3 timesmore than females2,4,5,6.The initial pathological changes are initiated bymacrophage infiltration that leads to synovitis andenthesitis. The macrophages are later replaced bylymphocytes, leading to release of large number ofinflammatory mediators, most significant of which areTNF, vascular endothelial growth factor, and IL-1. Theseinflammatory mediators lead to bone erosion, pannus,and granulation tissue formation. The eroded bone healsby osseous ankylosis1. There are 2 basic pathologicallesions: synovitis of the diarthrodial joints & inflammationat the fibro-osseous junctions of the syndesmotic joints &tendons. The preferential involvement of the insertion oftendons and ligaments (entheses) is seen8. Pathologicalchanges proceed in 3 stages- inflammatory reactionwith ground cell infiltration, granulation tissue formation& erosion of adjacent bone; replacement of granulationtissue by fibrous tissue; and ossification of fibrous tissueleading to ankylosis of joint8. Ossification across surfaceof disc gives rise to small bony ridges-syndesmophyteslinking adjacent vertebral bodies. If many vertebra areinvolved spine may become absolutely rigid8.The clinical features are insidious onset; dull painfelt in lower lumbar region, morning stiffness lasting forfew hours, asymmetric arthritis of other joints mainly oflower limbs. Neck pain and stiffness present in advancedcases. Physical findings include loss of spinal flexion,extension, lumbar lordosis, diminished chest expansion,and exaggerated thoracic kyphosis3. Modified New YorkCriteria, 1984 for diagnosis are:1. Low back pain of at least 3 months’ duration improvedby exercise and not relieved by rest2. Limitation of lumbar spine in sagittal and frontalplanes3. Chest expansion decreased relative to normal valuesfor age and sex4. Bilateral sacroiliitis grade 2 to 45. Unilateral sacroiliitis grade 3 or 4Definite AS diagnosed when:unilateral grade 3 or 4,or bilateral grade 2 to 4 sacroilitis and atleast one clinicalcriterion. CT and MRI can detect AS lesions earlier andwith greater consistency than plain radiography9.Extraskeletal Manifestation of ASalternate buttock pain, acute anterior uveitis (25–40%),9,10synovitis, enthesitis (heel, plantar),9peripheralarthritis (25–50%), chronic inflammatory bowel disease(26%), Psoriasis(10%)9,10, aortic incompetence, cardiacconduction defects, and fibrosis of the upper lobes of thelungs, cauda equina syndrome or renal amyloidosis9.In established cases posture is typical: loss of normallumbar lordosis, increased thoracic kyphosis & forwardthrust of neck; and in late cases these may become fixeddeformities. Spinal movements restricted in all directions,but loss of extension is always the earliest and the mostsevere disability. In advanced cases spine may becomecompletely ankylosed from occiput to sacrum, sometimesin position of grotesque deformity3.AS affects spinal and peripheral joints such as theshoulder, hip, knee, and ankle. The thoracic vertebraeare affected, and inflammation of the costovertebral,costosternal, and manubriosternal joints causespulmonary restriction and thoracic pain. As a result,people with AS demonstrate inspiratory muscle fatigueduring exercise and limited capacity of maximal oxygen.These restrictions lead to decreased daily activity andquality of life11.Due to the sporadic, progressive nature of AS,and unknown aetiology, management is difficult. Moreimportant for the long term management is rehabilitation
  6. 6. 2 Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2approaches which enable the patient to self-managesymptoms4. A growing body of research revealsthat exercise is as crucial as drug treatment in themanagement of AS11.A case report is selected of a patient of AS.Case Study of an Ankylosing Spondylitis PatientThe case study is of a 53 years old male having ASfor the last 33 years.There is a positive family history of AS, family of fourbrothers of which two have AS, though symptoms andcourse of disease is varied in all. One of his grandfather’ssecond cousins had a stooped posture and had backpain during his youth. In retrospect family and the doctorsthought he too would be an AS in absence of medicalreports. None of his children or his brothers’ children,age group 24 to 38, have AS till date or any associatedcomplaints.He was a young healthy adult till age of 20 years(1977) when he developed colitis. Thereafter he wasoperated for appendisectomy in January 1978. On the7th post – op day he developed severe pain in righthip joint, which subsided after strong pain relievers.Subsequently no problem for 11/2yrs. He was easilyfatigued during this duration required frequent rest. May1979 he had jaundice and subsequently had pain andswelling in right acromioclavicular joint. Two monthslater, movement of shoulder joint gradually reduced.Nearly four months his left acromioclavicular joint startedshowing similar signs. Pain in the upper region of spinestarted in early 1980. February 1980, pain appeared inright foot and two - three months later moderate neckpain developed. Within the next few months persistentback ache started. He consulted an orthopaedic surgeonin November 1980 and was diagnosed as an advancedcase of AS with HLA B-27 positive and ESR in rangeof 86. He was put on pain killers and the doctor thenadvised to refrain from doing exercises.Onset of acute pain in right hip joint by May 1981.Subsequently, severe pain in right hip occured every 2to 3 months, and walking was impossible for 2 to 3 daysduring each episode. Moderate to severe intensity painin right hip pain for four years, out of which 15 monthswere of severe, excruciating pain confining him to bed.A senior world renowned orthopaedic surgeon thenadvised him for exercises regularly to maintain his jointsmobility and flexibility; though by then the right hip jointhad considerably deteriorated. Right total hip arthroplastywas done on 23rd June 1983. 3 years later pain in lefthip joint started, patient confined to bed for four monthsand THR done on 24th August 1990. (Figure–1 x-ray B/LTHR). Revised THR for right hip done on 1st September2008 as constant pain and discomfort in the right hipjoint and radiologically signs of loosening were noticed.(Figure – 2 x-ray Rt. Revision THR). He has had multipleepisodes of acute iritis treated by cortisone therapy.Post primary THR in Mumbai the importance ofregular exercises, precautions and management of hisdisease was emphasized. He and his family memberswere well educated about the disease and its outcome.His positive attitude and adherence to the instructionsof his medical team gave him favourable results. Hefollowed a regulated daily routine with an exerciseschedule under supervision of physiotherapists.Since the last 6 years he has been undergoing dailyphysiotherapy of active, active assisted and mild resistedexercises maintaining his range of motion, musclestrength and posture. Off and on episodes of acutepain in the joints, especially at entheses sites noticed.In physiotherapy modalities like ultrasonic waves, laser,hot packs and cold packs have been used as per theindications. The best results have been gained withhot packs and supervised exercises. The things worthmentioning are1. Daily exercise regime has reduced pain & stiffnessand improved range of motion.2. Ability to maintain a fairly active life style and a positiveattitude.3. Despite early onset of disease stooped posture hasnot developed as lying down prone daily as a part ofexercise regime to counteract the flexed attitude.4. Pranayamas and regulated food habits.5. Faith in exercise regime.6. With proper precautions and care his bilateral THR’shave lasted for years, right primary THR - 25 years;left primary THR for 21 years and still doing well.DiscussionSubject discussed has a positive correlation withHLA-B27 as in other studies. G. Narsimulu et al reportthat AS is HLA-B27-associated chronic, inflammatoryrheumatic disease characterised by sacroilitis andspondylitis with formation of syndesmophytes leading toankylosis9. G Peh and Bedriye Mermerci Başkan et alshow approximately 90-95% of patients have the tissueFigure 1: (X-ray B/L THR)Figure 2: (X-ray Rt. Revision THR, Lt. Primary THR)
  7. 7. 3Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2antigen HLA-B272,6.Subject selected disease onset was at 20 years butdiagnosed at 22 years when symptoms manifested fully.Study report by A. A. Khalessi peak age of onset wasbetween 20–30 years, with an average 5–6year delayin diagnosis reported in the literature10. A Ghosh et alalso report age of onset in 2nd or 3rd decade of life andmales affected two to three times more than females3.Similar findings seen for our subject too.A. N. Shukla et al have shown that functionally, thepatient is most limited by the hip disease. THR offerssuch patients a new lease of life13. Our subject was mostaffected by hip disease. The hip joint involvement wassevere that within the initial few years of disease activityjoint deteriorated severely and patient was bed-riddendue to acute, debilitating pain in both hips on differentinstances. Jaypal Reddy Sangala et al report hipreplacement and spinal surgery have to be consideredin patients with refractory pain and/or disability1. G.Narsimulu and K. Suresh reported that THR is indicated inpatients with refractory pain or disability and radiographicevidence of structural damage, irrespective of age9. Itensures stability and mobility of the joint & most effectiveways of improving quality of life particularly in casesof AS14. Our subject also had marked improvement inquality of life as well as reduction in pain by THR.In subject selected THR in both hips have asurvivorship of more than 20 years, right side primaryTHRsurvived for 25 years and left side THR still continuing at21 years on. Revision THR for right was done 3 yearsago. Studies have also shown that survivorship analysiswith use of Kaplan-Meier method revealed that probabilityof survival of femoral component (with 95% confidenceintervals) was 91% (83 to 99%) at 20years and 83%(72 to 94%) at 30years. The probability of survival ofacetabular components was 73% (61 to 84%) at 20yearsand 70% (57 to 83%) at 30years. Probability that bothcomponents would survive was 91% (82 to 100%) at10years, 73% (61 to 84%) at 20years, and 70% (57 to83%) at 30 years. The Charnley low-friction arthroplastyprovided consistently good long-term results, with alow rate of complications and revisions, in this group ofyoung patients12.Studies show that age at onset in the patientswith peripheral arthritis was significantly younger thanin patients without peripheral arthritis. Patients withperipheral arthritis had a higher frequency of enthesitisand trauma history. Distribution of initially-affected joints-axial joints including hip and shoulder(53%), peripheraljoints(36%), and entheses(11%), in decreasing order, theaxial joints most commonly involved initially sacroiliacjoints(37%)5. In our case report similar features wereseen with initial involvement in hip joints, followed byshoulder joints, ankle joints and wrist joints, diseaseonset in 2nd decade and peripheral arthritis significantlynoticed.Acute anterior uveitis, most common extra-articularinvolvement reported to occur in 1.5-30% of patients,and is more common in HLA B27(+) than HLA B27(-)5.Our subject has had multiple episodes of iritis, requiringcortisone in most instances.The management can be considered as involvinga multi directional approach. The aims of treatment inA.S are to control pain, to maintain or improve function15,to improve mobility and strength, to prevent or reducespinal curve abnormalities3, & thus quality of life15.Physical treatments and medical treatment are mutuallycomplementary. Physical exercise is impossible until painand inflammation are medically controlled & stiffness andspinal deformities cannot be prevented by drugs alone3.Our subject has regularly followed an exerciseschedule maintaining his joints flexibility and functionalindependence and able to prevent a stooped posture.Physiotherapy remains the mainstay of management ofAS 9 statement emphasized by our subject too. Studiesindicate that regular exercises are of fundamentalimportance to prevent or minimize deformity.15 Studiesreport that physical therapy and exercise are necessaryadjuncts to pharmacotherapy11. Band et al discussinfluences of age upon treatment and conclude thatyounger patients, women and those with shorter diseaseduration respond better to physical therapy16. Carbon etal and Uhrin et al demonstrated that physical trainingpromotes a beneficial effect in flexibility and widenessof spinal movement due to release of analgesic andanti-inflammatory effect mediators16. These findingsconsistent with our patient,that regular exercises haveenabled him to improve his functional capacity andreduce fatigue.Rigid spine typical of an AS patient noticed byour subject also.(Figure 3.,3.2 and 3.3). A variety ofchanges occur in the spine, starting with small cornerFig. 3.1& 3.2: (X-rays cervical spine - syndesmophytes,straightening of neck, squaring of vertebrae)Fig. 3.3: (X-ray Lumbar spine syndesmophytes)
  8. 8. 4 Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2erosions, squaring of the vertebral bodies, progressingto syndesmophyte formation, interspinous ligamentossification, apophyseal joint fusion, and completevertebral fusion which produces the bamboo spineappearance6. The vertebral column transforms fromdynamic structure with ligamentous attachments into arigid column of tubular bone housing the spinal cord andneural elements10.Rigidity of thorax occurs in AS with bony ankylosisof thoracic vertebrae, costovertebral, costotransverse,sternoclavicular and sternomanubrial joints leading to apredominant diaphragmatic breathing. Patients with ASwho practice some regular physical activity present apreservation of their pulmonary function, measured byminute volume16. Our subject well informed about limitedpulmonary functions and has regularly practised deepbreathing exercises and yoga pranayamas to combat thedifficulty as much as possible.Efficacy of rehabilitation in warm climate has beenestablished. Hydrotherapy, immersion of the entirebody or parts of it in thermal water coming either fromsprings (mineral water) or other sources. Thermal water(between 30°C and 40°C) may increase the secretionof cortisol, ACTH, growth hormone and prolactin, thusreducing levels of inflammatory compounds such asprostaglandins and leukotriene17. Our subject alwaysfeels better with warm temperature. Peak rise in tempfatigues him easily and low temperatures he is extremelycold and uncomfortable.ConclusionAS is an inflammatory arthritis of unknown etiologywith progressive loss of joint mobility and unpredictable incourse. Physical therapy directed to improve joint mobility,decrease pain and postural deformity will increase thefunction, quality of life as well as physiological andpsychological well-being.Interest of conflict- authors reports no conflict ofinterest.References1. Jaypal Reddy Sangala, Elias Dakwar et al, NonsurgicalManagement of Ankylosing Spondylitis, Neurosurg Focus24 (1):E5, 2008.2. Bedriye Mermerci Başkan et al, Comparison of the BathAnkylosing Spondylitis Radiology Index and the modifiedStoke Ankylosing Spondylitis Spine Score in Turkishpatients with ankylosing Spondylitis; Clin Rheumatol (2010)29:65–70.3. A Ghosh, A Kole et al, Treatment of Ankylosing Spondylitiswith special reference to biologics: Single CentreExperience, J Indian Rheumatol Assoc 2004: 12: 54 – 57.4. Shawn Henderson; Rehabilitation Techniques in AnkylosingSpondylitis Management: a case report; J Can ChiroprAssoc 2003; 47(3) 161.5. Ji-Hyun Lee, Jae-Bum Jun; Higher Prevalence of PeripheralArthritis among Ankylosing Spondylitis Patients; J KoreanMed Sci 2002; 17: 669-73.6. W C G Peh, Clinics in Diagnostic Imaging, Singapore Med J2002 Vol 43(2): 107-111.7. Brionez, Tamar F; Reveille, John D; The Contribution OfGenes Outside The Major Histocompatibility Complex ToSusceptibility To Ankylosing Spondylitis; Current Opinion InRheumatology: July 2008 - Volume 20 - Issue 4 - p 384-391.8. Louis Solomon et al, Apley’s System of Orthopaedicsand Fractures, 8th edition, Arnold Publishers, ISBN 0 340763736, pages 59-60.9. G. Narsimulu, K. Suresh; Management of AnkylosingSpondylitis Medicine Update 2008, Vol. 18, 472-476.10. Alexander A. Khalessi et al; Medical Management ofAnkylosing Spondylitis, Neurosurg Focus 24 (1):E4, 200811. Gonca Ince et al; Effects of a Multimodal Exercise Programfor People With Ankylosing Spondylitis, Physical Therapy,July 2006, Vol. 86, No. 7, 924-935.12. David H. Sochart, Martyn L Porter; Long-Term Resultsof Total Hip Replacement in Young Patients Who HadAnkylosing Spondylitis. Eighteen to Thirty-Year Resultswith Survivorship Analysis, The Journal of Bone and JointSurgery79:1181-9 (1997).13. A. N. Shukla et al: Bilateral Total Hip Replacement InA Patient With Severe Ankylosing Spondilitis UtilizingContinuous Spinal Anaesthesia, The Internet Journal ofAnesthesiology, 2007 Volume 14 Number 2.14. Shahab-ud-din et al, Cemented Total Hip Replacement InPatients Younger Than 50 Years of Age, JPMI, 2005,Vol 19,No.4 , 416-419.15. Jane Kawar, Hisham Al-Sayegh, The Relationship BetweenClinical Activity and Function In Ankylosing SpondylitisPatients, Bahrain Medical Bulletin, September 2005, Vol.27,No. 3.16. Karin M. Goya et al; Regular Physical Activity PreservesThe Lung Function In Patients With Ankylosing SpondylitisWithout Previous Lung Alterations; Rev Bras Reumatol2009;49(2):132-9.17. Karin Öien Forseth et al, Comprehensive Rehabilitation OfPatients With Rheumatic Diseases In A Warm Climate: ALiterature Review; J Rehabil Med 2010; 42: 897–902.
  9. 9. 5Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2Efficacy of enhancement forearm supination on improvementof finger dexterity in hemiplegic cerebral palsy childrenAhmed M. AzzamDepartment of Physiotherapy for Developmental Disturbance and Pediatric Surgery, Faculty of Physical Therapy,Cairo University, Giza, EgyptAbstractObjectiveThe aim of this work was to show the effect of enhancementforearm supination on improvement of finger dexterity in hemiplegiccerebral palsy children.MethodThirty children were enrolled in this study and randomlyassigned into two groups; group A (specialized treatment programfor enhancement of supination plus traditional physiotherapyprogram) and group B (traditional physiotherapy program only).Nine peg hole test was used to detect and follow finger dexterity.This measurement were taken before initial treatment and after12 weeks post treatment. The children parents in group A wereinstructed to complete 3 hours of specialized treatment program forenhancement of supination plus thumb abduction supination splintat home as routine program.ResultsData analysis were available on 30 spastic hemiplegic CPchildren and it was insignificant in the variable related to age(p>0.05).Mean value of the time required to perform task in studygroup pre and post treatment was highly statistical significantdifferences p<.0001while The mean value of time required toperform task in the control group pre and post treatment wasstatistical significan differenc p<.05.ConclusionThe use of specialized treatment program for enhancement ofsupination plus traditional physiotherapy program are superior totraditional treatment program only for finger dexterity improvementafter 12 weeks follow up.Key WordsFinger dexterity, pronation deformity, spasticity, cerebral palsy.IntroductionCerebral palsy (C.P) is a non-progressive clinicalsyndrome that occurs as a result of damage to the motorareas of the immature brain, resulting in a variety ofmotor deficits7.The spastic type is the most common form of C.P,and considered to be a main contributor to both theimpairment of function and decreased longitudinalmuscle growth, leading to deformities1,5.Pronation deformity is commonly associated withelbowspasticity,wristspasticityorboth.Thesedeformitiesare most often treated together with the associateddeformities. They seldom require treatment individually.Pronation deformity of the forearm in hemiplegic cerebralpalsy is more common. Pronation bias makes it difficultfor a person to reach for a target under hand4,7.Pronation deformity of the forearm is the result ofover-activity of the pronator teres and pronator quadratesand weakness of the supinator. When combined withflexion contracture in young children, dislocation of theradial head may occur12,14.Spasticity and excessive neuro-muscular tone in theupper extremities often impair motor neuron functionalabilities. This is due to complex agonist and antagonisthyperactivity, particularly in the pronator teres and/orquadrates muscles3,7.The incidence rate of shortening was twice as highwhen associated with spasticity compared with patientswithout spasticity. The standard of care in treatingshortening includes physiotherapy and occupationaltherapy for shortening reduction and tone management.Stretching is considered one of the most integraltreatments in the reduction of shortening and this oftenrequires the greatest amount of time from the therapist.Passive stretching is commonly used for patients withexcessive pronation specially at home. Prolongedstretch may have also contributed to the decreasedspasticity. Prolonged, passive stretching decreasedreflex sensitivity, and the amplitude of peak-to-peakreflex decreased by 84.8%. The consistent stretchingemployed in this case was for 45 minutes, twice per day,for excessive forearm pronation2,8.MethodsSubjectThirty children from both sexes with hemiplegic CPwere enrolled for this study, aged 5 to 8 years at the timeof recruitment. The degree of spasticity ranged from 1 to+1‫‏‬ according to the modifiedAshworth scale.Assessmentwas performed to anti-gravity muscle groups. They wereable to follow simple verbal commands and instructionsduring both evaluation and treatment. Exclusion criteriafor all children were: (1) botulinum injections in the upperlimb in the past 12 months, (2) Prior surgery (i.e. tendontransfer/tendon lengthening), (3) auditory or perceptualproblems, or uncontrolled seizure disorder.Children were randomized into two groups. Theexperimental group (group A) received a traditionalphysiotherapy program plus specialized treatmentprogram to enhance supination in addition to thumbabduction supination splint. Control group (group B)received a traditional physiotherapy program only.Outcome MeasurementsThe clinical evaluation included history, and degreeof spasticity. All children were assessed for hand function
  10. 10. 6 Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2using the nine hole peg test. All measurements weretaken at baseline (Pre) and after 12-week of intervention(Post).Assessment of Hand FunctionThe nine hole pegs test used for data collection inthis study consists of a plastic console with a shallowround dish to contain the pegs on one end of the consoleand the nine-hole peg-board on the opposite end. Thetherapist centered the pegboard on the table to be infront of children. The shallow dish was oriented on theparticipant’s affected hand and the peg holes on thenon affected side. Children were given the opportunityfor a brief practice test prior to the actual test. Then thechildren were tested using their affected hand. The testswere timed, with a stopwatch, from the moment the childtouched the first peg until the moment the last peg hit thedish. The recorded score was the number of secondsrequired to complete the test. If the children dropped apeg or the trial was interrupted in any way, the evaluatorcued the child to stop and a new trial was initiated.The average of three trials produced higher test–retestreliability than a single trial considered three trials forincreased validity10.The size, shape, weight, texture, and slipperiness ofthe objects must be given careful consideration. Childrencan handle blocks and other objects with straight sidesmore effectively than round objects. Grasp of small tinyobject should not be the priority for children, People usean opposed pattern to grasp items as a cup(cylindericgrasp, a ball (aspheric grasp), a telephone receiverand a large block. Children with disability be assisted indeveloping skills of all types of opposed grasp pattern,power grasp, and lateral pinch to evaluate the skillacquisition3,5.Time, speed, accuracy and numbers of trials theyare movement parameters have to be evaluated in finemotor skills. A small object required longer reaction timethan the larger object. The first part of the movementseems to be unaffected by object size but for smallerobjects extra movement, time is spent in the last part ofmovement when we increase the speed of a movementthe accuracy will decrease.We used the following graduation to follow theimprovement in skill acquisitiona-Big object, rectangular shape, rough, heavyb-Big object, rectangular, rough, lightc-Big object, rectangular, Smooth, heavyd-Big object, circular, rough, heavye-Big object, rectangular, smooth lightf-Big object, circular, smooth, heavyg-Bigobject circular,smooth, lighth-Big object, rectangular, rough, lighti-Small, rectangular, rough, heavyj-Small, circular, rough, heavyk-Small, ectangular, smooth, heavyl-Small, rectangular, rough, lightm-Small, rectangular, smooth, lightn-Small, circular, smooth, heavyo-Small, circular, rough, lightp-Small, circular, smooth, light.Timing places high demands on the motor systemfor speed and efficiency with high demands for attentionand perception. Reaction time provided an indication ofan individual speed in preparing a response productionof fast arm movement may be affected by poor attentionas clumsy children. Increased numbers of trials indicateto increased reaction time and decrease of speed andaccuracy1,2.InterventionFor all children, the programs were conducted threetimes weekly, for 12 weeks. Each session lasted of 45 to60 minutes in an occupational therapy room, in additionto 3 hours of home program, 7 days a week during thetreatment period.Both groups (A and B) received a traditionalphysiotherapy program, as the following;1. Hot packs to improve circulation and relax muscletension applied on the forearm for 20 minutes.2. Facilitation of anti-spastic muscles of the wristextensors, elbow extensors, supinator: tappingfollowed by movement, quick stretch, triggering massflexion, biofeedback, weight bearing, clenching totoes, compression on bony prominence, rapping themuscle, approximation, vibration, irradiation to weakmuscles by strong muscles, ice application for brieftime [8]3. Prolonged stretch for 20 minutes to pronator teres,wrist and elbow flexors to gain relaxation6.4. Passive, gentle and gradual stretching to tightmuscles (i.e. pronators, wrist flexors, elbow flexors,shoulder adductor3.5. Graduated active exercise for upper limb muscles.6. Gait training using aids in closed environment usingobstacles, side walking then by pass walking tostimulate protective reaction for the hand.7. Balance training program which include static anddynamic trainingThe experimental group (group A) receivedspecialized treatment program to enhance supinationin addition to thumb abduction supination splint asfollowing;1. Facilitate supination with the forearm on a surface asin weight bearing on floor, or on mat, while seatedat a table the therapist place an object in the childhand, the child attempt to compensate for difficultywith supination by using wrist extension.2. Encourage the use of 45 to 90 degrees of supinationfollowed by grasp of an object with elbow in 90 degreesof flexion, the child encouraged to keep the thumb upas reaching and grasping large birthday candles thenput them into cake that require supination.3. Encourage lateral reach followed by grasp most of thechildren with a limited use of supination find it easier tocombine humeral abduction with external rotation andsupination than to use humeral flexion with externalrotation and supination.4. Encourage reaching by using shoulder flexion andexternal rotation by placing the object between leg
  11. 11. 7Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2and shoulder in sitting position depending on the childability to control external rotation and supination whilecompleting the reach.5. Encourage reaching across midline followingstrategies suggested for reaching in front of theshoulder.6. Supination Ideas (Turning the hand over, palm up)Children were ringing water out of a towel by twistingit, turning pages of a book. “Guess which hand”games, where something is hidden in one hand, thepartner guesses which by tapping the guest hand, Asimple slinky is a great toy to encourage supination,Build with cones, grasping a magnet (adapt type andsize to the child’s needs),The The path is held with thenon-affected hand and the child holds the magnet inthe affected hand, under the path to guide the car5.7. Thumb abduction supination splint: it is supplied inrolls of various lengths and widths the 5 cm width rollwas used for construction of the supination splints byplacing the loop of the roll through the child thumbthen on a dorsum of the hand so it comes out on theulnar side to volar part then dorsal again, overlap thepart around the wrist, then continually up to forearmthen around the elbow to epicondyles11.ResultsPatients CharacteristicsTable 1 shows the demographic and clinicalcharacteristics of all patients. There were 13 patients(43.3%) are boys and 17 patients (56.7%) as girls therewere 17 patients (56.7%) had mild degree spasticity, and13patients (43.3%) had moderated degree of spasticityon modified ashworth scale. Right hand dominancereported in 27patients (90%), while 3patients (10%)were left hand dominance. There was no significantdifference between both groups in terms of age (p=0.74),sex (p=0.5), degree of spasticity (p=0.23) and handdominances (p=0.5)Changes in the hand dexterityMean test scores and standard deviations for bothgroups are shown in the Table 2. The mean value offinger dexterity in both groups at baseline measurement(pre-treatment) was insignificant (p>.05).Both groups had a significant decline in the timerequired to complete the NHP board task post-treatment.The average reduction in the time required to completethe task trend to being highly significant in the studygroup (64.33±6.51 versus 49.33±11.47, P=0.001) thanin the control group (66.67±6.17 versus64.73±7.11,P=0.03). The percentage of reduction in the time requiredto complete the task were significant post-treatment withgreater percentage observed in the study group (23.3 %)compared to the control group (2.89%).Table 2: The average test time in seconds in both groups.Test time Study groupMean ± SDControl groupMean ± SDp-values(Betweengroup)Pre-treatment 64.33±6.51 66.67±6.17 0.32Post-treatment 49.33±11.47*†64.73±7.11* 0.01% of reduction 23.31†2.89% 0.01p-values(Within group)0.001 0.03*Significant (p<0.05) within group,† Significant (P<0.05) between groupDiscussionSupination is a particularly difficult movementcomponent for children with abnormal tone. Evenchildren with only slightly low tone tend to stabilize in fullpronation when engaging in fine motor tasks. Pronationinterfere significantly with thumb mobility and distal fingercontrol being able to hold various degrees of supination iscritical for higher levels hand skills, helpful in performingactivities. The most important range of supinationfor functional skills use is between full pronation andmidposition. During most skills that involve controlleduse of the radial finger and thumb, the forearm is inapproximately 30 to 45 degrees of supination12.The positon from which the hand is able to functionis when the forearm is midway between pronation andsupination, the wrist in extension, the thumb in abductionand digits in moderate flexion in order for the hand toassume or maintain this functional position there need tobe a balance between the extrinsic and intrinsic musclegroups of the forearm and hand, the wrist and digitaljoints.Spasticity cause the rate of the affected musclegrowth to be reduced causing disproportionate in musclesversus long bone growth. Consequently long bones growat a faster rate than muscles as the muscle sarcomeresare not arranged in the same longitudinal manner asthey are in normally innervated muscles. Thus muscleshortening occur as a result of dynamic stretch reflexand reduced sarcomere formation lead to decreased ofsarcomere numbers.The muscle that usually develop shortening firstis pronator teres muscle, consequently supination ofthe forearm will be restricted. By applying a low loadprolonged stress to the shortened muscles at the end oftheir available range, they will ultimately be able to growbecause the cross bridges between the myosine andactin filaments in the sarcomeres will be disrupted andTable 1: Patients characteristics.Variables Control group(n=15)Study group(n=15)p-valuesAge (years) 6.53±1.06 6.4±1.18 0.74Sex N (%)BoysGirls6(40%)9(60%)7(46.7%)8(53.3%)0.5Degree ofspasticity n(%)Grade 1Grade 1+10(66.7%)5(33.3%)7(46.7%)8(53.3%)0.23Hand dominancen (%)RightLeft13(86.7%)2(14.3%)14(93.3%)1(6.77%)0.5
  12. 12. 8 Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2periarticular connective tissue stiffness will be reduced14.When muscle is stretched on long run it responds byadding new sarcomeres. This makes them return to theiroptimum tension generating length with no change to themuscle tendon.Prolonged stretch is the key for decreasing ofspasticity via stimulation of muscle spindle and golgitendon organ. first step is firing of gamma fibers whichconnected with contractile part of intra-fusal muscle fiberproducing contraction of contractile part and stretchingof non contractile part of intra-fusal muscle fiber whichstimulate stretch receptors(flower-spray, annulo-spiralreceptors) sending impulses to Ia and II afferent to PHCto AHC to alpha motor neuron which produce contractionof extra-fusal muscle fiber lead to stimulation of golgitendon organ which sending impulses to Ib afferentto PHC to Ib inter-neuron which reverse signals intoinhibitory impulses which inhibit AHC which inhibit alphamotor neuron which inhibit extra-fusal muscle fiberproduce relaxation of spastic muscles. The passivestretch to contracted muscle and sheath which destructadhesions in muscle and sheath increasing their elasticityand maintaining it.It has been appeared that most long standingpronation deformity are due to a combination ofcontracture of the involved muscles and their sheathsin addition to spasticity of the involved muscles. Tightpronator muscles cause an imbalance in forearm motorcontrol which lead to poor hand functions and inabilityto perform ADL activity due to limited supination. Thespecialized treatment program produce improvementin all functional skills of the hand and dexterity of thefingers, which included the use of utensils for eating,improved handwriting skills13.ConclusionThe specialized treatment program outcome isto Reduce excessive forearm pronation in hemiplegiccerebral palsy patient. The benefit of this program whichincluded passive and prolonged stretching for contracturereduction and tone management respectively which leadto regained of supination and improvement of fingerdexterity in affected forearm in addition to the continueduse of the program in home therapy will allow the patientto retain both functional skills and the improvements inrange of motion.References1. Backman CA, Gibson GF, Parsons JR. Assessment of handfunction: The relationship between pegboard dexterity andapplied dexterity. Canadian Journal of Occupational Therap.1992; 59(4): 208–213.2. Chan TH, Forssberg H.An investigation of finger and manualdexterity. Perceptual and MotorSkills. DevelopmentalMedicine and Child Neurology .2002;90(6): 537–542.3. Eliasson AC, Burtner PA. The evidence-base for upperextremity intervention for children with cerebral palsy. InImproving hand function in children with cerebral palsy:Theory, evidence and intervention.; Journal of Pediatrics.2008;67(8):231-2364. EliassonAC, Krumlinde LU, Shaw K E,Wang CY .Effectsof constraint-induced movement therapy in young childrenwith hemiplegic cerebral palsy. Developmental Medicineand Child Neurology.2010; 47(4):266-275.5. Exner C E,Lieber RL. In-hand manipulation skills in normalyoung children: A pilot study. OT Practice.2009; 56(7): 63–72.6. Graham K, Shaw K E. Botulinum toxin-A in cerebralpalsy: functional outcomes. Journal of Pediatrics, 2000;137(3):300-303.7. Graham K and Selber PMusculoskeletal aspects of cerebralpalsy. The Journal of Bone and Joint Surgery.2003; British98(2):157-166.8. Hoare BJ, Russo RO. Upper-limb movement trainingin children following injection of botulinum neurotoxinA. In International Handbook of Occupational TherapyInterventions Edited by Springer Publishers2009;P:343-350.9. Hoare BJ, Wallen MA, Imms C, etal. toxin A as an adjunct totreatment in the management of the upper limb in childrenwith spastic cerebral palsy. Developmental Medicine andChild Neurology.2010;52(9):543-550.10. Hoare BJ, Imms CG, Carey LJ ,Wasiak J K. Constraint-induced movement therapy in the treatment of the upperlimb in children with hemiplegiccerebral palsy: a Cochranesystematic review. Clinical Rehabilitation,2008; 21(8):675-685.11. Howard JH, Soo BK, Graham HK, Reddihough DS,etal. Cerebral palsy in Victoria: motor types, topographyand gross motor function. Journal of Paediatric ChildHealth.2009; 41(7):479-48312. Kuhtz PH, Krumlinde LU, Eliasson CO ForssbergGH.Quantitativeassessmentofmirrormovementsinchildrenandadolescents with hemiplegic cerebral palsy. DevelopmentalMedicineand Child Neurology. 2000;42(6):728-736.13. Lieber RL, Friden JH. Spasticity causes a fundamentalrearrangement of muscle-joint interaction. DevelopmentalMedicineand Child Neurology.2005; 25(2):265-270.14. Rosenbaum PG, aneth NO, et al. The definition andclassification of cerebral palsy. Developmental Medicineand Child Neurology.2009; 109:8-14.
  13. 13. 9Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2A comparative study on effectiveness of ultrasound therapyand low level laser therapy in the management of second stagepressure soresAnil Rachappa Muragod1, Sreekumaran P2, Danesh K U31Lecturer, KLEU Institute of Physiotherapy Belgaum, 2Professor and Principal, Nitte Institute of Physiotherapy,3Associate Professor, Nitte Institute of Physiotherapy, Mangalore, IndiaAbstractObjectiveThe purpose of this study was to compare the effectivenessof Ultrasound and Low Level Laser Therapy (LLLT) on secondstage pressure sores so as to be able to deliver better therapy forpressure sore patients on wound healing.MethodsForty subjects were taken for the study along with the routinemedical management. 20 subjects receive the pulsed ultrasoundtherapy three times a week for four weeks with frequency of 3 MHz,and intensity of 0.5W/cm2 to 0.8 W/cm2, for five min with directtechnique using hydrogel sheet. Another 20 subjects received theLLLT. The laser emission device used was Gallium Arsenide (GaAs)(904 nm) laser. It was made of a semiconductor infrared radiationsource. The non contact method of application was used with 0.5 to4.0 J/cm2for 2 min for three times a week for 4 weeks. The woundswere traced before starting the treatment and after 4 weeks oftreatment, on transparent paper and wound area was calculatedwith digitizer (AutoCAD software).ResultsThe results showed a significant (p = 0.001) decrease inpressure sore surface area in both ultrasound and laser group.When both the groups were compared, the laser therapy is found tobe more beneficial than the ultrasound therapy (p=0.046).ConclusionBoth ultrasound and laser can be used in the management ofpressure sores. However in the present study it is seen that LLLTis more beneficial than the ultrasound therapy in the managementof pressure sores.Key WordsUltrasound therapy; Low Level Laser Therapy; Pressuresores; Wound healing; Physical therapy.IntroductionThe term pressure sore is used to describe anylocalizedareasoftissue necrosisresultingfromischaemiain skin and subcutaneous tissue subjected to pressure.The condition is widespread and its effects, costlyprevention and treatment deserve careful examination.There are numerous approaches to the problem, rangingfrom the patho-physiology and biomechanics of theulcer’s origin to the pharmacology and biophysics of itstreatment. Increasingly, physiotherapists are called uponto contribute to the treatment and they have a growingarray of techniques at their disposal1.The problems related to wound healing are still thecause of significant morbidity and mortality. In spinal cordinjury and immobilization one of the main problems isdecubitis or pressure ulcers. Much time and money arespent treating this problem. Studies on wound healinghave increased our knowledge and understanding ofthese pressure ulcers, which constitute an importantclinical problem in rehabilitation medicine2.Current management of pressure sore involvestreatment of malnutrition and the general condition,Debridement, Surgical management3. In physiotherapyvarious methods of treatments can be given for openwounds namely Ice therapy, Ultra violet rays, Ionozonetherapy, Ultra sound therapy, Pulsed high frequencyenergy,4Diathermy, Negative pressure therapy, Infraredradiation5, and Laser therapy6.In literature, there are not much of comparativestudies has been done between ultrasound and lasertherapy on wounds healing2. The present study wasaimed at comparing the effectiveness of ultrasoundtherapy and LLLT in the management of pressure soreshence we can recommend making use of the effectivetherapy.MethodologyMethodsThe study was conducted in K.S.Hegde CharitableHospital, Deralakatte, Mangalore both inpatient andoutpatient Physiotherapy department after approval fromthe institutional ethical committee. Inclusion criteria wereallthesubjectswithsecondstagepressuresores.Tumors,Metal implants (local), Photo allergy Burns, Tuberculosis,Skin disease like Psoriasis, History of long-term steroidtherapy and radiation, Uncontrolled diabetes, Vasculardiseases, Infected pressure sores, Pressure sores otherthan the pelvic region, were excluded from the study.40 subjects with, second stage pressure sores samplehas been taken by convenient sampling. A consent letterwas obtained from each subject and then subjects weredivided in to 2 groups. Group 1 Pressure sore gettingUltrasound therapy with routine medical managementGroup 2 Pressure sore getting Low-level laser therapywith routine medical management.Group 1 Pressure sore getting Ultrasound therapywith routine medical managementAfter the preparation of subject and equipment group1 received the pulsed ultra sound therapy with pulsedratio of 1:4, with frequency 3 MHz, and intensity of 0.5to 0.8 W/cm2, for five min, for three times a week forfour weeks1,4,7, 8, 9,10. Ultra sound therapy application wasdone by solid sterile gel as couplant with Polyurethanedressing film. The flexible sheet, cut to an appropriatesize, is placed over the open wounds with the little sterilenormal saline to ensure that there are no air bubbles
  14. 14. 10 Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2between the gel sheet and the pressure sore. Theoutside surface of the gel sheet was slightly wetted and itwill allow the treatment head to move smoothly over it11.Group 2 Pressure sore getting Low-level lasertherapy with routine medical managementAfter the preparation of subject and equipmentgroup 2 received the Gallium arsenide (SemiconductorIR laser) Laser therapy. The wave length of laser devicewas 904nm with power of 0.5 to 4 J/cm2 for two min, for3 times a week for 4 weeks2,6,12,13,14. Non contact methodof application was used with base of wound ware visualdivided in to square centimeter areas (grid” technique)and each square area will be treated with the above laserparameters. The laser probe is held perpendicular to thecenter of each square at a distance of 0.5 to 1 cm fromthe wound surface and is kept in the entire centimetersquare in a circular motion. Each square centimeterof involved tissue is stimulated equally for effectivecoverage6.Wound measurementThe area of pressure sore was traced by steriletransparency paper (cleaned with spirit). The area ofpressure sore were measured by Digitizer15,16,17. Pressuresore were measured before starting the treatment andrepeated at the end of 4 weeks of treatment.Data AnalysisThe area of pressure sore is measured by digitizerwith AutoCAD software. The scores were recordedas per cm2 area. The data was analyzed using MannWhitney ‘U’ test for ultrasound group and laser group.The Wilcoxon’s signed rank sum test was used forcomparing the surface area before starting the treatmentand after four weeks of treatment.ResultsThe results were measured according to woundsurface area before starting the treatment and afterfourth week of treatment. None of the pressure soreswere healed completely. Using statistical methods thedata analysis was done. The results obtained are asfollows.Table I: Comparison of Ultrasound group and Laser group(Group statistics)Group NMean(cm2)S.D. ZBeforetreatmentUltra soundgroup20 4.7940 3.890.7300Laser group 20 4.9425 2.63After 4 weeksof treatmentUltra soundgroup20 3.2581 2.500.4870Laser group 20 2.6927 1.40In the above table comparison is being donebetween ultrasound group and laser group beforestarting the treatment. The numbers of patients in bothgroups were 20. The mean surface area for ultrasoundgroup is 4.7940 cm2 and for laser group it is 4.9425 cm2.The standard deviation was 3.89 and 2.63 for ultrasoundand laser group respectively.After 4 weeks of treatment the mean surface area forultrasound group was 3.2581 cm2 with standard deviationof 2.50. In case of laser group, the corresponding meansurface area is 2.6927 cm2with standard deviation of1.40.Table II: Paired Sample testGroup Paired Difference Z pMean(cm2)SDUltrasound group 1.5359 1.40 3.920 0.001 VHSLaser group 2.2498 1.24 3.980 0.001 VHSThe paired differences are indicated in the abovetable for both ultrasound and laser group. The paireddifference for the mean surface area in ultrasound groupis 1.5359 cm2with standard deviation of 1.40. The resultis very highly significant (p= 0.001).The paired difference for the mean surface area inlaser group is 2.2498 cm2 with standard deviation of1.24. The result shows that there is reduction in a meansurface area, which is, very highly significant (p=0.001).Table III: Difference between ultrasound group and laser group.Group N Mean (cm2) S.D. ZUltrasound group 20 1.5359 1.40 2.012Laser group 20 2.2498 1.24 P=0.046 (S)The table indicates the mean reduction in surface areaFig. 1: Administration of Ultrasound treatment.Fig. 2: Administration of Laser Treatment.
  15. 15. 11Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2between ultrasound group and the laser group. Themean surface area for ultrasound group is 1.5359 cm2with standard deviation of 1.40. For the laser group, themean reduction in surface area is 2.2498 with a standarddeviation of 1.24. When both the groups are compared,the laser group shows significant reduction in surfacearea as compared to ultrasound group (p=0.046).This table shows that LLLT is more beneficial than theultrasound therapy in the management of pressure soresas it comparatively reduces the surface area of pressuresoresDiscussionRecently, some physical methods, includingtherapeutic ultrasound and laser treatment were foundto accelerate and facilitate wound healing scar quality.However, conflicting findings have been reported insome studies and some investigators found no treatmenteffect on accelerating the repair of wounds2.The ultrasound benefits patients with venous ulcers.Eriksson et al showed no benefit treating with ultrasoundtwice weekly at 1 MHz with a continuous spatial averageintensity of 1.0 W/cm2. Where as Dyson et al showedsignificant benefit treating ulcers three times weekly at3 MHz with an SATA intensity of 0.2 0 W/cm2(1:4 pulseratio) Collam et al used a higher ultrasound intensity(Continuous SATA intensity of 0.5 W/cm2) then of Dysonet al once weekly at 1 MHz and found a significantbenefit. When Lundeberg et al however, used the sameSATA intensity dosage as callam et al but in a pulsedmode with a pulse ratio of 1:9 the treatment showed onlya clear tendency to benefit healing18.In some animal studies, researchers found thatultrasound at the intensities of 0.1W/Cm2and 0.5 W/Cm2 accelerates the inflammatory phase of repair. Thisreported accelerated repair agrees with the findings fromseveral other suggestions that low dose ultrasound ofapproximately 0.5 W/Cm2pulsed with a frequency of 1to 3 MHz promotes the wound healing2. The biologicalprocess, which have been found to be specificallyaffected by ultrasound include, general protein andcollagen synthesis by fibroblasts, fibroblasts motility,permeability of fibroblasts membrane, lysosomal fragility,tensile strength and elasticity of scar tissue, modificationof contraction in skin wounds1. There fore our treatmentprotocol includes pulsed ultrasound with a dose of 0.5 to0.8W/Cm2at frequency of 3 MHz for 3 times a week for4 weeks. The result of the study also supports the otherstudies.Laser can be classified as surgical (High power) andnon surgical (Low Power) for therapeutic purposes. Nonsurgical lasers are widely used as tissue stimulator toimprove wound repair. They also have anti inflammatoryand analgesic effects19. Yong et al tested the responseof macrophage like cells to laser irradiation and non-coherent light. They found calcium uptake showedmaximum enhancement at the energy density of 4 to 8J/cm2, with wave length of 660, 820 (laser) and 870 nmand a pulse repetition rate (PR) of 5000 or 16pps2. It hasbeen noted that in clinical practice, ulcers that appearto plateau in their healing process respond favorablyto a change of PR from 5000 to 16pps until healing iscomplete or the next plateau occurs18.As the wound lacks the usual protective layersof dermis, the dosages applied during treatment willbe much lower than during application over intact skinand typically cited radiant exposures are somewherein range of 1- 10 J/ cm2, with 4 J/ cm2 being mostcommonly recommended as Mester Protocol12.Stimulating non healing human wounds with He Ne andargon lasers showed that it can increase the collagensynthesis, diminished the cellular substances, significantvascularation and increase in tensile strength6. Theinfrared and red pulsed monochromatic light with variedpulsation and wavelengths have increased healing rateand shortened healing time in pressure ulcers20.The issue of significant thermal change iscontroversial, although some studies conclude thatthe low energy laser does not produce significanttissue temperature changes. A wide variation exists inrecommendations for the optimal energy for differentconditions the usual ranges are from 0.5 to 10 J/Cm2.Generally, a laser wavelength of 600 to 984 nm is usedin physical medicine and a laser wavelength of 632.8nm He Ne and 904 nm Ga As are most frequentlyused in wound healing2. Therefore we have used theGa As (semiconductor infrared radiation source) withwavelength of 904 nm and power of 0.5 to 4 J/cm2. Theresult of the study also supports the other studies.The study showed that ultrasound therapy andFig. 3: Tracing of wound on transparent paper.Fig. 4: Comparison of Mean surface area between Ultrasoundand Laser Groups.4.793.264.942.690123456MeanValueUltra Sound Group Laser GroupBefore Starting the treatment After 4 weeks of treatment
  16. 16. 12 Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2laser therapy treatment both have beneficial effect onpressure sores (p=0.001) and when we compare theeffects between both group the laser therapy showsbetter results than the ultrasound therapy (p=0.046).Limitations of the studyThere was no control group, so the study could notfind the effect is due to medical management or withultrasound or laser management. The study was doneconsidering only size of the pressure sore. The age,cause for the pressure sore and predisposing factorswas not considered.Recommendation for further studiesSeparation between age groups, cause andpredisposing factors in each group will give better results.Further study can be done between ultrasound therapyand LLLT with controlled group with larger sample size.Use of histological investigations to know the resultslike cellular content, granulation, tissue formation andcollagen deposition will give better and more accurateresults.ConclusionThe results of the current study found that bothultrasound and LLLT can be used in the management ofpressure sore patients with routine medical management(p=0.001). However the results of this study shows thatLLLT is more beneficial than the ultrasound therapy inthe management of pressure sores (p=0.046).References1. T. Mcdiarmid, P N Burns, G T Lewith, D Machin. Ultrasoundand the treatment of pressure sores. Physiotherapy Feb1985; Vol 71(2): pp. 66-70.2. Huseyin Demir, Solmaz Yaray, Mehmet Kirnap, KadirYaray. Comparison of the effects of laser and ultrasoundtreatment on experimental wound healing in rats. Journalof Rehabilitation Research and Development. September/October 2004. Vol 41. Number 5, pp 721-728.3. C.R.W. Edwards, I.A.D. Bouchier, C. Haslett, E.R. Chilvers.Davidson’s Principles and Practice of medicine. 17th ed.Edinburg London Churchill Livingstone. 1996.4. Sylvia Fernandez. Physiotherapy prevention and treatmentof pressure sores. Physiotherapy Sep 1987; Vol 73(9): pp.450-454.5. Glenn Irion. Comprehensive Wound Management. UnitedStates of America: SLACK Incorporated. 20016. Prem P.Gogia. Clinical wound management. United statesof America; Edition 1 Slack incorporated 1995.7. Mary Dyson, J.B. Pond. The effect of Pulsed Ultrasound ontissue Regeneration. Physiotherapy 56 (4): 136-142.8. Barbara J, Behrens Susan L, Michloritz. Physical agentsTheory and Practice for the Physical Therapist assistant:United States of America; FA Davis Company Philadelphia;1996.9. Alain-Yvan Belanger. Efficiency-Based Guide to TherapeuticPhysical Agents. United States of America: LippincottWilliams & Wilkins 2001.10. FlemmingK, Cullum N. Therapeutic ultrasound for venousleg ulcers (Cochrane Review) In: The Cochrane Library,issue 1, 2004 Chichester, UK: John Wiley and Sons, Ltd.11. John Low and Ann Reed. Electrotherapy Explained.Principles and Practice. 3rd ed. Printed and bound in Indiaby Replica Press Pvt Ltd Delhi. Butter worth Heinemann2000.12. Sheila Kitchen and Sarah Bazen, Clayton’s Electrotherapy.10E London, W. B, Sunders Company Ltd 1996.13. Robert L Ashford, Kathleen M Lagan, David G. Baxter. Theeffectiveness of combined phototherapy/ low intensity lasertherapy is effective on neuropathic foot ulcer. British journalof therapy and rehabilitation 1995 April; 2(4): 195-198.14. www.thorlaser.com15. Richard W Bohannon and BarbaraA, Pfaller. Documentationof wound surface area from tracings of wound perimeters.Physical therapy, 1983 Oct; 63: 1622 – 1624.16. Cheryl Majeske. Reliability of wound surface areameasurement. Physical Therapy 1992 Nov/Feb; 72: 138-141.17. Lagan KM, Dusoir AE, McDonough SM, Baxter GD. Woundmeasurement; the comparative reliability of direct versusphotographic tracings analyzed by Planimetry versus digitizingtechniques. Arch Phy Med Rehabil 2000; 81: 1110-6.18. Ethne L Nussbaum, Irene Biemann Betsy Mustard.Comparison of ultrasound/ultraviolet –C and laser fortreatment of pressure ulcers in patients with spinal cordinjury. Physical Therapy/Volume 74, number 9 September1994. pp.812-82219. Aymann Nassif Pereira, Carlos de paula Eduardo, EdmirMatson, Marcia Martins Marques. Effect of low powerlaser radiation on cell growth and procollagen synthesis ofcultured fibroblast. Lasers in Surgery and Medicine, 2002;31: 263-267.20. Schubert V. Effect of phototherapy on pressure ulcershealing in elderly patients after a falling trauma.Aprospectiverandomized, controlled study. Photodermatol photoimmunolPhotomed. 2001 Feb; 17(1): 32-8.
  17. 17. 13Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2Comparison of the effects of therapeutic ultrasound v/smyofascial release technique in treatment of plantar fasciitisApeksha O. Yadav1, R. Lakshmiprabha21M.P.T., 2Asst. Professor, Physiotherapy School & Centre, Seth G. S. Medical College & KEM Hospital, Parel, MumbaiAbstractBackgroundPlantar fascia acts as a truss, maintaining the mediallongitudinal arch of foot & assists during gait cycle, facilitates shockabsorption during weight bearing activities. Plantar fasciitis (PF) ismost common cause of inferior heel pain. Therapeutic ultrasound(U.S) is the most common treatments used in management of softtissue lesions. Myofascial release (MFR) is a non invasive & safetechnique with virtually no side effects; it comes with a record ofgood results.AimTo compare effects of U.S v/s MFR technique in treatment ofPF.Setting & DesignA Prospective experimental study was undertaken to compareeffects of U.S v/s MFR in treatment of PF.Methods and Material60 subjects were alternately allocated into two groups U.S(Group A-30 subjects) & MFR technique (Group B-30 subjects).Conventional exercises were common. Outcome measures wererecorded on first & tenth day using Visual analog Scale (VAS) forpain intensity & Foot Function Index (FFI) for functional outcome.Statistical AnalysisFor intergroup comparison of sex distribution, Chi-Squaretest was used. For intragroup comparison of VAS & FFI, WilcoxonSigned Rank test was used & for intergroup comparisons of VAS &FFI, Mann-Whitney U test was used.Result60 Subjects were divided into two groups & their age & sexwere matched which was found non significant p=0.1405. VAS onfirst day was non significant for both groups with p=0.981 were ason tenth day both groups showed statistically significant differencein reduction of pain on VAS p=0.023 but intergroup analysis showedthat group B is statistically more significant. Same for FFI p=0.272on first day were as on tenth day both groups showed statisticallysignificant difference in improvement of functional outcome on FFIp=0.023 but intergroup analysis showed group B is statisticallymore significant.ConclusionU.S & MFR technique were found to be effective but MFRtechnique was more effective than U.S.Key WordsPlantar Fasciitis, Therapeutic Ultrasound, Myofascial releaseTechnique.IntroductionPF is a painful inflammatory condition causedby excessive wear to the plantar fascia of the foot orbiomechanical faults that cause abnormal pronation offoot. Classic presentation of PF is pain on sole of footat the inferior region of heel. Patient reports pain to beparticularly bad with first step taken on rising in morningor after an extended refrain from weight bearing activity.Pain is usually experienced along the plantar aspect ofthe heel where plantar fascia inserts on medial tubercle ofthe calcaneus. Excessive pronation of the subtalar joint,which may be reinforced by hypomobile gastrocnemius–soleus muscles, predisposes foot to abnormal forcesand irritation of plantar fascia. Conversely, stress forceson fascia can also occur with an excessively high arch.Pressures transmitted to irritated site with weight bearingor stretch forces to the fascia, as when extending thetoes during push-off, causes pain.Its a condition, which can be treated by a widevariety of methods like manual therapy, stretchingexercises, taping, orthotic devices, night splints,electrical modalities, etc. Various methods of treatmentexist with own claims of success without any attemptsof comparing maximal effective method and very fewstudies have been conducted to support these therapies.Manual therapy includes various joint mobilizationand soft tissue manipulation techniques for PF. Thereis a growing body of literature in MFR’s effectivenessin various soft tissue conditions. MFR therapy refersto a class of manual technique that is used to relieveabnormal constriction of tense fascia. MFR stem fromthe foundation that fascia, a connective tissue foundthroughout the body, reorganizes itself in response tophysical stress and thickness along the lines of tension. By myofascial release there is a change in viscosity ofground substance to a more fluid state which eliminatesfascia’s excessive pressure on pain sensitive structureand restores proper alignment. Hence this technique isproposed to act as a catalyst in resolution of PF.In a study done by Suman Kuhar, concluded thatMFR is an effective therapeutic option in treatment of PF.Similarly US is one of the most commonly usedtreatment modality in management of soft tissue lesions.US consists of inaudible high-frequency mechanicalvibrations created when a generator produces electricalenergy that is converted to acoustic energy throughmechanical deformation of a piezoelectric crystal locatedwithin the transducer. Waves produced are transmittedby propagation through molecular collision and vibration,with a progressive loss of the intensity of the energyduring passage through tissue (attenuation), due toabsorption, dispersion or scattering of wave. Althoughmany laboratory-based research studies demonstrated anumber of physiological effects of US upon living tissue,there is remarkably little evidence for benefit in treatment
  18. 18. 14 Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2of soft tissue injuries. Pain relief through US can beexplained through thermal and non-thermal physicaleffects in tissues.US’s non thermal effects helps by stimulatinghistamine release from mast cells and factors frommacrophages that accelerates normal resolution ofinflammation as suggested by Young and Dyson,cavitations, acoustic streaming and micromassage. Allthis contributes to reducing pain and improving functionaloutcome in PF patients.Studies to find effectiveness of US in treatment ofPF are sparse. Also comparison between US and MFR islacking. Hence the present study was undertaken with anintention to find out and compare effectiveness of US v/sMFR a newer technique towards betterment in treatmentof PF.Material & MethodsThis Prospective experimental study carried outover one year from March 2008 to March 2009 atPhysiotherapy OPD in Tertiary Care Hospital. Materialsused were ultrasound machine (EMS – Electro sound),aquasonic gel, tennis ball and a napkin (Figure 1).60 subjects (both males and females) were selectedwith a medical diagnosis of PF, they were alternatelyassigned into two groups i.e. group A and groupB. Subjects with infective conditions of foot, tumor,calcaneal fracture, metal implant, radiological diagnosisof calcaneal spur, dermatitis, impaired circulation inlower extremity, referred pain, any neurological deficit,uncontrolled diabetes mellitus and subjects who receivedCorticosteroid injection in heel preceding 3 months wereexcluded from study. Study was approved by InstitutionalEthics committee (EC/53/08) and written consent wastaken from all participants to undergo treatment for 10consecutive days. Objective assessment of the involvedfoot for tenderness, pain on plantar fascia stretch,swelling and temperature was done. Pain intensity wasassessed on VAS. Patients were asked to mark their painintensity on the scale and functional evaluation was doneon a questionnaire in the form of FFI on 1st & 10th day.Subjects in group A were treated with pulsed US(Figure 1) having an intensity of 1W/cm2, frequencyof 1MHz for 7mins and with conventional exercisesconsisting of intrinsic muscle strengthening in this thepatient is sitting on a chair with foot flat on the end ofa towel placed on a smooth surface. Keeping the heelin contact with the floor, the towel is pulled towards thebody by curling the towel with the toes, plantar fasciastretching (Figure 2) in this the patient is comfortablysitting on chair with tennis ball under their foot. Thenthey roll the ball with the help of their foot in forward andbackward direction, tendoachilles stretching (Figure 3)in this the patient is asked to stand facing a wall andplace the affected leg behind the contralateral leg. Pointthe toes of the affected foot towards the heel of the frontfoot and lean towards the wall. Then bend the frontknee while keeping the back knee straight and the heelfirmly on the ground. Then they are supposed to holdthe stretch for 1min and repeat 5 times and active anklerange of motion exercises.Subjects in group B received MFR (trigger band)(Figure 4) in this the patient was in supine with thetherapist at the foot end of the couch. The therapistuses a closed fist to contact the sole of the patient’s footjust proximal to the metatarsal heads. While applyingpressure to the plantar aspect of the foot, the therapistpositions the foot into dorsiflexion & toe extension. Thenthe therapist drags his/her fist over the plantar fasciacontacting the restricted layer and applies pressure inthe length of the fascia maintaining the same pressurethroughout and then releases it, along with the sameconventional exercise program as in group A.All subjects were advised not to stand in sameposition for long period of time, not to walk bare foot andfootwear modifications were given.Statistical analysis: Data was assessed for normaldistribution using the Kolmogorov Smirnov test and wasnot found to be normally distributed and hence the Mann– Whitney U test was used for intergroup comparison.For intragroup comparison Wilcoxon Signed Rank testwas used. Data analysis of intergroup comparisons ofsex distribution was done using Chi- Square test.ResultsAbove table reveals that age of the patients wereranging from 30 - 62 years with average age of 42.7 years(Lower limit CI 40.069 - Upper limit CI 45.331) amongGroup A and 40.13 (Lower limit CI 37.362- Upper limitCI 42.904) with 58 Degree of Freedom. among Group Bwhich were comparable and difference was statisticallynot significant.Figure 1: Therapeutic Ultrasound applications.Figure 2: Plantar fascias stretching.
  19. 19. 15Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2The number of females in group A were more incomparison to group B but the difference was statisticallynot significant and hence the groups were age and sexmatched.Above table shows that mean Visual analogue scalescore was 5.223 for group A (Lower limit CI 4.994- Upperlimit CI 5. 452) and 5.18 for group B (Lower limit CI5.013- Upper limit CI 5.347) with 58 Degree of Freedomwhich were same and difference was statistically nonsignificant (p=0.981).Post treatment score i.e. on tenth day showed thatmean Visual analogue scale score had a significant fallin both the groups. Both the groups showed statisticallysignificant difference in reduction of pain on VAS butIntergroup analysis showed that group B is statisticallymore significant than group A (p=0.02).Above table shows that mean Foot Function Index(FFI) score was 59 for group A (Lower limit CI 55.997-Upper limit CI 62.003) and 57.2 for group B (Lowerlimit CI 53.653- Upper limit CI 60.747) with 58 Degreeof Freedom. Which was same and difference wasstatistically non significant (p=0.272).Post treatment score on day ten showed that meanFoot Function Index score had a significant fall in bothgroups which indicates that there was an improvement infoot function. Both groups showed statistically significantdifference in improvement of functional outcome on FFIbut on Intergroup analysis group B was found to bestatistically significant than group A (p=0.03).Analysis of pre and post test results showed thatsubjects in groups A and B had statistically significantimprovement like reduction in pain on VAS andimprovement in functional outcome on FFI however groupB showed statistically more significant improvement thangroup A.DiscussionAim of study was to compare the effects of USv/s MFR in treatment of PF. A prospective study of 60subjects was carried out. Outcome measures wereassessed using VAS for pain and FFI for functionaloutcome. Subjects were divided into two groups; GroupA received US plus conventional exercise programand Group B received MFR plus conventional exerciseprogram. Outcome measures were assessed on dayone pre treatment and on tenth day post treatment. Dataobtained was analyzed statistically intragroup resultsshowed statistically significant reduction in pain on VASand improved functional outcome on FFI. However,when intergroup comparison was done, both groupswere found to be statistically significant in reducing painand improving functional outcome in patients with PFbut group B was found to be statistically more significantthan group A.Various methods of treatment exist with own claimsof success without any attempts of comparing themaximal effective methods. The objective of this studyTable 2: Comparison of pain on VAS in group A and group BGroup A Group B P value (Mann Whitney Test)Pre Day 1 5.223 ± 0.61 5.18 ± 0.44 (P= 0.981)Post Day 10 3.673 ± 0.871 3.163 ± 0.90 -Mean Change Pre – Post 1.583* 2.017* (P =0.023)P value (Wilcoxon Rank Test) (P < 0.0001) (P < 0.0001)*p<0.05 significantFigure 3: Tendo Achilles stretching. Figure 4: Myofascial release trigger band technique.Table 1: Demographic dataPARAMETERS Group A Group BNo. of Patients 30 30*Age (Yrs)MeanSDRange42.7±7.04732 - 6240.13±7.42230 – 59† Sex (%)MaleFemale13 (22%)17 (28%)15 (50%)15 (50%)*Mann Whitney U Test (b/w groups) p=0.1405 Not Significant†Chi square test
  20. 20. 16 Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2was to compare the effects of US v/s MFR in PF.Analysis of VAS and FFI in Group A showed thatresults where statistically significant on tenth day statingthat US was effective. According to a study performed byHana Hronkova, group which received US for PF showedsignificant reduction in pain. In contrast a study done byCrawford F, et al in 1996 therapeutic ultrasound wasgiven to patients with heel pain and found no evidence tosupport the effectiveness of US . Pulsed ultrasound wasused as it’s preferred for soft tissue repair as affirmed byYoung , 1 MHz was chosen as it is capable of reaching todeeper layer. Pain relief could have occurred due to nonthermal effects of pulsed ultrasound in form of stimulationof histamine release from mast cells and factors frommacrophages that accelerated the normal resolutionof inflammation (as suggested by Young and Dyson)cavitations, acoustic streaming and micromassage.Although the results are contradictory to a review carriedout by Robert and Baker of 35 randomized controlledtrials looking at evidence of the biophysical effects ofultrasound out of which only two trials were found to bemore effective than placebo ultrasound and ten of the 35trials studied were judged to be robust .Similarly analysis of VAS and FFI in Group B showedstatistically significant result on tenth day stating thatmyofascial release was effective.MFR uses hands on manipulation to promotehealing and in relieving pain. Injuries, stress, traumaand poor postures can cause restriction to fascia. Goalof myofascial release is to release fascia restriction andrestore its tissue. This technique is used to ease pressurein the fibrous bands of the connective tissue, or fascia.Gentle and sustained stretching of myofascial release isbelieved to free adhesions and soften and lengthen thefascia. By freeing up fascia that may be impending bloodvessels or nerves, myofascial release is also said toenhance body’s innate restorative powers by improvingcirculation and nervous system transmission. Somepractitioners contend that the method also release pent-up emotions that may be contributing to pain and stressin the body. Myofascial release works on a broader swathof muscles and connective tissue.Movement has been likened to kneading a piece oftaffy- a gentle stretching that gradually softens, lengthens,and realigns the fascia. Direct MFR method worksdirectly on the restricted fascia. MFR seeks for changesin the myofascial structures by stretching, elongation offascia or mobilizing adhesive tissues. DiGiovanna andSchionitz have described several principles underlyingMFR.This include,• Increased circulation to the area of restriction deliversoxygenated blood and nutrients to the tissue andremove harmful metabolic waste product.• Increased venous and lymphatic drainage decreaseslocal swelling and edema caused by tissueinflammation• Elasticity and flexibility of connective tissue elongatesconnective tissues secondary to mechanical loading• Increased temperature causes an increase in elasticityand stretch of muscle.With the two techniques used in the study the roleof conventional exercises were to stretch the tightenedstructures like the plantar fascia and tendo Achillestendon to break the vicious cycle which aggravatesthe condition, to maintain and restore the properbiomechanics, and maintain the integrity of muscles andrelated tissues.After this study now I use myofascial release as atreatment method for treating PF patients as it is beingfound to be more effective. It can be given manually. Itcan also be taught to the patients as a home exerciseprogram. Therefore myofascial release is a good adjunctfor treatment of PF.References1. Kisner C, Colby LA. The ankle and foot. Therapeuticexercise-Foundation and Techniques, 5th edition. NewDelhi, Jaypee Brothers, 2007; 776-7.2. Barnes, J F. Mind and Body Bioenergy of healing, PT andOT Today, 1996.3. Travell, J. Simons. Myofascial pain and dysfunction. Thetrigger point manual. Vol.1. Williamsand Willkins.Baltimore.1983.4. Kuhar S, Khatri S, Jeba C. Effectiveness of MyofascialRelease in Treatment of Plantar Fasciitis: A RCT.IJOPT2007;1.5. Young SR and Dyson M. Macrophages responsiveness totherapeutic ultrasound. Ultrasound in medicine and Biology.1990; 16,261-9.6. Budiman -Mak E, Conrad KJ, Roach K. The foot functionindex: A measure of foot pain and disability. Jr. ClinicalEpidemiology. 4:561-70, 91.7. Crowford F. Snaith M. How effective is therapeutic ultrasoundin the treatment of heel pain? Ann Rheum Dis.1996; 55:265-7.8. Young S. Ultrasound therapy. In: Kitchen S. and Bazin S.(Eds) Clayton’s Electrotherapy, 10th edition. Philadelphia,WB Saunders, 1996; 243-67.9. Roberts VJ, Baker KG. A review of therapeutic ultrasound:Effectiveness studies? Physical Therapy 2001; 81:1339-50.10. DiGiovanna EL., Schionitz S. Principles of manipulativetechniques. In: Spinaris T, DiGiovanna EL, Eds. Anosteopathic approach to diagnoses and treatment, 2ndedition. Philadelphia, Lippincott-Raven, 1997; 83-5.Table 3: Comparison of FFI in group A and group BGroup A Group B P value (Mann Whitney test)Pre Day 1 59 ± 8.0 57.2 ± 9.4 (P = 0.272)Post Day 10 34.63 ± 11.13 28.93 ± 7.18 -Mean Change Pre – Post 24.36* 28.26* (P = 0.03)P value (Wilcoxon Rank test) (P = 0.0001) (P = 0.0001)*p<0.05 significant
  21. 21. 17Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2Slow breathing training on cardio-respiratory control andexercise capacity in persons with essential hypertension – arandomized controlled trialBalasubramanian Sundaram, Purvesh J. Maniyar, Varghese John. P, Vijay Pratap SinghSrinivas College of Physiotherapy and Research Centre, Pandeshwar, Mangalore -1AbstractBackgroundIn persons with hypertension there is decreased exercisetolerance and elevated total peripheral resistance due to autonomicimbalance. Slow breathing improves autonomic imbalance byreducing sympathetic overactivity in hypertensive patients.AimTo find the effect of slow breathing training on cardio-respiratory control and exercise capacity in patients with essentialhypertension.SettingMedicine Out-Patient Department of a tertiary care hospital.DesignRandomized controlled trial.MethodsForty persons with essential hypertension of age group 35 –60 years were recruited and randomly allocated in to 2 groups;experimental group (n=20), who received slow breathing exercisestwice a week for 4 weeks along with pharmacological treatmentand control group (n=20), who received pharmacological treatmentalone. After 4 weeks, persons in both the groups were measuredfor outcome variables like submaximal exercise capacity by using 6minute walk test (6 MWD), Systolic Blood Pressure (SBP), DiastolicBlood Pressure (DBP), Heart Rate(HR) and Respiratory Rate (RR).ResultsA statistically significant difference was found in exercisegroup between pre and post intervention for all the outcomevariables, whereas for control group no significant difference wasfound between pre and post intervention. Between the exerciseand control group, a statistically significant difference was foundfor the variables, HR (P =0.009), SBP (P =0.012), DBP (P =0.000)and RR (P =0.000), but there was no significant difference in meandifference of 6 MWD (95% CI = -4.443, 2.543; P =0.585) betweenthe groups.ConclusionSlow breathing training significantly improves cardio-respiratory control but it fails to improve the exercise capacity inpatients with essential hypertension.KeywordsSlow breathing exercises, Blood pressure, Autonomicimbalance, Exercise tolerance, Sympathetic overactivity.IntroductionHypertension means increase in normal bloodpressure both in SBP and DBP. According to the JointNational Committee - seventh report (JNC-VII), SBPabove 140-160mmHg and DBP above 90-100mmHg isconsidered as hypertension (Stage-1)1. Approximately90-95% of individuals with hypertension have no specificcause for their disease and are said to have Primary orEssential hypertension. The remainder has Secondaryhypertension resulting from other identifiable medicalproblems, such as renovascular or endocrine disease.Regardless of the underlying causes, it results due tofailure of control mechanisms that is responsible forlowering blood pressure2.Hypertension is a leading cardiovascular diseasein the industrialized nations of the world. A study on theprevalence of hypertension on urban community in Indiarevealed that the systolic hypertension (140mm of Hg) is40.9% and diastolic hypertension (90mm of Hg) is 29.3%among study population3.If hypertension is not controlled then there will befuture cardio-vascular complication like Atheroscleroticheart disease, congestive heart failure, cerebrovascularaccidents, aneurysm, peripheral vascular disease andrenal failure2.Primary prevention of hypertension can be doneby pharmacological or non-pharmacological (change inlife style, weight loss, alcohol and dietary salt restrictionand moderate intensity exercises) managementwhich reduces morbidity and mortality associated withhypertension4.Autonomic imbalance has a major role in etiologyof hypertension which is characterized by increase insympathetic activity. One of the mechanisms associatedwith autonomic imbalance is reduced baroreflexsensitivity which in turn fails to reduce sympathetic over-activity5. In hypertension, chemoreflex activation can alsobe an additional mechanism responsible for increase insympathetic activity6.During rest, individuals with essential hypertensionhave increased total peripheral resistance and a lowor normal stroke volume. When they are exercising,the stroke volume increases subnormally and the heartrate during peak exercise is lower. The cardiac output istherefore lower, exercise time is decreased, the anaerobicthreshold is reached earlier and maximal oxygen uptakeis reduced. Exercise capacity in hypertensive individualsis reduced as much as 30% compared to age-matchednormotensive controls7.Breathing exercise and ventilatory training cantake on many forms including diaphragmatic breathing,segmental breathing, ventilatory muscle training, etcfor the relief of dyspnea with exertion and to promoterelaxation and stress8. Breathing exercises controlledat 6 rate per minute (rpm) are known as slow controlledbreathing exercises which are characterized by increasedrespiratory amplitude (Tidal volume) and decreasedrespiratory rate9. Respiratory retraining using the slow
  22. 22. 18 Indian Journal of Physiotherapy & Occupational Therapy. April-June 2012, Vol. 6, No. 2breathing technique appears to be a useful adjunctivefor cardio-respiratory control in hypertensive persons10.Slow breathing at 6 cycles/ minute has the effect ofentraining all R-R interval fluctuations, thereby causingthem to merge at the rate of respiration and to increasein amplitude which activates Hering-Breuer reflex andenhances the central inhibitory rhythms which in turnreduces the chemoreflex sensitivity and enhance thebaroreflex efficiency11-13. It occurs because the changesin sympathetic activity and in baroreflex sensitivity areinterrelated14.Thus, this study aimed to find the effect of slowbreathing exercises on cardio-respiratory control andexercise capacity in persons with essential hypertension.MethodologyParticipantsThe source of data was from a medicine out-patientdepartment of a tertiary care hospital. By purposivesampling 40 participants were recruited in the studybased on the following inclusion criteria; Persons whowere having Systolic blood pressure between 140-160mm of Hg and Diastolic blood pressure between 90-100mm of Hg, according to JNC-VII criteria and also whowere diagnosed as Essential or Primary hypertensionwith the age group between 35–60 years. Those whowere having secondary hypertension due to Liver/Heart/Renal failure, recent cardiovascular events, pulmonarydiseases, diabetes mellitus, neuropathies, autoimmunediseases, cardiac arrhythmias, cigarette smoking,alcohol consumption, use of oral contraceptives, use ofneuroleptics/anti-arrhythmic and Lithium were excludedfrom the study.After being approved by the Institution’s Ethicaland Scientific Review Committee, an informed writtenconsent was obtained from all the patients who werewilling to participate in the study after explaining thepurpose and procedure of the study.RandomizationThe recruited participants were allocated into twogroups (intervention group and control group) randomlyby using simple randomization (computer generatedrandom numbers) procedure. Sequence generation andallocation concealment were done with the help of aBiostatistician, hence the anticipated selection bias wasavoided. To eliminate the measurement bias the therapistwho was measuring the outcome variables was blinded.ToolsThetoolsusedinthestudywereSphygmomanometer,Stop watch, Measuring tape, Stethoscope and Weighingmachine. The following outcome measures were used inthis study; 6 minute walk test, Heart rate, Blood pressure,and Respiratory rate.ProcedureThe participants in both the groups were continuedwith their pharmacological treatment but the experimentalgroup was only treated with slow breathing technique,additionally.Then, the baseline characteristics like bloodpressure, heart rate, respiratory rate and sub-maximalexercise capacity were measured for all the subjectsin both the groups. The submaximal exercise capacitywas measured by using 6 minute walk test accordingto American Thoracic Society (ATS) guidelines15whichpossesses good reliability and validity16.The training protocol for breathing control wasapplied using Diaphragmatic, Intercostal, and Upperchest breathing patterns to make them aware of theirrespiratory movements. Persons were asked to liesupine, with knees flexed and feet flat on the floor, andraised their hands to the area of the chest related toeach breathing pattern: Diaphragm, Inter-costal musclesand Clavicular region. For each breathing pattern, theindividual was instructed to feel and identify the rib cagemotion and its amplitude. Then, they were also instructedto decrease their respiratory rates gradually whileincreasing respiratory amplitude. This procedure wasthen performed in sitting position, in the same manner asperformed in supine position.After 4 weeks, post intervention outcome measures(6 minute walk test, Heart rate, Blood pressure, andRespiratory rate) were recorded for all the participants inboth the groups.ResultsFor data analysis, statistical software SPSS (v 16)was used. Descriptive statistics were calculated for allthe variables. Shapiro- Wilk test of normality was donefor all the variables. Based on its results, Wilcoxin

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