Indian Journal ofPhysiotherapy and Occupational TherapyAn International JournalISSN P - 0973-5666ISSN E - 0973-5674Volume ...
INDIAN JOURNAL OF PHYSIOTHERAPY ANDOCCUPATIONAL THERAPYEditorDr. Archna SharmaHead, Dept. of Physiotherapy, G.M. Modi Hosp...
Contentswww.ijpot.comJan.-March. 2011Volume 5, Number 1Indian Journal of Physiotherapy and Occupational Therapy. Jan. - Ma...
85 Efficacy of deep transverse friction massage in treatment of chronic ankle sprainPooja K Arora, Sujata Yardi, Kunal Pat...
1Aditi Bhatia / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol.5, No.1Footwear effects on...
2 Aditi Bhatia / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1footwear and as n...
3Aditi Bhatia / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1Graph-3 Compariso...
411. Duncan PW, Weiner DK, Chandler J, Studenski SA.Functional reach: a new clinical measure of balance. JGerontol A Biol ...
5The effect of short term dynamic and isometric resistance trainingin knee osteoarthritisAjit Singh*, Shekhar***Assistant ...
6previous six months, systemic inflammatory disease e. g. gout,rheumatoid arthritis, ankylosing spondylitis, had metallic ...
7The results of the resistance training tested in the currentstudy appear to have a greater percentage impact on improving...
821. Barrett DS, Cobb AG, Bentley G. Joint proprioception innormal, osteoarthritic and replaced knees. J Bone JointSurg Br...
9Multimodal therapy in cervicogenic headache- a randomizedcontrolled trialAkanksha Sharma*, Unaise Abdul Hameed*, Shalini ...
10physiotherapy department of Bhagwan Mahavir Hospital (Delhi).The subjects were screened using a screening form relevant ...
11group at the baseline and at the end of 1st, 2ndweek but significantdifference was found at the 3rd( p=0.05) and 4thweek...
12DiscussionThe results of the study demonstrates that patients withcervicogenic headache receiving multimodal therapyexpe...
137. International Headache Society Classification Committee.Classification and diagnostic criteria for headachedisorders,...
14Combined effectiveness of Maitland’s mobilization and patellartaping in patellofemoral osteoarthritis: A randomised clin...
15Materials and methodsSource of Data: KLES Dr. Prabhakar Kore hospital and MRCand BM Kankanwadi Ayurveda Hospital and MRC...
163. Isometric exercises: Static quadriceps exercises will begiven in long sitting/supine position with a towel placedunde...
171. Naslund J , Nusland UB, OdenbringS, Lundeberg T.Comparision of Symptoms and Clinical finding in subgroupsof individua...
Ijpot jan march 2011 mulligan deepak kumar
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  1. 1. Indian Journal ofPhysiotherapy and Occupational TherapyAn International JournalISSN P - 0973-5666ISSN E - 0973-5674Volume 5 Number 1 January - March 2011website: www.ijpot.com
  2. 2. INDIAN JOURNAL OF PHYSIOTHERAPY ANDOCCUPATIONAL THERAPYEditorDr. Archna SharmaHead, Dept. of Physiotherapy, G.M. Modi Hospital, Saket, New Delhi 110 017E-mail: editor.ijpot@gmail.comExecutive EditorDr. R.K. Sharma, New DelhiNational Editorial Advisory BoardProf. U. Singh, New DelhiDr. Dayananda Kiran, IndoreDr. J.K. Maheshwari, New DelhiDr. Suraj Kumar, New DelhiDr. Renu Sharma, New DelhiDr. Veena Krishnananda, MumbaiDr. Jag Mohan Singh, PatialaDr. Anjani Manchanda, New DelhiDr. M.K. Verma, New DelhiDr. N. Padmapriya, ChennaiDr. G. Arun Maiya, ManipalProf. Jasobanta Sethi, BangaloreProf. Shovan Saha, ManipalProf. Narasimman S., MangaloreKamal N. Arya, New DelhiDr. Nitesh Bansal, NoidaDr. Aparna Sarkar, NoidaDr. Amit Chaudhary, FaridabadDr. Subhash Khatri, BelgaumDr. S.L. Yadav, New DelhiDr. Sohrab A. Khan, Jamia Hamdard, 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 Odlak, TurkeyPrint-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 journalfor all Physiotherapists & Occupational therapists provides professionals with a forum to discuss today’s challenges -identifying the philosophical and conceptual foundations of the practics; sharing innovative evaluation and tretmenttechniques; learning about and assimilating new methodologies developing in related professions; and communicatinginformation about new practic settings. The journal serves as a valuable tool for helping therapists deal effectively withthe challenges of the field. It emphasizes articles and reports that are directly relevant to practice. The journal is nowcovered by INDEX COPERNICUS, POLAND. The journal is indexed with many international databases, Like PEDro(Australia).The Journal is now covered with EBSCO (USA) database. The journal is registered with Registrar on Newspapers forIndia vide registration DELENG/2007/20988Website : 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.EditorDr. Archna SharmaAster-06/603, Supertech Emerald CourtSector – 93 A, ExpresswayNOIDA 201 304, Uttar PradeshPrinted, published and owned byDr. Archna SharmaPrinted atProcess & SpotC-112/3, Naraina Industrial Area, Phase-INew Delhi-110 028Published atAster-06/603, Supertech Emerald Court, Sector – 93 A,Expressway, NOIDA 201 304, Uttar PradeshDean (R&D), Saraswathi Institute of Medical Sciences, Ghaziabad (UP)
  3. 3. Contentswww.ijpot.comJan.-March. 2011Volume 5, Number 1Indian Journal of Physiotherapy and Occupational Therapy. Jan. - March. 2011, VOL 5 NO 11 Footwear effects on balance and gait in elderly women of Indian population between the ages 55and 75 yearsAditi Bhatia, Sumit Kalra5 The effect of short term dynamic and isometric resistance training in knee osteoarthritisAjit Singh, Shekhar9 Multimodal therapy in cervicogenic headache- a randomized controlled trialAkanksha Sharma, Unaise Abdul Hameed, Shalini Grover14 Combined effectiveness of Maitland’s mobilization and patellar taping in patellofemoralosteoarthritis: A randomised clinical trialAlok Kumar, Ganesh B. R.18 Maximal oxygen consumption as a function of anthropometric profiling in a group of trainedIndian athletesAmrith Pakkala, Ankita Dutta, N.Veeranna, S.B.Kulkarni21 Titanic splintB.Anandha Priya, Snehal Pradip Desai24 Normative data of Jebsen Taylor Hand Function Test [modified version] on indian populationB.Anandha Priya, Snehal Pradip Desai27 Effect of 2-week and 4-week wobble board exercise programme for improving the muscleonset latency and perceived stability in basketball players with recurrent ankle sprainA.S. Dinesha , Arun Prasad.B33 A comparative study of the therapeutic effect of pelvic floor exercises and perineometer amongwomen with urinary stress incontinenceMs. K. Vairajothi, T.V. Chitra, Professor, R.Baranitharan, V.Mahalakshmi36 A study of effects of gluteal taping on TD-parameters following chronic stroke patientsBhatri Pratim Dowarah40 Role of physiotherapy in palliative careBinoy Mathew K V.43 Comparing effectiveness of antero-posterior and postero-anterior glides on shoulder range ofmotion in adhesive capsulitis - a pilot studyHarsimran K, Ranganath G, Ravi SR47 Effect of 12 weeks weight bearing and non weight bearing aerobic exercises on overweight andobese individualsJ. Deepa, Monalisa Pattnaik, P.P Mohanty, Venkadesan. R52 Effect of functional strength training on functional motor performance in young children withcerebral palsyDharam Pani Pandey, Vimal Tyagi56 Effect of post isometric relaxation on pain intensity, functional disability and cervical range ofmotion in myofacial pain of upper trapeziusDheeraj Lamba, Satish Pant60 The effect of foot orthoses on energy consumption in runners with flat footF.Farmani, M.Sadeghi,H.Saeedi, M.Kamali63 A study of prevalence of Developmental Coordination Disorder (dcd) at kattankulathur, chennaiMr.ganapathy Sankar U, Ms. S.saritha66 Dynamic standing balance in individuals with osteoarthritis knee- a comparison with matchedcontrolsR.HariHaran70 Effect of play therapy in children with attention deficit hyperactivity disorder - a single blindedrandomized controlled studyJagatheesan Alagesan,Sardesai A. Shradha,Sankar B. Mani73 A study of effectiveness of wheelchair skill training program (wstp) in teaching wheelie tooccupational therapy studentsKamal Narayan Arya77 Perception and functional wellbeing of patients receiving physiotherapy services in amultispecialty hospital – prospective observational trialT. Lavinia Marwein1, Baskaran Chandrasekaran, Bidhan Chandra Sharma80 Effect of concurrent quantitative feedback training on intra-rater and inter-rater reliability ofgrade iii mobilization over fourth lumbar spinous processNidhi Gautam, Shallu Sharma
  4. 4. 85 Efficacy of deep transverse friction massage in treatment of chronic ankle sprainPooja K Arora, Sujata Yardi, Kunal Pathak90 Comparative analysis of 12 minute walk test and modified shuttle walk test in normal subjectsRicha Rai, Sujata Yardi95 Cervical spinal mobilization versus TENS in the management of cervical radiculopathy: Acomparative, experimental and randomized controlled trialRonald Prabhakar, G. J. Ramteke100 Home based constraint-induced therapy for children with hemiplegic cerebral palsy: A pilotstudySaleh AL-Oraibi, Hashem Abu Tariah103 Taping and OKC exercises versus taping and CKC exercises in treating patients with patellofemoralpain syndromeYehia N. Abd Elhafz , Mohammed S. Abd El Salam , Samiha M. Abd Elkader107 Cardiovascular responses to McKenzie lumbar spine exercises in hypertensive individualsPrabhu. R, Nambiar V.K, Ravindra .S, Kommineni. P112 Care allowance for people in need of care in Turkey: An ethical and social evaluationSema OÐLAK , Erdem ÖZKARA116 Comparative study of anaerobic capacity in sprinters and foot ball playersD.s.sakthivelavan, S.sumathilatha119 Effect of varying abdominal pressures on pulmonary function in seated tetraplegic patients: Acase reportShweta Gore, Sivakumar T.122 Stabilization exercises in postnatal low back painTarek A. Ammar, Katy Mitchell, Amir Saleh125 Efficacy of neural mobilization in sciaticaSharma Vijay., Sarkari E. and Multani N.K128 Prevalence of various health problems in traditional goldsmithAnup Pednekar, Anu Arora, Sujata Yardi133 Effect of 12-weeks posterior tibial nerve stimulation in treatment of overactive bladderAnwar Abdelgayed Ebid137 Comparison of manual physical therapy and conventional physical therapy programs inosteoarthritis of kneeDheeraj Lamba, Satish Chandra Pant140 Efficacy of home based pulmonary rehabilitation program on pulmonary functions and quality oflife in asthmatic childrenGanesan Kathiresan , Andrew J Newens142 The relative efficacy of mobilization with movement versus Cyriax physiotherapy in the treatmentof lateral epicondylitisPooja Bhardwaj, Amit Dhawan147 Use of electrical stimulator to detect neurosensory changes - a case reportPrachur Kumar, C.S Ram, Suhas.S.Godhi150 Relationship between depression and duration from the onset of injury in traumatic spinalcord injured patientsRenu Singh, Ms. Ruby Aikat154 Efficacy of Mulligan Concept (NAGs) on Pain at available end range in Cervical Spine: A RandomisedControlled TrialKumar D, Sandhu J S, Broota AIndian Journal of Physiotherapy and Occupational Therapy. Jan. - March. 2011, VOL 5 NO 1
  5. 5. 1Aditi Bhatia / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol.5, No.1Footwear effects on balance and gait in elderly women of Indianpopulation between the ages 55 and 75 yearsAditi Bhatia*, Sumit Kalra***Student, **Lecturer, Banarsidas Chandiwala Institute of Physiotherapy, New Delhi.AbstractPurposeTo determine effects of different footwear and barefoot conditionon measurement tools like FRT, TUG and TMW in elderly womenof Indian population.SubjectsSixty women, aged 55 to 75 years.MethodsEach subject performedthe Functional Reach Test (FRT), TimedUp and Go (TUG) and Ten Metre Walk (TMW) while wearingwalking shoes, heel shoes, and barefooted. One-way repeated-measuresanalysis of variance (ANOVAs) and a Tukey HonestlySignificant Difference test were used to compare the outcomesfor the 3 footwear conditions.ResultsSubjects performed better in the FRT when barefooted orwearing walking shoes compared with when they wore heelshoes. For TUG and TMW, the women were slowest wearingheel shoes, with no significant differences in walk shoes andbarefoot.ConclusionFor administration of measurement tools like FRT, TUG andTMW in clinical settings and for research purposes, footwearshould be consistently standardised from one patient or subjectto another or from one facility to another. Moreover, balanceand gait in elderly women can be improved through correctfootwear recommendation.IntroductionPhysical function refers to the normal performance of anindividual in managingADLs andrepresents an important aspectof the individual’s overall health. Physical function impairs ifbalance and gait are altered. Many falls experienced by olderpeople result from age-related deterioration of the balance andneuromuscular systems(1). Most falls occur during motor tasks(2)and footwear has been identified as an environmental risk factorfor both indoor and outdoor falls(3). By altering somatosensoryfeedback to the foot and ankle and modifying frictional conditionsat the shoe-sole/floor interface, footwear influences posturalstability and the subsequent risk of slips, trips, and falls, therebyimpairing balance and gait.Wearing different footwear or being barefooted influencesbalance and gait. When walking barfooted, proprioception andplantar sensitivity provide optimal input to the postural controlsystem. However, wearing a shoe,provide more grip than theplantar sole of the foot, protecting the foot from mechanical insultand irregularities in walking surfaces, thereby reducing the riskof slipping(4).Moreover, in heeled shoes, heel elevation is associatedwith an increased risk of falling in older people by elevating andshifting the wearer’s center of mass (COM) forward, high-heelshoes affect balance control and lead to postural and kinematicadaptations(5). In a plantar-flexed ankle position adopted whenwearing elevated heel shoes, calcaneal eversion is reduced,which is often noted in high-heeled gait, and foot rollover in theshoe is absent(6), these later adaptations might prevent the footfrom pronating, affecting the foot’s natural shock-absorptionmechanism(4)and thus leading to falls.Heeled shoes cause abnormal forces across patellofemoraland medial compartments of knee which are typical anatomicalsites of degenerative joint changes(7). First metatarsophalangealjoint reaction forces were twice as large in high heels comparedto barefoot walking(8).With increasing risk of slips, trips and falls due to footwear,evaluation of physical impairments and functional limitationshasbecome an essential part of research related to clinical practisefor proper diagnosis as to give proper and accurate managementand early rehabilitation. Evaluation of balance and gait can bedone by available multiple instruments such as SharpenedRhomberg, One Leg Stance Test, Functional Reach, Timed UpAnd Go, Berg Balance Scale, Gait Speeds etc(9). Among thephysical performance measures that fulfill these requirementsare the Functional Reach Test (FRT), the Timed Up and GoTest (TUG), and measures of self-selected gait speed such asthe 10-Meter Walk Test (TMW). All 3 of these scales arecontinuous measures and, therefore, theoretically moreresponsive to change than categorical scales(10).The FRT captures the ability to control movement of thecenter of gravity over a fixed base of support, in the standingposition with excellenttest-retest reliability(11). Concurrent validityas a marker of physical frailty in community-dwelling elderlypeople(12), predictive validity in identifying risk of falls incommunity-dwelling male veterans(13)and sensitivity to changein balance in inpatient male veterans undergoing physicalrehabilitation(14)have been reported for the FRT. Older adultshave shorter distances of functional reach when compared withyoung adults(15). The average reach length of females is 13.5%smaller than that for the corresponding males(16).The TUG is typically used to evaluate basic mobility inelderly people. Podsiadlo and Richardson(17)reported anexcellent intrarater reliability and interrater reliability for asubgroup of 22 people. Women performed significantly pooreron TUG(18). TUG shows a trend towards age related declines asmeasured for both male and female subjects(19).The TMW is a measure of self-selected walking speed(20)which, according to Cress et al(21)is the best predictor of self-perceived function and overall physical performance. Thecomfortable walking speed of older adults was an average of71% to 97% slower than that of young adults(22). Gait velocitywas higher for women than for men(23).Standardization of test procedures is often critical for reliablegeneralization of results from one patient to another. The typeof footwear worn by the patient or subject is not consistentlystandardized in the administrationof the FRT, TUG, and TMW.Inprevious studies in which the FRT was used as an outcomemeasure, theauthors rarely mentioned footwear when describingthe measurement procedures(24). Footwear also is notstandardized for the TUG or TMW and reported as regular
  6. 6. 2 Aditi Bhatia / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1footwear and as normal walking shoes(25)respectively.Several investigators have reported other effects offootwear. Few studies included older women like a study doneby Solveig et al(32), reported that walking shoes, heel shoes andno shoes affect the gait pattern of older women of Americanpopulation. However, no study encompassed the effect offootwear on FRT, TUG, and TMW scores amongst elderly womenof Indian population.The purpose of our study was to determine the effects offootwear on FRT, TUG, and TMW scores in elderly women ofIndian population. The focus of our study was limited to elderlywomen because they are at higher risk for disablementthan aremen(26). In addition, women wear high-heeled dress shoes thatmay have a great impact on balance and gait performance.We hypothesized that elderly women of Indian populationshow low FRT scores, larger TUG scores and slower selfselected gait speeds with heel shoes, with no significantdifferences in walk shoes versus barefoot condition.MethodSubjects-60 healthy female subjects were taken.Inclusion criteria-(1) Between age group of 55 to 75 years,(2) Owned at least one pair of walking shoes and at least onepair of dress shoes (with heel height of atleast 1 inch)(3) Wore these shoes at least occasionally(4) Had at least 90 degrees of shoulder flexion(5) No history of any balance problem(6) Able to stand unsupported for 30 seconds or more,(7) Could walk independently at least 20 m and turn 180degrees,(8) Did not wear a lower-extremity brace or orthosis,(9) Should be able to stand barefoot on the floor.Exclusion criteria-(1) Ability to understand standardised test instructions,(2) Any psychological disorder,(3) Any neurological disorder,(4) Any recent or acute fracture of lower limb,(5) Any recent lower limb surgery,(6) Any inflammatory condition, joint infection of lower limbjoints,(7) Any diabetic or lower limb neuropathy,(8) Tendoachilles not stretchable to 90 degrees,(9) Any shoulder pathologies or deformities,(10) Any spinal pathology,(11) Wore any lower extremity brace or orthosis,(12) Foot deformities, foot abnormalities like painful corns andulcers.Instrumentation-1. Walking shoes2. Dress shoes of atleast 1 inch heel3. Yardstick4. Measuring tape5. Digital stop watch6. Chair with arm rest, cushioned back and seat. The chairshould have seat height 44cm, seat depth 44cm and armheight 63cm.ProcedureAll the subjects who were willing and fulfilling inclusioncriteria were taken for the study and explained about the testingprocedure. They were asked to sign an informed consent. Thesubjects were asked to perform FRT, TUG and TMW under threefootwear conditions (barefoot, walk shoes and heel shoes) fortwo trials. To avoid undue fatigue subject rested 3minutesbetween footwear conditions and 1minute between differentfunctional measurements.Data analysisA one-way repeated-measures ANOVA was used for eachtest to compare the outcomes on the FRT, TUG, and TMW forthe 3 different footwear conditions. A post hoc comparisonsamong footwear conditions were performed using the TukeyHonestly Significant Difference (Tukey HSD) test with asignificance level of P<.05. The 95% confidence interval (95%CI) also was calculated for each point estimate.ResultsTable 2: Comparison of TUG in different footwear conditions(barefoot) walk shoes and heel shoes)TIMED UP AND GO TEST (TUG) in secondsBAREFOOT WALK HEELSHOES SHOESMEAN 12.375 12.208 14.477STANDARD 3.709 3.696 3.856DEVIATIONTable 1: Comparison of FRT in different footwear conditions(barefoot) walk shoes and heel shoes)FUNCTIONAL REACH TEST (FRT) in cmBAREFOOT WALK HEELSHOES SHOESMEAN 8.267 8.162 6.612STANDARD 2.672 2.682 2.371DEVIATIONTable 3: Comparison of TMW in different footwear conditions(barefoot) walk shoes and heel shoes)TEN METRE WALK (TMW) in metre/secondBAREFOOT WALK HEELSHOES SHOESMEAN 0.544 0.554 0.465STANDARD 0.129 0.133 0.098DEVIATIONGraph-1 Comparison of FRT in different footwear conditions(barefoot, walk shoes and heel shoes)Graph-2 Comparison of TUG in different footwear conditions(barefoot, walk shoes and heel shoes)
  7. 7. 3Aditi Bhatia / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1Graph-3 Comparison of TMW in different footwear onditions(barefoot, walk shoes and heel shoes)gait speed than with no shoes.Though barefoot walking increases precise foot positionawareness, but elderly women cannot be advised to walk withoutshoes because barefoot walking can cause cuts, abrasions,bruises, punctures, wounds from foreign objects. Moreoverhookworm larvae can easily burrow through a bare human foot.In addition individuals with diabetes mellitus which affectsensation with in feet are at a greater risk of injury when walkingwithout shoes so they can only be advised to walk with shoeswith no or minimal heel.It is also important to note that during the testing, subjectswore their own shoes, because testing in new shoes mayinfluence postural responses to footwear. Moreover in clinicalsettings, subjects are generally assessed in their own shoes.This study also indicates that during assessments andfollowups of elderly women of balance and gait abilities,comparative analysis should be drawn in similar footwearcondition with its proper documentation.Results of current study suggest that correct footwearrecommendation can help to improve balance and gait abilitiesin elderly women. But further research is needed to identifyimportant shoe characters that can help to improve balance andgait abilities in elderly women.ConclusionBased on the findings of this study, it can be concludedthat scores of FRT, TUG and TMW are affected by type offootwear condition in elderly women. It is also important to keepthe footwear constant and properly documented when using FRT,TUG and TMW in clinical settings and research purposes. Inaddition, improvement of gait and balancein elderly women canbe undertaken by proper footwear intervention and it issuggested that elderly females should be advised to wearminimal heel shoes as it can prevent further risk of falls as theycan walk barefoot.References1. Lord SR, Sherrington C, Menz HB. Falls in older people:Risk factors and strategies for prevention. 2nd ed.Cambridge (England): Cambridge University Press; 2001.2. Hill K, Schwarz J, Flicker L, Carroll S. Falls among healthy,community-dwelling, older women: A prospective study offrequency, circumstances, consequences and predictionaccuracy. Aust N Z J Public Health. 1999; 23(1):41-48.3. Berg WP, Alessio HM, Mills EM, Tong C. Circumstancesand consequences of falls in independent community-dwelling older adults. Age Ageing. 1997;26(4):261-68.4. Jasmine C. Menant, Hylton B. Menz, Bridget J. Munro,Stephen R. Lord. Optimizing footwear for older people atrisk of falls. JRRD, 2008; 45: 1167-11825. Snow RE, Williams KR. High heeled shoes: Their effect oncenter of mass position, posture, three-dimensionalkinematics, rearfoot motion, and ground reaction forces.Arch Phys Med Rehabil. 1994;75(5):568-76.6. Ebbeling CJ, Hamill J, Crussemeyer JA. Lower extremitymechanics and energy cost of walking in high-heeled shoes.J Orthop Sports Phys Ther. 1994;19(4):190-96.7. D.Kerrigan, J.Lelas, M.Karvosky. Women’s shoes andosteoarthritis. The Lancet, Vol 357:1097-1098.8. McBride ID, Wyss UP, Cooke TD, Murphy L, Phillips J,Olney SJ. First metatarsophalangeal joint reaction forcesduring high-heel gait. Foot Ankle. 1991 Apr;11(5):282-89. Anemaet, Wendy K. Functional Tools forAssessing Balanceand Gait Impairments. Topics in GeriatricRehabilitation.1999;15(1):66-8310. Maki B. Gait changes in older adults: predictors of falls orindicators of fear? J Am Geriatr Soc.1997; 45:313–320.The ANOVAs revealed an overall footwear condition effectfor FRT scores of subjects (F=7.908; df=2; P<.001), for TUGscores (F=6.807; df=2;P<.001), and for TMW scores (F=9.739;df=2; P<.001).Tukey HSD post hoc pair-wise comparisons revealed thatthe subjects performed better on the FRT when they werebarefoot or worewalking shoes compared with when they woreheel shoes(HSD.05=5.060 and HSD.05=4.655 respectively) withno significant difference between the barefoot and walking shoeconditions(HSD.05=.405).Subjects when performing TUG performed better in barefootand walking shoes compared with when they wore heel shoes(HSD.05=4.33 and HSD.05=4.68 respectively) with no significantdifference between the barefoot and walking shoe conditions(HSD.05=.344).In TMW test, subjects performed better in barefoot andwalking shoes compared with when they wore heel shoes(HSD.05=4.996 and HSD.05=5.628 respectively) with no significantdifference between the barefoot and walking shoe conditions(HSD.05=.632).DiscussionThe results of the study indicates that in elderly women,type of footwear is an important factor while measuring andanalysing findings of common clinical tests like FRT,TUG andTMW.The results of this study indicates that FRT scores are betterin walk shoes or no shoes in comparison to heel shoes.The results of FRT scores are quite consistent with findingsof Lord and Bashford(27)who studied the effects of footwear onbalance in 30 women aged 60 to 89 years using a swaymeter.These women performed better in flat shoes or barefoot thanwhen they wore high heeled shoes.The lack of differences in FRT scores between barefootand walking shoes condition is consistent with study by Briggset al(28). They found no effect of wearing shoes versus not wearingshoes on performance in sharpened Rhomberg and OLSTamong older women with no known pathology.Footwear effects on TUG and TMW showed worseperformances with heel shoes with no significant differncesbetween barefoot and walk shoes walking. These performancesin heel shoes condition agrees with observations of Snow RE etal(29)whose studies demonstrated slower gait in high heeledshoes compared with low heeled shoes. The decreased scoresof TUG and TMW in heels is supported by work of de Lateur(30)which states that increased heel heights corresponds todecreased gait speeds and step length.According to Menant et al(31), elevated heel shoes lackcomfort, stability and lead to a conservative walking patterncharacterised by increasing step width and double support time.The study also indicates that there is no significantdifference in walk shoes versus barefoot condition of TUG andTMW scores, contradicting the study of Solveig et al(32)whichstates that walk shoes give lower TUG scores and faster selected
  8. 8. 411. Duncan PW, Weiner DK, Chandler J, Studenski SA.Functional reach: a new clinical measure of balance. JGerontol A Biol Sci Med Sci.1990; 45:M192–M197.12. Weiner DK, Duncan PW, Chandler J, Studenski SA.Functional reach: a marker of physical frailty. J Am GeriatrSoc.1992; 40:203–20713. Duncan PW, Studenski SA, Chandler J, Prescott B.Functional reach: predictive validity in a sample of elderlymale veterans. J GerontolABiol Sci Med Sci.1992; 47:M93–M98.14. Weiner DK, Bongiorni DR, Studenski SA, et al. Doesfunctional reach improve with rehabilitation?Arch Phys MedRehabil.1993; 74:796–800.15. Hageman P, Blanke D.Age and Gender Effects on PosturalControl Measures, Archives of Physical Med and Rehab.Vol 76:961-965.16. Sen Gupta AK, Das B. Maximum Reach Envelope forSeated and Standing Females and Males for Industrial WorkStation Design. Ergonomics 2000;43 (9): 1390-404.17. Podsiadlo D, Richardson S. The timed “Up & Go”: a test ofbasic functional mobility for frail elderly persons. J AmGeriatr Soc.1991; 39:142–148.18. Luc vereck, Floris Wuyts. Clinical assessment of balance:normative data, gender and age effects. InternationalJournal of Audiology, 2008, vol-47, pages 67-75.19. Teresa M Steffen, TimothyAHacker, Louise Mollinger.Age-and Gender-Related Test Performance in Community-Dwelling Elderly People: Six-Minute Walk Test, BergBalance Scale, Timed Up & Go Test, and Gait Speeds.Phys Ther. 2002;82:128–137.20. Duncan PW, Studenski SA. Balance and gait measures.In: Lawton MP, Teresi JA, eds. Annual Review ofGerontology and Geriatrics: Focus on AssessmentTechniques. New York, NY: Springer Publishing Co Inc,1994:76–92.21. Cress ME, Schechtman KB, Mulrow CD, et al. Relationshipbetween physical performance and self-perceived physicalfunction. J Am Geriatr Soc.1995; 43:93–101.22. Bohannon RW. Comfortable and maximum walking speedof adults aged 20-79 years: reference values anddeterminants. Age Ageing.1997; 26:15–19.23. Tommy Oberg, MD, Alek Karsznia, Kurt Oberg. Basic gaitparameters:Reference data for normal subjects,10-79 yearsof age. Journal of Rehabilitation Research andDevelopment. 1993;Vol.30:210–22324. West SK, Rubin GS, Munoz B, et al. Assessing functionalstatus: correlation between performance on tasksconducted in a clinic setting and performance on the sametask conducted at home—The Salisbury Eye EvaluationProject Team. J Gerontol A Biol Sci Med Sci.1997;52:M209–M217.25. Schenkman M, Cutson TM, Kuchibhatla M, et al. Reliabilityof impairment and physical performance measures forpersons with Parkinson’s disease. Phys Ther.1997; 77:19–27.26. Lewis M. Older women and health: an overview. WomenHealth.1985; 10:1–16.27. Lord SR, Bashford GM. Shoe characteristics and balancein older women. J Am Geriatr Soc.1996; 44:429–433.28. Briggs RC, Gossman MR, Birch R, et al. Balanceperformance among noninstitutionalized elderly women.Phys Ther.1989; 69:748–75629. Snow RE, Williams KR. High heeled shoes: their effect oncenter of mass position, posture, three-dimensionalkinematics, rearfoot motion, and ground reaction forces.Arch Phys Med Rehabil.1994; 75:568–576.30. de Lateur BJ, Giaconi RM, Questad K, Ko M, Lehmann JF.Footwear and posture: Compensatory strategies for heelheight. Am J Phys Med Rehabil. 1991 Oct;70(5):246-54.31. J. Menant, J. Steele, H. Menz, B. Munro, S. Lord. Effects ofwalking surfaces and footwear on temporo-spatial gaitparameters in young and older people. Gait & Posture,Vol29; 392-39732. SolveigAArnadottir and Vicki S Mercer Effects of Footwearon Measurements of Balance and Gait in Women betweenthe Ages of 65 and 93 Years Phys Ther Vol. 80, No.1,January 2000, pp.17-27Aditi Bhatia / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
  9. 9. 5The effect of short term dynamic and isometric resistance trainingin knee osteoarthritisAjit Singh*, Shekhar***Assistant Professor, Department of Orthopaedics, Rohilkhand Medical College, Bareilly, **Assistant Professor, Department ofPhysiotherapy, Jaipur College of Physiotherapy, JaipurCorresponding author:DrAjit Singh,Assistant Professor , Department of Orthopaedics,Rohilkhand Medical college, Pilibhit bypass Road, Bareilly. PIN-243006.E-mail: ajitsingh2409@gmail.comPhone number: (0581)2526011Mobile number: 09319930079, 9458407500AbstractBackground and purposeSince strength training affects the outcome of OA knee,thus this study aims to assess the effect of short term (3 weeks)multiple angle isometric resistance training and dynamicresistance training on pain and function among adults with OAknee.Study designA pre-post experimental design.SubjectsA total of sixty subjects were selected on the basis ofinclusion and exclusion criteria; Group 1 (n=30) wasadministered with multiple angle isometric resistance trainingand Group 2 (n=30) was administered with dynamic resistancetraining.MethodsThe muscle strength was measured using strain gauge,pain of the subjects was evaluated on Visual analog Scale,function of knee was measured on reduced WOMAC scale.ResultsThe result indicates that both the interventions were equallyeffective in reducing pain, improving isometric strength ofquadriceps, and improving functional status.ConclusionDynamic or isometric resistance training improvesfunctional ability and reduces knee joint pain of patients withknee OA.KeywordsDisability; dynamic resistance training; isometric exercises;knee osteoarthritis.IntroductionOsteoarthritis (OA) is common, progressive health problemamong adults. It is the most prevalent disease in our society,with a world wide distribution and is the second most commoncause of disability among older adults1. It is estimated that 80%of all adults at or over age 65 years exhibit radiographic evidenceof OA2. When symptoms of the disease affect the knee, as in10% of all adults, it results in a limited ability to complete activitiesof daily living (ADLs)3. Many studies have indicated that theprimary lesion of OA is in the articular cartilage4. Quadricepsstrength, knee pain, and age are more important determinantsof functional impairment in elderly subjects than the severity ofknee osteoarthritis as assessed radiographically5.Among these,quadriceps weakness may be the most amenable to treatmentfor the prevention of knee OA.Treatment options in OA knee may be classified asnonpharmacologic, pharmacologic, or surgical. Given theirrelatively low toxicity and cost, nonpharmacological strategies(such as physical therapy, including exercise) are recommendedas the first-line treatment for the knee OA6. The primary goals ofphysical therapy are to reduce pain and decrease disability7.Physical therapy encompasses a variety of treatment modalitiesfor knee OA, including manual joint mobilization, exerciseprescriptions, hydrotherapy, massage, knee tapping, kneebraces, and shoe insole. Numerous studies have documentedthe symptomatic benefits of isometric exercise for individualswith knee OA.6,8,9,10Functional ability requires movement of thejoint over a functional range. Isometric resistance trainingimproves muscle strength only at joint angle at which the trainingtakes place11,12, this specificity of training principle may limit howmuch isometric training can affect performance of functional taskthat requires joint movement beyond the joint angle prescribedin the isometric training. A possible advantage of isometrictraining may be that it does not stress the joint over a functionalrange of motion. Reduced joint movement may result in lesspain during and after the resistance training.In contrast, dynamic resistance training in non-OAsubjectsimproves the strength of the trained muscle over the entire rangeof motion(ROM). It has been reported that dynamic resistancetraining correlates with improve knee strength, increasedneuromuscular performance on selected functional tasks.Although, dynamic resistance training improves strengths andfunctioning over the training ROM, the joint is being loaded whileit is moved, which may result in pain in OA patients.Since strength training affects the outcome of OA knee,thus this study aims to assess the effect of short term multipleangle isometric resistance training and dynamic resistancetraining on pain and function among adults with OA knee.MethodThe study was conducted using pretest post testexperimental design at Ortho & Physiotherapy OPD, RohilkhandMedical College, Bareilly on 60 subjects who were randomlydivided into two equal groups. A total of sixty, both male(n=33)and female(n=27) patients were included in the study. Thecriteria for inclusion were: pain in and around knee; radiologicalevidence of primary osteoarthritis with grade II, III on Kellgrane-Larance scale13; age between 50 -75 years; unilateral or bilateralinvolvement, in case of bilateral more symptomatic knee wasincluded. Subjects were excluded if they had any deformity ofknee, hip, or back, limitation in knee range of motion, history ofbony or soft tissue injury to knee joint, backache with radiatingpain to leg, any central or peripheral nervous systeminvolvement, received steroid or intra articular injection withinAjit Singh / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
  10. 10. 6previous six months, systemic inflammatory disease e. g. gout,rheumatoid arthritis, ankylosing spondylitis, had metallic implant,uncooperative patients or mentally unstable. Patient takingnon-steroidal anti- inflammatory drugs had been on stable doseover the last two weeks.ProcedureAfter screening for inclusion and exclusion criteria thesubjects were randomly assigned into two groups with 30subjects in each group and informed consent was obtained fromthe subjects. Randomization was done by permuted blockrandomization.InterventionAll the subjects received hot pack at the affected knee jointand resistance training exercises according to their respectivegroups. The intervention was given for three weeks (3 days/week). Hot packs were given after the exercise session withpatient in supine lying.Group A: hot packs with multiple angle isometric resistancetraining at 30 , 60 and 90 degree of knee flexion.Group B: hot packs with dynamic resistance training.The outcome measurements in this study were isometric kneeextensor strength at 30 , 60 and 90 degree of flexion, reducedWOMAC14score and VAS15score.Measurement of isometric strengthThe isometric strength of quadriceps femoris was measuredby using a strain gauge at baseline (before intervention) andrecorded as ISO01, ISO02, ISO03 and at the end of interventionrecorded as ISO31, ISO32, ISO33 for isometric strength at 30,60, 90 degree of knee flexion respectively. During the testingsubjects were made to sit on quadriceps table with knee joint at30 , 60 and 90 degree of flexion .thigh was stabilized with belts;the shin pad was adjusted at 5.1 cms (2 inches) superior to themedial malleolus. The fulcrum of the lever arm was aligned withthe most distal part of lateral epicondyles of the femur. The straingauge was attached to the distal end of the quadriceps tablearm.Subjects were given verbal encouragement in order tomotivate to attain maximum effort during the 5 secondscontraction. Each test included 3 consecutive trials with 30seconds rest in between the trials. The mean of 3 readings wasused for the purpose of analysis.Measurement of functional scoreThe functional score was assessed by using reducedWOMAC scale. The reading were taken at baseline (beforeintervention) and after the end of three weeks and marked asWOMAC0 and WOMAC3 respectively.Measurement of pain intensityPain was assessed using a horizontal analog scale. Thereading were taken at the baseline and at the end of interventionand marked as VAS0 and VAS3 respectively.Data analysisA pre-post experimental (parallel group) study was usedfor the study. Data was analyzed using the SPSS 15 software.Paired t-test was used for comparison of strength with the groups.Independent t-test was used to compare the strength betweenthe groups, the values of both of the two groups i.e. group A andGroup B were compared at baseline and post intervention. Thetest was applied at 95% confidence interval. The results weretaken to be significant if p<0.05.ResultsWithin group analysis in Group A and B revealed that therewas a statistically significant difference (p<0.05) in isometricstrength of quadriceps at 30, 60, and 90 degrees of knee flexionafter 3 weeks of training, when compared to the baseline values.The mean improvements in isometric strength in Group A at 30owas 3.34±1.06; at 60owas 4.12±1.52 and at 90owas 3.55±1.06.Within Group B the mean improvements in isometric strength at30owas 3.75±1.47; at 60owas 4.51±1.32 and at 90owas3.71±1.29. (Table. 1)Both Group A and B showed a statistically significantdifference (p<0.05) in VAS Score after 3 weeks of training whencompared with baseline values. The mean improvements in VASScore was 4.3±1.6 in Group A and 4.36±1.56 in Group B.(Table.2).Within group analysis in both groups revealed that therewas a statistically significant difference (p<0.05) in WOMACScore after 3 weeks of training when compared with baselinevalues. The mean improvement in WOMAC Score was11.4±4.15in Group A and 12.33±4.08 in Group B .(Table. 3)DiscussionThis study provides important information about the efficacyof Dynamic resistance training and Multiple angle isometricresistance training on quadriceps strengthening in OA patients.Both the two groups showed a significant reduction in pain,improvement in isometric strength of quadriceps, andimprovement in functional index scale from their base line values.But when compared between the groups, there was no significantdifference observed. Thus, the old idea that isometric exerciseis the only correct exercise for people with arthritis is challengedby this study.Table 3 : Within group analysis of WOMACPre TestMean±SD Post TestMean±SD t pGroup A 20.73±3.75 9.33±2.76 10.68 <.05Group B 22.67±3.79 10.33±3.73 11.7 <.05Table 1 : Isometric strength of quadriceps at 30, 60, and 90 degrees of knee flexion after 3 weeks of training.Knee Flexion Pre TestMean±SD Post TestMean±SD t value p valueGroup A At 3005.01±1.71 8.34±2.31 -12.19 <.05At 6006.25±2.07 10.37±2.89 -10.45 <.05At 9005.66±1.98 9.21±2.39 -12.93 <.05Group B At 3004.70±1.26 8.46±1.53 -9.87 <.05At 6006.12±1.47 10.63±1.76 -10.12 <.05At 9005.50±1.44 9.22±1.59 -11.07 <.05Table 2 : Within group analysis of VAS ScoresPre TestMean±SD Post TestMean±SD t pGroup A 6.84±1.17 2.57±1.11 10.32 <.05Group B 6.83±1.38 2.47±1.39 10.89 <.05Ajit Singh / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
  11. 11. 7The results of the resistance training tested in the currentstudy appear to have a greater percentage impact on improvingactual functional measures and reducing pain than previousexercise interventions. The Fitness Arthritis and Seniors Trial16reported a modest 8%to 10% improvement in pain andfunctioning scores as a result of 18 months of aerobic orresistance exercise among their sample of knee OA patients.This modest, although signiûcant, effect of a long-term exerciseprogram, which included resistance training, was also reportedby Rogind et al17. Even the previously cited reviews10,18of theliterature indicated that exercise seems to have a small tomoderate effect on joint pain and functional outcome measureswith a more moderate effect on self-perceived measures offunctioning. Our ûndings suggest that resistance traininginterventions reduced pain and increased functional abilitysimilarly or to a greater extent than the previously studiedinterventions and that too in a lesser duration. This may bepossibly due to the fact that, the present interventions wereprimarily resistance training and may have required a higherintensity of training than the previous studies. The results of thisstudy support the efficacy of resistance training program inmanagement of OA patients, which is in agreement with variousother studies which support that activities involving strengtheningof quadriceps are helpful in the management of OA kneepatients19.Several investigators20,21have reported declines in thesensorimotor function of the quadriceps (proprioception) amongknee OA patients. This decline may be a primary factorcontributing to the development and progression of knee OA22.If proprioception is impaired, the timing of the eccentriccontraction of the quadriceps during weight-bearing activitieswill be clumsy, thus resulting in higher impact and impulsiveloads being transmitted through the joint23. These higher loadsbeing transmitted through the knee joint will lead to microtraumato the articular cartilage and/or the subchondral bone, whichare characteristics of knee OA24. A hypothesized outcome ofresistance training of the leg is an increased sensitivity in thesensorimotor structures of the quadriceps including the musclespindles and Golgi tendons25. Resistance training has beenshown to increase the alpha motor discharge or tone of themuscles trained. This alpha motor neuron activity is reciprocallyinfluenced by muscle spindles and Golgi complex within themuscles. Thus, regular resistance training may lower the impactand impulsive loads through the knee joint not by only increasingthe strength of the muscle surrounding the knee joint but alsoby increasing sensitivity and coordination of the proprioceptorswithin the quadriceps muscle26.Pain is a major factor to the disability in the patients withosteoarthritis knee. Hence, reduction in pain can explain aconcomitant improvement in the functional status of the patients.Disability in OA is due not only to the arthritis but also to theinactivity associated with the disease and with aging. It hasbeen postulated that resistance training increases the hyaluronlevels in the OAknee patients. With repeated muscle contractionthere occurs a synovial cell stimulation which is responsible foractivating hyaluron synthesis. This viscous hyaluron is muchsuited to joint lubrication and thus help in alleviating pain. Thusit can be the factor that could have lead to a reduction in painafter resistance training.References1. Felson DT, Naimark A, Anderson J, KazisL, CastelliW,Meenan RF. The prevalence of knee osteoarthritis inthe elderly. The Framingham Osteoarthritis Study. ArthritisRheum 1987; 30: 914-8.2. Lawrence JS, Bremner JM, Bier F. Osteo-arthrosis:prevalence in the population and relationship betweensymptoms and x-ray changes. Ann Rheum Dis 1966; 25:1-24.3. Rejeski WJ, Craven T, Ettinger WH Jr, McFarlane M,Shumaker SJ. Self-efûcacy and pain in disability withosteoarthritis of the knee. Gerontol B Psychol Sci Soc Sci1996; 51: 24-9.4. Mao-Hsiung Huang, Rei-Cheng Yang, Chia-Ling Lee, Tien-Wen Chen, And Ming-Cheng Wang. Preliminary Results ofIntegrated Therapy for Patients With Knee Osteoarthritis.Arthritis Care & Research 2005; 53(6): 812–20.5. McAlindon T E, Cooper C , Kirwan J R , Dieppe P A ,Determinants of disability in osteoarthritis of the knee.Annals of the Rheumatic Diseases 1993; 52: 258-262.6. Jordan K, N Arden, et al. EULAR recommendations 2003:An evidence based approach to the management of kneeOsteoarthritis: report of a task force of the StandingCommittee for International Clinical Studies IncludingTherapeutic Trials (ESCISIT). Ann Rheum Dis 2003; 62:1145-1155.7. Vogels E, Hendriks H, Vanbar M et al. Clinical practiceguidelines for physical therapist in patients with OA of thehip or knee. Royal Dutch society for physical therapy, 2003.8. Alan E. Mikesky, Steven A. Mazzuca, Kenneth D. Brandt,Susan M. Perkins, Teresa Damush and Kathleen A L.Effects of Strength Training on the Incidence andProgression of Knee Osteoarthritis,Arthritis & Rheumatism2006; 55(5): 690-699.9. Gail D D, Stephen C A et al, Physical Therapy TreatmentEffective For Osteoarthritis Of The Knee: RandomizedComparison Of Supervised Clinical Exercise And ManualTherapy Procedures Versus A Home Based ExerciseProgram. Physical Therapy 2005; 85: 1301-1317.10. Robert J Petrella, Is exercise effective treatment ofosteoarthritis of the knee?, Br J Sports Med 2000;34:326-331.11. K Kubo, K. Ohgo et al, Effects of isometric training atdifferent knee angles on the muscle tendon complex in vivo.Scand J Med Sci Sports 2006; (16): 159-16712. Jonathan PF, Hawker K, Leach B, Little T, Jones DA.Strength training: Isometric training at a range of joint anglesversus dynamic training. J Sports Sci 2005; 23: 817-824.13. Kellgren JH, Lawrence JS. Radiological assessment ofosteoarthrosis. Ann Rheum Dis 1957; 16: 494-501.14. Whitehouse SL, Lingard EA, Katz JN, Learmonth ID.Development and testing of a reduced WOMAC functionscale. J Bone Joint Surg Br 2003;85:706–11.15. Donald, Buckingham et al. The validation of visual analogscale for chronic and experimental pain. Pain 1983; 17,45-56.16. Ettinger WH Jr, Burns R, Messier SP, et al. A randomizedtrial comparing aerobic exercise and resistance exercisewith a health education program in older adults with kneeosteoarthritis. The FitnessArthritis and Seniors Trial (FAST).JAMA 1997;227:25-31.17. Rogind H, Bibow-Nielson B, Jensen B, Moller H, Frimodt-Moller H, Bliddal H. The effect of a physical training programon patients with osteoarthritis of the knees. Arch Phys MedRehabil 1998;79: 1421-7.18. Van Baar ME, Assendelft W, Dekker J, Oostendorp R,Bijlsma J. Effectiveness of exercise therapy in patients withosteoarthritis of the hip or knee. Arthritis Rheum1999;42:1361-9.19. A Pendleton, N Arden,M Dougados,M Doherty, BBannwarth, et al, EULAR recommendations for themanagement of knee Osteoarthritis: report of a task forceof the Standing Committee for International Clinical StudiesIncluding Therapeutic Trials (ESCISIT), Ann Rheum Dis,2000;59:936–944.20. Koralewicz LM, Engh GA. Comparison of proprioception inarthritic and age-matched normal knees. J Bone Joint SurgAm 2000;82:1582-8.Ajit Singh / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
  12. 12. 821. Barrett DS, Cobb AG, Bentley G. Joint proprioception innormal, osteoarthritic and replaced knees. J Bone JointSurg Br 1991;73: 53-5.22. Hurley MV. Quadriceps weakness in osteoarthritis. CurrOpin Rheumatol 1998;10:246-50.23. Radin EL, Martin B, Caterson B, Boyd R, Goodwin JJ.Effects of mechanical loading on tissues of the rabbit knee.J Orthop Res 1984;2:221-34.24. Radin EL, Yang KH, Riegger C, Kish VL, O’Connor M.Relationship between lower limb dynamics and knee jointpain. J Orthop Res 1991;9:398-405.25. Hutton RS, Atwater SW. Acute and chronic adaptations ofmuscle proprioceptors in response to increased use. SportsMed 1992;14: 406-21.26. Hakkinen K, Kallinen M, Izquierdo M, et al. Changes inagonist-antagonist EMG, muscle CSA and force duringresistance training in middle-aged and older people. J ApplPhysiol 1998;84:1341-9.Ajit Singh / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
  13. 13. 9Multimodal therapy in cervicogenic headache- a randomizedcontrolled trialAkanksha Sharma*, Unaise Abdul Hameed*, Shalini Grover***MPT Student, Faridabad Institue of Technology, Faridabad. *Assistant Professor, DTHS, MREI, **Assistant Professor, DTHS,MREI.AbstractStudy designThe study was a randomized controlled trial. This studywas reviewed and approved by the research review committeeat Faridabad Institute of Technology. (Faridabad)Aims and objectivesTo determine the effectiveness of multimodal therapy thatis a combination therapy including cervical mobilization andexercise therapy in patients with cervicogenic headache.Summary of background dataThere is lack of quality of Randomized Controlled Trialsanalyzing the combined use of cervical mobilization as well asexercise therapy intervention although there is evidencesuggesting that multimodal treatment therapy is superior for neckdisorders Moreover much of the research on cervicogenicheadache has concentrated on the use of spinal manipulationtechniques alone as well as in combination with other modalitiesbut the use of vertebral mobilization techniques along withexercise therapy in the form of multimodal therapy have certainlybeen ignored.MethodsIn this study 27 subjects who met the inclusion criteria wererandomized into three groups- multimodal therapy, exercisetherapy and control group. The primary Outcome measures wereHeadache Frequency, Intensity and Duration. Secondaryoutcome measures were – Neck Disability Index Score andPerformance Index of Deep Neck Flexors.ResultsThe results of the study demonstrates that patients withcervicogenic headache receiving multimodal therapyexperienced a significantly greater improvement in HeadacheFrequency, Intensity, Duration, Neck Disability and PerformanceIndex of Deep Neck Flexors when compared to exercise therapygroup as well as control group. Also exercise therapy alone alsoresulted in significant improvement across all outcomes; howeverthe level of significance is less than multimodal therapy group.Moreover the control group did not demonstrate significantimprovement across all outcomes at all level of comparison withrespect to time.ConclusionMultimodal therapy is significantly more effective thanexercise therapy as well as control intervention in patients withcervicogenic headache.IntroductionHeadaches which are believed to originate from structuresin the neck have been given various names, ranging from broadterms such as “cervical”, “occipital” and “cervicogenic to specificterms such as third nerve occipital headache1.The prevalenceof cervicogenic headache in the general population is estimatedto be 0.4% – 2.5%, but is as high as 20% in patients with chronicheadache. The mean age of patients with this condition is 42.9years and it is four times more prevalent in women2.The World Cervicogenic Headache Society3has definedcervicogenic headache as referred pain perceived in any partof the head and caused by a primary nociceptive source in themusculoskeletal tissues that are innervated by the cervicalnerves.Cervicogenic headache arises primarily frommusculoskeletal dysfunction in the upper three cervicalsegments4. The pathway by which pain originating in the neckcan be referred to the head is the trigeminocervical nucleus,which descends in the spinal cord to the level of C3/4, and is inanatomical and functional continuity with the dorsal gray columnsof these spinal segments. Hence, input via sensory afferentsprincipally from any of the upper three cervical nerve roots maymistakenly be perceived as pain in the head, a concept knownas convergence5.The location of symptoms is usually unilateral and doesnot change sides; they begin in the neck and spread to the head.Pain can range from a dull, deep ache to a heavy pressure ofmoderate or severe 6, 1. Cervicogenic headaches may be presentupon waking or can begin or worsen in intensity as the daygoes on, especially with sustained neck postures or movements.While this type of headache can begin at any age, it oftenincreases in frequency and intensity over a period of years andmay or may not accompany a history of neck trauma or cervicaljoint degenerative disease6.The most effective form of treatment for cervical headachehas not been established, but a variety of invasive andnoninvasive treatments have been reported. Many authors havereported the effectiveness of manual therapy in reducing oralleviating headache but little attention has been afforded to themuscle system, although muscle impairments are listed as acharacteristic of cervicogenic headache7and specific deficits inwhat can be identified as muscle control of the region have beenidentified8.9. Moreover very few studies have incorporated thecombined use of manual as well as exercise therapy in form ofmultimodal therapy10, 11, 6although there is evidence to suggestthat multimodal therapy is superior for neck disorders 12.It should be noted that, out of these aforementioned studies,study by Beeton K., Jull G.11and Shannon M. Peterson 6is asingle case study with one subject so the results cannot begeneralized to the entire cervicogenic headache population. Thework of Jull et al.10provides the highest level of evidenceregarding the impact of the combined program or multimodaltherapy, but there is lack of more of such kind of evidence tomake definitive recommendations about the effectiveness ofmultimodal therapy to the cervicogenic headache population.So the present study aims to fulfill the gap in literatureregarding the use of multimodal therapy including cervical spinemobilization as well as exercise therapy interventions in patientswith cervicogenic headache.MethodsThe study was a randomized controlled trial. Underconvenience sampling, subjects were recruited from theAkanksha Sharma / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
  14. 14. 10physiotherapy department of Bhagwan Mahavir Hospital (Delhi).The subjects were screened using a screening form relevant tothe inclusion and exclusion criteria. Those who fulfilled thesymptomatic criteria underwent a physical examination ofcervical spine, which included manual palpation of upper cervicaljoints relevant to the inclusion criteria. Qualifying subjects werethen randomly allocated to one of the three groups- group A(Multimodal therapy group), group B (Exercise therapy group)and group C (Control group) by simple random sampling. 9subjects in each group completed the treatment.Inclusion criteria -: 1) Age -20-50 years. 2) Unilateral orunilateral dominant side headache associated with the neck painwhich may project to the forehead, orbital region, temples, vertex,or ears. 3) Headache frequency of at least 1 per week over aperiod of 2 months to 5 years. 4) Pain precipitated or aggravatedby specific neck movements or sustained neck posture. 5)Resistance to or limitation of active and passive (accessory orphysiological) neck movements in the upper cervical spineocciput, and/or palpable tenderness. 7) All subjects fulfilled thefirst four criteria and had at least one component of fifth criterion.8) Sufficient English language skills to complete thequestionnaire.Exclusion criteria-:1) Subjects with bilateral headaches. 2)Subjects with features suggestive of migraine. 3) Subjects withconditions or diseases which are contraindicated for mobilizationtreatment: Paget’s disease, rheumatoid arthritis, ankylosingspondylitis, spondylolistheses, cervical fractures, osteoporosis,osteomyelitis, malignancy, pregnancy, and spinal cordsyndromes. 4) Subjects with radicular signs and symptoms intothe upper limbs or exhibited a positive vertebral artery test duringthe screening evaluation. 5) Subjects with hypermobility ofcervical spine.InterventionsGroupA(Multimodal therapy group ) received cervical spinemobilization , exercise therapy intervention including low loadexercise regimen and active ROM exercises of cervical spineand postural correction intervention , Group B (exercise therapygroup) group received low load exercise regimen , active ROMexercises of cervical spine and postural correction interventionand Group C (Control group) received postural correctionintervention only.(1) Cervical spine mobilization- Treatment consisted ofmobilization techniques to the limited and painful segmentfound on passive accessory and physiological testing. Thesubjects were given cervical spine mobilization (postero-anterior central vertebral pressure) as described byMaitland13.Fig.1: Postero-anterior central vertebral pressurejerky craniocervical flexion movement.Training commenced at the target level that the subjectcould achieve with a correct movement of craniocervical flexion.They were then trained to be able to sustain progressivelyincreasing ranges of craniocervical flexion using feedback fromthe pressure sensor, which was placed behind the neck. Foreach target level, the contraction duration is increased to 10seconds, and the subject was trained to perform 10 repetitions.At that stage, the exercise was progressed to train at the nexttarget level.Fig. 2: Training the craniocervical action with the use offeedback pressure biofeedbackAkanksha Sharma / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1(2)Low load exercise regimen-This program used low-loadendurance exercises to train muscle control of cervicoscapularregion14. The subject were guided by the feedback from thepressure sensor to sequentially reach 5 pressure targets in 2–mm Hg increments from a baseline of 20 mm Hg to the finallevel of 30 mm Hg.Subjects were instructed to “gently nod theirhead as though they were saying ‘yes’.” The physical therapistthen identified the target level that the subject could hold steadilyfor 10 seconds without resorting to retraction, and without a quick,(3)Active range of motion exercise included cervical spineflexion, extension, side flexion and rotation. The subjects wereadvised to perform 10 repetitions of each exercise twice a day.(4) Postural correction intervention included training to sitin an upright neutral posture while gently retracting and adductingtheir scapula. Training of neck flexors and scapular muscleswas also incorporated in postural correction interventionperformed with 10 repetitions twice daily. Exercises which wereincluded are upper cervical flexion in supine as well as sitting,cervical rotation in sitting ,lower trapezius exercise in prone andfacing wall, arm slide and scapula adduction.Treatment was given three times per week for four weeks,for a minimum of eight and maximum of twelve sessions.Outcome measures-:The primary outcome measures were -:(a) Change inheadache frequency was recorded as the number of headachedays in the past week, (b) Change in headache intensity wasrated on a Visual analogue scale (VAS) ,(c) Headache durationwas the average number of hours that headaches lasted in thepast week.The secondary outcome measures were-: (a) Disability (asmeasured by Neck disability indexNDI). (b) Performance indexof deep neck flexors was calculated using craniocervical flexiontest.Statistical analysisReadings of the variables taken at the baseline and at theend of first , second , third and fourth week were analyzed forintragroup differences using repeated measure ANOVA andpaired samples t-test with Bonferroni correction. Intergroupdifferences were analyzed using one way ANOVA.For intergroup differences result was considered significantif p value d” 0.05 and for intragroup differences result wasconsidered significant if p-valued”0.01.ResultsAnalysis of headache frequency between group A and B atbaseline, at the end of 1,2, 3 and 4 week suggested that therewas no significant difference between the group. Analysis ofheadache frequency between group B and C suggested thatthere was no significant difference between the group. Analysisof headache frequency between group C and A at baselinesuggested that there was no significant difference between the
  15. 15. 11group at the baseline and at the end of 1st, 2ndweek but significantdifference was found at the 3rd( p=0.05) and 4thweek (p=0.011)Analysis of VAS scores between group A and B at baseline, at the end of 1st,2nd, 3rdand 4thweek suggested that there wasno significant difference between the group at the baseline butsignificant difference was found at the end of 1st(p=0) 2nd(p=0),3rd(p=0) and 4th(p=0) week.Analysis of VAS scores between groupB and C suggested that there was no significant differencebetween the group at the baseline and at the end of 1stweek at2nd,3rdand 4th week. Analysis of VAS scores between group Cand group A suggested that there was no significant differencebetween the group at the baseline but significant differencewas found at the end of 1st(p=0), 2nd(p=0), 3rd (p=0)and 4th(p=0)week.Analysis of headache duration between group A and B atbaseline , at the end of 1,2, 3 and 4 week suggested that therewas no significant difference between the group at the baseline,but significant difference was found at the end of 1st(p=0.019),2nd( p=0.007) , 3rd(p=0.001) and 4th(p=0.001) week. Analysis ofheadache duration between group B and C suggested that therewas no significant difference between the group at the baselineand at the end of 1st, 2nd,3rdand 4thAnalysis of headache durationbetween group C and group A suggested that there was nosignificant difference between the group at the baseline , at theend of 1st, 2ndweek but significant difference was found at theend of3rd(p=0.001) and 4th(p=0.001) week .Analysis of NDI scores between group A and B at baseline, at the end of 1,2, 3 and 4 week suggested that there was nosignificant difference between the group at the baseline, butsignificant difference was found at the end of 1st(p=0) 2nd(p=0),3rd(p=0) and 4th (p=0)week. Analysis of NDI scoresbetween group B and C suggested that there was no significantdifference between the group at the baseline and at the end of1stweek at 2nd, 3rdand 4thweek.Analysis of NDI scores betweengroup C and group A suggested that there was no significantdifference between the group at the baseline but significantdifference was found at the end of 1st(P=0), 2nd(p=0), 3rd(p=0)and 4th(p=0)week.Analysis of performance index of deep neck flexors betweengroup A and B at baseline, at the end of 1,2, 3 and 4 weeksuggested that there was no significant difference between theAkanksha Sharma / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1group at the baseline but significant difference was found at 1st(p=0), 2nd(p=0) ,3rd(p=0)and 4th (p=0)week. Analysis ofperformance index of deep neck flexors between group B andC suggested that there was no significant difference betweenthe group at the baseline but significant difference was found at1st(p=0.003), 2nd(p=0), 3rd(p=0) and 4th(p=0) week. Analysis ofperformance index of deep neck flexors between group C andGroup A suggested that there was no significant differencebetween the group at the baseline, but significant differencewas found at the end of 1st(p=0) ,2nd(p=0),3rd(p=0)and 4th(p=0)week.Fig. 5: Comparison of mean values of headache duration frombaseline to 4thweek.Fig. 6: Comparison of mean values of NDI scores from baselineto 4thweek.Fig. 7: Comparison of mean values of performance of deepneck flexors from baseline to 4thweekFig. 8: Percentage of improvement in all outcome measuresacross all three groups.Fig. 3: Comparison of mean values of headache frequencyfrom baseline to 4thweek.Fig. 4: Comparison of mean values of headache intensity frombaseline to 4thweek.
  16. 16. 12DiscussionThe results of the study demonstrates that patients withcervicogenic headache receiving multimodal therapyexperienced a significantly greater improvement in headachefrequency, intensity, duration, neck disability and performanceindex of deep neck flexors when compared to exercise therapygroup as well as control group. The results of the present studyare in accordance with the studies by Beeton and Jull G11, Jullet al0and Shannon M. Peterson6.It is important to understand the underlying mechanisms oftreatment effect, although they were not addressed directly inthe study. Mobilization has been suggested to affect painprocessing at the spinal cord level via a phenomenon known asthe gate control theory, which was first described by Melzackand Wall15in 1965. Moreover there is research to suggest thatafferent input induced by manual therapy procedures maystimulate neural inhibitory systems at various levels in the spinalcord and may also activate descending inhibitory pathways forexample lateral periaqueductal grey area of midbrain16.Also worth mentioning is the fact that multimodal therapyaddressed both articular as well as muscular dysfunction whichare characteristics of cervicogenic headache8thereby resultingin significantly more improvement in multimodal therapy groupthan exercise therapy or control group.Results of the present study also demonstrated thatexercise therapy alone also resulted in significant improvementacross all outcomes; however the level of significance is lessthan multimodal therapy group. The significant improvement inthe exercise therapy group can be attributed to low load exerciseregimen which was used to train muscle control of cervicoscpularregion. Also the results are in accordance with the single casestudy by Beeton and Jull11, in which the headache log revealedthat the complete resolution of headache at 6 weeks coincidedwith the time frame when DCF training was initiated.So exercise therapy could be used as an alternative therapyin patients with cervicogenic headache manifesting certain otherconditions which contraindicate the use of cervical spinemobilization.(Example- pregnancy, rheumatoid arthritis,osteoporosis , malignancy etc.).In the present study although control group did notdemonstrate significant improvement across all outcomes atall level of comparison with respect to time but significantimprovement was still seen in headache frequency , VAS score, headache duration , neck disability index scores as well asperformance index of deep neck flexors. This improvement canbe attributed to the postural correction intervention beingimparted to the group and also to the recovery associated withpassage of time.An important issue to address is the role of placebo.Placebo effect refers to an improvement in the patients’ condition,which is not directly attributable to the treatment. It is not yetknown why this occurs but without a control group for comparisonit is hard to know if a placebo effect is taking place. Theimprovement may occur because the patient had a “belief” inthe treatment and /or confidence in the practitioner. Theimprovement may also have occurred as a natural course ofthe condition regardless of the intervention. This is an importantconsideration as only the work of Jull et al.10utilized controlgroup for comparison. The present study too utilized a controlTable 1: Percentage of improvement in all outcome measures across all three groups.Outcome measure Percentage of improvementA (Multimodal therapy) B (Exercise therapy) C (Control)Headache frequency 56.89% 29..66% 15.69%Headache intensity 83.89% 18.24% 8.0 %Headache duration 60% 26.48% 18.76%Neck disability index score 92.92% 20.62% 12.36%Performance index of 401.27% 311.67% 46.67%deep neck flexorsgroup to know if placebo effect is taking place or not.The treatment protocol used in the present study includedcervical mobilization and not the manipulation because there isample literature to suggest that there are substantial risksassociated with cervical manipulation such as stroke or death.The present study describes the multimodal approach forthe management of cervicogenic headache by physical therapist.It is essential that the underlying impairment of decreasedmobility, strength, endurance and postural control to beaddressed while dealing with the subjective complaints of thepatient. A comprehensive treatment approach in the form ofmultimodal therapy addresses all these impairments byemphasizing on restoration of normal joint mobility, strengtheningof postural muscles and postural retraining.Result may be difficult to generalize to other population inwhich the patient differ from the sample. Also because a feweligible subjects refused to participate in the study, so populationeventually composed of volunteers. Although it does not affectthe validity of the finding it may limit generalizibility to otherpopulation and setting.Other limiting factors were inability to keep the subject ortherapist unaware intervention being delivered i.e. lack ofblinding, small sample size as well as absence of follow up.ConclusionThe Conclusion of the study is that the multimodal therapythat is a combination of cervical spine mobilization and exercisetherapy is significantly more effective than exercise therapy aloneand no treatment in patients with cervicogenic headache.The results of the study demonstrates that patients withcervicogenic headache receiving multimodal therapyexperienced a significantly greater improvement in headachefrequency, intensity, duration, neck disability and performanceindex of deep neck flexors when compared to exercise therapygroup as well as control group.References1. Sydney Kim Schoensee, Gail lensen, Garvice Nicholson,Marilyn Gossman, Charles Katholi: The Effect ofMobilization on Cervical Headaches. JOSPT. 21 (4):184-196, 1995.2. David M. Biondi, DO .Cervicogenic Headache: A Reviewof Diagnostic and Treatment Strategies, JAOA, 105 (4) ;16-22, April 2005 .3. World Cervicogenic Headache Society. CervicogenicHeadache Definition.Available at: http: //www. Cervicogenic.com/definit2.html. Accessed: 1998.4. Bogduk N. Headache and the neck. In: Goadsby P,Silberstein S, editors. Headache. Melbourne, Australia:Butterworth-Heinemann; 1997.5. Toby Hall, MSc, Post-Grad Dip Manip Ther, Kathy Briffa,PhD, and Diana Hopper, PhDClinical Evaluation ofCervicogenic Headache:AClinical PerspectiveJ Man ManipTher. 2008; 16(2): 73–80.6. Shannon M. Petersen, Articular and Muscular Impairmentsin Cervicogenic Headache: A Case Report, J. Orthop SportPhys Ther.2003; 33:21–30.Akanksha Sharma / Indian Journal of Physiotherapy and Occupational Therapy. 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  17. 17. 137. International Headache Society Classification Committee.Classification and diagnostic criteria for headachedisorders, cranial neuralgias, and facial pain. Cephalalgia1988; 8:9–96.8. Jull G, Barrett C, Magee R, et al. Further characterizationof muscle dysfunction in cervical headache. Cephalalgia1999; 19:179–85.9. Watson DH, Trott PH. Cervical headache: An investigationof natural head posture and upper cervical flexor muscleperformance. Cephalalgia 1993; 13: 272–84.10. Gwendolen Jull, Patricia Trott, Helen Potter et al ARandomized Controlled Trial of Exercise and ManipulativeTherapy for Cervicogenic Headache, SPINE Volume 27,Number 17, pp 1835–1843,2002.11. Beeton, K., & Jull, G. Effectiveness of manipulativephysiotherapy in the management of cervicogenicheadache: a single case study. Physiotherapy, 80(7), 417-423, 1994.12. Aker PD, Gross AR, Goldsmith CH, et al. Conservativemanagement of mechanical neck pain: Systematic overviewand meta-analysis. BMJ 1996; 313:1291–6.13. Geoffary Douglas Maitland. Maitland vertebral manipulation7thedition 2005 p-229-301.14. Jull G. Management of cervical headache .Manual therapy1997;2(4);182-90.15. Melzac R, Wall PD. Pain mechanisms: a new theory.Science. 1965; 150:971-979.16. M. Sterling, G. Jull et al Cervical mobilization: concurrenteffects on pain sympathetic nervous system activity andmotor activity Manual Therapy, volume-6, May 2001, page72-81.Akanksha Sharma / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
  18. 18. 14Combined effectiveness of Maitland’s mobilization and patellartaping in patellofemoral osteoarthritis: A randomised clinical trialAlok Kumar*, Ganesh B. R.***Physiotherapist,**Assistant Professor, KLE’U Institute of Physiotherapy Belgaum, KarnatakaAbstractPurpose of the studyTo find out the effectiveness of medial and lateral tapingwith Maitland’s mobilization in patellofemoral joint osteoarthritis.Materials & methods60 subjects having clinical diagnosis of osteoarthritis ofpatellofemoral joint were randomly allocated to two study groups.Group Areceived Short wave diathermy (20mins/day), Maitlandmobilization, Isometric exercises, Medial taping using adhesivetape and group B received lateral taping and other treatmentsame as group A for 6 times / week for 2 weeks. The outcomewas assessed in terms of VAS, and Western Ontario andMcMaster University Osteoarthritis Index on first and last day ofintervention.ResultsThe demographic data was well matched in both the groups.Pain intensity in terms of VAS and Western Ontario andMcMaster University Osteoarthritis Index decreased significantlyin both the groups after the treatment. Comparing the two groupsbetter effect was seen in group B (p=0.0001)for VAS and(p=0.0001) for WOMAC.ConclusionThe present study demonstrates evidence to support theuse of physical therapy regimen in the form of medial and lateraltaping along with conservative physical therapy treatment inrelieving pain, well being in subjects with subacute and chronicpatello femoral osteoarthritis. The study also demonstrated thatlateral Taping Technique were more effective in decreasing painand disability.KeywordsPatellofemoral osteoarthritis, Taping, Maitland Mobilisation,SWD, Exercises.IntroductionThe knee joint is one of the most common sites ofinvolvement because of its weight bearing requirement, highmobility and lack of intrinsic stability. Patellofemoral jointosteoarthritis is one of the most common musculoskeletaldisorder1.It is reported to affect 15-30% active adult population 21-25% of the adolescents and greater then 25% among the athleticgroup. Incidence reported to be higher in females. It isconsistently reported with the activities such as ascending anddescending stairs, squatting1.Patellofemoral pain in elderlypatient is usually due to degenerative arthritis of the knee joint.Symptoms presented in the patellofemoral arthritis are painaround and anterior to patella, crepitus, giving away of the kneeand episode of patellofemoral instability along with stiffness andswelling2. Extensor mechanism provides stability topatellofemoral joint during physical activity. Tracking is thechange in the position of patella relative to femur during kneeflexion and extension3. Patellofemoral pain syndrome is relatedto abnormalities of extension mechanism. Many authors haveproposed the primary cause of patellofemoral pain syndrome islateral tracking of patella3. Clinically Patellofemoral osteoarthritisdemonstrated squatting, stair ascending and descending, cyclingand sitting with knee flexed or prolonged period of time4.Degenerative changes are usually more prominent in the medialcompartment of the knee, leading to varus (bow leg) deformities5.Physiotherapy treatment options have been recommendedto relieve pain which includes short wave diathermy, Maitland’smobilisation, isometric exercise and taping etc. Among whichshort wave diathermy plays an important role in pain relief,decrease tissue viscosity and with this muscular and tendinouscontractures. Additionally, the deep heating effect of continuousshort wave diathermy induces an anti-inflammatory response,stimulate connective tissue repair, reduce joint stiffness, musclespasm and pain6.Maitland’s mobilization is another physiotherapy technique,which involves to reduce pain and stiffness by using variousgrades of mobilization7.Exercise is another approach in the treatment ofPatellofemoral arthritis, which is targeted to improve thequadriceps muscle strength. Isometric contraction of quadricepsmuscle helps to increase the strength and prevents themaltracking of patella8.Many studies have shown patellar taping is helpful todecrease pain and improve patellar tracking. Knee taping is oneof the strategy recommended by American College ofRheumatology, based on the theory of patellar maltracking.McConnell has divised a system of treatment for patellofemoralarthritis by taping the patella in medial and lateral direction9.A study was done on patellofemoral pain syndrome usingthree different methods of taping techniques (Medial, Lateral &Neutral) and found that all three methods of taping produced asignificantly greater degree a pain relief. Further they concludedthat lateral taping is effective in immediate reduction of pain10.Hence the present study is being undertaken with theintention to compare the combined effectiveness of Maitland’smobilisation and patellar taping in patellofemoral osteoarthritis.HypothesesNull Hypothesis {Ho}: There will be no beneficial effect to thesubjects treated with Maitland’s mobilization and medial or lateralpatella taping.Alternative Hypothesis {Ha}: There will be beneficial effect tothe subjects treated with Maitland’s mobilization and medial orlateral taping.Objectives of the Study1. To assess the effectiveness of medial taping technique withMaitland’s mobilization in patellofemoral joint osteoarthritis2. To assess the effectiveness of lateral taping technique withMaitland’s mobilization in patellofemoral joint osteoarthritis3. To compare the effectiveness of medial and lateral tapingwith Maitland’s mobilization in patellofemoral jointosteoarthritisAlok Kumar / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
  19. 19. 15Materials and methodsSource of Data: KLES Dr. Prabhakar Kore hospital and MRCand BM Kankanwadi Ayurveda Hospital and MRC Belgaum.Method of collection of dataStudy Design: Randomised Clinical Trial.Sample Size: 60 Participants.Duration of Data Collection: 9 MonthsParticipants: Both men and women with pain in anteroior kneejoint and radiologically diagnosed as patellofemoral arthritis &who are referred to the physiotherapy OPD, KLES Dr. PrabhakarKore hospital and MRC and BM Kankanwadi Ayurveda HospitalBelgaum.Sampling Methods: Simple random sampling method will beused for this study. 60 participants will be randomly allocatedinto two groups as follows.Group A: Short wave diathermy + Maitland mobilization +Isometric exercises + Medial taping.30 participants.Group B: Short wave diathermy + Maitland mobilization +Isometric exercises + Lateral taping: 30 participants.Materials usedRecord or data collection sheet,Consent form, WoodenPlinth, Towel, WOMAC, Tape.Equipment usedShort wave diathermy,[Electrowave 400 Technomed] Madein IndiaInclusion criteria1. Participants with radiological diagnosed as patellofemoralosteoarthritis.2. Both Men and women > 40 years ofage.3. Average knee pain e” 3 cm on visual analogue scale.4. Those who are willing to participate in the study.Exclusion criteria1. Concomitant pai n from other knee structures, hip or lumbarspine.2. Traumatic injury to the knee joint with in 6 months of study.3. Severe medical condition precluding safe testing or a pastallergic tape reaction.4. Metallic implants in the lower limbs.5. Impaired thermal sensation.ProcedureAll participants with patellofemoral arthritis who report tothe physiotherapy department will be screened. After findingtheir suitability as per the inclusion and exclusion criteria theywill be requested to participate in the study. A written consentwill be obtained from the participants. Their demographic data,weight, height and initial assessment of VAS score and WOMACwill be recorded. After this 60 participants were randomlyallocated to 2 groups of 30 each.Group A: short wave diathermy, Maitland’s mobilisation,isometric exercises and medial patellar taping.1. Subject will be in sitting/supine position and short wavediathermy pads will be applied in contraplanar method for20 minutes per day.192. Maitland Mobilization: Oscillatory movements are given tothe patella in different directions as required. Patient insupine position and therapist stands by the right side.Medial glide: Pads of the thumb are placed on the lateralborder and push the patella medially.(Photo No.1)Lateral glide: Pads of the thumb are placed on the medial borderand push the patella laterally.(Photo No. 2)Superior glide: Place the heel of the hand against inferiormargin of the patella and directs the forearm superiorly.(PhotoNo. 3)Inferior glide: Place the heel of the hand against superiormargin of the patella and directs the forearm inferiorly.(PhotoNo.4)[Photograph No.1][Photograph No.2][Photograph No.3][Photograph No.4]All the four Maitland’s patellar glides will be given to boththe groups (A & B).Alok Kumar / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1
  20. 20. 163. Isometric exercises: Static quadriceps exercises will begiven in long sitting/supine position with a towel placedunderneath the popliteal fossa and will instruct the patientto press the rolled towel. Contraction will be maintained for6 seconds and repeated for 10 times with 10 seconds restbetween each repetition.154. Medial taping- The patella is displaced medially usingmanual pressure and then maintained in own position bytape across the middle of the patella using light to moderatepressure.Group B: short wave diathermy, Maitland’s mobilisation,isometric exercise and lateral patellar taping.1. Lateral taping- Same technique is used but the patella isglided in the lateral direction. Tape will be retained for 24hrs.2. Rest of the procedure are same as Group A.Review of litratureAn ultrasonographic study was done to see the effects ofrepetitive shortwave diathermy in patients with knee osteoarthritisand indicates that shortwavediathermy in patients with knee osteoarthritis cansignificantly reduce both synovial thickness and knee pain11.The current findings and the statistical difference confirmsthat a combination of Maitland mobilization with isometric kneeexercise is more effective than isometric knee exercise indecreasing pain, dysfunction, stiffness and improving thefunctional capacity in patients with Patellofemoral arthritis7.Comparative study of different patella taping techniques,like medial, neutral and lateral tape showed that medial tape ismore effective in reducing pain in patient with Patellofemoralpain syndrome irrespective of how taping was applied12.A study was done on patellofemoral osteoarthritis usingthree different methods of taping techniques ( Medial, Lateral &Neutral) and found that all three taping technique produced asignificantly greater degree a pain relief. Further they concludedthat lateral taping is effective in immediate reduction of pain13.A study was done to determine the efficacy of physicaltherapy and exercises for osteoarthritis of the knee and authorsconcluded that patients with osteoarthritis who are treated witha regimen that combines manual physical therapy with isometricexercise have improved function and less reported pain andstiffness than patients who are not treated with a physical therapyprogram. This type of treatment may decrease the need for kneesurgery14.Data analysisThe independent variables were SWD, Maitland’smobilization, isometric exercises, medial, lateral taping anddependent variables were Pain (VAS) and WOMAC. Analysiswas performed by statistical means, standard deviation andPaired and Unpaired t test is used for comparison within thegroups and between the groups.ResultsIn the present study, within group analysis showed that painrelief and WOMAC was statistically significant in the two thegroups (p<0.0001). where as considering in between groupanalysis reviled that Group B (p= 0.0001) was highly significantas compared to Group A.DiscussionThe present clinical trial was conducted to compare theeffectiveness of medial and lateral patellar taping combinedwith Maitland’s Mobilization with a common treatment ofshortwave diathermy and exercises to the two groups.The results from the statistical analysis of the present studysupported alternative hypothesis which stated that there will bebeneficial effect to the participants treated with medial and lateralpatellar taping with Maitland’s mobilization. The mean values ofdata from present study indicates that the group B treated withcombination of lateral patella taping with Maitland’s mobilizationshowed better pain relief on visual analogue scale and thephysical function capacity.Mei Hwa Jan et al attempted a study to quantify thethickness of synovial sac and pain index before and afterapplication of short wave diathermy for patients with kneeosteoarthritis. The result of study showed that the application ofshort wave diathermy in patients with knee osteoarthritis cansignificantly reduce both synovial thickness and kneepain6.Hence in present study it can be postulated that painreduction could be because of short wave diathermy application.A study showed that patellar taping using a medial glide,neutral glide, and lateral glide technique produced a significantaverage reduction in pain in patients with patellofemoral painsyndrome. Both neutral glide and lateral glide producedsignificantly greater degrees of pain relief than the medial glidetaping technique13.A clinical analysis study of alignment, pain parameters,common symptoms and functional activity level showed thatthere were no radiographic signs of malalignment of the patella.This strongly supports the previous studies that the success ofpatellar taping is not based upon realignment of the patella13.The present study demonstrated that the application ofMaitland’s Mobilization had shown significant change in painand physical functional outcome. However, these findings areconsistent with studies conducted in other joints of the bodythat have shown similar effects with the Maitland’s Mobilisationtechniques. Wright in 1995 has postulated that the mechanismsresponsible for manual therapy treatment results in decrease inpain on VAS. The results also showed changes in joint, muscle,pain and motor control systems15.On the contrary, Maitland’s mobilisation technique wasfound effective in decrease in pain and stiffness. Manipulativetherapy lays stress on treatments to regain both angular andlinear movements. Different grades of mobilization, accordingto Maitland’s concept, will produce selective activation of differentmechanoreceptors. Clinically, resistance due to pain andstiffness melts under mobilization or manipulation16.WOMAC a self reported measure designed to determinepatients response to three different functional criteria namelythe pain, stiffness and physical function. This could be attributedto frequent complaints of patellofemoral joint stiffness in individualwith patellofemoral pain syndrome as individuals with chronicpatellofemoral pain syndrome often misinterpret chronic painas stiffness17.Patellofemoral osteoarthritis presents a serious health careproblem and produces a huge burden on society. Simple, safe,physical treatment procedures such as lateral taping combinedwith other simple non invasive interventions such as Maitland’sjoint mobilization could be of great value. This provides a lowcost, easy means of treatment in subjects with Patellofemoralosteoarthritis.ConclusionIn conclusion, the present randomized clinical trial providedevidence to support the use of physical therapy regimen in theform of Lateral Patellar Taping and Maitland’s Mobilisation inrelieving pain, stiffness and, functional well being in subjectswith patellofemoral osteoarthritis. In addition, results supportedthat combination therapy is of great value which can be usefulin improving quality of life as patellofemoral osteoarthritis is aheterogeneous condition.ReferencesAlok Kumar / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1
  21. 21. 171. Naslund J , Nusland UB, OdenbringS, Lundeberg T.Comparision of Symptoms and Clinical finding in subgroupsof individuals with patellofemoral Pain. PhysiotherapyTheory and Practice 2006;22(3);105-182. Cibulka MT, Threlkeld J. Walkens patello femoral pain andasymmetrical Hip Rotations 2005;85(11):1201-73. S. Werner, E. Knutsson, E. Eriksson. Effect of patella onconcentric and eccentric torque and EMG of knee extensorand flexor muscles in patients with patellofemoral painsyndrome. Knee surgery, sports traumatol, arthrosocopy;1993; 1:169-177.4. Aroll B, Ellis Pegler, Edwards A, Sutcliffe G. Patellofemoralpain syndrome. American Journal of the Sport Medicine1997; 25(2) : 207-11.5. Harrison’s principles of Internal medicine. McGraw HillCompanies. 2005; 16thed vol.II: 2036-2045.6. By Mei - Hwa Jan, Huei-Ming Chai, Chung-Li Wang, Yeong-Fwu Lin and Li-Ying Tsai. Effects of repetitive shortwavediathermy for reducing synovitis in patients with kneeosteoarthritis: an ultrasonographic study. Physical therapyjournal, 2006; vol 86(2): 236-244.7. G.D.Maitland. Peripheral manipulation,3rdedition; 2003:250-55.Butter worth-Heinemann.8. Key M crossley,Bill vicenzino. Targeted physiotherapy forpatellofemoral joint arthritis. BMC MusculoskeletalDisorders 2008, 9:122doi:10.1186/1471-2474-9-122.9. G Kelly Fitzgerald and Carol Oatis. Role of Physical Therapyin management of knee osteoarthritis. Current Opinion inRheumatology, 2004; 16:143-147.10. Tony Wilson, Nicholas carter, Gareth Thomas.Amulticenter,single- masked study of medial, neutral and lateral patellartaping in individuals with patellofemoral pain syndrome.Journal of orthopaedics sports physical therapy; 2003;volume 33(8):437-443.11. By Mei - Hwa Jan, Huei-Ming Chai, Chung-Li Wang, Yeong-Fwu Lin and Li-Ying Tsai. Effects of repetitive shortwavediathermy for reducing synovitis in patients with kneeosteoarthritis: an ultrasonographic study. Physical therapyjournal, 2006; vol 86(2): 236-244.12. Ng, G.Y. Cheng, J. M. The effects of patellar taping on painand neuromuscular performance with Patellofemoral painsyndrome. Clinical rehabilitation, 2002 ;16:821-27.13. Tony Wilson, Nicholas carter, Gareth Thomas.Amulticenter,single- masked study of medial, neutral and lateral patellartaping in individuals with patellofemoral pain syndrome.Journal of orthopaedics sports physical therapy; 2003;volume 33(8):437-443.14. Deyle G D et al. Effectiveness of manual physical therapyand exercise in osteoarthritis of the knee. A randomizedcontrol trial. Ann Intern Med, American Academy of FamilyPhysician 2000; 132: 173-81.15. Wright A. Hypoalgesia post manipulative therapy: A reviewof the potential neurophysiological mechanism. ManualTherapy 1995;1:6-11.16. Wyke, B. D: Articular Neurology and Manipulative therapy,R. M. Lincoln Institute of Health Sciences 1980, 67-72.17. Karrie L, Hamstra WC, Swanik B, Ennis TY, Swanik KA.Joint Stiffness and pain in individuals with patellofemoralpain syndrome; 2005; 35: 495- 501.Akanksha Sharma / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1

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