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  • 1. Volume 7 Number 1 January-March 2013Published, Printed and Owned : Dr. R.K. SharmaDesigned and Printed : Devtech Publishers & Printers Pvt. Ltd., FaridabadPublished at :Editor : Dr. R.K. Sharma, Mobile:4 Floor, Statesman House Building,Barakhamba Road,Connaught Place,New Delhi-110 001th91-9971888542, Fax No: +91 11 3044 6500
  • 2. Devtech Publishers & Printers Pvt. Ltd., FaridabadSub EditorKavita Behal SharmaMPT (Ortho)4 Floor, Statesman House Building, Barakhamba Road,Connaught Place, New Delhi-110 001th4 Floor, Statesman House Building, Barakhamba Road,Connaught Place, New Delhi-110 001thNishat Quddus, New Delhi
  • 3. IIndian Journal of Physiotherapy andOccupational Therapywww.ijpot.comVolume 07 Number 01 January - March 20131. 3 Weeks Continuous Passive Motion Vs Joint Mobilization and their Combination in ..................................................... 01Knee Stiffnes - A Comperative StudyAnil kumar, Santosh Metgud2. Comparison of Blood Pressure and Heart Rate between Young Males and Females ......................................................... 06During Dominant and Non-Dominant Single-Leg StanceAnkita Samuel, Manish Rajput, Chhavi Gupta, Sumit Kalra3. Effectiveness of Transcutaneous Electrical Nerve Stimulator (TENS) in Reducing ........................................................ 11Neuropathic Pain in Patients with Diabetic NeuropathyApeksha O. Yadav, G. J. Ramteke4. Evaluation of effects of Nebulization and Breathing Control in Asthmatic Patients .......................................................... 14Kesharia, Amita Mehta5. Effect of Neuromuscular Electrical Stimulation Combined with Cryotherapy on ............................................................. 21Spasticity and Hand Function in Patients with Spastic Cerebral PalsyChandan Kumar, Vinti6. Phonophoresis in Continuous Mode Ultrasound has Significant effect in the Reliving .................................................... 26Pain in Upper Trapezius Tender PointChhavi Gupta, Manish Rajput, Ankita Samuel, Sumit Kalra7. Prediction of Relationship of Visual Attention Deficits to Balance and Functional ............................................................ 31Outcome in Persons with Subacute StrokeChintan Shah, Hasmukh Patel, Komal Soni, Dhaval Desai, Harshit Soni8. The effects of Therapeutic Application of Heat or Cold Followed by .................................................................................. 37Static Stretch on Hamstring Flexibility Post Burn ContractureEmad T. Ahmed, Safa S. Abdelkarim9. Pulsed Electromagnetic Therapy Improves Functional Recovery in Children with Erbs Palsy ...................................... 42Reda Sarhan, Enas Elsayed, Eman Samir Fayez10. Effectiveness of PNF Stretching and Self Stretching in Patients with Adhesive .................................................................. 47Capsulitis - A Comparative StudyHarshit Mehta, Paras Joshi, Hardik Trambadia11. Effect of Modified Hold-Relax and Active Warm-Up on Hamstring Flexibility ................................................................. 52Swapnil U Ramteke, Hashim Ahmed, Virenderpal Singh, Piyush Singh12. A Comparative Study of effectiveness between Superficial Heat and Deep Heat along with .......................................... 58Static Stretching to Improve the Plantar Flexors Flexibility in Females Wearing High Heel Foot WearsHasmukh Patel, Dhaval Desai, Harshit Soni, Komal Soni, Chintan ShahContentsContent Final.pmd 2/7/2013, 8:06 PM1
  • 4. II13. Influence of different Types of Hand Splints on Flexor Spasticity in Stroke Patients......................................................... 65Eman Samir Fayez, Hayam Mahmoud Sayed14. Interferential Current Therapy versus Narrow Band Ultraviolet B Radiation in the Treatment ...................................... 70of Post Herpetic NeuralgiaIntsar Salim. Waked15. Effect of the Duration of Play on Pain Threshold and Pain Tolerance in Soccer Players ................................................... 76Shahid Raza, C.S. Ram, Jamal Ali Moiz16. Neuromuscular Electrical Stimulation Versus Intermittent Pneumatic Compression on .................................................. 81Hand Edema in Stroke PatientsEman S.M.Fayez, Hala Ezz Eldeen17. A Combination Approach using Manual Therapy and Exercise in the Treatment.............................................................. 87of Shoulder Impingement SyndromeAnnamma Mathew, Abedi Afsaneh18. Musculoskeletal Pain among Computer Users .......................................................................................................................... 90Shweta Keswani, Lavina Loungni, Tiana Alexander, Hebah Hassan, Shatha Al Sharbatti, Rizwana B Shaikh, Elsheba Mathew19. A Report of Body weight Supported Overground Training in Acute Traumatic Central Cord Syndrome .................... 96Asir John Samuel, John Solomon, Senthilkumaran, Nicole Dsouza20. Effects of Ischemic Compression on the Trigger Points in the Upper Trapezius Muscle ................................................... 99Bhavesh H. Jagad, Karishma B. Jagad21. Prevalence of Upper Limb Dysfunction in Subjects with Chronic non Specific ................................................................ 105Neck Pain in Bangalore City, KarnatakaKinchuk DB, Soumya G, Payal D22. Randomized Controlled trial of Group Versus Individual Physiotherapy Sessions for .................................................. 110Genuine Stress Incontinence in WomenKomal Soni, Harshit Soni, Dhaval Desai, Chintan Shah, Hasmukh Patel23. A Study of Electromyographic Changes in Muscle Post Exercise Induced Muscle Soreness ........................................ 116Manish Rajput, Ankita Samuel, Chhavi Gupta, Sumit Kalra24. Effect of Pelvic Floor Muscle Strengthening Exercises in Chronic Low Back Pain ........................................................... 121Manisha Rathi25. Comparing Hold Relax - Proprioceptive Neuromuscular Facilitation and Static Stretching.......................................... 126Techniques in Management of Hamstring TightnessAli Ghanbari, Maryam Ebrahimian, Marzieh Mohamadi, Alireza Najjar-Hasanpour26. Reliability and Feasibility of Community Balance and Mobility Scale (CB&MS) in Elderly Population ..................... 131NagaRaju, Arun Maiya, Manikandan27. Core Stability Training with Conventional Balance Training Improves Dynamic Balance in......................................... 136Progressive Degenerative Cerebellar AtaxiaKhan Neha Tabbassum, Nayeem-U-Zia, Harpreet Singh Sachdev, Suman K28. Restoration of Normal Length of Upper Trapezius and Levator Scapulae in .................................................................... 141Subjects with Adhesive CapsulitisPandit Niranjan Hemant, Mhatre Bhavana Suhas, Mehta Amita Anil29. Comparison of Vmo/Vl Ratio in Patello-Femoral Pain Syndrome (Pfps) Patients: A Surface Emg Study .................. 148Nishant H NarContent Final.pmd 2/7/2013, 8:06 PM2
  • 5. III30. A Study to Check Added effects of Electrical Stimulation with Task Oriented Training in ............................................ 154Hand Rehabilitation among Stroke PatientsParas Joshi31. Relationship of Cognition, Mobility and Functional Performance to Fall .......................................................................... 160Incidence in Recovering Stroke PatientsParas Joshi, Hardik Trambadi32. Reliability of Modified Modified Ashworth Scale in Spastic Cerebral Palsy ..................................................................... 165Divya Gupta, Pooja Sharma33. Evaluation of Pulmonary Function Tests in Patients Undergoing Laparotomy ................................................................ 170Nahar P S, Shah S H, Vaidya S M, Kowale A N34. Evaluation of Standardized Backpack weight and its Effect on Shoulder & Neck Posture............................................. 176Pardeep Pahwa35. Effect of Abductor Muscle Strengthening in Osteoarthritis Patients: A Randomized Control Trial .............................. 185Nishant H Nar36. Effects of Scapular Stabilization Exercises and Taping in Improving Shoulder Pain & ................................................. 191Disability Index in Patients with Subacromial Impingement Syndrome Due to Scapular DyskinesisBhavesh Patel, Praful Bamrotia, Vishal Kharod, Jagruti Trambadia37. Effects of Osteopathic Manipulative Treatment in Patients with ......................................................................................... 196Chronic Obstructive Pulmonary DiseasePraniti P. Bhilpawar, Rachna Arora38. Comparison of Stretch Glides on External Rotation Range of Motion in ........................................................................... 202Patients with Primary Adhesive CapsulitisParas Joshi, Bhavesh Jagad39. A Study of Electromyographic Activity of Masseter Muscle After Gum Chewing in Young Adults ............................ 208Preeti Baghel, Nidhi Kalra, Sumit Kalra40. A Study to Evaluate the effect of Fatigue on Knee Joint Proprioception............................................................................. 213and Balance in Healthy IndividualsPurvi K. Changela, K. Selvamani, Ramaprabhu41. Effect of Core Stabilization and Balance-Training Program on Dynamic Balance ............................................................ 218Rabindra Basnet, Nalina Gupta42. A Retrospective Analysis of Disability-Related Data on Disabled ....................................................................................... 223Children and their Families in TurkeyRasmi Muammer43. Effect of Postural Brace for Correcting Forward Shoulder Posture and Kyphosis in ....................................................... 228Patients with Chronic Obstructive Pulmonary Disease: A Pilot StudyRavi Savadatti, Gajanan. S. Gaude, Prashant Mukkannava44. Effect of Neck Extensor Muscles Fatigue on Postural Control Using Balance Master ..................................................... 234Reshma S.Gurav, Rajashree V.Naik45. Aerobic Capacity in Regular Physical Exercise Group and Indian Classical Dancers: .................................................... 238A Comparative StudyRupali B. Gaikwad, Vijay Kumar R. waghmare, D.N. ShenviContent Final.pmd 2/7/2013, 8:06 PM3
  • 6. IV46. Comparative Study to Determine the Hand Grip Strength in Type-II Diabetes ................................................................ 243Versus Non-Diabetic Individuals - A Cross Sectional StudyJayaraj C. Sindhur, Parmar Sanjay47. Study of Correlation between Hypermobility and Body Mass Index in Children aged 6-12 Years ............................... 247Parmar Sanjay, Praveen. S. Bagalkoti, Rajlaxmi Kubasadgoudar48. Comparison of Reaction Time in Older Versus Middle-aged ................................................................................................ 250Type II Diabetic Patients - An observational StudyShruti Bhat, Sanjiv Kumar49. Effect of Rehearsal Digit-Span Working Memory Intervention on Sensory Processing ................................................... 254Disorder in children with Autism: A Pilot StudySmily Jesu Priya V, Jayachandran V, Noratiqah S, Vikram M, Mohamad Ghazali M, Ganapathy Sankar U50. Evaluation of Inter-Rater Reliability to Measure Hand and Arm Function in ................................................................... 259Reaching Performance Scale for Stroke PatientsSureshKumar T., Leo Rathinaraj A.S., Jeganathan A., Vignesh waran Vellaichamy51. Effect of Incentive Spirometry on Cardiac Autonomic Functions in Normal Healthy Subjects ..................................... 264Trupti Ajudia, Pravin Aaron, Subin Solomen52. Concurrent Validity of Clinical Chronic Obstructive Pulmonary Disease (COPD) ......................................................... 270Questionnaire (CCQ) in South Indian PopulationC.M. Herbert, V.K. Nambiar, M. Rao, S. Ravindra53. To Study the effect of Mental Practice on one Leg Standing Balance in Elderly Population........................................... 274Vidya V Acharya, Saraswati Iyer54. Effect of Midprone Decubitus on Pulmonary Function Test Values in ................................................................................ 280Young Adults with Undesirable Body Mass Indices (BMI)Junaid Ahmed Fazili, Ajith S, A.M.Mirajkar, Mohamed Faisal C K, Ivor Peter DSa55. Comparison of Quality of Life in off-pump Versus on-pump Coronary ............................................................................ 285Artery bypass Graft (CABG) Patients before and after Phase II Cardiac RehabilitationNikhil Vishwanath, Ajith S, Ivor Peter DSa, M.Gopalakrishnan, Mohamed Faisal C KContent Final.pmd 2/7/2013, 8:06 PM4
  • 7. 3 Weeks Continuous Passive Motion Vs JointMobilization and their Combination in KneeStiffnes - A Comperative StudyAnil kumar1, Santosh Metgud21Post Graduate, 2Asst Prof, KLE University Institute of PhysiotherapyABSTRACTStudy design: Randomized clinical trial.Objectives : To determine the effect of continuous passive motion in treatment of knee joint stiffness. Todetermine the effect of joint mobilization in the treatment of knee joint stiffness. To determine thecombined effectiveness of continuous passive motion and joint mobilization in the treatment of kneejoint stiffness.Methods : The present randomized clinical trial was conducted among 45 participants which includedboth male and female symptomatic individuals between the age of 18 to 50 years with knee jointstiffness. Pre-interventional and post-interventional outcome measurements were taken in the form ofRange Of Motion, KOSADLS.Results : In the present study, intra - group analysis showed that improved range of motion andfunctional outcome was statistically significant in all the three groups (p=0.0001) whereas consideringthe reliability and validity of Knee Outcome Survey Of Activity Daily Living Scale, the between groupanalysis revealed that Group C was significant as compared to Group A and Group B in knee range ofmotion and in functional outcome Group B was significant compared to Group A and C .Conclusion : In conclusion, the present randomized clinical trial provided evidence to support thephysical therapy regimen in the form of continuous passive motion with joint mobilization in improvingrange of motion, improving functional performance in subjects with post operative knee joint stiffness.Keywords: Knee Joint Stiffness; Joint Mobilization; Continuous Passive Motion; ExerciseINTRODUCTIONThekneeisacomplex,compound,condyloidvarietyof a synovial joint. It actually comprises three functionalcompartments: the femuro-patellar articulation consistsof the patella, and the patellar groove on thefront of the femur through which it slides; and themedial and lateral femuro-tibial articulations linkingthe femur, or thigh bone, with the tibia, the main bone ofthe lower leg.1Knee injuries from trauma or overusecan cause pain, swelling and sometimes disability, shortor long-term depending on how bad the injury is.Injuries can occur to the bones, the ligaments, thecartilage or the tendons.2Incidence of fractures was 100 per 10,000 populationfor males and 81 per 10,000 population for females.Below the age of 55 years of all fractures showed ahigher incidence amongst males but amongst the over55, there was consistent fall in male:female incidenceratio with some sites showing a striking femalepreponderance.3Continuous passive motion (CPM) refers to passivemotion performed by a mechanical device that moves ajoint slowly and continuously through a controlledrange of motion. CPM is effective in lessening thenegative effects of joint immobilization and alsoimproves the recovery rate and ROM after a variety ofsurgical procedures. It also prevents development ofadhesions and contractures and thus prevents jointStiffness. It also provides a stimulating effect on thehealing of tendons and ligaments and enhances healingof incisions over the moving joint.4CPM is used1. Anil Kumar 2nd april-1-5.pmd 2/7/2013, 8:08 PM1
  • 8. 2 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1following various types of reconstructive joint surgerysuch as knee replacement and ACL reconstruction.5Joint mobilization stimulates biological activity bymoving synovial fluid, which brings nutrients to theavascular articular cartilage of the joint surfaces andintra-articular fibrocartilage of the menisci6. Atrophyof the articular cartilage begins soon afterimmobilization is imposed on joints7,8,9.Maitland techniques involve the application ofpassive and oscillatory movements to spinal, vertebraland peripheral joints to treat pain and stiffness of amechanical nature. The techniques aim to restoremotions of spin, glide and roll between joint surfacesand are graded according to their amplitude10.METHODStudy design is randomized clinical trial. Data wascollected from KLES Dr. Prabhakar Kore Hospital ,Belgaum.Studyperiodofoneyear(Feb2011toJan2012).Sample size – Forty five (45) participantsInclusion Criteria• Both male and female participants with knee jointstiffness of duration more than 2 months.• Post fracture stiffness of knee joint• Ligament injuries of grade 1 and 2• Age group between 18-50 years.Exclusion Criteria• Total Knee Replacement.• Osteoarthritis of knee joint.• Knee joint effusion.• Bone tumour’s around knee joint• Osteoporotic patients• Knee joint malignancy• Any local or systemic infection.PROCEDUREOnce the patient was included in the study, thedemographicdatawascollectedrangeofmotion(ROM)was measured and scores on the scale was noted onday 01 and on day 21 in the study groups. Once allmeasurements obtained subjects was randomlyallocated into 3 Groups viz. group A, Group B, andGroup C. Final scores on the scale and range of motionwas measured after 3 weeks of treatment and was thensubjected to statistical analysisParticipants of all the 3 Groups i.e.Group A - Hot moist pack with Continuous passivemotion and exercise for affected knee joint stiffness.Group B - Hot moist pack with Joint Mobilizationand Exercise for affected knee joint stiffness.Group C – Hot Moist pack, Continuous PassiveMotion,JointMobilizationandExerciseforaffectedkneejoint stiffness.Moist heat therapy was given as conventionaltreatment for a period of 15 minutes, 2 sessions/day for3 weeks prior to the CPM and Joint mobilization.The patient was asked to rest supine on thetreatment table with affected leg on CPM machine. Thespeed was kept constant, so that a full cycle lasts for 45to 60 seconds. The treatment was given for 40 minutesdaily in split sessions i.e 20 minutes in the morningand 20 minutes in the afternoon, supervised byphysiotherapist. The range was adjusted individuallyand increased gradually by 10 degrees daily withinparticipant’s limits of pain. CPM was given for 3weeksduring which various parameters was monitored.Anterior-posterior glideThe physiotherapist performed an anteriortibiofemoral glide on participant’s operative limb, thephysiotherapist grasps the dorsal aspect of theparticipant’s proximal lower leg with one hand andholds it firmly against his body while placing his otherhand over the dorsal lateral aspect of the tibia just distalto the knee joint. He passively moves the knee joint tothe maximum available knee-extension ROM. He thenglides the participant’s tibia in an anterior directionparallel to the surface of the femoral condoyle to thepoint where the resistance provided by the knee limitedfurther movements. The mobilization was given for 10repetitions for 5 times. Total duration lasted for 20 mins.Posterior- Anterior glideThe physiotherapist performed an posteriortibiofemoral glide on participant’s operative limb, the1. Anil Kumar 2nd april-1-5.pmd 2/7/2013, 8:08 PM2
  • 9. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 3physiotherapist grasps the dorsal aspect of theparticipant’s proximal lower leg with one hand andholds it firmly against his body while placing his otherhand over the dorsal lateral aspect of the tibia just distalto the knee joint. He passively moves the knee joint tothe maximum available knee-flexion ROM. He thenglides the participant’s tibia in an posterior directionparallel to the surface of the femoral condoyle to thepoint where the resistance provided by the knee limitedfurther movements. The mobilization was given for 10repetitions for 5 times. Total duration lasted for 20 mins.Exercise like open kinetic chain exercise and closedkinetic exercise was given to the patients. Open kineticchain exercise is typically non weight bearing exercisessuch as knee extension performed when sitting on a legextension machine. Closed chain exercise includes asquat or step-up.the exercises were done twice a dayand it comprise of 3 sets of 15 repetitions with equalhold and contract time.OUTCOMESRange of motion was measured with a UniversalGoniometer and Physical function outcome measuredby Knee outcome survey activities of daily living scale,awellvalidated,self-report,self-completequestionnairewas used.Statistical AnalysisStatistical analysis for the present study was donemanually as well as using the statistics software SPSS13 version so as to verify the results obtained. For thispurpose the data was entered into an excel spreadsheet, tabulated and subjected to statistical analysis.Various statistical measures such as mean, standarddeviation (SD) and test of significance such as pairedsample test for within group analysis and betweengroup analysis was done with Multiple Scheffe Test,ANOVA was used for age and demographicdistribution.RESULTSTable 1. Age distribution & Anthropometric variablesGroups Mean Age Mean Height Mean Weight Mean BMI(Years) (mts) (Kgs) (Kg/mt2)Group A 36.80±10.23 1.67 ± 0.05 67.8 ± 10.15 24.2± 3.86Group B 34.86 ± 7.94 1.65±0.052 65.8 ± 8.82 23.92± 2.31Group C 32.80 ± 7.84 1.67±0.08 65.6 ± 9.06 23.37 ± 2.01F-Value 0.785 0.512 0.253 0.513P-Value 0.463 0.603 0.778 0.603Table 2. Intra group mean differenceGroupA p GroupB P GroupC Ppre Post Pre Post pre postKOSADLS 49.2±8.47 75.6±12.83 0.00 52.5±6.9 88.2±6.37 0.00 56.3±9.90 85.6±8.5 0.00ROM-FLEX 41.3±13.1 91.0±22.25 0.00 45.7±13.9 105±19.7 0.00 40.4±10.8 109±17.7 0.00ROM –EXT 40.5±13.4 91.9±20.0 0.00 45.6±13.9 105±19.7 0.00 42.9±9.91 109.3±16.35 0.00Table 3. Inter group comparison using Multiple Scheff testGroups KOSADLS ROMMD P Flexion ExtensionMD P MD PA-B -9.38 0.035 -10.06 0.213 -10.06 0.213A-C -2.90 0.709 19.20 0.006 -19.20 0.006B-C 6.48 0.190 -9.13 0.227 -9.13 0.227DISCUSSIONResults of the study were focused on theimprovement of knee range of motion and percentageof activity of daily living based on knee outcome surveyof activity of daily living scale Score. It was notifiedthat there was recovery of all the above parameters inall the three groups.Both the three groups had equal number ofparticipants and showed no statistical significancewith respect to their gender distribution, which could1. Anil Kumar 2nd april-1-5.pmd 2/7/2013, 8:08 PM3
  • 10. 4 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1have altered the results of the study and were wellmatched.The average age in the present study was 34.82,ranging from 18-50 years. When compared between thethree groups showed equal distribution and has nostatistically significant difference in age between thegroup. A study conducted by Peter J. Millett(2004) hastaken the age group of 18-57 years with average of totalparticipants was 35.6, which coincides with the presentdata.11.Macrae and wright in 1969 showed a substantialdifference in stiffness between male and female kneejoint. Males are much stiffer than females even whenage, size of thigh, and size of knee is taken into account.It is interesting to note that while this work shows thatfemales are less stiff than males. The finding of thisstudy correlates with the above reference sincemaximumnumberofpatientswasmales,showingmorestiffness than females.12Hutchinson M studied ongenderdifferenceinactivekneejointstiffnessconcludedthat females have reduced active stiffness compared toage matched males. The present study correlates withthe above study in gender differences and has no effectson altering the results between the groups.13When the intra group mean values of active kneerange of motion of flexion was analysed, it showedstatistically significant improvement in knee flexionrange of motion in both the groups pre to postintervention, with the p values of 0.000 in both thegroups, but when comparison was done inter-group,group C showed more improvement in knee range ofmotion as compared to group A and B. In the presentstudy increase in range of motion, with the applicationof continuous passive motion in one group and jointmobilization in another group is consistent with thefindings of previous studies. This is the first study tilldate has compared the combined effect of continuouspassive motion and joint mobilization. Present resultsshowed that continuous passive motion with jointmobilization is better than giving individually.In the present study the application of moist heatfor 15 mins in all three groups prior to CPM and jointmobilization showed increase in range of motion.Knight et al. Investigated the effect of 15 min hot packapplication paired with static stretching on plantarflexor extensibility over four weeks and noted increasesin range of motion. These findings suggest that hot packapplication may be a beneficial modality whenincreased range of motion is desired.14The results of the present study group receivingCPM, has shown that alone CPM is not a beneficialmethod to mobilize post-operative knee stiffness. Assuggested by Bearpre et. al., (2001), a prospective,investigator-blindedRCTcomparedthreerehabilitationregimens in patients who had undergone primary TKAfor osteoarthritis. The results suggest that adjunct CPMand adjunct SB may not provide additional therapeuticbenefitinanactivemobilizationregimenfollowingTKAfor osteoarthritis. Hence the present study consistentwith the above study as the result concluded the same.The study done by Beaupre et. al., hypothesized thatcontinuouspassivemotionmaynotprovidetherapeuticeffect in active mobilization of post-operative kneestiffness.15In the present study, group receiving CPM only,showed an average increase in ROM for post operativeknee stiffness of 49.733, which was less compared tothe other 2 groups ie., group B-59.80 and group C-68.93.The present study correlates with the study done byEngstrom et al. (1995) reported on a prospectiverandomized study of 34 patients with unilateralanterior cruciate ligament ruptures. Engstrom et alconcluded that after six weeks follow–up, there was nodifference in ROM between the two groups, and jointswelling was more pronounced in the early activemotion group. The data suggests that CPM did notimprove ROM.16Randall et al, showed that in patients withsupracondylar fracture, mobilization and exercise ledto a greater increase in joint movement than exercisealone. The present study is in consistent with the abovestudyastheresultsconcludedthesame.Hencetheeffectof joint mobilization has an effect in increasing rangeof motion17.Michael A. Hunt, Stephen R. found the effect ofanterior tibiofemoral glides on knee extension duringgait in patients with decreased range of motion afteranterior cruciate ligament reconstruction. The authorsconcluded that a single session of anterior tibiofemoralglides increases maximal knee extension during thestance phase of gait in patients with knee extensiondeficits. In the present study 21 sessions of mobilizationincreased maximal knee extension range of motion andcould not comment on the immediate effect of jointmobilization18.In the present study closed kinetic chain exerciseswere performed by the participants for 10 repetitionsper session with each contraction held for 10 seconds,which is consistent with the findings of Cristina Mariaand Nunes Cabral.19Study done by Mei Hwa Jan MS et al to investigatethe effect of weight bearing exercises on function, painand knee strength in patients with knee stiffness. Theresults showed that weight bearing exercises wereeffective in decreasing pain and disability andincreasing knee strength.201. Anil Kumar 2nd april-1-5.pmd 2/7/2013, 8:08 PM4
  • 11. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 5The findings of the present study show thatimproving ROM by joint mobilization is effective whichwas due to stimulation of biological activity by movingsynovial fluid, which brings nutrients to the avasculararticular cartilage of the joint surfaces and intra-articular fibrocartilage of the menisci21.CONCLUSIONIn conclusion, the present randomized clinical trialprovided evidence to support the physical therapyregimen in the form of continuous passive motion withjoint mobilization in improving range of motion,improvingfunctionalperformance insubjectswithpostoperative knee joint stiffnessLIMITATIONS• Intermediatereadingsoftheoutcomemeasureswasnot noted.• There was no control group in the present studyREFERENCES1. Thieme Atlas of anatomy; Anatomy andmusculoskeletal system, Thieme.2006, ISBN 1-58890-419-429.2. Cole PA, Ehrlich MG. Management of theCompletelyStiffPediatricKnee.JPedOrthop;1997;17:67-73.3. L J Donaldson , Acook. Incidence of fractures in ageographically defined population. Journal ofEpidemiology and Community Health;1990;44:241-2454. Lastayo, PC; Continuous passive motion for theupper extremity. In Hunter, JM, Mackin, EJ.Callabon AD (eds) Rehabilitation of the Hand;Surgery and Therapy, 1995. ed 4.5. O’ Driscoll, SW, Giori, NJ; Continuous PassiveMotion Theory and Principles of ClinicalApplication. J Rehabil Res Dev 2000.37 (2);179.6. Norkin , C, Levangie, P; Joint Structure AndFunction ;A comprehensive analysis, ed 2, FA,Davis, Philaephia.1992;56-70.7. Akeson, WH, Billot JR. Effects of immobilizationof joints. Clinical Orthop 1987:219:28.8. Donatelli , R, Owens- Burkhart, H; effects ofimmobilization on extensibility of particularconnective tissue; J Orthop Sports PhysicalTherapy.1981.3:67.9. Enneking, WF, Horowitz,M; The intra-articulareffects of immobilization on the human knee. JBone Joint Surgery Am.1972. 54:978.10. G. D. Maitland. Peripheral Manipulation, 3rdedition. 2003:250-255.11. Peter J. Millet, MD. Early ACL reconstruction incombined ACL-MCL injuries, Journal KneeSurgerie. 2004. 17:94-98.12. Macrae IF. The measurement of stiffness humanjoint, 2000, 24:43-4713. Hutchinson M. Gender differences in active kneejoint stiffness. Sports Med, 1995:19:288-30214. Knight CA, Rutledge CR. Effect of superficial heat,deep heat and active exercise warm up on theextensibility of plantar flexors. Phys Therapy,2001.81:1206-1214.15. Beaupre CA et al. Exercise combined withcontinuous passive motion or slider board therapycompared with exercise only. Physical Therapy,2001:81(4); 1029-1037.16. Engstrom B, SperberA, Wredmark T. Continuouspassive motion in rehabilitation after anteriorcruciateligamentreconstruction.KneeSurgSportsTraumatol Arthrosc. 1995;3(1):18-20.17. Randall T, Portney L, Harris BA: Effects of jointmobilization on joint stiffness and active motionof the metacarpal phalangeal joint. J Orthop SportsPhys Ther 1992, 16:30-36.18. Michel A. Hunt. Stephen R. Effect of anterior tibio-femoral glides on knee extension during gait inpatients with decreased range of motion afteranterior cruciate ligament reconstruction; 2010.Vol-6 Pages 235-241.19. Cristina Maria, Nunes Cabral, Effect of a closedkinetic chain exercise protocol on patellofemoralsyndrome rehabilitation, 2007 XXVISBSSymposium.20. Mei-Hwa Jan MS PT, Effect of weight bearingversus non weight bearing exercise on function,walking speed and position sense in participantswith knee osteoarthritis. Archives of physicalmedicine and rehabilitation; 2009. vol 90, issue 6:897-90421. Norkin, C, Levangie, P; Joint Structure andFunction: A Comprehensive Analysis, ed 2. FADavis, Philadelphia, 1992.1. Anil Kumar 2nd april-1-5.pmd 2/7/2013, 8:08 PM5
  • 12. 6 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Comparison of Blood Pressure and Heart Rate betweenYoung Males and Females During Dominant andNon-Dominant Single-Leg StanceAnkita Samuel1, Manish Rajput1, Chhavi Gupta1, Sumit Kalra21Student-Bachelors of Physiotherapy, 2Assistant Professor, Banarsidas Chandiwala Institute of PhysiotherapyABSTRACTBackground: It has been observed that Blood Pressure and Heart Rate of an individual changes withposture. This study is performed to study the change in Blood Pressure and Heart Rate while standingon dominant and on non-dominant single -leg stance in males and females.Objective: The objective of this study is to compare the significant changes in Blood Pressure and HeartRate in young college going males and females while standing on there dominant and non-dominantlower limb (single-leg stance).Subjects: 200 subjects (100-males, 100-females) of the age group of 18 to 25yrsStudy Design: Co-relationalData Analysis: P-Value was calculated for the systolic and diastolic blood pressure separately and aswell as of Heart Rate in resting, single-leg stance on dominant leg and single-leg stance on non-dominant leg in both Males and Females.Conclusion: From The study it can be concluded that while training any individual on single -legstance on dominant and non-dominant a therapist should take care of the blood pressure and HeartRate specially while working on hypertensives, amputees, individuals with cardio-vascular,neurological, psychological and neuro muscular disorders.Keywords: Heart Rate, Blood PressureINTRODUCTIONHuman Heart rate can vary as the body’s need toabsorb oxygen and excrete carbon dioxide changes,such as during exercise or sleep.The one-leg stance is a valid measure to assesspostural steadiness in a static position by temporalmeasurement. The examination of balance with one-leg stance test is a functional and logical approach,since transient balancing on a single limb is essentialfor normal gait and critical activities of daily living suchas turning, stair climbing and dressing and it is alsoessential for sports person who need goodproprioception to be good in their field of sports.In addition to identifying single-leg balance testingas a reliable indicator of functional instabilities.Freeman and colleagues provided sound support forthe use of single-leg proprioceptive training to decreasethe effects of functional instabilities. Since that time,clinicians have continued to use single-leg stancemanipulations for both the evaluation andrehabilitation of proprioceptive deficits related toorthopedic injury.During rehabilitation, this method is used both fora baseline measurement of balance and to progresspatients as they recover.Short-term cardiovascular responses to posturalchange involve complex interactions between theautonomic nervous system, which regulates bloodpressure, and cerebral auto regulation, whichmaintains cerebral perfusion. A physiologically basedchange is used to describe effects of gravity on venousblood pooling during postural change. Two types ofcontrol mechanisms are included:1) Autonomic regulation mediated by sympatheticand parasympathetic responses, which affect heart2. Ankita 5th april --6-10.pmd 2/7/2013, 8:08 PM6
  • 13. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 7rate, cardiac contractility, resistance, andcompliance, and2) Auto regulation mediated by responses to localchanges in myogenic tone, metabolic demand, andCO2concentration, which affect cerebrovascularresistance.The change on Heart Rate are due to muscularactivity changes when posture changes, abdominalwall tension increases while standing on single leg,the aortic pressure increases according to Marey’s lawand also due to carotid sinus reflex.The Blood Pressure and Heart Rate vary inrespiratory, neurological, psychological and in cardio-vascular disorders. BMI also plays a major role when itcomes to one leg standing, the individuals with BMImore than of 25cm2/kg has a higher Blood Pressureand Heart Rate while standing on single leg.Static contraction of muscles on a large scale, e.g.with the knees bent as described, soon causes aremarkably large rise of systolic and diastolic blood-pressures, comparable to what may be induced bystrenuous muscular exercise, but differing in certainrespects in the mechanism of its production.Assumption of the upright posture requires promptphysiological adaptation to gravity .There is aninstantaneous descent of ~500 ml of blood from thethorax to the lower abdomen, buttocks, and legs. Inaddition, there is a 10-25% shift of plasma volume outof the vasculature and into the interstitial tissue. Thisshift decreases venous return to the heart, resulting in atransient decline in both arterial pressure and cardiacfilling. This has the effect of reducing the pressure onthe bar receptors, triggering a compensatorysympathetic activation that results in an increase inheart rate and systemic vasoconstriction (counteringthe initial decline in blood pressure). Hence,assumption of upright posture results in a 10-20 beatper minute increase in heart rate, a negligible change insystolic blood pressure, and a ~5 mmHg increase indiastolic blood pressure. Assumption of the uprightposture requires prompt physiological adaptation togravity.The response of blood pressure to change in bodyposition is well suited as a measure of cardiovascularreactivity for epidemiological studies. Severalexperimental studies have suggested a differentialresponse of blood pressure to standing due to ethnicity1and gender2, 3.As it always seen that men have more muscle poweras compared to women, indirect evidence indicates19,20that women will experience less compressive force andintramuscular pressure in the muscle21,22,23, allowinggreater perfusion and oxygen supply compared withthe men during the sustained contraction during thechange in posture.It also seen that women have lower risks ofcardiovascular events than men. They are alsocharacterized by different spectral indexes of HRV24,and by higher HRV entropy25.The need of this study is to have a betterunderstanding that how does Blood Pressure and HeartRate changes in young individuals who are under goingphysiotherapy to increase their proprioception, balanceand co-ordination, a hypertensive individual ,anindividual using prosthesis or an amputee (any limb),an individual under going any cardio-vascular,neurological, psychological or neuro-muscular disorderwhen they stand on there single lower limb (dominantor non-dominant) and does the gender of the individualplays in any significant role in it.METHODOLOGYRESEARCH DESIGN- Co-relationalSAMPLE SIZE- 200 (male-100, female-100)SOURCE OF SUBJECTS - Students from variouscolleges in Delhi.SAMPLE DESIGN- Random samplingINCLUSION CRITERIA27, 28:1. Males and Females in the age group of 18 to 25years2. BMI between 18 to 25 kg/m2EXCLUSION CRITERIA1. BMI less than 18 and more than 25 kg/m22. A diagnosed case of any cardio-vascular,respiratory, psychological or neurological disorder.3. Any bony/Muscular deformity present of upperlimb, lower limb or spine4. Any pain in upper limb, lower limb or spine5. Use of any limb prosthesis6. Any limb amputation7. Subjects are not involved in any physical ormuscular activity in last one hour before testing.2. Ankita 5th april --6-10.pmd 2/7/2013, 8:08 PM7
  • 14. 8 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1INSTRUMENTATION1. The Omron M6 (HEM-7001-E) digital bloodpressure and heart rate monitor.2. A stop watch3. Football4. measuring tape5. weighing tapeINDEPENDENT VARIABLES1. Age2. Height3. WeightDEPENDENT VARIABLES1. Blood pressure (both systolic and diastolic)2. Heart ratePROCEDURETotal of 265 subjects were taken out of which 200subjects fulfilling the inclusion criteria and afterchecking that they had not gone for any vigorousphysicalormuscularactivityinlastonehourweretakeninto consideration. The procedure was explained to thesubjects and a written consent was taken afterexplaining the benefits and clearing the doubts of thesubject regarding study. To check the lower limbdominance subjects were asked to kick a football andthe leg from which he/she kicked was considered ashis/her dominant leg. After this subject’s BP and HRwas taken while sitting on chair. They were given a restperiod of 5 minutes then, they were made to stand ontheir dominant leg for a minute. After which their BPand HR was recorded in seated position, and they weremade to rest for 5 minutes again. Post rest period thesubjects were asked to stand on their non-dominant legfor a minute this time again their BP and HR were takenin seated position.RESULTP-value of the collected data was calculated usingSPSS software version 16FEMALESTable 1. Resting and DominantS. No. P-Value1 Systolic 0.0142 Diastolic 0.8903 Heart Rate 0.291Table 2. Resting and Non-DominantS. No. P-Value1 Systolic 0.0002 Diastolic 0.4803 Heart Rate 0.056Table 3. Dominant and Non-DominantS. No. P-Value1 Systolic 0.1972 Diastolic 0.0723 Heart Rate 0.436MALESTable 4. Resting and DominantS. No. P-Value1 Systolic 0.4262 Diastolic 0.4733 Heart Rate 0.737Table 5. Resting and Non-DominantS. No. P-Value1 Systolic 0.2822 Diastolic 0.1693 Heart Rate 0.070Table 6. Dominant and Non-DominantS. No. P-Value1 Systolic 0.1982 Diastolic 0.0733 Heart Rate 0.430MALES AND FEMALESTable 7. Resting and DominantS. No. P-Value1 Systolic 0.0322 Diastolic 0.7253 Heart Rate 0.339Table 8. Resting and Non-DominantS. No. P-Value1 Systolic 0.0012 Diastolic 0.273 Heart Rate 0.092. Ankita 5th april --6-10.pmd 2/7/2013, 8:08 PM8
  • 15. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 9Table 9. Dominant and Non-DominantS. No. P-Value1 Systolic 0.6952 Diastolic 0.4933 Heart Rate 0.171Table 10. Dominant (male & female)S. No. P-Value1 Systolic 0.0002 Diastolic 0.0003 Heart Rate 0.05Table 11. Non-Dominant (male & female)S. No. P-Value1 Systolic 0.0692 Diastolic 0.003 Heart Rate 0.00DISCUSSIONVariation of heart rate is associated with posturalchange26. In accord with previous reports, this studyshowed that HR was highest in standing on Non-Dominant leg compared to sitting or lying positions4-11.Thus, the hypothesised that the increase in HR withstanding follows a decease in venous return due to“venous pooling” in the lower limbs due togravitational effects12. The increase in peripheral venousvolume is accompanied by an increase in both venousand arterial pressure in the lower extremities. The shiftinbloodvolumefromthecentraltotheperipheralsysteminduces a decrease in venous return and central venouspressure. The smaller the venous return, the smallerthe end-diastolic and subsequent stroke volume. Areduction in venous return will lead to a reducedcardiac output, which in turn will lead to a reductionin baroreceptor stimulation in the aorta and carotidarteries13. This reduction in baroreceptor firing resultsin decreased parasympathetic and increasedsympatheticactivity14, 11.Thesetwoactionsdirectlyaffectthe cardiovascular centre in the medulla oblongatawhich increases the HR, the arteriolar and venoustones, and the cardiac contractility to compensate forthe decrease in stroke volume and provide a cardiacoutput which can meet body demands. Upon returningthe posture from sitting to lying, the increase in venousreturn increases the stroke volume through the FrankStarling mechanism, thus a lower heart rate is sufficientto maintain the cardiac output demanded by the body.In present study we can conclude that not onlythe HR but BP also changes significantly while onstanding on dominant single-leg and on non-dominantsingle-leg in Males and Females. Haemodynamics canbedisturbedevenbyslightmovements15.Inaccordwithprevious findings4-11, our results showed that withrespective of the postural change, i.e. standing ondominant and non-dominant leg there was a significantincrease in HR and decrease in BP. Although muscleactivityincreasesbodyoxygenconsumptionandenergyexpenditure, the temporal increase in HR and decreasein BP associated with changing position suggests thatit is likely to have resulted from the metabolic orhormonal consequences of increased muscle activity.We speculate that this increase was largely induced bythe skeletal muscle reflex15-17. Although anticipation ofexercise may also cause a rapid increase in heart rate18.The changes in BP and HR were significantly seenwith respect to gender also. Both the systolic anddiastolic BP in males increases while standing on theresingle-leg and that too on there non-domianat legwhereas there was increase in HR in case of females ontheir non-dominant leg.REFERENCES1. Ventner CP, Joubert PH. The relevance of ethnicdifferences in hemodynamic responses to thehead-up tilt maneuver to clinical pharmacologicalinvestigations. J Cardiovasc Pharmacol.1985;7:1009 –1010.2. Gotshall RW, Tsai PF, Bassett Frey MA. Gender-based differences to the cardiovascular responseto standing. Aviat Space Environ Med.1991;62:855–859.3. Schondorf R, Low PA. Gender related differencesin the cardiovascular responses to upright tilt innormal subjects. Clin Auton Res. 1992;2: 183–187.4. Hollander, A.P. and Bouman, L.N. Cardiacacceleration in man elicited by a muscle-heartreflex. J. Appl. Physiol. 38: 272-278 ,1975.5. Iellamo, F., Legramant, J.M., Massaro, M., Galante,A., Pigozzi, F.,Nardozi, C. and Sangilli, V.Spontaneous baroreflex modulation of heart rateand heart rate variability during orthostatic stressin tetraplegics and healthy subjects. J. Hypertens.19: 2231-2240,2001.6. Jacob, G., Ertl, A.C., Shannon, J.R., Furlan, R.,Robertson, R.M. and Robertson, D. Effect ofstanding on neurohumoral responses andplasma volume in healthy subjects. J. Appl.Physiol. 84: 914-21,1998.7. Pump,B.,Christensen,N.J.,Videbaek,R.,Warberg,J., Hendriksen, O. and Norsk, P. Left atrialdistension and antiorthostatic decrease in arterialpressure and heart rate in humans. J. Am. Physiol.273: H2632-H2638, 1997.8. Pump, B., Gabrielsen,A., Christensen, N.J., Bie, P.,Bestle, M. and Norsk, P. Mechanisms of inhibitionof vasopressin release during moderateantiorthostatic posture change in humans. Am. J.Physiol. 277: R229-R235, 1999.2. Ankita 5th april --6-10.pmd 2/7/2013, 8:08 PM9
  • 16. 10 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 19. Pump, B., Kamo, T., Gabrielsen, A. and Norsk, P.Mechanisms of hypotensive effects of a posturechange from seated to supine in humans. Acta.Physiol. Scan. 171: 405-412, 2001.10. Saborowski, F., Krahe-Fritsch, G., Krakau, M.,Wallbrueck, K. and Schaldach, M. The effects oforthostasis on the ventricular-evoked response.Eur. J. Appl. Physiol. 2: 333-338, 2000.11. .Shamsuzzaman, A.S.M., Sugiyama, Y., Kamiya,A., FU, Q. and Mano, T. Head-up suspension inhumans:effectsonsympatheticvasomotoractivityand cardiovascular responses. J. Appl. Physiol.84:1513-1519, 1998.12. Borst,C.,Wieling,W.,vanBrederode,J.F.M.,Hond,A., de Rijk, L.G. and Dunning, A.J. Mechanisms ofinitial heart rate response to postural change. Am.J. Physiol. 243: H676-H681, 1982.13. Mohrman, D.E. and Heller, L.J. CardiovascularPhysiology 4thEdition. McGraw-Hill HealthProfessions Division, 1997: pp 179-183.14. Ewing, D.J., Hume, L., Campbell, I.W., Murray,A.,Neilson, J.M. and Clarke, B.F. Autonomicmechanisms in the initial heart rate response tostanding. J. Appl. Physiol. 49: 809-814, 1980.15. Kjaer, M., Hanel, B., Worm, L., Perko, G., Lewis,S.F., Sahlin, K., Galbo, H. and Secher, N.H.Cardiovascular and neuroendocrine responses toexercise in hypoxia during impaired neuralfeedback from muscle. Am. J. Physiol. 277: R 76-R85, 1999.16. Leshonower, B.G., Potts, J.T., Garry, M.G. andMitchell, J.H. Reflex cardiovascular responsesevoked by selective activation of skeletal muscleergoreceptors. J. Appl. Physiol. 90: 308-316, 2001.17. McArdle,W.D., Katch, F.I. and Katch, V.L.Essentials of Exercise Physiology. 2nd Edition.Philadelphia: Lippincott Williams & Wilkins. 2000.18. Heatherk.Vincen,PhD,KelleyM.Lamb,BS,Timi.Day, PT, Susan M. Tillman, PT, Kevin R.Vincent,MD, PhD, Steven Z. George, PT, PhD.Morbid Obesity is Associated with FEAr ofMovement and Lower Quality of Life in PatientswithKneePain-Relateddiagnosis.Volume2,Issue8, August 2010, pg713-72219. . Hicks AL, Kent-Braun J, and Ditor DS. Sexdifferences in human skeletal muscle fatigue.Exerc Sport Sci Rev 29: 109–112, 2001.20. . Hunter SK and Enoka RM. Sex differences in thefatigability of arm muscles depends on absoluteforce during isometric contractions. J Appl Physiol91: 2686–2694, 2001.21. Sadamoto T, Bonde-Petersen F, and Suzuki Y.Skeletal muscle tension, low, pressure, and EMGduring sustained isometric contractions inhumans. Eur J Appl Physiol 51: 395–408, 1983.22. Sejersted O, Hargens A, Kardel K, Blom P, JensenO, and Hermansen L. Intramuscular fluidpressure during isometric contraction of humanskeletal muscle. J Appl Physiol 56: 287–295, 1984.23. Barnes WS. The relationship between maximumisometric strength and intramuscular circulatoryocclusion. Ergonomics 23: 351–357, 1980.24. Sztajzel, J., Jung, M., and Bayes de, LunaA.Reproducibility and gender-related differencesof heart rate variability during all-day activity inyoung men and women. Ann NoninvasiveElectrocardiol 2008;13:270-277.25. Ryan,S.M.,Goldberger,A.L.,Pincus,S.M.,Mietus,J., and Lipsitz, L. A. Gender- and age-relateddifferences in heart rate dynamics: are womenmore complex than men? J Am Coll Cardiol1994;24:1700-1707.26. Oida, E., Kannagi, T., Moritani, T. and Yamori, Y.Physiological significance of absolute heart ratevariability in postural change.Acta. Physiol. Scan.165: 421-422, 1999.27. Heatherk.Vincen,PhD,KelleyM.Lamb,BS,Timi.Day, PT, Susan M. Tillman, PT, Kevin R.Vincent,MD, PhD, Steven Z. George, PT, PhD.Morbid Obesity is Associated with FEAr ofMovement and Lower Quality of Life in PatientswithKneePain-Relateddiagnosis.Volume2,Issue8, August 2010, pg713-72228. Stewart, Manual of Physiology,” Toronto, 1918, p.107.2. Ankita 5th april --6-10.pmd 2/7/2013, 8:08 PM10
  • 17. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 11Effectiveness of Transcutaneous Electrical NerveStimulator (TENS) in Reducing Neuropathic Pain inPatients with Diabetic NeuropathyApeksha O. Yadav1, G. J. Ramteke21Assistant Professor, 2Director & Principal, Department of Physiotherapy, Ravi NairPhysiotherapy College, DMIMS (DU) Sawangi (M) WardhaABSTRACTObjective: To evaluate the effectiveness of TENS in reducing neuropathic pain in patients with DiabeticNeuropathy.Design: Prospective Experimental Study.Participants and Outcome Measure: 20 Patients with a diagnosis of Diabetic Neuropathy were includedin the study and they were explained regarding the treatment & its duration. Outcome measures wererecorded before & after the treatment session using numerical pain rating scale.Result: After collecting data statistical analysis was done using Students paired t test to determine theeffect of TENS and it showed a significant difference in reduction in pain post treatment.Conclusion: It can be concluded that High frequency TENS can be given to Diabetic Neuropathypatients for three weeks to achieve pain reduction.Keywords: Diabetes, Neuropathic Pain, Transcutaneous Electrical Nerve Stimulator.INTRODUCTIONDiabetes mellitus is caused by an insufficientinsulin-mediated response to blood glucose. Peoplewith the disorder are classified as being insulindependent (ie, having type I diabetes) or non-insulindependent (ie, having type II diabetes) depending onwhether they require exogenous insulin for survival. Afrequent sequella of both types of diabetes is thedevelopment of peripheral neuropathy in either motoror sensory nerves, or both.1Crawford2estimated that 13million people in the United States have diabetes, and30% to 40% of these people are believed to have at leastsensory neuropathy.3A consequence of any neuropathy affecting motorand sensory peripheral nerves is reduction or loss ofstrength and sensation. Another potential consequenceof peripheral neuropathy in people with diabetes issevere, unremitting pain.1, 4People with painful diabeticneuropathy describe their pain as constant, burning,or searing. Allodynia, to light touch, the experience oflight touch as painful, frequently develops, and evencontact with bedclothes can be painful. Deep pain,described as being located in the centre or marrow ofthe bone, can also occur. When pain is severe, peoplewith diabetic neuropathy may have difficulty sleepingand can experience depression and weight loss.1Diabetic peripheral neuropathy (DPN) endoneurialhypoxemia – is the most common complication ofdiabetes, estimated to affect 50% to 90% of patients,depending on the criteria used for diagnosis5-10.Itsprevalence increases with the patient’s age, durationof diabetes, and poor glycemic control.11-14DPNisoftenreferredtoastheforgottencomplicationbecause, despite how commonly it occurs, it is thechronic diabetes complication that is least oftenaddressed by health care providers.15Results of the 2005American Diabetes Association (ADA) National Surveyfound that only one in four patients surveyed whoexperiencesymptomsofDPNhavebeendiagnosedwiththe condition.16This is partly because manypractitioners have had very little success with itstreatment as well as a lack of awareness of availabletreatment strategies. A wide range of treatments areavailable for neuropathic pain, however, many patientsremain inadequately treated. This prescribing patternsuggests that no one treatment addresses all factors.Foot complications are the greatest burden of all seriouschronic complications among patients with diabetes.3. apeksha 25th may--11-13.pmd 2/7/2013, 8:08 PM11
  • 18. 12 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1As many as 40% to 60% of lower-extremity amputations(LEAs) are related to DPN, and more than 50,000 LEAsare performed each year in this country.17,18Approximately 15% of patients with diabetes willdevelop a foot ulcer and one in six will need to have anamputation. Additionally, half of those patients whodevelop an ulcer will have one on the opposite footwithin 3 years 19-21.Short of ulceration and amputation,DPN limits mobility, impairs sleep, and seriously affectsoverall QoL. It is a progressive disease that may actuallybegin before any alteration in sensation is detected.Forreductionofthesymptomsofdiabeticperipheralneuropathy some modalities have been used are;- TENS- Micro vascular therapy- Monochromatic near infrared treatment.By using high frequency TENS, reduction in thesymptoms of diabetic peripheral neuropathy can beachieved.David & Somers in a case study stated that by usinghigh frequency TENS for 20 minutes daily for 3 weeksover lumbar region relieves pain of neuropathy of a 73years old lady the outcome were measured by theregular assessment and by using VAS as it is reliableand valid tool for the quantification of perceived pain,the intensity of perceived pain was reduced from 7.4 to4.6 cm on the VAS and reduction of pain was gradualin given 3 weeks22.Dinesh Kumar, MD, Inderjeet S. Julka, MD, MichaelS. Alvaro, DPM & Howard J. Marshall, DPM, did threeindependent studies utilizing TENS & amitriptyline torelieve DPN pain was reviewed. There were 14 patientsinthisgroup.Twoofthemdidnottolerateamitriptyline.Symptomatic improvement occurred in 12 (85%)patients; 11 received the combination of amitriptylineand electrotherapy and 1 received electrotherapy only.Threepatientsimprovedby3paingrades,8by 2grades,and 1 by 1 grade. Five (36%) of them experiencedcomplete symptomatic relief.Material and Methodology: This is a Prospectiveexperimental study carried out in Physiotherapy OPDin Tertiary Care Hospital. Material used were TENSapparatus. 20 subjects were selected with a diagnosisof Diabetic Neuropathy. Both Males and Females wereincluded.Patientsrecentlyunderwentsurgeryforlowerlimb fracture with an implant and patients withpacemakers were excluded from the study. Study wasexplained to them & written consent was taken fromthemtoundergotreatmentforthreeweeks.Observationswere recorded using numerical pain rating scale pretreatment i.e. 1week before the commencement ofprogram and post treatment i.e. third week after thecompletion of treatment program. Patient was assessedbefore starting the treatment. Patient was made to lie inprone position and then the TENS electrodes wereapplied on the lumbar region with the use of aqua sonicgel.Frequencyusedwas80Hertz.Durationoftreatmentwas 20 mins daily for three weeks.STATISTICAL ANALYSISTable 1: Comparison of Numerical Pain Rating Scale before and after treatmentA: Descriptive StatisticsMean N Std. Std.Deviation Error MeanBefore Treatment 6.46 20 0.88 0.19After Treatment 4.11 20 0.56 0.12B: Students paired t testPaired DifferencesMean Std. Std. Error 95% Confidence Interval t df p-valueDeviation Mean of the DifferenceLower UpperBefore t/t-After t/t 2.35 0.88 0.19 1.93 2.76 11.81 19 0.000 S,p<0.0520 patients diagnosed of diabetic neuropathybetween the age group of 60 to 80, were given treatmentwith high frequency TENS for 3 weeks, showed a meanrating of pain before the treatment was 6.46cms on NPRSand mean reduction of the symptoms after 3 weeks was4.11cms on the same scale showing improvement.3. apeksha 25th may--11-13.pmd 2/7/2013, 8:08 PM12
  • 19. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 13CONCLUSIONIt can be concluded that, treatment with highfrequency TENS for 3 weeks given to patients with adiagnosis of diabetic neuropathy shows significantreduction of neuropathic pain.REFERENCES1. Watkins PJ. Natural history of diabeticneuropathies. QJ Med. 1990; 77:1209 –1218.2. Crawford JM. The pancreas. In: Kumar V, CotranRS, Robbins SL, eds. Basic Pathology. 6th ed.Philadelphia, Pa: WB Saunders Co; 1997:557–578.3. Harris M, Eastman R, Cowie C. Symptoms ofsensory neuropathy in adults with NIDDM in theUS population. Diabetes Care. 1993; 16: 1446–1452.4. Horowitz SH. Diabetic neuropathy. Clin Orthop.1993; 296:78–85.5. DyckPJ,KratzKM,KarnesJL,etal.Theprevalenceby staged severity of various types of diabeticneuropathy, retinopathy, and nephropathy in apopulation-based cohort: the Rochester DiabeticNeuropathy Study. Neurology. 1993; 43: 817–824.6. Tavaloki M, Mojaddidi M, Fadavi H, Malik RA,Pathophysiology and treatment of painful diabeticneuropathy. Curr Pain Headache Rep. 2008; 12:192–197.7. ShawJE,ZimmetPZ.Theepidemiologyofdiabeticneuropathy. Diabetes Rev. 1999; 7: 245–252.8. Gregg EW, Sorlie P, Paulose-Ram R, et al.Prevalence of lower-extremity disease in the USadult population e”40 years of age with andwithout diabetes: 1999–2000 National Health andNutrition Examination Survey. Diabetes Care.2004; 27: 1591–1597.9. Daousi C, MacFarlane IA, Woodward A, et al.Chronic painful peripheral neuropathy in anurban community: a controlled comparison ofpeople with and without diabetes. Diabet Med.2004; 21: 976–982.10. Davies M, Brophy S, Williams R, Taylor A. Theprevalence,severity,andimpactofpainfuldiabeticperipheral neuropathy in type 2 diabetes. DiabetesCare. 2006; 29: 1518–1522.11. Boulton AJM. Management of diabetic peripheralneuropathy. Clin Diabetes. 2005; 23: 9–15.12. Tamer A, Yildiz S, Yildiz N, et al. The prevalenceof neuropathy and relationship with risk factorsin diabetic patients: a single-center experience.MedPrinc Pract. 2006; 15: 190–194.13. Valensi P, Giroux C, Seeboth-Ghalavini B, AttaliJR. Diabetic peripheral neuropathy: effects of age,duration of diabetes, glycemic control, andvascular factors. J Diabetes Complications. 1997;11: 27–34.14. Booya F, Bandarian F, Larijani B, et al. Potentialrisk factors for diabetic neuropathy: a case controlstudy. BMC Neurol. 2005; 5:24.15. Marks JB. The forgotten complication. Clin Diab.2005; 23: 3–4.16. American Diabetes Association survey finds mostpeople with diabetes don’t know about highlyprevalent, serious complication.w w w . d i a b e t e s . o r g / f o r - m e d i a /2005pressreleases/ diabeticneuropathy.jsp.Accessed Sept. 21, 2009.17. Borssen B, Bergenheim, Lithner F. Theepidemiology of foot lesions in diabetic patientsaged 15-50 years. Diabetic Med. 1990; 7: 438–444.18. Reiber GE, Boyko EJ, Smith DG. Lower extremityfootulcersandamputation.InDiabetesinAmerica.2nded. 1995. Washington, DC. Department ofHealth and Human Services.19. GordoisA, Scuffham P, ShearerA, et al. The healthcare costs of diabetic peripheral neuropathy in theU.S. Diabetes Care. 2003; 26: 1790–1795.20. Reiber GE, Vilekyte L, Bokyo EJ, et al. Causalpathways for incident lower-extremity ulcers inpatients with diabetes from two settings. DiabetesCare. 1999; 22: 157–162.21. Pecoraro RE, Reiber GE, Burgess EM. Pathways todiabetic limb amputation. Basis for prevention.Diabetes Care.1990; 13: 513–521.22. Somers DL, Somers MF. Treatment of neuropathicpain in a patient with diabetic neuropathy usingtranscutaneous electrical nerve stimulationappliedtotheskinofthelumbarregion.PhysTher.1999; 79: 767–775.23. DineshKumar,MD,InderjeetS.Julka,MD,MichaelS. Alvaro, DPM & Howard J. Marshall, DPM.Diabetic Peripheral Neuropathy. Effectiveness ofelectrotherapy and amitriptyline for symptomaticrelief Diabetes Care. Diabetes Care.1998; 21: 1322-1325.3. apeksha 25th may--11-13.pmd 2/7/2013, 8:08 PM13
  • 20. 14 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Evaluation of effects of Nebulization and BreathingControl in Asthmatic PatientsKesharia1, Amita Mehta21M.P.Th.,CardiovascularandRespiratorySciences,2Professor & Head, P.T. School and Centre, Seth G.S.M.C. andK.E.M. Hospital, Parel, Mumbai.ABSTRACTBackground: Asthma is a disease characterized by airflow limitation that is either fully or partiallyreversible. There is a growing realization that in asthma the airflow limitation leads to further mechanicalconsequences that result in dyspnea which is also a very important domain along-with airflow limitationto build up strategies to effectively cope up with asthma. To treat asthma effectively means to achieve abetter level of control of asthma. Various strategies have been adopted by the patients themselves tokeep their asthma level in control and avoid frequent exacerbations. Asthma has many dimensions toit rather than only airway obstruction.Asthma is affected by anxiety, cold, emotional quotient & also bythe level to which other non- pharmacological means to control asthma adopted by the patient likeyoga, meditation and various breathing strategies. It was seen that pharmacological measures thoughwere very essential to treat asthma, but along-with its long term use; factors like adverse effects ofmedications, patients non-compliance, cost effectiveness of treatment, patients sense of satisfaction oftheir disease control came into focus. Hence, various non-pharmacological measures were researchedin the past trials, of which breathing control was one of the measures used.Purpose: The purpose of our study was to evaluate the effects of nebulization and breathing control(N+B combination) as against only breathing control(B) on airway obstruction [by measuring peakexpiratory flow rate(PEFR), forced expiratory volume in 1st second(FEV1) and dyspnea [by measuringrespiratory rate (RR) and rate of perceived exertion (RPE)] in asthmatic patients.Method: In total, 60 patients were selected according to the inclusion and exclusion criteria. Writteninformed consent was taken from the patients and asthmatic patients were randomly allocated to twogroups either N+B or only B. Parameters PEFR, FEV1, RR and RPE on Borgs modified 10 point categoryratio scale were obtained before and after the treatment session. Data was analyzed using SPSS 15. Forstatistical significance, p value of <0.05 was considered.Results: There was a statistically significant improvement in PEFR, FEV1, RR and RPE in both thegroups. However, there was no statistically significant difference in PEFR and FEV1 i.e. airwayobstruction between the two groups. But, there was a statistically significant difference in RR and RPEi.e. dyspnea between the two groups, with breathing control showing greater improvement in dyspnea.Conclusion: Thus, asthmatic patients not only could reverse their airway obstruction (PEFR, FEV1)with Breathing control but also improved in terms of dyspnea (RR, RPE) as compared for Nebulizationand Breathing control group. Nebulization and Breathing control group though it showed statisticalsignificant improvement in airway obstruction(PEFR,FEV1) than only Breathing control; but the overallenergy expenditure and thermogenic effect of nebulization with salbutamol did not help reversedyspnea(RR and RPE)to the effect the breathing control could to.Keywords: Asthmatics, Nebulization, Breathing control, Airway obstruction, Dyspnea.INTRODUCTIONAsthma is a problem world wide, with an estimated300 million affected individuals.1The WHO hasestimated that 15 million disability adjusted life years(DALY‘S)arelostannuallyduetoasthma.Absencefromschool and days lost from work are substantial social& economic consequences of asthma in studies fromIndia.1In Asthma, the predominant feature clinically isepisodic shortness of breath, physiologically episodicairway obstruction characterized by expiratory airflowlimitation & pathologically airway inflammation,which persists even during the asymptomatic periods.Airway narrowing is the final common pathwayleading to symptoms and physiological changes inasthma.4. bhakti 22ND oct--14--20.pmd 2/7/2013, 8:08 PM14
  • 21. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 15Severity determines both the severity of theunderlying disease and its responsiveness to treatment,but it may change over months or years. Therefore,periodic assessment of asthma control is more relevantand useful. Asthma is a growing problem with a hugeeconomic burden. The annual cost of asthma to theNHS, constitutes about 83% i.e. Majority of it is due tomedications. Accordingly, the development andevaluation of interventions to prevent asthma, to reduceits severity or improve its prognosis are the priorityresearches.2Pharmacotherapy is the mainstay of asthmamanagement, but the outcomes remain suboptimal forcomplex reasons including under treatment and non-compliance. 3Also, many patients have concerns aboutregular medications and many use non-pharmacological and complementary therapiesincluding breathing modification techniques. 3Therehas recently been renewed interest in the breathingtechniques used in asthma.3A 2000 systematic review of breathing techniquesconcluded that too few studies had been carried out towarrant firm judgments, but that collectively the dataimplied that physiotherapeutic breathing techniquesmay have some potential benefit4. A 2004 Cochranereviewofbreathingexercisesforasthmaconcludedthat,due to the diversity of breathing exercises and outcomesused, it was impossible to draw conclusions from theavailable evidence5.A 2007 RCT demonstrated that breathing retrainingand relaxation significantly reduced respiratorysymptoms and improved health-related quality of lifein a cohort of patients with asthma.6A 2008 RCT addsfurther strong support to this work, also findingsignificant reduction in asthma symptoms.7Thus, various Physical therapy interventions aimedat overcoming dyspnea by overcoming early airwayclosure were chosen: Nebulization with selective B-2sympathomimetic bronchodilator i.e. Salbutamol &Breathing control- wherein during inspiration normaltidal volume breaths are taken; with more effective useof diaphragm as it itself is an active inspiratory muscleduring inspiration and during expiration, use of Pursedlip Breathing is emphasized.Thus, it was important to understand the effect ofphysiotherapeutic techniques on dyspnea as a resultof airway obstruction in asthmatic patients & toappropriately emphasize breathing control techniquesin addition to pharmacological treatment & hence theabove study was undertaken.Methodology Study design- Experimental study- ARandomized controlled trial. Study setting-Physiotherapy department, Seth G.S.M.C and K.E.M.H,Mumbai. Sample size- 60 patients with asthma whosatisfied the inclusion criteria were selected. Inclusioncriteria- Clinically diagnosed asthmatics in the agegroup of 18-35 8years, either sex included, who werereferredforphysiotherapytreatment.Exclusioncriteria-Asthmatics with acute exacerbation in previous week1.Asthmatics with status asthmaticus9. Use ofbronchodilator puff, oral medications within last 6hours and patients on intravenous medications9.Patients having cardiac impairments, cardiac failure,hypertensives, those receiving Digitalis, in CorPulmonale9. Patients with other respiratory conditions,neurological, musculoskeletal and orthopediclimitations. Duration of study-2010-11PROCEDUREThe study was approved by the ethics committee forresearch on human subjects (ECRHS) of the institute &written informed consent was taken from patients.Patients were assigned randomly in two groups bycomputer generated random number chart and given a30 minutes session:Group I: Nebulization for 10 minutes and breathingcontrol for 20 minutes.(N+B)Group II: Breathing control for 30 minutes. (B)Starting position for both the groups-Patient sittingsupported with back support and hip knee flexed andboth hands placed just below the xiphisternum.GROUP I: Asthmatic patients were given nebulizationand all the factors affecting deposition of drug particlesin the airways was taken into consideration.9Asthmaticpatients were nebulized using salbutamol (Asthalin)with saline in the ratio of 1:1 i.e. 2 ml of Asthalin in 2 mlof saline; with Pulmomist nebulizer in relaxed sittingposition with head and neck adequately supported.Patients were asked to inhale the aerosol generated witha slight pause after inspiration9. Nebulization was givenfor 1st10 minutes and same patients were givenbreathing control for next 20 minutes (during whichtime the peak effect of nebulization was also reached).Patients were given Breathing control immediately byusing84. bhakti 22ND oct--14--20.pmd 2/7/2013, 8:08 PM15
  • 22. 16 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1a) Proper relaxed sitting position-sit with hip kneeflexion and lower back supported creating aposterior pelvic tilt position which facilitates use ofdiaphragm more effectively.b) During inspiration-controlled diaphragmaticbreathing (only tidal volume breaths i.e.-normalinspiration was emphasized).c) Relaxation of upper chest and shoulders by givingverbal commands and proprioceptive feedbackwhere necessary.d) During expiration-pursed lips breathing (PLB) wasgiven.Group II: Patients in this group were given 30 minutessession of breathing control only 10. The procedure forthe breathing control technique is same as above.Parameterslike–PEFRandFEV1(usingMini-WrightDigital Peak flow meter), RPE on Borg‘s 10 point scale,RR using watch were taken before and after theprocedure time for both the groups. Both the PEFR andFEV1 were taken in the standing position and the bestof the three efforts was taken.1BTS Guidelines 11werefollowed: PEF was recorded as the best of the threeforced expiratory blows from total lung capacity with amaximum pause of 2 seconds before blowing, withpatient in standing position. Further blows were doneif the larger of the 2 PEFR was not within 40 L/min.RESULTSStatistical analysis was done using software SPSSversion 15.The normal distribution of data was foundout with Kolmogorov-Smirnov Test. The collected datawas analyzed statistically with Paired t Test, Unpairedt Test, Mann Whitney U Test and Chi Square Test asappropriate. Characteristics of 60 asthmatic patients(Mean [95% C.I.]), Median (Range) is:Parameters N+B B P Value SignificanceNo. of Cases (N) 30 30 - -Age(years)* 30.33[27.33, 33.33] 31.37[29.21, 33.53] 0.498 NsMale:Female** 10:20 9:21 0.781 NsSeverity (I:Mp:Mop:Sp)** 7:9:9:5 9:9:7:5 0.919 NsPefr*( Liters/ Minute) 256.50[213.08,299.92] 278.00[235.14,320.86] 0.474 NsFev1*(Liters) 1.31[1.06, 1.56] 1.60[1.34, 1.86] 0.112 NsRr *(Breaths/ Minute) 32.267[30.185, 34.349] 32.667[30.572,34.581] 0.774 NsRpe** (on Borgs’s 10 Point 2:0:5:12:9:2 2:0:5:10:10:3 0.75 NsScale At The Markof 0:0.5:1:2:3:4)I:-Intermittent, MP:-Mild persistent, MoP:-Moderatepersistent, SP:-Severe persistent, NS-Non-Significant.Thus, the data for each of the parameter in N+B and Bgroup is statistically not significant & hence werecomparable. Following is the graphical representationof comparison within & between groups for all theparameters taken in the study.1) Evaluation of peak expiratory flow Rate (PEFR) in N+B and B group4. bhakti 22ND oct--14--20.pmd 2/7/2013, 8:08 PM16
  • 23. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 172) Evaluation of forced expiratory volume in 1stsecond (FEV1) in N+B and B group3) Evaluation of Respiratory Rate (RR) in N+B and B group4. bhakti 22ND oct--14--20.pmd 2/7/2013, 8:08 PM17
  • 24. 18 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1DISCUSSIONToreducetheairwayobstruction;twophysiotherapymodalitiesmainlynebulizationwithbronchodilatorandbreathing control were used. Thus, the overallcomparison between the two groups stated that: ForAirway Obstruction in two groups-The difference in PEFR between both the groups i.e.;in nebulization and breathing control (N+B) andbreathing control (B) was not statistically significant(p=0.10). Similarly, the difference between the % changePEFR in (N+B) and (B) was not statistically significant(p=0.381). The difference in FEV1 between both thegroups i.e.; in nebulization and breathing control (N+B)and breathing control (B) was not statisticallysignificant (p=0.906). Similarly, the difference betweenthe % change FEV1 with (N+B) and (B) was notstatistically significant (p=0.21). For Breathing controlin two groups-The difference in RR between both the groups i.e.; innebulization and breathing control (N+B) and4) Evaluation of perceived exertion (RPE) in N+B & B groupbreathing control (B) was statistically significant(p<0.001); indicating that breathing control (B) groupimprovedbetterpostintervention.ThedifferenceinRPEbetween both the groups i.e.; in nebulization andbreathing control (N+B) and breathing control (B) wasstatistically significant (p=0.028); indicating thatbreathing control (B) group improved better postintervention.Hence,boththemaneuvershelpeffectivelyin improving airflow obstruction (PEFR, FEV1) anddyspnea (RR, RPE). Breathing control is more effectivein relieving dyspnea.In a study done by Kendrick, et al it wasfound that the Modified Borg’s Score(MBS) is a validand reliable assessment tool for dyspnea and correlatedwell with other clinical parameters and could be usefulwhen assessing and monitoring outcomes in patientswith acute bronchospasm. In asthmatics, the mean MBSrating decreased from 5.1 at baseline to 2.4 aftertreatment. The mean PEFR increased from 286 atbaseline to 414 after treatment. In the asthma group,there was a significant negative correlation between4. bhakti 22ND oct--14--20.pmd 2/7/2013, 8:08 PM18
  • 25. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 19change score in MBS & change scores in the PEFR frompre-scores to post-scores (r = -.31, P < .05). As the PEFRscoreincreased,theMBSscoredecreased;thusthebetterthe patients’ peak flow scores, the lower the patient’sdyspnea ratings12. Thus, the above may be one of thereasons the improvements in our study of decrease inairway obstruction and improvement in dyspnea gohand in hand.Ambroso et al, found that inhaled salbutamolsignificantly increases the resting metabolic rate of thepatient due to thermogenic effects of salbutamolnebulization which may not effectively help to decreasethe perceived exertion and thus respiratory rate13.Theabove may be one of the reasons why nebulizationcomponent may have added the energy expenditureand hence dyspnea in terms of RR and RPE. This alsoemphasizes that PLB in our study does not increase theenergy cost of breathing as the dyspnea in terms of RRand RPE improve. By learning and understandingBreathing control, patients control their own breath,thus anxiety is also reduced; which is also one of thefactors why they perceive less dyspnea.However, Lewis et al in a systematic reviewevaluated the short term effects on outcomes related tothe mechanism of intervention and physiologicaloutcomes. A beneficial effect was found for abdominalmovement, diaphragm excursion, respiratory rate, tidalvolume, arterial oxygen saturation. However, breathingcontrolhadadetrimentaleffectontheworkofbreathingand dyspnea. The study proposed that when used as asole intervention, there was a beneficial effect onoutcomes related to the mechanism of intervention andphysiological outcomes. Only in people with severerespiratory disease, breathing control resulted in adetrimental effect on dyspnea and work of breathing.There was no clear evidence on gas exchange andenergy cost of breathing14.Thus, the physiotherapeutic techniques used invarious above studies helps control the symptoms ofasthma and hence their manifestation. Also, most ofthe studies have evaluated the long term i.e. At least 1month and 6 month results of lung function and overallasthma control; but immediate effects of breathingcontrol were not studied. Thus, the improvements inlung function measures of PEFR and FEV1based onbreathing control techniques suggest that there isimmediate improvement in lung function measures.Asthma is a chronic disease; the goal of treatmentshould be to decrease its overall manifestation andachieve a better level of control and hence improve theoverall Quality of life. Though, nebulization by B-2agonists showed immediate improvement in asthmasymptoms and lung function in terms of PEFR andFEV1. However, regular inhalation of B-2 agonists wasassociated with deterioration of asthma control andsuch trends in treatment may be an important causalfactor in the worldwide increase in the morbidity fromasthma. Whereas, when intervention with breathingcontrol was performed not only was there immediateimprovement in measures of PEFR and FEV1 andoverall symptoms; but also studies support the view ofregular use of breathing control techniques helps toachieve both the goals of treatment i.e. Decrease inoverall manifestation of asthma and improve Qualityof life. In view of all the above, breathing control is animportant technique to intervene dyspnea along-withproper pharmacological treatment.CONCLUSIONAll 30 patients in (N+B) and all 30 patients in (B)group responded and improved with intervention.Asthmatic patients showed statistically significantimprovement in airway obstruction and dyspnea withnebulization and breathing control and with onlybreathing control also. There was no statisticallysignificant difference between the groups in terms ofairway obstruction as measured by PEFR and FEV1.There was a statistically significant difference betweenthe groups in terms of dyspnea as measured by RR andRPE. Breathing control is more effective to reducedyspnea.Acknowledgement - NoneConflict of interest- NoneSource of support - Professor and Head ofPhysiotherapy Department.REFERENCES1. Global Initiative for asthma: global Strategy forAsthma Management and Prevention: GINA 2008Update. Bethesda, MD: National, Heart, Lung andBlood Institute, National Institutes of Health.Definition and Overview, Diagnosis andclassification, pg. 1-23.Available from URL: http://www.ginasthma.org2) Cristopher A Kellett, Jacqueline A Mullan.Breathing Control Techniques in the Managementof Asthma.Volume 88, Issue 12, Pages 751-758(December 2002).3) M Thomas, R K McKinley, S Mellor, G Watkin, EHolloway, J Scullion, D E Shaw, A Wardlaw, D4. bhakti 22ND oct--14--20.pmd 2/7/2013, 8:08 PM19
  • 26. 20 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Price, I Pavord. Breathing exercises for asthma: arandomised controlled trial .Thorax 2009; 64:55-61.4) E. Ernst. Breathing techniques - adjunctivetreatment modalities for asthma? A systematicreview Eur Respir J 2000; 15: 969-972.5) Hollway E, Ram FS. Breathing exercises forasthma. Cochrane Database Syst Rev 2004;1):CD001277.6) Elizabeth A Holloway, Robert J West. Integratedbreathing and relaxation training (the Papworthmethod) for adults in asthma with primary care: aRCT. Thorax 2007; 62: 1039-1042.7) Cowie RL, Conley DP, Underwood MF. ARCT ofthe Buteyko technique as an adjunct toconventional management of asthma. Respir Med2008:726-732.8) Donna Frownfelter, Elizazbeth Dean. Cardiopulmonary Pathophysiology. In Marjory Frazer,Donna Morrisey editors. Principles and practiceof Cardio pulmonary physical therapy; 3rdedition,Mosby Inc; 2006. P. 77,391,420-421.9) R.B. Cole. Bronchodilator Drugs. In: editors.Respiratory Diseases. 2ndedition. ChurchillLivingstone Inc.; 1981:pg. no.190.10) C A Slader, H K Reddel, L M Spencer, E GBelousova, C LArmour, S Z Bosnic-Anticevich, FC K Thien, C R Jenkins.Double blind randomisedcontrolled trial of two different breathingtechniques in the management of asthmaThorax 2006;61: 651-656.11) Diagnosis of Asthma. Evidence 2.5.2.PeakExpiratory Flow Monitoring. Edinghburgh: SIGN2009.Available from url: Usefulness of the modified 0-10 Borg scale inassessing the degree of dyspnea in patients withCOPD and asthma Authors: San Diego, California.KarlaR.Kendrick,SunitaC.Baxi,RobertM.Smith,Emergency Department and Urgent Care Clinic,Veterans Administration San Diego HealthCareSystem, San Diego, Calif.13) PAmoroso, S R Wilson, J Moxham, J Ponte.Acuteeffects of inhaled salbutamol on the metabolic rateof normal subjects .Thorax 1993;48: 882-885.14) Lewis LK, Williams MT, Olds T. Short-term effectson outcomes related to the mechanism ofintervention and physiological outcomes butinsufficient evidence of clinical benefits forbreathing control: a systematic review. Aust JPhysiother. 2007;53(4):219-227.4. bhakti 22ND oct--14--20.pmd 2/7/2013, 8:08 PM20
  • 27. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 21Effect of Neuromuscular Electrical Stimulation Combinedwith Cryotherapy on Spasticity and Hand Function inPatients with Spastic Cerebral PalsyChandan Kumar1, Vinti21AssistantProfessor,2M.p.t(Neurology-student)),M.M.InstituteOfPhysiotherapyAndRehabilitation,Mullana,AmbalaABSTRACTPurpose: To determine the effectiveness of Neuromuscular electrical stimulation combined withCryotherapy on spasticity and hand function in patients with spastic Cerebral Palsy. Children with CPoften demonstrate poor hand function due to spasticity in wrist and finger flexors.Methodology: This was an experimental study of 30 spastic CP patients aged 5-15 yr with mild tomoderate spasticity.All the subjects were divided into two groups (A& B) with equal subject number ineach group. Group A were treated with passive stretching, cryotherapy followed by NeuromuscularElectrical Stimulation (NMES) and Group B treated with passive stretching and cryotherapy, 3 times aweek on alternate days for 6 weeks. Spasticity and hand function were assessed pretreatment and posttreatment using the Modified Ashworth Scale (MAS) and Manual Ability Classification System (MACS).We tried to find out the additional effect of NMES on spastic CP patients.Results: Showed that both the group improved significantly but group A improved much better thangroup B.Conclusions: This study suggests that NMES combined with cryotherapy is more effective as comparedto cryotherapy alone in reducing spasticity and improving hand function in spastic CP patients.Keywords: Spasticity, Cerebral Palsy, Neuromuscular Electrical Stimulation, Cryotherapy.INTRODUCTIONCerebral palsy is a well-recognizedneurodevelopmental condition beginning in childhood& persisting throughout the lifespan. Cerebral palsy isa group of permanent disorders of the development ofmovement and posture, causing activity limitation, thatare attributed to non-progressive disturbances thatoccurred in the developing fetal or infant brain. Themotordisordersofcerebralpalsyareoftenaccompaniedby disturbances of sensation, perception, cognition,communication, and behavior; by epilepsy, and bysecondary musculoskeletal problems.1Cerebral palsyis the commonest physical disability in childhood,occurring in 2.0 to 2.5 per 1000 live births.2The causesare congenital, genetic, inflammatory, infections, anoxic,traumatic & metabolic. The injury to the developingbrain may be prenatal, natal or postnatal.3Causes ofCP were prenatal in 50% of the cases, perinatal in 33%,postnatal in 10%, and mixed in 7%.475% of childrenwith CP have spastic cerebral palsy.3Spasticity isclassically defined as a tonal abnormality of skeletalmuscle characterized by a velocity-dependentresistance to passive stretch.5Studies done to find outdevelopment of spasticity with age shown that thedegreeofmuscletoneincreasedupto4yearofage.After4 year of age the muscle tone decreased each year upto12 year of age.6Physiotherapy Treatment For SpasticityVarious treatment approaches & modalities tomanage spasticity associated with spastic cerebral palsyinclude the use of oral neuropharmacological agentsor injectable materials such as botulinum-A toxin7,surgical treatment through tendon transfer8or selectiverhizotomy9. The other treatment approaches areapplication of cryotherapy10, progressive resistiveexercises to improve muscle strength, repetitive passiverange of motion exercises to improve & maintain jointmobility. Passive, static, gentle stretches are performedon individual joints to decrease & prevent jointcontractures. Neurodevelopmental treatment (NDT),sensory integration, electrical stimulation, constrainedinduced therapy & orthosis are also used inmanagement of cerebral palsy.11, 125. chandan kumar 17TH april-21-25.pmd 2/7/2013, 8:08 PM21
  • 28. 22 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1CRYOTHERAPYCold application has been used for some time toreduce spasticity clinically. Decrease in resistance topassive stretch lasts from a few minutes up to 24 hours.Cold anesthesia of peripheral sensory end-organschanges the balance of facilitatory-inhibitory influencesplaying on the anterior horn cell in favor of inhibition.Unmasking of spasticity permits strengthening ofvoluntary mechanisms normally snowed under byundesired reflexes.10Neuromuscular Electrical StimulationNeuromuscular electrical stimulation has gainedsupport since its inception as a treatment for cerebralpalsy in the 1970s. With neuromuscular electricalstimulation, electrical stimulation of sufficient intensitygenerally to produce visible muscle contraction isapplied at the muscle motor point. Electrical stimulationis thought to improve strength, reduce spasticity of theantagonist muscle, reduce co-contraction, and createsoft-tissue changes permitting increased range ofmotion.13There are few studies that report theeffectiveness of NMES and cryotherapy on reduction ofspasticity & improvement of hand function in patientswith spastic cerebral palsy and found that both themodalities used are effective and none of the twomodalities is superior to other.14Therefore, aim of thisstudy is to determine the effectiveness ofNeuromuscular electrical stimulation combined withCryotherapy on spasticity and hand function inpatients with spastic Cerebral Palsy.In present study, hand function is measured usingthe Manual Ability Classification System (MACS)instead of Zancolli system14because a review ofclassification systems of upper limb function &deformity in cerebral palsy supports the use of MACSto classify upper limb function and Zancolli system isrecommended to classify thumb, hand &wristdeformity.15METHODOLOGY30 subjects were selected by means of conveniencesampling based on inclusion and exclusion criteria.All the parents received a written explanation of thetrial before entry into the study and then gave signedconsent to participate their children in the study. Thepatients were randomly allocated into 2 groups.INCLUSION CRITERIA1. Patient diagnosed with spastic cerebral palsy(quadriplegic and hemiplegic).2. Patient having wrist flexor spasticity upto Grade 3according to Modified Ashworth Scale.3. Age 5-15 yr, both male & female.4. Patient who can comprehend and comply withinstructions.5. Normal skin sensation of upper limb.EXCLUSION CRITERIA1. Dermatological problems2. Seizures3. Patients on muscle relaxing medications4. Patient having contracture or deformity of upperlimb5. Patient undergone any surgery for upper limbPROCEDUREThirty patients of CP who fulfill the inclusion criteriawere included in this study. Total numbers of patientswere equally divided into two groups (A & B). Eachgroup contained 15 patients. All participants wereevaluated by modified ashworth scale for wrist flexorspasticity and manual ability classification system forhand function.Modified Ashworth Scale measure spasticity and isapplied manually to determine the resistance of muscleto passive stretching. This scale has been shown toovalid and reliable.16Manual Ability Classificationsystem describes how children with cerebral palsy (CP)use their hands to handle objects in daily activities.MACS describe five levels. The levels are based on thechildren’s self-initiated ability to handle objects andtheir need for assistance or adaptation to performmanual activities in everyday life. The objects referredto are those that are relevant and age-appropriate forthe children, used when they perform tasks such aseating, dressing, playing, drawing or writing.17MACShas shown to be valid and reliable.18All patients wereassessed by modified ashworth scale and manualability classification system before and after givingintervention.5. chandan kumar 17TH april-21-25.pmd 2/7/2013, 8:08 PM22
  • 29. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 23The technique for application of passive stretchingwas based on passive range of motion (PROM)therapeutic exercises described by Kisner and Colby.19The PROM consists of moving the elbow, wrist, fingersand thumb passively and holding it in position for 60seconds. This procedure was repeated 5 times givingduration of 5 minutes bout. The procedure of passivestretching was given prior to every treatment session inall the subjects, both in group A & B.Treatment procedure for group A subjectsThe subject was placed in sitting position. The entireforearm from elbow to the fingers was carefully anddecently exposed. The area was cleaned with cottonwool and with methylated spirit. The upper limb of thesubject was positioned on a pillow on the plinth withthe shoulder in mild abduction. The forearm was alsopositioned in mid flexion and supination with thefingers and thumb in anatomical position .The icelollipop was applied to the flexor compartment of theforearm and gently massaged using stroking techniquefrom the proximal to the distal end of the forearm. Thiswas applied continuously for 20 minutes. The sequenceof treatment was 3 times a week on alternate days for 6uninterrupted weeks.After cryotherapy, subjects received electricalstimulation to the dorsum of the forearm. The electricalstimulation was consist of a dual channel devise withcurrent outcome between 0 and 100 MA , pulse widthof 200 microseconds and the pulse set between 30 and40 Hz to produce tolerable muscle contraction. Theelectrical stimulation was applied for duration of30minutes, 3 times in a week on alternate days for aperiod of 6 uninterrupted weeks.Treatment procedure for group B subjectsFollowing the application of passive stretching, thesubjects received Cryotherapy as describe for thesubjects in group A.Data and Statistical AnalysesComparisonwasperformedbetweenthegroupsfirstat baseline level. Then again, comparisons were doneafter treatment at 6 week as well as from baseline to 6week and results were noted. Wilcoxon signed ranktest and Mann Whitney U test was used to analyze thepreandposttreatmentvaluesofMASscoresandMACSscores within the groups and between the groupsrespectively. The level of significance was set at p<0.05.Data were analyzed using SPSS 17.0.RESULTSPatients in both the groups were assessed at baselinelevel for spasticity with modified ashworth scale &hand function with manual ability classification scaleprior to the commencement of the treatment sessions.Post-test measurements were taken after 6 weeks aftercompletion of treatment sessions. There were no dropouts in the study. A total of 16 female and 14 malesubjects participated in the study.Demographic characteristics of both the group areshown in table 1.Table: 1 Demographic characteristic of the subjectsVARIABLES GROUP A GROUP BSex F:M 7:8 9:6Mean Age 7.53 ± 1.35 7.66 ± 1.63Spastic CP (Type)Quadriplegic (%) 8 (53%) 7 (46%)Right Hemiplegic (%) 5 (33.3%) 5 (33.3%)Left Hemiplegic (%) 2 (13.3%) 3 (20%)Dominating hand (number)Right hand 15 15Above table showing that subjects in both the groupsare matched for baseline levelTable: 2 Baseline score of MAS and MACS ofboth the groupMAS MACSA B A BMean± S.D 2.46±0.611 2.33±0.587 4.60±0.632 4.53±0.639P value (<0.05) 0.59 0.77Above table showing mean value of baseline scoresof MAS & MACS of both groups. After analysis, the pvalue is >0.05 which is statistically non-significant.Table: 3 Pre and Post value of MAS and MACS ofgroup AGROUP AVariables Mean±S.D p value (<0.05)Pre value Post valueMAS 2.466±0.611 1.333±0.408 0.0003MACS 4.60±0.632 2.53±0.833 0.0003Above Table showing mean value of pre MAS andpost MAS & pre MACS and post MACS of group A.After analysis, p value is <0.05 which is statisticallysignificant.5. chandan kumar 17TH april-21-25.pmd 2/7/2013, 8:08 PM23
  • 30. 24 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Table: 4 Pre & post value of MAS andMACS of group BGROUP AVariables Mean±S.D p value (<0.05)Pre value Post valueMAS 2.333±0.587 1.666±0.308 0.0008MACS 4.53±0.639 3.46±0.828 0.0005Above Table showing mean value of pre MAS andpost MAS & pre MACS and post MACS of group B.After analysis, p value is <0.05 which is statisticallysignificant.Table: 5 Post intervention MAS and MACS value ofgroup A & BMAS MACSA B A BMean ± S.D 1.33±0.408 1.66±0.308 2.53±0.833 3.46±0.828P value (<0.05) 0.02 0.01Above Table showing mean value of postintervention scores of MAS & MACS of both groups.The result obtained from the study data showed thatthere was significant difference within group A and Bin reducing spasticity and improving hand function.GroupAshowedmoresignificantdifferenceinoutcomemeasures in comparison to group B.DISCUSSIONIn this experimental design study, result showedthe combined effect of neuromuscular electricalstimulation and cryotherapy on spasticity and handfunction in patients with spastic cerebral palsy. Theresults support the hypothesis that NMES along withcryotherapy produce good results as compared tocryotherapy alone. Cold facilitates alpha-motor neuronactivity and decreases gamma motor neuron firingthrough stimulation of cutaneous afferents. There isalso a decrease in the afferent-spindle discharge bydirect cooling of the muscle. When nerves are cooled,synaptic transmission are impeded or blocked byaltering the transmembrane ionic flow. The possibleexplanation of the mechanism of relief of spasticity canbe that cold anesthesia of peripheral sensory end-organs changes the balance of the sum of facilitatory-inhibitory influences playing on the anterior horn cellin favor of inhibition. Unmasking of spasticity permitsstrengthening of voluntary mechanisms normallysnowed under by undesired reflexes.10The results of this study are supported by previousstudies which tell that the neuromuscular electricalstimulation is helpful in increasing muscle strength byincreasing cross sectional area of the muscle & byincreasing recruitment of Type 2 muscle fibers.12WithNMES,unusedmusclescanbestimulatedwhenneededand the sensory input from NMES can give addedsensory awareness of what is happening in the handto allow motor learning to occur and to permit motorcontrol.20Neuromuscular electrical stimulation, whenapplied to the peripheral muscles has a direct effect onthe cerebral cortex.21In group A as we have givencryotherapy first and after that NMES, combined effectof both the modalities leads to significant improvementin experimental group.Result of this study showed that improvement ismore significant in subjects of group A treated withcryotherapy followed by neuromuscular electricalstimulation when compared with subjects of group Btreated with cryotherapy alone (table 5). This showedthat additional improvement in group A is because ofneuromuscular electrical stimulation. First cryotherapyhas reduced spasticity in wrist flexors and then NMESapplied to wrist extensors has further reduced spasticityin wrist flexors via reciprocal inhibition and increasedstrength in wrist extensors. Few studies have been doneon neuromuscular electrical stimulation andcryotherapy in isolation which shows their effectivenessbut the result obtained from this study is novel thatproves the combined efficacy of neuromuscularelectrical stimulation and cryotherapy on spasticity.Neuromuscular electrical stimulation is a non-invasivetherapy and offers a better clinical outcome.CLINICALIMPLICATIONThe results of the present study enlighten the use ofcombination therapy approach (NMES+Cryotherapy)as an more effective approach than the eitherintervention alone in the clinical settings for themanagement of spasticity and hand function in patientswith spastic cerebral palsy.Limitations of the studySubjective measures used for measuring spasticityand hand function challenges the results obtained. Nofollow up was taken to see the long term effects.Dominating hand was only treated in quadriplegics toavoid collecting paired data.5. chandan kumar 17TH april-21-25.pmd 2/7/2013, 8:08 PM24
  • 31. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 25Future Research SuggestionFuture research can be done using objectivemeasures for measuring spasticity and hand function.There should be long term follow up of the patient todetermine the sustained effects of combination therapy(NMES+Cryotherapy).CONCLUSIONThis study describes the management of spasticcerebral palsy patients with hand functionimpairments, who responded favorably to anintervention program focused NMES and cryotherapy.REFERENCES1. Rpeter,P.Nigel,Gmurray,Gmartin.TheDefinitionand classification of cerebral palsy. DevelopmentalMedicine & Child Neurology. 2007; 49(109):8–14.2. Reddihough Dinah S, Collins Kevin J. theepidemiology and causes of cerebral palsy.Australian Journal of Physiotherapy. 2003; 49:7-12.3. S. chitra, M nandani. Cerebral palsy-definition,classification, etiology and early diagnosis. Indianjournal of pediatric. 2005: 865-868.4. HolmVanjaA.theCausesofCerebralPalsy.JAMA.1982; 247:1473-1477.5. R Susan, G Joan T. Non operative management ofspasticity in children. Child nervous system. 2007;23:943-956.6. H Gunnar, W philippe. Development of spasticitywith age in a total population of children withcerebral palsy. BMC Musculoskeletal Disorder.2008; 9:150-159.7. Patel Dilip R, S olufemi. Pharmacologicalintervention for reducing spasticity in cerebralpalsy. Indian journal of pediatrics. 2005; 72:896-872.8. Das Shakti P, Mohanthy Ram N, Das Sanjay K.Management of upper limb in cerebral palsy-roleof surgery. IJPMR. 2002 April; 13:15-18.9. FJeanP,Jabdulrehman.Selectivedorsalrhizotomyin the treatment of spasticity related to cerebralpalsy. Child nervous system. 2007 July 21; 23:991-1002.10. Mead Sedwick, Knott Margaret. TopicalCryotherapy: Use for Relief of Pain and Spasticity.California Medicine. 1966; 105(3):179-18111. Sharan Deepak. Recent advances in managementof cerebral palsy. Indian journal of pediatric. 2005;72:969-973.12. Patel Dilip R. Therapeutic intervention in cerebralpalsy. Indian journal pediatrics. 2005; 72:979-983.13. Kemper Derek G, YasukawaAudyer M. Effects ofneuromuscular electrical stimulation treatment ofcerebral palsy on potential impairmentmechanism. Pediatric physical therapy. 2006;18:31-38.14. Akinbo S RA, Tella BA, OtunlaA. Comparison ofthe effect of neuromuscular electrical stimulationand cryotherapy on spasticity and hand functionin patient with spastic cerebral palsy. Nigerianmedical practitioner. 2007; 51:128-132.15. K McConnell, L Johnston, C Kerr. Upper limbfunction and deformity in cerebral palsy: a reviewof classification systems. Dev Med Child Neurol.2011; 53(9): 799-805.16. Bohannon Richard W, Smith Melissa B. InterraterReliabilityofaModifiedAshworthScaleofMuscleSpasticity. Physical Therapy 1987 Feb; 67(2):206-207.17. Kuijper M. A, Ketelaar M. Manual abilityclassification system for children with cerebralpalsy in a school setting and its relationship tohome self-care activities. American Journal ofOccupational therap. 2010; 64:614-620.18. Eliasson Ann-Christin, Krumlinde-SundholmLena, Rosblad Birgit, Beckung Eva, ArnerMarianne, OhrvallAnn-Marie, Rosenbaum Peter.The Manual Ability Classification System (MACS)forchildrenwithcerebralpalsy:scaledevelopmentand evidence of validity and reliability.DevelopmentalMedicine&ChildNeurology2006;48(7):549-554. DOI: 10.1017/S001216220600116219. Kisner C, Colby L. A. Therapeutic Exercise:Foundation and Techniques. 4thed. New Delhi:Jaypee Brothers, Medical Publishers (P) Ltd; 2003.20. Scheker L R, Ramirez S. Neuromuscular electricalstimulation and dynamic bracing as a treatmentfor upper extremity spasticity in children withcerebral palsy. Journal of hand surgery. 1999;24:226 -232.21. Han BS, Jang SH, Chang Y, Byun WM, Lim SK,Kang DS. Functional magnetic resonance imagefinding of cortical activation by neuromuscularelectrical stimulation on wrist extensor muscles.Am J Phys Med Rehabil. 2003 Jan; 82(1):17-20.5. chandan kumar 17TH april-21-25.pmd 2/7/2013, 8:08 PM25
  • 32. 26 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Phonophoresis in Continuous Mode Ultrasound hasSignificant effect in the Reliving Pain in Upper TrapeziusTender PointChhavi Gupta1, Manish Rajput1, Ankita Samuel1, Sumit Kalra21Student-bachelorsofPhysiotherapy,2AsstProfessor,BanarsidasChandiwalaInstituteofPhysiotherapyABSTRACTPurpose: The aim of this study was to find the significance of continous mode on the immediate effecton pain threshold and range of motion which follows a single treatment of tender points in the uppertrapezius muscle among using diclofenac sodium as coupling medium.Methods: 30 subjects presenting with upper trapezius muscles spasm, aged 20-30 years old, participatedin this Study. Subjects underwent a screening process to establish the presence of tender points inupper trapezius muscle. Subjects were divided randomly into 2 groups.Group A = continuous mode of ultrasound (0.8 w/cm2 for 5 minutes)Group B = pulsed mode of ultrasound (0.8 w/cm2 for 5 minutes)VisualAnalogue Scale and Range of Motion is assessed pre treatment and immediately post treatment.Result the p value of VAS (post treatment) and ROM (post treatment) in continous mode was 0.000Conclusion: continous mode of ultrasound is better for immediate pain relive as compared to pulsedmode when diclofenac sodium is used as the coupling medium.Keywords: Tender Point, Phonophoresis, Ultrasound, Diclofenac Gel.INTRODUCTIONNeck pain is common and can limit individual’sability to participate in normal daily activities. Neckpain frequently becomes chronic1.Tender point is defined as the places on musclesthat when touched with enough pressure, elicits afeeling of sensitivity in the location of point. Pain doesnot refer anywhere else in the body; pain is confined totender point itself. They are usually no bigger than 1cm2.The presence of tender points in patients is closelyassociated with their current anxiety, and patients witha history of psychological trauma associated withanxiety(forexample,childhoodtraumaorsexualabuse)have an increased number of tender points.4US is a modality which involves the generation ofhigh frequency sound waves, and their transmissionthrough the skin to the structures desired to be affected.USgeneratorsusedclinicallyarelimitedbygovernmentregulation to approximately 1,000,000 Hertz (1megahertz).5Phonophoresis was first used to treat polyarthritisof the hand by delivery of hydrocortisone ointment intoinflamed areas in 1954. Since then it has been reportedto be used in the treatment of various dermatologicaland musculoskeletal disorders.7The mechanism by which ultrasound enhances thetransdermal penetration of substances is not entirelyclear. One could think of the vasodilation observed onmacroscopic examination, but this would certainly notbe enough on its own, since it does not imply anychangeofthewaterproofkeratinlayeroftheskin,whichshould necessarily be altered.8Sodium Diclofenac was chosen for the experimentfor being a well-known and widely used nonsteroidalanti-inflammatory drug whose analgesic effectsmanifest quickly after administration.8Evidence fromclinical and pharmacological studies imply thatDiclofenac exerts its actions by inhibiting cycloxygenase6. chhavi gupta 5th april --26-30.pmd 2/7/2013, 8:08 PM26
  • 33. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 27(COX) enzyme. Inhibition of COX reduces theproduction of inflammatory mediators such asprostaglandins, interleukin-6 and substance P. It is alsosuggested that Diclofenac can alter G-protein mediatedsignal transduction pathways and exerts an enhancedeffect on hyperalgic muscle by directly interacting withnociceceptors.11Reliability of the visual analogue scale formeasurement of painA VAS is measurement instrument that tries tomeasure a characteristic or attitude that is believed torange across a continuum of values and can’t easily bedirectly measured.9Operationally a VAS is usually a horizontal line,100mm in length, anchored by word descriptors at eachend. The patient marks the line the point they feel whichrepresents their perception of their current state. TheVAS score is determined by measuring inn millimetresfromlefthandendofthelinetothepointthatthepatientmarks.9Reliability of the VAS for acute pain measurementas assessed by the ICC appears to be high. Ninetypercent of the pain ratings were reproducible within 9mm. These data suggest that the VAS is sufficientlyreliable to be used to assess acute pain.10Reliability of GoniometerThe full-circle goniometer, or universal goniometer(UG), is a versatile device for recording measurementsof peripheral joint ROM in healthy subjects and inpatients. Based on a clinical study of 60 patients withorthopaedic disorders in a physical therapy outpatientdepartment, conclusion was drawn that AROMmeasurements on the cervical spine made by the samephysical therapist have good to high reliability,regardless of whether the therapist used the CROMdevice or the UG. Repeated measurements with the UGhad poor to fair between tester reliability.15The purpose of this study is to compare theeffectiveness of pulsed and continuous ultrasoundwith topical Diclofenac gel as the coupling medium inthe immediate pain relive of tender point.METHODOLOGYNumber and Source30 subjects were taken from young population.Inclusion Criteria1. Male or Female with age of 20-30 years.2. Subjects with upper trapezius muscle spasm.Exclusion Criteria1. Subjects with trigger point of trapezius muscle.2. Subjects with musculoskeletal disorder that wouldlimit performance in these subjects.3. Skin disorders which would irritate by eitherincrease in warmth of the part or by the lubricantswhich might be used, e.g. eczema.4. In presence of malignant tumours.5. In case of any previous fracture or surgery at neck.6. All contraindications of ultrasonic therapy.Method of selecting & assigning subjects to groups40 subjects having an upper trapezius muscle spasmwereconsideredforthisstudy. Theywerethenscreenedto remove the subjects who did not fulfil the criteria forthe study. After screening, the subjects they wererandomly divided into two groups.Instruments and Tool used1. Ultrasound machine Meditek Ultrasonic digital ,Meditek cooperation2. Diclofenac sodium gel3. Ultrasound gelResearch DesignIt is an experimental design.VariablesIndependent variables- Ultrasonic TherapyDependent variables- Visual Analogue ScalePROCEDURESubjects fulfilling the inclusion criteria were takeninto consideration. The procedure was explained to thesubjects and a written consent was taken afterexplaining the benefits and clearing the doubts of thesubject regarding study.After pain level assessment byhelp of visual analogue scale (VAS) and Range ofMotion using the universal goniometer they wererandomly divided into two groups namely, A and B.6. chhavi gupta 5th april --26-30.pmd 2/7/2013, 8:08 PM27
  • 34. 28 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Group A were given pulsed ultrasound with diclofenacsodium as coupling medium and Group B were givencontinuous ultrasound with diclofenac sodium ascoupling medium. The ultrasound was given for 5minutes at 0.8 w/cm2 16. After the treatment pain leveland Range of Motion is taken again.RESULTA paired sample t test reveal a statistically reliabledifference between the mean number of VAS pre andpost in continous mode (M= 6.7333, s =1.03280) and(M= 3.9333, s =1.48645) that the t(14)=12.582, P(á)= .000at two tail test.A paired sample t test reveal a statistically reliabledifference between the mean number of ROM pre andROM post in continous mode (M=27.0000, s=5.29150)and (M= 37.0667, s = 4.19977) that the t(14) = -11.093,P(á)= .000 at two tail test.A paired samples t test reveal a statistically reliabledifference between the mean number of VAS pre andVAS post in pulsed mode (M=-6.8000, s = 1.32017) and(M 4.4000, s=1.50238) that the, t(14) =8.806, P(á) = .000.attwo tail test.A paired samples t test reveal a statistically reliabledifference between the mean number of ROM pre andROM post in pulsed mode (M=-23.7333, s=10.73357)and (M=33.7333, s=9.51290) that the, t(14) = -10.569,P(á) = two tail test.An independent-samples t-test was conducted tocompare VAS post treatment in pulsed mode andcontinous mode. There was a significant difference inthe scores for pulsed (M=4.4, SD=1.5) and continous(M=3.93, SD=1.48) conditions; t(28)=0.855, p = 0.400.the result suggest that VAS decreases more in continousmode than in pulsed mode.An independent-samples t-test was conducted tocompare ROM post treatment in pulsed mode andcontinous mode. There was a significant difference inthe scores for pulsed (M=33.73, SD=9.51) and continous(M=37.06, SD=4.19) conditions; t(28)=-1.24, p=0.225.The result suggest that ROM increases more incontinous mode.6. chhavi gupta 5th april --26-30.pmd 2/7/2013, 8:08 PM28
  • 35. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 29Hence it can be said that continuous mode has moreof a thermal effect rather than non-thermal.Mild heating has the effect of reducing pain andmuscle spasm and promoting healing process. Kramer(1987), investigating the increase in conduction velocityin motor and sensory nerves following therapeuticultrasound, concluded that this was likely to be relatedto the heating effect of ultrasound.12Diclofenac sodium is a very commonly used non-steroidal anti-inflammatory drug (NSAIDs). It is ananalgesic-anti-pyretic-anti-inflammatory drug, similarin efficacy to naproxen. It inhibits PG synthesis and issomewhat COX-2 selective.13The mechanism by which ultrasound enhances thetransdermal penetration of substances is not entirelyclear. One could think of the vasodilation observed onmacroscopic examination, but this would certainly notbe enough on its own, since it does not imply anychangeofthewaterproofkeratinlayeroftheskin,whichshould necessarily be altered.18No volunteers presented any complication of anykind nor did they report any discomfort with thetreatment at any time, all of them resuming normal lifeimmediatelyaftertheendoftreatmentApartfromslightredness and a temperature increase on touch, no signof local irritation was detected by macroscopicinspection of the irradiated areas.8CONCLUSIONThe study concludes that continous mode ofultrasound is better for immediate pain relive ascompared to pulsed mode when diclofenac sodium isused as the coupling medium for immediate pain relivein tender point in muscles all over the body.REFERENCES1. Ali Gur; Physical Therapy Modalities inManagement of Fibromyalgia; CurrentPharmaceutical Design, 2006 12, 29-352. Haraldsson B, Gross A, Myers CD, Ezzo J, MorienA,GoldsmithCH,PelosoPMJ,BrønfortG,CervicalOverview Group. Massage for mechanical neckdisorders. Cochrane Database of SystematicReviews 2006, Issue 3. Art. No.: CD004871. DOI:10.1002/14651858.CD004871.pub33. Sheila Kitchen, Electrotherapy Evidence-basedPractice, Eleventh Edition, pg 221-228DISCUSSIONAccording to the unpaired t test done between postvalues of VAS in case of pulsed mode and continousmode the p value is <0.005. The post value of ROM inpulsed mode and continous mode the p value is <0.005.In this study, the clinical efficacy of diclofenac gelas a coupling agent using continuous mode of wascompared with pulsed mode.According to the study, by using continuous modeof ultrasound there is more pain relive rather than byusing pulsed mode.Continuous mode has been recommended formuscular cellular disorders such as muscle spasm, jointstiffness or pain whereas pulsed mode is preferred forsoft tissue repair.12This could be because in pulsed mode the timeaverage intensity is reduced which reduces the amountof energy available to heat the tissues while ensuringthat the energy available in each pulse is high enoughfor mechanical or non-thermal effects rather than thethermal effects to predominate.126. chhavi gupta 5th april --26-30.pmd 2/7/2013, 8:08 PM29
  • 36. 30 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 14. Sangita Chakrabarty, Md, Msph, Roger Zoorob,Md, Mph; Fibromyalgia; American FamilyPhysician; Volume 76, Number 2 July 15, 20075. Sunday Akinbo, Oluwatoyosi Owoeye, SundayAdesegun; Comparison of the TherapeuticEfficacy of Diclofenac Sodium and MethylSalicylate Phonophoresis in the Management ofKnee Osteoarthritis; Turk J Rheumatol2011;26(2):111-1196. PeterCroft,JonathanBurt,JoannaSchollum,ElaineThomas, Gary Macfarlane, Alan Silman; Morepain, more tender points: is fibromyalgia just oneend of a continuous spectrum?; Annals of theRheumatic Diseases 1996; 55: 482-4857. Giovana c. Rosim, Cláudio Henrique Barbieri,Fernando Mauro Lanças, and Nilton Mazzer;Diclofenac Phonophoresis In Human Volunteers;Ultrasound in Med. & Biol., Vol. 31 No. 3 pp. 337-343, 20058. Russell Rothenberg, MD; Fibromayalgia,pathophysiology and treatment; Fibromyalgiafrontiers, 2010, vol. 18, No. 19. Prerna Paul et. al.; Effect of Lumbar StabilizationExercise in Treatment of Young Individuals WithNon Specific Low Back Pain; The PhysiotherapyPost; July-September 2011. Vol 3, No. 310. Afyonkarahisar, Turkey; Effectiveness ofUltrasound Therapy in Cervical Myofascial PainSyndrome: A Double Blind, Placebo-ControlledStudy; Turk J Rheumatol 2010; 25: 110-511. Robert D Gerwin; A review of myofascial pain andfibromyalgia – factors that promote theirpersistence; ACUPUNCTURE IN MEDICINE2005; 23(3):121-134.12. John low BA(Hons.), FCSP, DipTP, SRP,Ann ReedBA, MCSP, DipTP, SRP; Electrptherapt ExplainedPrinciples and Practice, 3rd edition, pg 172-19613. KD Tripathi; Essentials of Medical Pharmacology;6th edition; page 184-19414. Bijur PE, Silver W, Gallagher EJ.; Reliability of thevisual analog scale for measurement of acute pain;Acad Emerg Med. 2001 Dec;8(12):1153-715. James W Youdas, James R Carey and Tom RGarrett; Reliability of Measurements of CervicalSpine Range of Motion-comparison of ThreeMethods; PHYS THER. 1991; 71:98-10416. Kamal Dua, V.K.Sharma, UVS Sara, D.K.Agrawal,M.V.Ramana; Penetration Enhancers for TDDS:ATaleoftheUnderSkinTravelers;Adv.inNat.Appl.Sci., 3(1): 95-101, 20096. chhavi gupta 5th april --26-30.pmd 2/7/2013, 8:08 PM30
  • 37. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 31Prediction of Relationship of Visual Attention Deficits toBalance and Functional Outcome in Persons withSubacute StrokeChintan Shah1, Hasmukh Patel2, Komal Soni1,Dhaval Desai1, Harshit Soni11Lecturer, Spb Physiotherapy College, Surat, 2Clinical Therapist, U. N. Mehta Institute ofCardiology and Research Centre, AhmedabadABSTRACTBackground: Stroke is a focal neurological disorder lasting for more than twenty-four hours, giving riseto functional disabilities in speech, vision, balance and ADL. As stroke has been found to impairvision, balance and ADL, this study is done to predict the relationship of visual attention deficits tobalance and functional outcomes in persons with subacute stroke. Awareness of such relationshipmay be of useful assistance to the physiotherapists in planning treatment interventions in personswith subacute stroke.Objective: To predict and estimate strength of the relationship of visual attention deficit to balance andfunctional outcomes in persons with subacute stroke.Materials and Methods: 50 subjects with subacute stroke were selected for the study. All the patientswere assessed on the basis of Star Cancellation Test (SCT), Berg Balance Scale (BBS) and Barthel Index(BI) for visual attention, balance and functional outcomes respectively both at the time of dischargefrom the hospital and also after 6 months post-stroke. At the end of the study, visual attention scoreswere correlated (using Pearson product correlation "r" value) with the balance scores and functionaloutcome scores obtained at the time of discharge from the hospital and 6 months post-stroke.Result: Mean±SD of scores for Star Cancellation test, Berg Balance scale and Barthel index measured atthe time of discharge from hospital and 6 months post stroke was 48.09±2.04, 49.86±1.91, 40.00±2.00,42.60±1.90, 70.00±10.00, 75.10±9.92 respectively. Moreover, there was strong positive and highlysignificant correlation of SCT scores with BBS scores and BI scores both at the time of discharge and 6months post stroke.Interpretation & Conclusion: Visual attention deficit is an important factor to predict the balance andfunctional outcomes in persons with subacute stroke.Keywords: Stroke, Visual Attention Deficit, Balance, Functional Outcome.Corresponding author:Chintan ShahB-701, Aagam Vihar Apt, Opp Lakhoz Club, Umra,Surat-07, Gujarat, IndiaE-mail: chintoo601@gmail.comINTRODUCTIONStroke is an acute onset of neurological dysfunctiondue to an abnormality in cerebral circulation withresultant sign and symptoms that correspond toinvolvement of focal areas of brain.1Cognitive deficitsare common after stroke2,3and have been linked to poorrecovery of ADL (Activities of Daily Living) abilitiesand rehabilitation outcome.4,5For many people, theseimpairments are the major obstacles preventing theirreturn to independence and quality of life.6Attention is one of the aspects of cognitivefunctioning that has been reported as the basis for othercomponents of cognition.7Visual attention is a type ofselective attention that lays a very important role inbalance because balance is maintained mainly byfeedback through eyes, ears and vestibular apparatus.In this visual contribution is inevitable and if there isvisual inattention, then there will be difficulty infeedback mechanism and this will directly affect thebalance and eventually ADLs. Visual impairmentscommonly encountered by patient with hemiplegiainclude poor eyesight, diplopia, homonymoushemianopia, damage to visual cortex and retinaldamage.8In its purest form, unilateral spatialinattention is defined as a condition in which anindividual with normal sensory and motor system fails7. chintanshah 23rd april-31-36.pmd 2/7/2013, 8:08 PM31
  • 38. 32 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1to orient toward, respond to, or report stimuli on theside contralateral to the cerebral lesion.9Attention isalso a key component in learning new motor skills,particularly in the early stages of learning.10This clearlyportraits that attentional component plays a veryimportant role in motor learning and also depictsimportance of attention in rehabilitation of strokepatients especially in Motor Relearning Programmewhich is the latest approach in physiotherapyrehabilitation.In stroke, physical impairments include motor,sensory, balance, urinary impairment, speech disorder,perceptual problems, etc. Balance has been defined asthe ability to maintain upright posture.11,12In stroke,one’s ability to balance may be impaired because ofdeficitsofstrength,rangeofmovements,proprioception,vision, vestibular function and endurance.13Studieshave showed that balance and perceptual disturbanceare found as risk factors for falls in stroke patients.14ADL are the activities necessary for daily self care,personal maintenance and independent communityliving such as feeding, bathing, dressing, hygiene, andphysical mobility.15Studies have reported decline incognition, mobility and functional daily activity afterstroke.16Also the presence of visual field deficit is beingreported as a significant prognostic sign, predictingboth a higher death rate following stroke and poorperformance in ADLs, even following rehabilitation.17,18Further, attention deficits being common amonghospitalized people with stroke, a study describingassociation between distractibility, auditory selectiveattention, balance and function impairments shownthat those who scored well on the auditory selectivetest had better balance scores at the final assessmentthan those with auditory selective attention deficits ordistractibility.19However there are no clear cut studies that showthat whether visual attention deficits correlate withbalance, and eventually functional outcomes insubacute stroke patients. Keeping in view the abovepoint, this study is set out to predict the relationship ofvisual attention deficits to balance and functionaloutcome in patients with subacute stroke.The aims and objectives of the study were1. To find out the relationship between visualattention deficits and balance at the time ofdischarge and after 6 months post-stroke.2. To find out the relationship between visualattention deficits and functional performance at thetime of discharge and after 6 months post-stroke.METHODOLOGYStudy design: An Observational Correlation studySample size: 50 individualsSampling method: Purposive sampling techniqueStudy Setting: Laxmi Memorial College ofPhysiotherapy and A.J. Hospital and Research Centre,MangaloreStudy duration: 6 months (from the time of discharge ofpatient from the hospital upto 6 months post-stroke).Inclusion criteria1. Above 50 years of age.2. Both sexes.3. All type of stroke and first time stroke.4. Attention deficits should be present in the patient.5. Deemed to be fit by the physician and medicallystable.6. Subjects should undergo continuous conventionalphysiotherapy.Exclusion criteria1. Major musculoskeletal problems (amputation orrecent joint replacement surgery).2. Any other neurological disorders in addition tostroke.3. Severe perceptual disorders.4. Severe cognitive deficit (Mini Mental StateExamination score < 23/30).Materials used: Test paper of size 8.5 inch x 11 inchwith 52 large stars, 13 letters and 10 short wordsinterspersed with 56 small stars for the testing of visualattention. Other materials included were pencil, stopwatch/wrist watch, ruler, two standard chairs (onewith and one without arm-rest), foot-stool or step.(Fig: 1)7. chintanshah 23rd april-31-36.pmd 2/7/2013, 8:08 PM32
  • 39. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 33Outcome MeasuresStar Cancellation Test (SCT) to assess visual attention,Berg Balance (BB) scale to assess balance andBarthel Index (BI) to assess functional performance(ADL).PROCEDUREAfter signing the written informed consent (toparticipate in the study and to allow reproduction oftheir photographs) subjects were made to participatein study and baseline measurements of demographicfactors and outcome measures were recorded. Everypatientsweregivenproperinstructions(butnotraining)prior to assessing the outcome measures viz. StarCancellation Test (Fig: 2), Barthel Index (Fig: 3) and BergBalance Scale (Fig: 4)All outcome measures were taken at the time ofdischarge from hospital and later 6 months after stroke.Following the recording of the above parameters,the obtained scores were tabulated and comparedamong both the study groups.Ethical Consideration: Procedures followed were inaccordance with the ethical standards of HelsinkiDeclaration of 1975, as revised in 2000.20Fig: 1 Tools UsedFig. 3 stepping activity for Barthel IndexFig. 4 Therapist Testing Berg Balance ScaleFig. 2 Star Cancellation Test7. chintanshah 23rd april-31-36.pmd 2/7/2013, 8:08 PM33
  • 40. 34 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Statistical AnalysisOf the 50 participants who participated in the study,none were lost to follow up assessment at the end of thestudy.At the end of the study, visual attention scores werecorrelated with the balance scores and functionaloutcome scores both at the time of discharge from thehospital and also after 6 months post-stroke. Pearsonproduct correlation “r” value was used to find therelationship among the variables. P value< 0.01 wastaken up for statistical significance. Data analysissoftware SPSS 13.0 version has been used for the dataanalysis of present study.Table 1: Descriptive statistics for Outcome measuresStar Cancellation test Berg Balance Scale Barthel IndexTime of After Time of After Time of AfterDischarge 6 months Discharge 6 months Discharge 6 monthsMin 45 51 37 43 55 85Max 47 53 40 46 60 90Mean 48.06 49.86 40.00 42.60 70 75.10Std. Deviation 2.045 1.917 2.000 1.906 10.000 9.923Table 2: Correlation of SCT scores with the BBS scores & BI scores at the time of discharge from the hospitalr value P Level ofSignificance/InterpretationStar Cancelation test Berg Balance Scale .978 .000 HS(Time of Discharge) (Time of Discharge)Barthel Index .978 .000 HS(Time of Discharge)As shown in table 2, there is strong positive and highly significant (p<0.01) correlation between SCT scores (atthe time of discharge) and BBS scores (at the time of discharge) and also between SCT scores (at the time ofdischarge) and BI scores (at the time of discharge).Table 3: Correlation of SCT scores with the BBS scores & BI scores after 6 months post stroker value P Level ofSignificanceStar Cancelation test Berg Balance Scale(After 6 months) (After 6 months) .951 .000 HSBarthel Index(After 6 months) .966 .000 HSRESULTSGraph 1: Age & Gender distribution of the subjectsAs shown in table 3, there is strong positive andhighly significant (p<0.01) correlation between SCTscores (6 months post stroke) and BBS scores (6 monthspost stroke) and also between SCT scores (6 monthspost stroke) and BI scores (6 months post stroke).7. chintanshah 23rd april-31-36.pmd 2/7/2013, 8:08 PM34
  • 41. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 35Table 4: Correlation of SCT scores at the time of discharge with theBBS scores & BI scores after 6 months post stroker value P Level ofSignificanceStar Cancelation test Berg Balance Scale .944 .000 HS(Time of Discharge) (After 6 months)Barthel Index(After 6 months) .970 .000 HSAs shown in table 4, there is strong positive andhighly significant (p<0.01) correlation between SCTscores (at the time of discharge) and BBS scores (6months post stroke) and also between SCT scores (atthe time of discharge) and BI scores (6 months poststroke).DISCUSSIONStroke is a focal neurological disorder lasting formore than 24 hours, giving rise to functional disabilitiesin speech, vision, balance and ADL. Hence, in our studywe have tried to predict the relationship between visualattention deficits, balance and functional outcomes inpersons with subacute stroke. Results from our studyindicates that attention deficits were present among thepersons with subacute stroke, Sinclair R (1995) alsoreported similar findings using some of the samesubtests among subacute stroke patients.19Moreover,the visual attention deficits have a significant influenceon the balance both at the time of discharge from thehospital and also after 6 months post-stroke. Sebstinaand Vyas (2001)21also concluded that cognitive andperceptual deficits following stroke influences sittingand standing balance among patients. Visual attentionhas directly proportional relation with balance.However, findings of Stapleton and colleagues (2001)suggested a weak or no relationship between attentiondeficits and balance control, but their sample size beingtoo small (n=13) the results can be doubted for beingstatistically significancant.22There was significant correlation between the SCTscores at the time of discharge from the hospital withthe BBS score and BI score after 6 months post-stroke.Thus, the present study not only finds the relationshipbetween visual attention, balance and functionaloutcome but it also predicts the balance and functionaloutcome after 6 months with the visual attention scoreat discharge. However, present study showed thatvisual attention deficits affect the balance andfunctional outcome significantly but visual attentiondeficit is not the only factor that can affect the balanceand functional outcome. The assessment of suchattention deficits post-stroke may be a useful tool inpredicting functional recovery and response torehabilitation. Awareness of possible deficits ofattention may be of assistance to physiotherapists inplanning interventions with patients recovering fromstroke.Limitations of the study• The study was done on a small sample size.• The study only included visual attention amongthe various types of attention.• Only old aged i.e. above 50 years patients withsubacutestrokewereassessedtofindtheprediction,young age stroke patients were not at all assessed.Scope of further studies• In future studies, all types of attention (sustainedattention, divided attention, etc.) other than visualattention can be taken as predictor of balance andfunctional outcomes.• Same study can be done in subacute stroke patientswithout ongoing physiotherapy.• BBS does not include gait items so some other scalecan be used to assess the dynamic balance ofsubjects with stroke.CONCLUSIONVisual attention deficits are an important factorresponsible for predicting balance and functionaloutcomes in persons with subacute stroke. There issignificant one to one relationship between visualattention deficit to balance and functional recovery inpersons with subacute stroke.ACKNOWLEDGMENTSWe are thankful to all our subjects who participatedwith full cooperation and showed voluntary interest7. chintanshah 23rd april-31-36.pmd 2/7/2013, 8:08 PM35
  • 42. 36 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1REFERENCES1. Susan B. O’Sullivan, Thomas J. Schmitz, PhysicalRehabilitation: Assessment & treatment, 4thEdition: Jaypee Brothers, 2001:519-5812. Hom J, Reitan RM. Generalized cognitive functionafter stroke. J Clin Exp Neuropsychol. 1990Oct;12(5):644-654.3. Pedersen PM, Jørgensen HS, Nakayama H,Raaschou HO, Olsen TS..Orientation in the acuteand chronic stroke patient: impact on ADL andsocial activities. The Copenhagen Stroke Study.Arch Phys Med Rehabil. 1996 Apr;77(4):336-339.4. WadeDT,SkilbeckC,HewerRL.Selectedcognitivelosses after stroke. Frequency, recovery andprognostic importance. Int Disabil Stud. 1989 Jan-Mar;11(1):34-39.5. Benson C, Lusardi P.Neurologic antecedents topatient falls. J Neurosci Nurs. 1995 Dec;27(6):331-337.6. Polly Laidler, Stroke Rehabilitation-structure andstratergy, 1stEdition, 1994: 99-1147. Whyte J .Attention and arousal: basic scienceaspects. Arch Phys Med Rehabil. 1992Oct;73(10):940-949.8. Susan B. O’Sullivan, Thomas J. Schmitz, PhysicalRehabilitation: Assessment & treatment, 4thEdition: Jaypee Brothers, 2001: 961-999. Dascy Umphred, Neurological rehabilitation, 4thEdition:821-85110. Schmist R, Motor Control and Learning: Abehavioral emphasis (2ndEdition)Champaing, IL:Human Kinetic Publisher11. Nashner LM (1989) Sensory, neuromuscular andbiomechanical contributions to human balance.In: Proceedings of the American Physical TherapyAssociation Forum. Nashville. TN. pp. 5-12.12. Roberta Newton. Review of tests of standingbalance abilities. Brain Injury 1989; 3(4):335-4313. Nashler L: Evaluation of postural stability,movement and control. In Hasson(ed): Clinicalexercise physiology, Philadelphia, CV Mosby, 199414. Lars Nyberg, Yngve Gustafson. Patient Falls inStroke Rehabilitation: A Challenge toRehabilitation Strategies. Stroke, 1995;26:838-4215. Susan B. O’Sullivan, Thomas J. Schmitz, PhysicalRehabilitation: Assessment & treatment, 4thEdition: Jaypee Brothers, 2001:328-32916. Medline plus, a service of the us national libraryof medicine and the national institute of health,15th may, 200817. Pak R and Dombrovy ML: Stroke. In Good, DCand Couch JR(eds): Handbook ofNeurorehabilitation. Marcel Dekker, Newyork,1994:46118. Armin F. Haerer. Visual Field Defects and thePrognosis of Stroke Patients, Stroke 1973; 4:163-16819. Sinclair R, A study examining sitting balance andthe presence of attention deficit post-stroke, MscThesis, University of Southampton, UK, 1995.20. WMA Declaration of Helsinki - Ethical Principlesfor Medical Research Involving Human Subjects.[59thWMA General Assembly Seoul, Korea, Oct2008].Available from: SebstinaA.Borges,OnaA.Vyas. Studyaddressingthe impact of cognitive and perceptual deficits onsitting and standing balance following CVA.Journal of occupational therapy;33(1):april- july 2001.22. Stapleton, T., Ashburn, A. and Stack, E. (2001) Apilot study of attention deficits, balance controland falls in the subacute stage following stroke.Clinical Rehabilitation;15(4):437- 444.7. chintanshah 23rd april-31-36.pmd 2/7/2013, 8:08 PM36
  • 43. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 37The effects of Therapeutic Application of Heator Cold Followed by Static Stretch on HamstringFlexibility Post Burn ContractureEmad T. Ahmed1, Safa S. Abdelkarim21AssistantProfessorofPhysicalTherapy,PhysicalTherapyDepartmentforSurgery,FacultyofPhysicalTherapy,CairoUniversity,Egypt,2PhysicalTherapist,NaserHospital,Cairo,EgyptABSTRACTObjective : The purpose of this study was to determine the best warming up modality prior to staticstretching exercises to increase flexibility in post burn contracture of the hamstring muscle, as measuredby knee extension range of motion.Materials and methods: Thirty male patients ranging in age from 18 to 27 years and who had decreasedhamstring muscle flexibility as a result of partial thickness burn were classified into 3 equal groups 10of each, Group (1): received 1 minutes of stretching exercise in addition to ultrasound , Group (2):received 1 minutes of stretching exercise in addition to cold application. And Group (3): received 1minutes of sating stretching only.All groups received stretching exercises 5 days per week for 8 weeks.Measurements of knee extension range of motion were conducted before treatment, post 2 weeks oftreatment, and after 4 weeks of treatment.Results: The one way analysis of variance was used to compare knee extension range of motion whichrevealed that both treatment group (ultrasound and cold application) had significant (P< 0.05) gains inknee extension ROM after 2 and 4 weeks post stretching exercises.Conclusion: The results of this study suggest that either deep hot or cold application in addition tostretching exercise is more effective than static stretching alone to improve a hamstring muscle.Keywords: : Burn, Contracture, Range of motion, Ultrasound, Cold application, Flexibility.Corresponding author:Emad T.AhmedDesignations: Faculty of Physical Therapy,Cairo University, Cairo, EgyptAddress: Taif, KSA, Box: 2425INTRODUCTIONContractures are defined as an inability to performfull range of motion of a joint.1They result from acombination of possible factors- limb positioning,duration of immobilization and muscle, soft tissue, andbony pathology. Individuals with burn injuries are atrisk for developing contractures. Patients with burnsoften are immobilized, both globally, as a result ofcritical illness in the severely burned, and focally, as aresult of the burn itself because of pain, splinting, andpositioning. Burns, by definition, damage the skin andalso may involve damage to the underlying soft tissue,muscle, and bone. All of these factors contribute tocontracture formation in burn injury.Contractures place patients at risk for additionalmedical problems and functional deficits. Contracturesinterfere with skin and graft healing. Functionally,contractures of the lower extremities interfere withtransfers, seating, and ambulation. Contractures of theupper extremities may affect activities of daily living,such as grooming, dressing, eating, and bathing, as wellas fine motor tasks.2,3Ill treatment or inadequate splinting andrehabilitation after burn injuries inevitably result indebilitating post burn contractures that impair variousfunctional abilities of the involved limb. Among these,hamstring post burn contracture remain a frequentproblem due to difficulties of knee extension againstthe contractile evolution of the scar 4.Historically, clinicians have prescribed differentstatic stretching techniques as a means of increasingflexibility 5. Research has shown static stretch to beeffective in increasing the length of connective tissue6.Warren et al explored the effects of stretching on rat tailtendon6.They found that low-load, long duration8. Emad cairo-37-41.pmd 2/7/2013, 8:08 PM37
  • 44. 38 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1stretching of rat tail tendon was more effective inincreasing rat tail tendon length than high load, shortduration stretching6. Therapists often use deep heatingmodalities to increase tissue extensibility to allow forincreased efficacy of stretching techniques. Wessling eta1 found that static stretch combined with ultrasoundincreased the extensibility of triceps surae muscle(measured by changes in dorsiflexion) more than staticstretch alone 7. Laboratory studies also indicate thatpassive warming of the musculotendinous unitincreases its extensibility 8.9. Noonan et al and Strickleret al interpreted their research as evidence that passivewarming may decrease the possibility of strain injurysecondary to extensibility changes 8.9.The basis for using cold in combination withstretching, like heat, is pain reduction and decreasedmuscle guarding. Cold may relieve pain by acting as acounterirritant10The purpose of our study was to determine if theapplication of a superficial heating or cooling modality,followed by a 1-minute static stretch to the hamstringmuscle, increases the efficacy of the hamstring stretchalone.Subjects material and methodSubjectsPatients treated from burn injuries at El-Husseinteaching hospital were randomly selected forparticipation in this study. This study eligibilityrequired that patients be more than 18 years of age; 3 to8 months after the occurrence of the burn injury; hadunilateral scars across popliteal fossa of the knee andthe percentage of burn did not exceed 20%, and had nohistory of other lower extremity pathology.Inclusion assessment to participate in the study,subjects must have exhibited unilateral tight hamstringmuscles. Operationally defined as having greater than30 degrees loss of knee extension . In addition, subjectswho were not involved in any exercise activity at thestart of the study had to agree to avoid lower extremityexercises and activities other than those prescribed bythe research protocol. During the 8 weeks of training 20male subjects, with age range from 18 to 32 years, metthe established criteria and completed the study.Group assignmentTo ensure equal distribution of hamstring musclecontracture, the patients were stratified into threegroups based on their degree of hamstring musclecontracture. Patients assigned to group 1 (n=10 patients,age=23.80 years, and range=60.2) served as treatmentgroup 1 and received deep heat in addition to staticstretch for 1 minute. Patients assigned to group 2 (n=10patients, age=24.30 years, and range=60.2) served astreatment group 2 and received cold in addition to staticstretch for 1 minute. Patients assigned to group 3 (n=10patients, age=24.30 years, and range=60.2) served ascontrol group 3 and received stretch only for 1 minute.INSTRUMENTATIONMeasurement toolsA double-arm (30.5 cm) clear plastic goniometer wasused to measure knee extension ROM. Prior to datacollection; we performed a pilot study to establish intra-tester reliability of measurements of knee extensionROM. A test-retest design was used on 10 subjects ofsimilar hamstring contracture, with measurementstaken week a part. Reliability was determined using anintraclass correlation coefficient. An ICC of 0.96 wasconsidered appropriate for continuing the study.Treatment toolsA sonopulse 434 ultrasound unit was used toadminister the deep heat as warming up prior tostretching, on the other hand, Enraf nonius chilling unitC5wasusedtodelivercoldattemperatureaveragefrom-12°C to - 6°C prior to stretch.Experimental procedureMeasurement protocolMeasurement of knee extension ROM was madewith the subject lying supine with the opposite lowerextremity extended and the lower extremity beingmeasured positioned at 90 degrees of hip flexion. Thegreater trochanter and lateral epicondyle of the femurand the lateral malleolus were palpated and served aslandmarks during measurement. We attempted tomaintain hip flexion at 90 degrees while the tibia wasmoved into the terminal position of knee extension,which was defined as the point at which the subjectreported feeling of discomfort. Zero degree wasconsidered to be 90 degrees of knee flexion. Thegoniometric value was recorded. The measurement ofknee extension ROM was considered to be an indirectmeasure of hamstring muscle flexibility, with hamstringmuscle tightness being the purported cause of a lack ofknee extension ROM. All subjects were measured onthe same day and at the same time, before they hadstretching for that day. Measurements were taken before8. Emad cairo-37-41.pmd 2/7/2013, 8:08 PM38
  • 45. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 39treatment, post 2 weeks of treatment and post 4 weeksof treatment.Treatment protocolUltrasound treatments were performed using ansonopulse 434 ultrasound unit at a frequency of 1 MHzwith an intensity of 1.5 W/cm2. A water based gel,maintained at room temperature, was used as aconducting medium. A template was placed over themusculotendinous junction of the hamstring musclegroup to ensure that the treatment area remained atfour times the effective radiating area of the transducerhead. The principle investigator performed alltreatments using the same ultrasound unit which hadbeenrecentlycalibrated.EachUStreatmentlastedsevenminutes. If subjects complained of intense heat or anyabnormal sensations, treatment was discontinued.The cold treatment consisted of a -12°C gel packwrapped in one layer of a wet terry cloth towel appliedto the posterior thigh for 20 minutes. The stretch onlygroup received no modality.All subjects were in a proneposition for the duration of their treatments. At the endof 20 minutes, the hot or cold treatments were removed.All subjects then performed the static stretch to thehamstrings by the following method. In a long sittingposition, each subject rested the heel of the untreatedlower extremity along the medial surface of the treatedthigh. The subject then reached forward to grasp theankle of the treated lower extremity. Each subject thenperformed one continuous stretch to pain tolerance,without bouncing, for 1 minute.DATA ANALYSISThe equivalence of treatment groups regarding theamount of knee flexion contractures prior to the studywas checked by conducting one way analysis ofvariance on knee range of motion. Inferential analysisof the data obtained in this study was done via 2 X 3analysis of variance experimental design for treatments-by-treatments by subjects. For all statistical tests andallfollow-uptests,the0.05levelofprobabilitywasused.RESULTSThe descriptive characteristics of the subjects in bothtreatment groups and control group are shown in table(1) There was no statistical difference between the twotreatment groups and control group regarding the age,depth of burn, percentage of burn and the duration postburn.Table (1): Descriptive characteristics of patients in the three groups .Comparison G 1 G 2 G3 P value SignificanceMean ±SD Mean +SD Mean +SDAge in years s 22.880±2.064 22.760±2.589 23.420± 2.669 P>0.05 NSDepth of burn in millimeters 2.519±0.3644 2.488±0.3672 2.620± 0.5714 P>0.05 NSDuration post burn in months 4.125±0.8345 4.750± 1.035 4.375±0.9161 P>0.05 NS% of burn 16.388±0.5463 16.375±0.9223 16.550±1.589 P>0.05 NSTable (2): Comparison between two treatment groups and control group mean results measured before theapplication of any treatment modality.Comparison Pre treatment measurementG1 G2 G1 G3 G2 G3Mean 60.780 61.620 60.780 62.520 61.620 62.520SD 2.619 1.844 2.619 1.085 1.844 1.085Sig. NS NS NSP-value P>0.05 P>0.05 P>0.05S= Significant, HS= Highly significant , NS= not significantIn the first treatment group (ultrasound andstretching), the mean values for knee extension were60.7 degrees (SD = ± 2.619), for the pre-testmeasurement, 61.620 degrees (SD = ± 1.844), for thesecond treatment group i.e: cold application andstretching, and 62.520 degrees (SD = ± 1.085) forcontrol group i.e: stretching only. One way analysisof variance demonstrated no statistically significantdifference between the two treatment groups andcontrolgroupkneeextensionrangeofmotion(P>0.05)table(2).8. Emad cairo-37-41.pmd 2/7/2013, 8:08 PM39
  • 46. 40 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Table (3): Comparison between two treatment groups and control group mean results measured after 2 weeks ofthe application of any treatment modality.Comparison Post (1) treatment measurementG1 G2 G1 G3 G2 G3Mean 73.450 70.190 73.450 67.380 70.190 67.380SD 2.061 1.996 2.061 1.248 1.996 1.248Sig. S HS SP-value P<0.01 P<0.001 P<0.05S= Significant, HS= Highly significant , NS= not significantIn the first treatment group (ultrasound andstretching), the mean values for knee extension were73.450 degrees (SD = ± 2.061), for the post(1) treatmentmeasurement, 70.190 degrees (SD = ± 1.996), for thesecond treatment group i.e: cold application andstretching, and 67.380 degrees (SD = ± 1.248) for controlgroup i.e: stretching only. One way analysis of variancedemonstrated a statistically significant differencebetween the two treatment groups and control groupregarding knee extension range of motion (P<0.01)table(3).Table (4): Comparison between two treatment groups and control group mean results measured after 2 weeks ofthe application of any treatment modality.Comparison Post (2) treatment measurementG1 G2 G1 G3 G2 G3Mean 93.290 87.960 93.290 84.830 87.960 84.830SD 2.418 1.435 2.418 1.760 1.435 1.760Sig. S HS SP-value P<0.001 P<0.001 P<0.05S= Significant, HS= Highly significant , NS= not significantIn the first treatment group (ultrasound andstretching), the mean values for knee extension were93.290 degrees (SD = ± 2.418), for the post(2) treatmentmeasurement, 87.960 degrees (SD = ± 1.435), for thesecond treatment group i.e: cold application andstretching, and 84.830 degrees (SD = ± 1.760) for controlgroup i.e: stretching only. One way analysis of variancedemonstrated a statistically significant differencebetween the two treatment groups and control groupregarding knee extension range of motion (P<0.01)table(4).DISCUSSIONOur study was designed to obtain a more thoroughunderstanding of stretching protocols for increasingROM and how the use of therapeutic physical agentscan affect these protocols in the clinical setting.According to the data, in a treatment lasting 4 weeks orless, cold packs, or ultrasound prior to stretching orstretching alone achieved similar results in increasingknee extension ROM.The results of the current study support the findingsof other studies that static stretching is effective inincreasing hamstring length11,12.The results indicated that either deep heating orcold application followed by static stretching for oneminute was more effective in increasing knee extensionROM than static stretching alone for one minute after 3to 8 months post burn contracture. These results goeshand in hand with those of Wessling et al13, whoclaimed that a significant increase in ankle dorsiflexionwith the use of ultrasound combined with static stretchcompared to static stretch alone.Ultrasound and other deep heating modalities arebelieved to cause collagen to become more extensible,thus increasing the efficacy of a stretch13,14.Fischer andSolomon suggest that heating of the skin reducesgamma motor neuron excitability15. This woulddecrease the sensitivity of muscle spindles, which maydecrease muscle guarding. On the other hand,Brodowicz et al16observed that ice application duringstretching increased hamstring flexibility, whereas heatand static stretching was not effective.Cold may reduce muscle guarding by reducing theactivity of the muscle spindles. Knuttsson and Mattssonsuggest that superficial cooling can cause reduction ingamma motor neuron activity through the stimulationof skin receptors17. On the other hand , Newton found8. Emad cairo-37-41.pmd 2/7/2013, 8:08 PM40
  • 47. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 41the use of vapocoolants, in a spray and stretchtechnique, did not increase passive hip flexion inhealthy adults18.CONCLUSIONAll experimental groups in this study producedincreases in the extensibility of the hamstring muscle,resulting in increases in PROM when compared withthe control group. The group receiving ultrasound priorto stretching obtained the greatest increases in kneeextension PROM over a 4-week period. This study willallow clinicians more options in effectively increasingthe extensibility of the hamstring muscles. In addition,the results of this study will permit the clinician thechoice of a cost-effective treatment alternative in an eraof more stringent reimbursement.ACKNOWLEDGEMENTWe are indebted to Cairo University, Cairo, Egypt,Faculty of Physical Therapy, Department of Physicaltherapy for Surgery, for their permission tocommencement the study in the El-Hussein TeachingHospital / physiotherapy departments and to theparticipants.Conflict of interestWe certify that there is no conflict of interest withany financial organization regarding the materialdiscussed in the manuscript.Source of fundingThis research received no specific grant from anyfunding agency in the public, commercial, or not / forprofit sectors.Ethical clearanceWe certify that this study involving human subjectsis in accordance with Helsinky declaration of 1975 asrevised in 2000 and that it has been approved by therelevant ethical committee.REFERENCES1. Mosby’s Dictionary. 6th ed. St. Louis: Mosby, Inc.;2002.2. PalmieriTL,PetuskeyK,BagleyA,etal.Alterationsin functional movement after axillary burn scarcontracture: a motion analysis study. J Burn CareRehabil 2003;24:104–8.3. Kowalske KJ, Voege JR, Cromes GF Jr., et al. Therelationship between upper extremitycontractures and functional outcome after burninjury (abstr). Proc Am Burn Assoc 1996;28:55.4. Nisanci M., Ergin E.R., Selcuk I. & Mustafa S.:Treatment modalities for post burn axillarycontractures and the versatility of the scapularflap. Burns, 28: 177-180, 2002.5. StanishWD,Hubley-KozeyCL:Neurophysiologyof stretching. In: D’ Ambrosia R, Drez D (eds),Prevention and Treatment of Running Injuries,Thorofare, NJ: Slack, 1989.6. WarrenCG,LehmannJF,KoblanskiJN:Elongationof rat tail tendon: Effect of load and temperature.Arch Phys Med Rehabil. 52:465-472, 1971.7. Wessling D, DeVane D, Hylton C: Effects of staticstretch versus static stretch and ultrasoundcombined on triceps surae muscle extensibility inhealthy women. Phys Ther 67:674-679, 1987.8. Noonan TI, Best TM, Seaber AV, Garrett WE:Thermaleffectsonskeletalmuscletensilebehavior.Am J Sports Med 2 1 :5 17-522, 1993.9. Strickler T, Malone T, Garrett WE: The effects ofpassive warming on muscle injury. Am J SportsMed 18:141-145, 1990.10. Fruhstorfer H, Hermanns M, Latzke L: The effectsof thermal stimulation on clinical andexperimental itch. Pain 24:259-269, 198611. Gajdosik RL: Effects of static stretching on themaximal length and resistance to passive stretchof short hamstring muscles. J Orthop Sports PhysTher 14:250-255, 1991.12. Henricson AS, Fredriksson K, Persson I ,PereiraR, Rostedt Y, Westlin N: The effect of heat andstretching on the range of hip motion. J OrthopSports Phys Ther 13:110-115, 1984.13. Wessling D, DeVane D, Hylton C: Effects of staticstretch versus static stretch and ultrasoundcombined on triceps surae muscle extensibility inhealthy women. Phys Ther 67:674-679, 1987.14. Lehmann JF, Masock AJ, Warren CG, Koblanski J:Effect of therapeutic temperatures on tendonextensibility. Arch Phys Med Rehabil51:481-485,1970.15. Fischer E, Solomon S: Physiological responses toheat and cold. In: Licht S(ed), Therapeutic Heatand Cold (2ndEd), pp 126-1 69. Baltimore, MD:Waverly Press, 1965.16. Brodowicz,g.r.,r.Welsh,andj.Wallis.Comparisonstretching with ice, stretching with heat, orstretching alone on hamstring flexibility. J.AthleticTrain. 31(4):324–327. 1996.17. Knuttsson E, Mattsson I: Effects of local coolingon monosynaptic reflexes in man. Scand J RehabilMed 1 :126-132,196918. Newton RA: Effects of vapocoolants on passivehip flexion in healthy subjects. Phys Ther 65:1034 - 1036, 1985.8. Emad cairo-37-41.pmd 2/7/2013, 8:08 PM41
  • 48. 42 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Pulsed Electromagnetic Therapy Improves FunctionalRecovery in Children with Erbs PalsyReda Sarhan1, Enas Elsayed2, Eman Samir Fayez21PhysicalTherapyDepartment,Al-HussienUniversityHospital,Al-AzharUniversity,2DepartmentofPhysicalTherapyforNeuromuscularDisorders&Surgery,FacultyofPhysicalTherapy,CairoUniversity,EgyptABSTRACTPurpose: The purpose of the study was to evaluate the influence of pulsed electromagnetic field therapy(PEMFT) on functional recovery in Erb palsy.Design: Randomized controlled trial.Subjects: Thirty patients were included (16 males and 14 females) with age ranged from six to twelvemonths (mean=7.3±1.1).Methods: Children were divided randomly into two equal groups, control and experimental. Bothgroups received a physiotherapy training program; in addition, the study group received PEMFT for 30min. Treatment regimen was once a day, three times/ week for three months. Measurements of theaffected upper extremity (length, girth and width, muscle strength and range of motion) were carriedout before and after treatment.Results: There was significant improvement in most of the measured test parameters in the study groupcompared to those of the control group.Conclusion: Pulsed electromagnetic therapy, in conjunction with conventional therapy program, waseffective in improving functional recovery in children with Erbs palsy.Keywords: Pulsed electromagnetic therapy, Brachial plexus injuries, Erbs palsy.INTRODUCTIONObstetric brachial plexus lesions (OBPLs) aretypically caused by traction to the brachial plexusduring labor. The incidence of OBPLis about 2 per 1000births. Most commonly, the C5 and C6 spinal nervesare affected. The prognosis is generally considered tobe good, but the percentage of children who haveresidual deficits may be as high as 20% to 30%1. Theincidence ranges from 0.38 to 3 per 1000 live births inindustrialized countries. The difference in incidencemaydependonthetypeofobstetriccareandtheaveragebirth weight of infants in different geographic regions.Improvements in obstetric technique have lowered theprevalence of obstetrical brachial plexus palsy to therange of 0.19-2.5 per 1000 2. The incidence of permanentimpairment is 3-25% and the rate of recovery in the firstfew weeks is a good indicator of final outcome.Complete recovery is unlikely if no improvement isnoted in the first two weeks of life 3.The neonatal injuryis clinically classified according to the nerve rootsinvolved. Injuries affecting the upper plexus(C5,C7roots) or so-called Erb’s injuries are dominant,compared to injuries in which the C8eT1 nerve rootsare also affected 4.Children with BPL are at risk for developingcomplications such as progressive contractures, bonydeformities, scoliosis and posterior shoulderdislocation5. Most infantile injuries to the brachialplexus predominantly involve the upper trunk (C5,6);the classic Erb’s palsy which results from excessivelateral traction on the head away from the shoulder.The infant with upper plexus palsy (C5, 6, 7) keeps thearm adducted and internally rotated with the elbowextended, forearm pronated, wrist flexed and the handin a fist. In the first hours of life, the hand also mayappear flaccid but strength soon returns 5. Papazianand associates 6reported that unfavorable functionaloutcome is related more often to aberrant reinnervationthan to lack of reinnervation. Aberrant reinnervation isespecially common in brachial plexus lesions secondaryto the close proximity of the nerves involved.9. Eman-42-46.pmd 2/7/2013, 8:08 PM42
  • 49. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 43The application of pulsed electro-magnetic fieldtherapy (PEMFT) for treating specific medicalproblemssuch as arthritis, chronic pain syndromes, woundhealing, insomnia, headache and others has steadilyincreased during the last decade7. Results from basicscience research demonstrated certain biologicaleffectsofPEMFTthatprovidearationaleforinvestigatingmorepotential clinical benefits. Human and animalorganisms consist of a large number of cells whichfunction electrically .These cells have rest potential thatis necessary for normal cellular metabolism. Diseasedor damaged cells have an altered rest potential. If theions move into an area of pulsating magnetic fields,they will be influenced by the rhythm of the pulsation.The rest potential of the cell is proportional to the ionexchange occurring at the cell membrane. The ionexchange is also responsible for the oxygen utilizationof the cell 8. Pulsating magnetic fields can dramaticallyinfluence the ion exchange at the cellular level andthereby greatly improve the oxygen utilization ofdiseased or damaged tissues. The deterioration of theoxygen utilization is known to be a problem in severalmedical branches, especially delayed healing. There areno contraindications to magnetic therapy except incases of hemorrhage or where electrical implants are inuse. Previous studies indicated that PEMF of properfrequency, intensity and duration provides beneficialeffects in a wide variety of cellular processes andmechanisms9. In the field of nervous tissue injuries,previousstudiesfoundpositiveeffectsofPEMFtherapy.Byers et al 10reported that PEMF stimulation enhancedearly regeneration of the transected facial nerve in rats.AIM OF THE STUDYThe purpose of the study was to evaluate theeffectiveness of PEMF in improving functional recoveryof the affected upper extremity in patients with Erb’spalsy.MATERIAL AND METHODThirty patients were included (sixteen boys andfourteen girls) suffering from Erb’s palsy. Regardingthe side of injury, there were 19 patients (57%) withright side and 11patients (33%) with left side. They wereselectedfromdifferentpediatricsout-patientclinics.Thechildren were divided into two equal groups (controland study groups). Inclusion Criteria: All patients werebetween six to twelve months in age, asymmetry Erb’spalsy was the sole reason for referral to the physicaltherapy out-patient clinic, onset of the injury was frombirth, all participants were having free passive ROM inall joints of the affected upper extremity, activemovement score grades ranged from two to four.Exclusion Criteria: History of malignancy,inflammatory diseases or any surgical intervention ofthe affected upper extremity. Informed consent wasobtained for all patients separately and signed by theparents of the patients.EVALUATIONAll children participated in one measurementsession before and after the suggested period oftreatment in warm environment with the affected armundressed. The affected arm length, forearm and handlength (cm), arm and forearm girth (cm) were measuredand recorded by means of tape measure. Range ofmotion of shoulder abduction and external rotation,elbow flexion and wrist extension was also evaluatedby using goniometer. The paediatric physiotherapistfacilitated maximal shoulder abduction and externalrotation, elbow flexion, forearm supination and wristextension of the affected upper extremity through play,and quantified them on the active movement scale andjoint movement grading scale.TREATMENTThe control group was assigned for conventionalphysical therapy exercise program consisting ofpositioning, facilitatory stimuli, functionalstrengthening exercises, passive range of motionexercises, stretching exercises, scapular mobilization,manipulative exercises and splinting. The study groupwas assigned for PEMF followed by the previouslymentioned physical therapy program. During PEMFapplication, the patient was placed in the supineposition and the affected arm was comfortably placedinsideaclosedpediatricscircuitcoil,usingPEMFdevice(EL0064 MAGNETO II). The device generated a puremagnetic field output signal that employed directcurrent with unidirectional biological frequencies 20Hz and intensity 0.3 mT (0.03 mT=30 Gauss). Inductionof treatment took place for 30 minutes. Treatment forboth groups continued for three months, three sessionsper week, each session lasted about one hour.Statistical AnalysisDatawaspresentedasmeanandstandarddeviation.Paired t-test was used to analyze the data within eachgroup and unpaired t- test was used to analyze thedata between study and groups. The p-value was <0.05.9. Eman-42-46.pmd 2/7/2013, 8:08 PM43
  • 50. 44 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1RESULTSUpper extremity length and girthThe findings revealed significant increase in meanvalues of arm and forearm length, and arm and forearmgirth in the study group after treatment compared tothat before treatment (p=0.0001, 0.01, 0.01, 0.0001respectively). Moreover, a significant difference wasshown between the study and control groups aftertreatment (table 1).Table (1): Comparison between study and control groups regarding upper extremity length and girth mean valuesbefore and after treatment.Test Parameters(cm) Pre(Mean±SD) Post(Mean±SD)Control group Study group t p Control group Study group t pArm length 16.27±5.27 15.33±4.53 -0.4 0.6 16.90±4.1 21.60±3.60 2.96 0.001*Forearm length 13.4333±3.28 12.93±3.19 -0.42 0.7 13.7333±3.06 17.03±4.15 2.48 0.02*Arm girth 16.30±2.10 15.55±2.1 -0.69 0.5 16.70±3.51 20.70±6.03 2.22 0.03*Forearm girth 14.03±2.33 13.65±2.30 -0.47 0.6 14.33±2.60 19.03±3.70 4.04 0.0001*Upper extremity muscle strengthThe results showed significant increase in meanvalues of strength of deltoid, external rotators, bicepsbrachii, supinator, and wrist flexors of the affected armin the study group after treatment compared to thatbefore treatment (p= 0.001, 0.0001, 0.02, 0.0001 and0.002 respectively). Additionally, a significantdifference was shown between the study and controlgroups after treatment (table 2).Table (2): Comparison between study and control groups regarding upper extremity muscle strength mean valuesbefore and after treatment.Muscle Strength Pre(Mean±SD) Post(Mean±SD)Control Study t p Control Study t pDeltoid 3.00±0.84 3.13±0.92 -0.33 0.77 3.25±0.70 4.8±0.77 -4.05 0.0001*External Rotators 2.60±0.74 2.6667±0.72 -0.3 0.77 2.87±0.83 4.6667±0.70 -3.7 0.0001*Biceps Brachii 3.00±0.93 3.13±0.91 -0.44 0.66 3.33±0.72 4.13±0.1 -2.24 0.04*Supinator 2.53±0.83 2.67±0.72 -0.45 0.7 2.87±0.74 4.40±0.91 -3.83 0.0001*Wrist Extensors 3.67±0.49 3.67±0.49 -1.5 0.1 3.87±0.64 4.6±0.5 -2.94 0.007*Upper extremity active ROMThere was significant improvement in the meanvalues of active ROM of the affected upper extremity inthe study group after treatment compared to thosebefore treatment (table 3).Table (3): Comparison between mean values of active range of motion before and after treatment in thestudy and control groupsROM Shoulder Shoulder external Elbow Forearm Wrist(degrees) abduction rotation flexion supination extensionPost Pre Post Pre Post Pre Post Pre Post Pre0.68 ± 0.34 1.27± 0.88 0.68±0.34 1.193± 0.27 0.63± 0.32 1.31± 0.26 0.65± 0.33 1.32± 0.18 1.13± 0.3 1.67± 0.19t 9.54 8.80 -8.80 -9.28 -2.62p 0.06 0.16 0.7 0.3 0.002DISCUSSIONObstetric brachial plexus palsy (OBPP) is acomplication of childbirth, which is characterized byoneormorenerveconductionblockswithinthebrachialplexus .These blocks range in severity and locationwithin the plexus and primarily affect the child’s abilityto move and effectively use their affected upperextremity 5.Thirty children with OBPPparticipated in the study.All were able to perform elbow and shouldermovements with gravity eliminated. Most of thosechildrenpresentedtotheout-patientclinicswithslightly9. Eman-42-46.pmd 2/7/2013, 8:08 PM44
  • 51. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 45different degrees of injury and respond differently totherapeutic interventions. Experience in treatingchildren teaches that children who present at sixmonths of age with no signs of recovery generally aresubjected to development of sequelae, including mildscapular winging, inability to fully supinate theforearm, limitation in shoulder abduction and forwardflexion. In the current study, there was no need forelectrophysiological monitoring or guide as musclestrength can be considered as an indicator for prognosisand recovery. This is supported by Yilmaz andcoworkers 11who compared magnetic resonanceimaging (MRI), electrophysiologic studies, and musclestrength scoring in infants with BPP to determinewhich indicator provided the most accurate prognosisof the outcome at one year. They found that scoring ofmuscle strength (eg, elbow flexion; wrist, finger, andthumb extension) was the most reliable measure, with94.8% confidence at 3 months.TherehavebeenfewreportsabouttheeffectofPEMFtherapy on muscle strength and functional activities inchildren with brachial plexus injuries (Erb’s palsy). Theresultsofthepresentstudyshowedclearlythebeneficialeffects of PEMFT on improving muscle strength, rangeof motion and functional activities of the affected upperlimb. These findings coincide with that of Zborowski etal12who evaluated the effects of a low frequencyelectromagnetic field on fast axonal transport changesin speeds and densities of retrograde fast organelletransport in the rat sciatic nerve. Preparations weremeasuredinvitrouponexposureto15and50Hzpulsedmagnetic fields with peak intensities of 4.4 and 8.8 mT.They reported that strong effects were observed inmyelinated axons. Such effects may eventually be usedas part of a neuroprosthesis to noninvasively modifyor couple to various parts of the nervous system. Thesefindings also, are supported by Sharrard et al14whoconcluded that pulsed electromagnetic fields haveencouraged healing of fractured bones and benefitedre-anastomosis of peripheral nerves after transection.Many mechanisms could explain the improvementin children with Erb’s palsy as biological stimulationby PEMF exposures can modify cellular functions inbone and nervous tissue, and evidence is accumulatingthat the regeneration capacity of the tissue may beaffected6. For example, selective changes in levels ofcalcium , cyclic adenosine monophosphate, thesynthesis of collagen and proteoglycans, DNA, andRNAhave been demonstrated in osseous, nervous, andmesenchymal tissue 12,13,15,16,17,18.CONCLUSIONThe results of the present study showed that themain advantages of PEMFT are the enhancement andaccelerationoftherecoveryofinjurednervetissue.Also,it indicates that PEMFT is a low-cost, non-invasive, nonthermal method of physical therapy modalities andshould be recognized as standard additional treatmentfor improving the functional recovery in patients withErb’s palsy.ACKNOWLEDGMENTThe invaluable assistance of the paediatric physicaltherapists in the out patients clinics to the study aremuch appreciatedREFERENCES1. Martin TA and obestetric brachial plexusinjuries.Neurosurg clin N Am.2009; 20, 1:14.2. 3-Pollack RN, et al. Obstetrical brachial palsy:pathogenesis, risk factors, and prevention. ClinObstet Gynecol 2000;43:236-46.3. Gilbert WM, Nesbitt TS, Danielsen B. “Associatedfactors in 1611 cases of brachial plexus injury”.Obstet Gynecol. 1999; 93(4):536-40.4. Else Spaargaren et al , Aspects of activities andparticipation of 7-8 year- old children with anobstetric brachial plexus injury ,European journalof pediatric neurology.2011; 1 5, 345-352.5. Alphonso DT . Causes of Neonatal BrachialPlexus Palsy. Bull NYU Hosp Jt Dis. 2011;69:11-166. Papazian O,Alfonso I, Yaylali I, Velez I, Jayakar P.“Neurophysiological evaluation of children withtraumatic radiculopathy, plexopathy, andperipheral neuropathy”. Semin Pediatr Neurol.2000; 7(1):26-35.7. Marko S. Expanding Use of PulsedElectromagneticFieldTherapies.ElectromagnBiolMed. 2007; 26: 257-2748. M.Cifraetal.Electromagneticcellularinteractions.Progress in Biophysics and Molecular Biology ,2011;105 : 223-2469. R. Lightwood. The remedial electromagnetic field.J. Biomed. Eng. 1989, 1 I:429-436.10. Byers J, Clark K, Thompson G. “Effect of pulsedelectromagnetic stimulation on facial nerveregeneration”. Arch Otolaryngol Head Neck Surg.1998;124(4):383-9.11. Yilmaz K, Caliskan M, Oge E, Aydinli N, TunaciM, Ozmen M. “Clinical assessment, MRI, andEMG in congenital brachial plexus palsy.” PediatrNeurol. 1999; 21(4):705-10.9. Eman-42-46.pmd 2/7/2013, 8:08 PM45
  • 52. 46 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 112. Zborowski M , Atkinson M , Lewandowski JJ ,Jacobs G , Mitchell D , Breuer A, Nosé Y. “In vitrolow frequency electromagnetic field effect on fastaxonal transport.” ASAIO Trans. 1988 Jul-Sep;34(3):669-7.13. Bassett CA, Chokshi HR, Hernandez E, PawlukRJ,Strop M. ”Theeffectofpulsingelectromagneticfields on cellular calcium and calcification of non-unions”. Brighton GT, Black J, Pollack SR. eds.Electrical Properties of Bone and Cartilage:Experimental Effects and Clinical ApplicationsNew York, NY Grune & Stratton Inc1979;427.14. Sharrard WJ, Sutcliffe ML, Robson MJ,MacEachern AG. ”The treatment of fibrous non-union fractures by pulsing electromagneticstimulation. “ J Bone Joint Surg Br. 1982;64:189-193.15. +Fitton-Jackson S, Bassett CA. ”The response ofskeletal tissues to pulsed magnetic fields.“ Richards RJ, Rajan KT.eds. Tissue Culture inMedical Research (“International Symposium onTissue Culture in Medical Research”) .New York,NY Pergamon Press Inc1980; 21.16. Eugene M.Goodman et al. Effects ofElectromagnetic Fields on molecules and cells,International review of cytology.1995; I58:279-338.17. Fitton-Jackson S, Farndale R. ”The influence ofpulsed magnetic fields on skeletal tissue grownin organ culture. “ Trans Orthop Res Soc.1981;6300+18. Shteyer A, Norton LA, RodanGA. ”Electromagnetically induced DNAsynthesis in calvaria cells. “ J Dent Res.1980;59A:362.9. Eman-42-46.pmd 2/7/2013, 8:08 PM46
  • 53. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 47Effectiveness of PNF Stretching and Self Stretching inPatients with Adhesive Capsulitis - A Comparative StudyHarshit Mehta1, Paras Joshi2, Hardik Trambadia31Physiotherapist,SamarpanOrthopedicHospital,Jamnagar,2Lecturer,KKShethCollegeofPhysiotherapy,3Lecturer,ParulInstituteofPhysiotherapy,VadodaraABSTRACTBackground: Adhesive capsulitis of shoulder is characterized by insidious and progressive pain andloss of active and passive mobility of glenohumeral joint. In many physical therapy programs forsubjects with adhesive capsulitis of shoulder mobilization techniques are an important part of theintervention. The purpose of this study is to compare the efficacy of PNF stretching techniques and Selfstretching techniques in subjects with adhesive capsulitis.Objective: To compare the effectiveness of PNF stretching and self stretching in improving ROM,shoulder pain & disability index in patients with adhesive capsulitis.Method: 30 subjects diagnosed by an orthopedic surgeon as having adhesive capsulitis of shoulderjoint and who showed a typical restriction of external rotation and abduction were selected. Subjectswere randomly taken, divided into two groups each of 15 subjects. GroupA: (n=15):- Treated with PNFstretching. Group B: (n=15):- Treated with self stretching. Analysis was based on ROM and ShoulderPain and Disability Index (SPADI) sub scores and total scores.Outcome measures: The following outcome measures were measured at baseline, 2nd week and 4thweek follow up.1. Active ROM of shoulder External rotation and Abduction.2. Shoulder pain and disability index (SPADI).Results: The ROM and SPADI percentage across baseline, 2nd week and 4th week follow up showed asignificant improvement statistically in their mean scores within Group A and Group B. Statisticallysignificant greater changes in score were found in PNF Stretching (Group A) for ROM and SPADI ascompared to Self Stretching (Group B).Conclusion: The results indicate that PNF Stretching (Group A) and Self Stretching (Group B) aresignificantly effective in improving ROM and SPADI (sub scores and total scores).However PNF Stretching (Group A) appears to be more effective in improving glenohumeral jointmobility and reducing disability as compared to Self Stretching (Group B).Keywords: Adhesive Capsulitis, PNF Stretching, self stretching, SPADI.INTRODUCTION“ADHESIVE CAPSULITIS” is a common but poorlyunderstood syndrome of painful shoulder stiffness.1Itis most common cause of pain & disability in shoulderin general population.2Frozen shoulder syndrome wasfirst describe by Duply in 1872. He used the term peri-arthritis scapula-humerale. In 1934 Codman used theterm ‘FROZEN SHOULDER’ first time to describe thecondition.1In 1945, Nevieser termed condition as“ADHESIVE CAPSULITIS” based on surgicallyexplored cases of frozen shoulder finding absence ofthe gleno- humeral synovial fluid as well as thickening& contraction of capsule which had become adherentto humeral head.3The prevalence of frozen shoulder is2% to 3% of general population it starts between age of40- 70 years. It is more commonly seen in females thanmales.2Currently adhesive capsulitis & frozen shoulder arethe preferred terms and can be used interchangeably.4Adhesive capsulitis has typically been classified into 210. hardik 16th april--47-51.pmd 2/7/2013, 8:08 PM47
  • 54. 48 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1forms, primary & secondary. In the primary form, noknown precipitating factors can be identified, so it isalso known as idiopathic type. The secondary form isassociated with other illness or events such as sometrauma or surgery.4The classic frozen shoulder has 3 stagesStage 1: Painful stage or Freezing phase (Lasts for 2 to 9months) 2, 6Stage 2: Stiffness or Frozen phase (Lasts for 4 to 12months) 2, 6Stage 3: Thawing phase (Lasts for 6 to 9 months) 2, 6Stage 1:- The “freezing” or “painful” stage, in whichthe patient has diffuse lateral shoulder pain beginsgradually and insidiously. Pain is the main initialcomplaint. The pain is worse at night & exacerbated bylying on the affected side, is often associated withsignificant disability.2Stage 2:- The “stiff” or “frozen” stage, in whichstiffness with decreased range of motion predominates.Pain, though still present with extreme movement,subsides and loss of movement becomes the patient’schief complaint. Ability to care for oneself and to workmight be significantly affected, especially if the patient’sdominant arm is involved.2Stage 3:- The “thawing” stage during which,exacerbations of pain still occur, often because ofexcessive activity. Gradually pain subsides andmovement becomes almost normal.Five methods developed to improve flexibility haveemerged: ballistic stretching, static stretching,proprioceptive neuromuscular facilitation stretchingtechniques(PNF),dynamicrangeofmotionusingactivecontraction and eccentric training.14OBJECTIVES OF THE STUDY1. To study the effectiveness of PNF stretching inimproving ROM, shoulder pain and disabilityindex in patients with adhesive capsulitis.2. To study the effectiveness of self stretching inimproving ROM, shoulder pain & disability indexin patients with adhesive capsulitis.3. To compare the effectiveness of PNF stretching andself stretching in improving ROM, shoulder pain &disability index in patients with adhesivecapsulitis.HYPOTHESISNull Hypothesis (H0)There is no significant difference between theeffectiveness of PNF stretching and self stretching inimproving ROM, shoulder pain and disability index inpatients with adhesive capsulitis.Alternate Hypothesis (H1)There is a significant difference between theeffectiveness of PNF stretching and self stretching inimproving ROM, shoulder pain and disability index inpatients with adhesive capsulitis.METHODOLOGYStudy design: Experimental study.Inclusion criteria• Symptomatic subjects between the age group of 40-60 (both male and female).• Subjects having stiff and painful shoulder for morethan 1 month.• Minimum 50 % of restriction in abduction andexternal rotation of shoulder joint.• Unilateral involvement and stage 2 adhesivecapsulitis.Exclusion criteria• History of recent shoulder trauma in and aroundshoulder joint.• Rotator cuff injuries or previous surgery• Intrinsic gleno- humeral pathology such asglenohumeral arthritis.• Diabetic patients.Tools used for the study:• Universal Goniometer• Shoulder pain and disability index10. hardik 16th april--47-51.pmd 2/7/2013, 8:08 PM48
  • 55. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 49Method of data collectionThe patients were evaluated using shoulderevaluation form. The patients were informed about thewholeprocedure,thetreatmentmeritsanddemeritsandawrittenconsentwereobtainedfromthemforvoluntaryparticipation in the study. They were randomly dividedin two Group A and Group B of 15 subjects each. Thebase line data of ROM of all the movements of shoulderwas obtained using universal goniometer. The pain anddisability data were obtained using SPADI to check forthe functional outcome. The ROM and SPADI weretaken at the baseline, after 2 weeks of the treatment andafter 4 weeks on follow up.Study Duration: 4 weeks.Techniques of applicationGroup A: PNF stretching.Starting position: Patient is in sitting position andtherapist in sitting at the side of the patient.(PNF stretching) Therapist will passively move theshoulder joint in external rotation until the stretch beginto feel “uncomfortable” to the subject. Then subjectswillbeaskedtoperformamaximalisometriccontractionfor 6 seconds followed by 10 seconds of relaxation.During the 10 seconds of relaxation a tester slowlyexternally rotates the subject’s shoulder joint, if thesubjects still consider the stretch to be uncomfortable; itis kept as previous position.Thesubjectsthenperform2more6secondsmaximalcontraction (total 3 contractions) with 10 secondrelaxation period in between.Same procedure is done to improve shoulderabduction. In this patient is in sitting position andtherapist stands at the back of the patient on the affectedside.Duration : It is given once in a day for 5 days in aweek for 4 weeks.Group B: Self stretching.Starting position: Patient is in standing position.Subjects is asked to place the upper extremity on afirm surface at 90° of forward elevation and greater than90° of horizontal abduction while turning the trunk inthe opposite direction to improve the external rotation.Subjects is asked to pull the elbow overhead withthe opposite arm to improve the abductionDuration : The stretching is given 3 times for 30seconds and 10 second relaxation between 2 stretch 5days in a week for 4 weeks.· Both the groups were given short-wave diathermybefore stretching procedure at the therapeuticfrequency of 27.12 MHz for 10 to 15 min.13Statistical Analysis• Post hoc analysis (Bonferroni test) is used tocompare the baseline, 15thday and 30thday scoresof ROM and SPADI within Group A and Group B.• Two wayANOVAtest is used to compare the meandifference across the time periods (Baseline, 15thdayand 30thday) between Group A and Group B.• P value < 0.05 is taken up for statistical significance.RESULTSTable 1:-Multiple comparisons of ACTIVE EXTERNAL ROTATION scores across different periods within Group Aand within Group B using post hoc analysis- Bonferroni test.Period Periods Mean Std. Error p-value Level of significanceAER in Group A Baseline 2ndwk -21.667 2.065 .000 HS at p < 0.014thwk -31.733 1.850 .000 HS at p < 0.012ndweek 4thwk -10.067 .658 .000 HS at p < 0.01AER inGroup B Baseline 2ndwk -14.400 2.908 .001 HS at p < 0.014thwk -21.800 2.694 .000 HS at p < 0.012ndweek 4thwk -7.400 .466 .000 HS at p < 0.0110. hardik 16th april--47-51.pmd 2/7/2013, 8:08 PM49
  • 56. 50 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Table 2:- Multiple comparisons of ACTIVE ABDUCTION scores across different periods within Group A andwithin Group B using post hoc analysis- Bonferroni test.Period Periods Mean Std. Error p-value Level of significanceAAB inGroup A Baseline 2ndwk -38.200 3.151 .000 HS at p < 0.014thwk -48.533 2.862 .000 HS at p < 0.012ndweek 4thwk -10.333 .779 .000 HS at P < 0.01AAB inGroup B Baseline 2ndwk -23.000 2.556 .000 HS at p < 0.014thwk -31.600 2.124 .000 HS at p < 0.012ndweek 4thwk -8.600 1.125 .000 HS at p < 0.01Table 3:- Multiple comparisons of Total SPADI scores across different periods within Group A and within Group Busing post hoc analysis- Bonferroni test.Period Periods Mean Std. Error p-value Level of significanceTotal SPADI in Group A Baseline 2ndwk 46.800 2.387 .000 HS at p < 0.014thwk 50.067 2.566 .000 HS at p < 0.012ndweek 4thwk 3.267 .330 .000 HS at P < 0.01Total SPADI in Group B Baseline 2ndwk 37.867 1.612 .000 HS at p < 0.014thwk 40.000 1.721 .000 HS at p < 0.012ndweek 4thwk 2.133 .291 .000 HS at p < 0.01From the above Table 1, 2 & 3 multiple comparisonof active external rotation, active abduction and totalSPADI scores shows that difference is statisticallysignificant from baseline to 2ndweek and 2ndweek to 4thweek, but the difference from baseline to 2ndweek and2ndweek to 4thweek is significantly higher in group Athan group BDISCUSSIONPrimary adhesive capsulitis affects 2% to 3% of thegeneral population and is the main cause of shoulderpain and dysfunction in individuals aged 40 to 70years. The etiology and pathology of this syndromeremains enigmatic. The physical therapy is commonlyprescribed for this condition. For predominant adhesivecapsulitis and associated soft tissue tightness,mobilizations techniques, PNF stretching techniqueshave been most commonly address in clinical treatmentapproaches and research studies.The result of present study examined the efficacy ofPNF stretching to self stretching in subjects withadhesive capsulitis both within groups and betweengroups. 30 subjects are taken who were diagnosed asadhesive capsulitis of shoulder by orthopedic and werenormally assigned to either PNF stretching (Group A)or Self stretching (Group B).PNF stretching utilizing a shortening contractionof the opposing muscle to the place the target muscleon stretch, followed by a static contraction of the targetmuscle, The inclusion of a shortening contraction oftheopposingmuscleappearstohavethegreatestimpacton enhancing ROM.17Some researchers have foundthat the alteration of stretch perception plays aimportant role in success of contract relax PNFstretching and contract relax stretch are recommendedto get greatest ROM gain.7PNF stretching and soft tissue mobilization is theapplication of specific and progressive forces with theintent of promoting changes in the myofascia, allowingfor elongation of shortened structures. PNF stretchingcombined with soft tissue mobilization and both areused to effect changes in myofascial length. Contract –relax PNF procedures have been shown to be effectivein increasing ROM. The immediate effects of PNFstretching and soft tissue mobilization interventionswere demonstrated in a another study using healthysubjects, where improvements were made in hip ROM.8One study done on overhand athletes for the effectsof proprioceptive neuromuscular facilitation shows thatContract – relax and hold relax PNF stretchingtechniques are effective in increasing ROM in overhandathletes.9Stretching import physiological changes such asremodeling of elastin and collagen molecules, thesechanges may be associated with alterations on themuscle tendon units and fascia, caused by increase ontissue elasticity. In other words, the range of motionwould be influenced by the increase on the length ofthe tissue.1010. hardik 16th april--47-51.pmd 2/7/2013, 8:08 PM50
  • 57. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 51In one study researchers have concluded that PNFstretching produce more tension in muscle and alsoprovide greatest potential for muscle lengthening thanstatic stretching. In another study researchers haveconcluded that PNF stretching shows greater ROMgains than static stretching.11In one study researchers concluded that 30 secondsstatic stretch was more effective then dynamic ROMtraining for improving ROM. Given the fact that 30seconds static stretch increase ROM more than 2 timesthat of dynamic ROM training.12Limitations1. In present study only 2 ROM (External Rotationand Abduction) are taken in outcome measures.2. In this study there is no control group is present.3. It’s a short duration study as study duration is 4weeks.4. In the present study the sample size is 30 that aresmall.CONCLUSION• PNF Stretching and Self stretching producedsignificant improvement in ROM and shoulderPain and Disability (SPADI Sub scores and Totalscores) values in patients with adhesive capsulitiswhen applied individually. However PNFStretching showed a significant improvement inROM and shoulder Pain and Disability Index(SPADIsubscoresandtotalscores),whencomparedto Self Stretching in individuals with adhesivecapsulitis.REFERENCES1. Giggs SM, Ahm A and Green A. IdiopathicAdhesive Capsulitis. A Prospective FunctionalOut Come, Study of non operative Treatment. JBone Joint Surg, Vol. 82, Oct-2000, 1398-1407.2. H.A.Anton. Frozen Shoulder. Can Fam Physician1993;39:1773-1777.3. R.A Donatelli, Physical Therapy of the Shoulder,3rdedition, CHARCHILL LIVINGSTONE. Pp257- 278.4. Rick Sandor. Adhesive Capsulitis; OptimalTreatment Of “Frozen Shoulder”. THEPHYSICIAN AND SPORTSMEDICINE, Vol.28,No.9, SEP-200.5. Henricus M Vermeulen, Wim R Obermann, Bart JBurger, Gea J Kok, Piet M Rozing, CorneliaHMvanden Ende. End- Range Mobilization techniquesin Adhesive Capsulitis of the Shoulder joint: AMultiple- Subject Case Report.6. S.B.Brotzman, K.E.Wilk, Clinical OrthopaedicRehabilitation, 2ndedition, Shoulder Injuries, page125-250.7. Mitchell UH, Myrer JW, Hopkins JT, Hunter I,Feland JB, Hilton SC acute stretch perceptionalteration contributes to the success of the PNF“contract-relax” stretch. J Sports Rehab. May 2007;16(2):85-92.8. Godges JJ, Matson-Bell M ,Thorpe D; Shah D, Theimmediate effect of soft tissue mobilization withPNF on gleno humeral external rotation &overhead reach; J Orthop Sports Phys Ther, Dec2003; 33 (12) : 713-718.9. DecicoPV,FisherMM,TheeffectsofPNFstretchingon shoulder ROM in overhead athletes. J SportsMed Phy Fitness, Jun 2005; 45(2):183-187.10. Luís Viveiros, Marcos Doederlein Polito, RobertoSimão and Paulo Farinatti Immediate and lateresponses of flexibility in the shoulder extensionin relation to the number of series and stretchingduration. Rev Bras Med Esporte. Nov/Dec 2004;Vol 10, N 6:464-467.11. Funk DC, Swank AM, Mikla BM, Fagan TA, FarrBK. Impact of prior exercise on hamstringflexibility: a comparison of proprioceptiveneuromuscular facilitation and static stretching. JStrength Cond Res. 2003 Aug; 17(3):489-92.12. Bandy WD, Irion JM, Briggler M. The effect of timeand frequency of static stretching on flexibility ofthe hamstring muscles. Phys Thera. 1998 Mar;78(3):321-2.13. Leung MS, Cheing GL. Effects of deep andsuperficial heating in the management of frozenshoulder. J. Rehabil Med. 2008 Feb; 40(2):145-50.14. Murphy DR.A critical looks at static stretching;are we doing our patient harm? Chriopract sportmed, 1991; 5:67-70.10. hardik 16th april--47-51.pmd 2/7/2013, 8:08 PM51
  • 58. 52 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Effect of Modified Hold-Relax and Active Warm-Upon Hamstring FlexibilitySwapnil U Ramteke1, Hashim Ahmed2,Virenderpal Singh3, Piyush Singh4ResearchStudent,JamiaHamdard,NewDelhi,2HeaddepartmentofPhysiotherapy,ShreyaHospital,Shalimar GardenExtension,Ghaziabad,U.P,3HeadofDepartmentofPhysiotherapy,MataGujriCharitableHospital,NewDelhi,3AssistantProfesor,IndianSpinalInjuryCenterofRehabilitation,NewDelhiABSTRACTObjective: The study aimed to find out how long the flexibility lasted after a one time modified holdrelax stretching & active warm up and its comparison with modified hold relax technique alone.Design: Pre-test, Post-test comparative study with repeated measures.Setting: Mata Gujri Fitness center, Kailash colony, New Delhi.Method: 30 male subjects were randomly assigned to two groups; Group A- Modified Hold Relax: Onthe 15 subjects a one time modified hold-relax stretching was performed.Group B: 15 male subjects completed an active warm up on treadmill followed by modified hold relaxstretching. The pre stretch measurement was taken by Active Knee Extension (AKE) test. After both theinterventions the post stretch measurements were taken at following intervals, 0, 6, 12, 18, 24 min,respectively.Results: A significant improvement in ROM was observed when post stretch measurements werecompared to pre test in both groups respectively. However, the flexibility lasted for longer duration thatis 12 min in group B when compared to group A that is 6 min.Conclusion: Both the methods are equally effective to improve the range of motion. But the improvedranges can be maintained for larger duration when active warm up was implemented prior to Modifiedhold relax stretching.Keywords: P.N.F, Active Warm up, AKE, Flexibility,INTRODUCTIONFlexibility is an essential component for normalbiomechanical functioning in sports. The length of themuscle tissue is thought to play an important role inefficacy and effectiveness of human movement.1Theoretically,amoreflexiblemuscle-tendonunitshouldbe more compliant to external loads, less stiff, and lesslikely to be injured.2In sports even small change inperformance can have a drastic effect on the outcome ofan event.Besides hamstrings strains in the athleticpopulation, hamstrings tightness as shown in somestudies have shown that reduced hamstring flexibilityis considered to be one of the leading cause/risk factorfor patellar tendinopathy and patellofemoral pain etc..3In the ACSM’s guidelines,a clinical evidence forrelationship between hamstring inflexibility withavulsion fractures of ischial tuberosity ,muscle strain,low back ache and increased sway back or round backposture has been mentioned.4Proprioceptiveneuromuscular Facilitation (PNF) exercises aredesigned to promote the neuromuscular response ofthe proprioceptors.There exists a limited data regardingthe lasting effects of increased ROM post stretching.The duration of increased flexibility in the previousresearch conducted by De pino et al, after one timestatic stretching was found to be of 3 minutes, furtherSpernoga et al carried out similar study in which, afterone time modified hold relax lasting effects remainedfor 6 minutes, but this is a very short span of time, tilldate limited studies have carried out to improve thelasting effects.5, 6.Hamstring flexibility has beenmeasured by active knee extension test, passive knee11. hashim 4th may--52-57.pmd 2/7/2013, 8:08 PM52
  • 59. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 53extension test, the sit and reach test and the assessmentof hip flexion. Range following the straight leg raise,however reliability of these methods has not beendemonstrated. An active knee extension test is howevera reliable method for assessment of hamstrings.7Warmup consists of active or passive warming of body tissuesin preparation of physical activity. 8. There is a widespread belief that a warm up contributes to improvedathleticperformance.9Activewarmupinvolvesexerciseand is likely to induce greater metabolic andcardiovascular changes than passive warm up.10To ourknowledge no specifically warm up oriented studieswith regards to modified P.N.F hold relax techniquehas been carried out to assess the lasting effects after aspecific warm up intensity.Thus present study aimed to extract the informationthat for how much duration the flexibility would beretained after a warm up and modified hold relaxtechnique. In many clinical situations, patients may beseen by practitioners once or twice a week, or even lesscommonly in non-acute situations. It is thereforeimportant to examine whether modified hold relaxstretchingproduceeitheragreaterorlongerlastingeffecton range of motion. The objective of this study was toinvestigate whether the application of a single sessionof modified hold relax was more effective, and haslonger lasting effect, than a single session of modifiedhold relax stretching with warm up on the extensibilityof the hamstring muscles measured by AKE over 6different time interval (pre-treatment, immediately, 6,12, 18 and 24 minutes) using goniometer.METHODThe 30 subjects were randomly allotted to Twogroups viz group A- Modified hold relax ,& Group Bactive warm up and modified hold relax.STUDY DESIGNPre test post test design with comparison in the twogroups with repeated measures.Instrumentation Goniometer,Treadmill(SportsArtFitness), Stop watch.Procedure In prestretch measurements, subjects inboth the groups performed a total of 6 AKEs with a 60-second rest period between repetitions. The sixth AKEwas recorded as the prestretch measurement. For Poststretch Measurement : AKE measurement were takenat 0 minutes (immediately) and at 6, 12, 18, and 24minutes after the final stretch in the group A The groupB underwent the same post stretch measurementprotocol immediately after performing warm up on atreadmill for 5 minutes followed by stretching. Themeasurement of the angle of knee joint ROM wasrecorded .The deficit (tightness) was calculated bysubtracting the available range from the full range.5For each stretch, the investigator passively stretchedthe hamstrings until the subject first reported a mildstretch sensation and that position was held for 7seconds. Next, the subjects were asked to performmaximal isometric contractions of the hamstrings for7 seconds by attempting to push their leg backtoward the table against the resistance of theinvestigator.5after the contraction, the subjects wereinstructed to relax for 5 seconds. The investigator thenpassively stretched the muscle until a mild stretchsensation was reported. The stretch was held foranother 7 seconds. This sequence was repeated 5 timeson each subject in these experimental groups.5Group B- Active Warm up and Modified hold RelaxMaximal heart rate was calculated by the formula,M.H.R=220-age.The difference between maximum heart rate andresting heart rate is known as heart rate reserve(HRR).Target heart rate = (HRR fraction) (HR max –HR at rest)+HR rest .The intensity fraction of HRR was selected at60 %. As per the ACSM’s position stand this percentagerepresents lower intensity values enough to producethe adequate training effects for cardio respiratoryfitness of warm up. 11.Fig.1: The Modified hold relax stretching technique.11. hashim 4th may--52-57.pmd 2/7/2013, 8:08 PM53
  • 60. 54 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1DATA ANALYSISThe alpha level of pd” 0.05 was accepted assignificant for all analyses. Mean values and theirstandard deviations were calculated for each variable.The one wayANOVA(analysis of variance) was carriedfor both the groups to compare the ROM within eachgroups to pre stretch measurements. A t-test wasperformed to compare ROM within both the groups.The data was further analyzed by Dunnet’s post hoctest.RESULTSThe ONE way analysis of variance revealed asignificantdifferencebetweenpretestandposttestROMmeasurements within groups respectively. However aDunnet’s post hoc analysis indicated that a significant(p<0.05) increase in hamstring flexibility wasmaintained in modified hold relax group for 6 min afterstretching protocol. Similarly increase in hamstringflexibility was maintained in Active warm up &Modified hold relax group for upto 12 min.Subject characteristicsThe subjects had following characteristics as meanand standard deviations values:Group A (Age = 23.00± 1.73) (Height=166.40, ±5.72)(Weight= 62.80 ± 6.75)(BMI= 22.67±2.16)GroupB (Age = 22.60±1.29) (Height=161.86, ±9.69)(Weight= 61.60 ±6.21)(BMI= 23.31±3.49)Table 1.Active Knee Extension Measurements in GroupA and Group BTime intvl Group A Group BMean s.d Mean s.dPrestretch 39.26 ± 3.76 38.66 ± 4.230 31.13 ± 3.75 28.73 ± 3.866 33.20 ± 3.87 31.20 ± 3.7412 36.06 ± 3.36 34.20 ± 4.3418 36.93 ± 3.80 35.60 ± 4.1124 38.13 ± 3.48 37.46 ± 4.65Fig. 2: The subject performing active warm up on the treadmillunder the supervision.Figure.3: Comparison between pre-test and post-test value ofrange of motion between the groups.Table.2: Between Group Comparison of Range ofMotion using t and p valuesTime period t-test for Equalityof Meanst p-valuePre Test 0.41 0.680 min 1.72 0.096 min 1.43 0.1612 min 1.31 0.1918 min 0.92 0.3624 min 0.44 0.66The subjects had following characteristics as meanand standard deviations values:11. hashim 4th may--52-57.pmd 2/7/2013, 8:08 PM54
  • 61. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 55Group A (Age = 23.00± 1.73) (Height=166.40, ±5.72)(Weight= 62.80 ± 6.75)(BMI= 22.67±2.16)GroupB (Age = 22.60±1.29) (Height=161.86, ±9.69)(Weight= 61.60 ±6.21)(BMI= 23.31±3.49)Table.3: Dunnett Post hoc analysis for comparinggroup BPost Pre Mean p-Treatment treatment Difference (I-J) value0 min Pre treatment -9.93 0.0006 min Pre treatment -7.46 0.00012 min Pre treatment -4.46 0.01918 min Pre treatment -3.06 0.17224 min Pre treatment -1.20 0.896DISCUSSIONVarious studies have been conducted in the past toassess the effects of various interventions on improvinghamstrings flexibility. However limited studies havebeen performed which evaluated the lasting effects.5,6,12These recently conducted studies on checking acuteeffects of stretching revealed that the flexibility wouldlast for 3 min after static stretching & for upto 6 minafter one time modified hold relax stretching. Theselasting effecs were present for very less duration.The relatively short time of increased hamstringflexibility may be due to several factors The mostprominent are the viscoelastic, thixotropic, and neuralproperties of the musculotendinous unit.Neural propertiesThe proposed neural inhibition reduces reflexactivity, which then promotes greater relaxation anddecreases resistance to stretch, and hence greater rangeof movement 13moreover, other research has found PNFtechniques to promote greater relaxation.14Viscoelastic propertiesPrevious researchers have attempted to explainimprovements in flexibility with viscoelastic properties,overcoming the stretch reflex, or increasing the stretchtolerance23. Musculotendinous units function in aviscoelastic manner, and, therefore, have the propertiesof creep and stress relaxation. Creep is characterizedby the lengthening of muscle tissue due to an appliedfixed load. Stress relaxation is characterized by thedecrease in force over time necessary to hold a tissue ata particular length.The musculotendinous unit deforms or lengthensas it is being stretched and goes through elastic andthen plastic deformation before completely rupturing.Our results suggest that a single session of hold-relaxstretching does not deform tissues enough to produce apermanent change (i.e., a plastic deformation in themusculotendinous unit). Therefore, the temporaryimprovement in hamstring flexibility may be attributedtochangesintheelasticregioncausedbyasinglesessionof hold-relax stretching.5Thixotropic PropertiesThixotropyisthepropertyofatissuetobecomemoreliquid after motion and return to a stiffer, gel like stateat rest. The thixotropic property of muscle is thought toresult from an increase in the number of stable bondsbetween actin and myosin filaments when the muscleis at rest. Hence, the stiffness of muscle increases.Because we asked our subjects to lie still in between thereadings, the thixotropic properties of muscle may haveplayed a part in reducing the time that hamstringflexibility was increased.A linear relationship exists between the time amuscle remains still and the stiffness of that muscle inresponse to a stretch, and indeed, flexibility decreasedin both groups as time passed .However, with activity,the muscle becomes more fluid-like because the stablebonds are broken or are prevented from forming. Basedon thixotropic properties, we would expect thetemporary increase in flexibility to bemaintainedduring periods of activity and to decrease duringperiods of inactivity.The present study revealed that there was nostatically significant difference in ROM gains in boththe groups. This shows that there is no extraimprovement/change in ROM when the modified holdrelax stretching was performed after the warm up. Thisfindings are similar to that of Cornelius et al in whichthey concluded that effective increases in tissue lengthwere not affected by warm up when a modified holdrelax technique was used.27In the present study, flexibility lasted for largerduration i.e. 12 minutes in Group B (modified hold relaxand active warm up) which may be due to the variousfactors. These findings are similar to that of variousstudies conducted by Cornelius which stated that raisedtissue temperature, coupled with stretch, would result11. hashim 4th may--52-57.pmd 2/7/2013, 8:08 PM55
  • 62. 56 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1in effective tissue elongation and longer lastingflexibility.27However; these studies did not measuredlasting effects.Influence of active warm upAn increase in intramuscular tissue temperaturehas a beneficial effect on ability of collagen and themyotendinous junction to deform. The effect oftemperature must also be considered in relation to theinnervations of the muscle tendon unit. There arereports in the literature that sensitivity of GTO tosustained stretch is increased with increase intemperature and that the GTOs sensitivity to tension isinversely correlated with the mechanical stiffness ofthe musculotendinous structure in which it lies.Possible effects of warm up due to elevatedtemperatures are decreased resistance of muscles andjoints, Greater release of oxygen from haemoglobin andmyoglobin,Speeding of metabolic reactions, Increased,nerve conduction rate, Increased thermoregulatorystrain.These all factors would have played an importantrole in improvement of the flexibility for group B byreducing the resistance to stretch. 28CONCLUSIONSThe result of our study leads to conclude that boththe techniques were equally effective for improvingROM acutely.The important finding from this study was that ifsubject specific active warm up was performed prior tomodified hold relax stretching ,the flexibility would lastfor about double the duration ,than that of modifiedhold relax technique.REFERENCES1. Maximal Length and Resistance to Passive Stretchof Short Hamstring Muscles Volume 14 Number 6December 1991 JOSPT,250-55.2. Magnusson SP, Simonsen EB, Aagaard P, GleimGW, McHugh MP, and Kjaer M. Viscoelasticresponsetorepeatedstaticstretchinginthehumanhamstring muscle. Scand J Med Sci Sports 5: 342-347, 19953. HopperD,2005,SDeacon,SDas,AJain,DRiddell,T Hall, K Briffa ,Dynamic soft tissue mobilizationincreases hamstring flexibility in healthy malesubjects, Br J Sports Med 2005;39:594–598.4. ACSM’s guidelines,1997.Exercise testing andPrescription,Lippincott Wilkins & Williams , 1997page13- 19.5. Spernoga S.G , Timothy L. Uhl, Brent L. Arnold,and Bruce M. Gansneder Duration of MaintainedHamstring FlexibilityAfter a One-Time, ModifiedHold-Relax Stretching Protocol ,JAthl Train. 2001Jan–Mar; 36(1): 44–48.6. DePino G.M,2000, Duration of MaintainedHamstring Flexibility After Cessation of an AcuteStatic Stretching Protocol Journal of AthleticTraining 2000;35(1):56–597. Gajdosik R,1983,Hamstring Muscle TightnessReliability of an Active-Knee-Extension TestVolume 63 / Number 7, July 1983,1085-10888. Knudson D ,2005, NSCAGuidelines, Warm up &Flexibility , LWW,166-181.9. Bishop, 2003 Warm Up II ,Performance ChangesFollowingActive Warm Up and How to Structurethe Warm Up, Sports Med 2003; 33 (7): 483-49810. Bishop D, 2003 Warm Up I ,Potential Mechanismsand the Effects of Passive Warm Up on ExercisePerformance, Sports Med 2003; 33 (6): 439-454.11. ACSM Position Stand on The RecommendedQuantity and Quality of Exercise for Developingand Maintaining Cardiorespiratory and MuscularFitness, and Flexibility in Adults. Med. Sci. SportsExerc., Vol. 30, No. 6, pp. 975–991, 1998.12. Draper D.O.2002;The Carry-Over Effects ofDiathermy and Stretching in DevelopingHamstring Flexibility ,Journal ofAthletic Training2002;37(1):37–413. Hutton R S 1993 Neuromuscular basis ofstretching exercises. In: Komi P V (ed). Strengthand power in sport, 1st edn, Vol 1. BlackwellScienti®c Publications, Oxford, pp 29-38;cross ref-Physical Therapy in Sport (2001) 2, 186-193.14. Etnyre B R, Abraham L D 1986b H-reflex changesduring static stretching and two variations of PNFtechniques J Athl Train. 2001 Jan–Mar; 36(1):44–48.15. Tanigawa MC. Comparison of the hold-relaxprocedure and passive mobilization on increasingmuscle length. Phys Ther .1972; 52 (7): 725-3516. Markos P.D.Ipsilateral & contra lateral effects ofPNF techniques on hip motion andelectromyographicactivity.PhysTher1979;59(11):1366-137317. Katz R, Penicaud A, Rossi A. Reciprocal Iainhibition between elbow flexors and extensorsin the human. J Physiol 1991; 437(1): 269-8611. hashim 4th may--52-57.pmd 2/7/2013, 8:08 PM56
  • 63. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 5718. Day BL, Marsden CD, Obeso JA, et al. Reciprocalinhibition between the muscles of the humanforearm. J Physiol 1984; 349 (1): 519-3419. Etnyre BR, Abraham LD. Gains in range of ankledorsiflexion using three popular stretchingtechniques. Am J Phys Med pas1986; 65 (4):189-9620. Osternig LR, Roberston RN, Troxel RK, Muscleactivation during proprioceptive neuromuscularfacilitation(PNF)stretchingtechniques.AmJPhysMed 1987; 66 (5): 298-30721. Moore MA,1980, Hutton RS. Electromyographicinvestigation of muscle stretching techniques.Med Sci Sports Exerc 1980; 12(5): 322-922. Osternig LR,1990, Roberston RN, Troxel RK, et alDifferential responses to proprioceptiveneuromuscular facilitation (PNF) stretchtechniques. Med Sci Sports Exerc 1990; 22 (1):106-101123. Garrett, WE. Muscle strain injuries: Clinical andbasic aspects. Med. Sci Sports Exerc. 22:436-443.199024. Magnusson SP, Simonsen EB, Aagard P, et al.Mechanical and physiological responses tostretching with and without preisometriccontraction in human skeletal muscle. Arch PhysMed Rehabil 1996; 77: 373-825. Magnusson SP. Passive properties of humanskeletal muscle during stretching maneuvers.Scand J Med Sci Sports 1998; 8: 65-7726. Halbertsma JP, Goeken LN. Stretching exercises:effect on passive extensibility and stiffness in shorthamstrings of healthy subjects. Arch Phys MedRehabil 1994; 75: 976-8127. CorneliusW.L,1992 ,The Effects of a Warm -up onAcute Hip Joint Flexibility Using a Modified PNFStretching technique.,1992, Journal of athleticTraining . volume 27, number 2,112-11428. McCardle ,Katch and Katch, 2001 , special aids toexercise training and performance ,Exercisephysiology, 5 th edition , Lippincott wilkins andWilliams, 574-575.11. hashim 4th may--52-57.pmd 2/7/2013, 8:08 PM57
  • 64. 58 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1A Comparative Study of effectiveness between SuperficialHeat and Deep Heat along with Static Stretching toImprove the Plantar Flexors Flexibility in Females WearingHigh Heel Foot WearsHasmukh Patel1, Dhaval Desai2, Harshit Soni2, Komal Soni2, Chintan Shah21ClinicalTherapist,U.N.MehtaInstituteofCardiology&ResearchCentre,Ahmedabad.2Lecturer,SPBPhysiotherapyCollege,SuratABSTRACTBackground: Lower extremity overuse injuries commonly occurs due to decreased flexibility of plantarflexor muscles in females wearing high heeled foot wears. Plantar flexors shortening are treated byvarious physiotherapeutic techniques. Superficial heat (moist heat) and Deep heat (ultra sound) alongwith static stretching are treatment techniques used in physiotherapy.Objective: To compare the effectiveness of superficial heat and Deep heat in combination with staticstretching in improving the plantar flexors flexibility in females wearing high heeled footwears.Method: The study included a sample of 40 individuals those who were wearing high heel > 2 inch.Out of that 20 individuals were in superficial heating group (group A) where moist heat wasadministered for 15 minutes to Achilles tendon, and remaining 20 individuals were in deep heatinggroup (group B) where continuous ultrasound with frequency of 1 MHz at an intensity of 1.5 W/Cm2was administered for 7 minutes to the Achilles tendon. Both the groups received 30 seconds of staticstretch with 4 repetitions performed 5 times per week. The duration of entire study was 3 weeks andboth the group received 1 session per day. Analysis was based on the Goniometer test score.Result: Both the group A and group B showed improvement in ankle ROM postintervention whencompared with preintervention measurement and tcalculated value for pre-postintervention measureswas statistically significant as it was above the t tabulated value. Moreover, Mean±SD of pre-postdifference in right ankle dorsiflexion ROM for group A was 2.90±1.37 and for group B was 4.25±0.85and Mean±SD of pre-post difference in left ankle dorsiflexion ROM for group A was 3.60±1.04 and forgroup B was 4.35±0.74. tcalculated value for pre-post ROM difference was statistically significant asit was above the t tabulated value of 1.96.Interpretation & Conclusion: There was significant difference between the two groups. In conclusionboth the treatment programs are highly significant and effective in improving the ankle joint ROM, butultrasound with deep heating property was found to be more superior as compared to moist heat packwith superficial heating property in improving plantar flexors flexibility in females wearing high heelfoot wears.Keywords: Flexibility, Ultrasound Therapy, Moist heat, Static Stretching.Corresponding author:Hasmukh PatelD-3 Kalyan Kunj, Radhaswami Road,Ranip, Ahmedabad, Gujarat, IndiaE-mail: hasmukhphysio@gmail.comINTRODUCTIONFlexibility as defined by Gummerson1is “Theabsolute range of movement in a joint or series of jointsthat is attainable in a momentary effort with the help ofa partner or a piece of equipment.”The different types of flexibility according to Kurzare:1) Dynamic flexibility2) Static-active flexibility3) Static-passive flexibilityTightness is a nonspecific term referring to mildshortening of a healthy musculotendineous unit. In thehuman body some muscle or a muscle group getstightness due to lack of proper exercise.2The plantar-flexor muscles play an important role in the gaitcycle12. Hasmukh patel 5th april--58-64.pmd 2/7/2013, 8:08 PM58
  • 65. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 59and in postural control. Lack of extensibility in thismuscle group may cause or be related to decreases inankle dorsiflexion, and it has also been hypothesizedto contribute to Achillestendinitis, shin splints,3plantarfasciitis,4and muscle strains.5Use of high heeled footwear has become a commontrend nowadays. Biomechanical problems which seemto be associated with long term use of such foot wearsresults in shin pain, ankle sprain and altered gaitpattern.6According to the American Orthopedic Footand Ankle Society, heel > 2 inches are consider as“high” which creates three to six times more stress onthe front of the foot than a shoe with a modest one-inchheel, and can lead to bunions, heel pain, toe deformities,shortened Achilles tendons, and Back Pain.7ALDALI Waleed et al. confirmed significant reduction incalf flexibility and ankle dorsiflexion range of motion(ROM) in 80 healthy college female students wearinghigh heeled shoes.8Many therapeutic maneuvers like differentstretching techniques namely static stretching, ballisticstretching, PNF stretching and cyclic stretching areuseful to increase ROM by enhancing soft tissueextensibility. Worrell TW demonstrated significantincrease in ankle dorsiflexion ROM in 11 female and 8male subjects who received 20 seconds of calf stretchingrepeated over 10 sessions followed by 10 close kineticchain gastronemius/soleus stretching sessions.9Heating modalities used in clinical setup forenhancing flexibility of muscle and promotingrelaxation are briefly divided into superficial and deepheating modalities. Ultrasound, SWD and MWD fall inthe category of deep heating modalities. David Draperevaluated tissue temperature rise during ultrasoundtreatment in 20 males and concluded that applicationof continuous ultrasound with 1MHz frequency and1.5 W/cm2intensity at the medial gastronemius musclefor 10 minutes in humans raised the mean temperatureto 40.3 °C, which was an increase of 4.9 °C.10Moist pack,IRR, Wax, etc fall in the category of superficial heatingmodalities. Funk D found that 20 minute moist heatapplication produced significantly more hamstringflexibility than 30 seconds of static stretching.11Individual studies have been done on Superficialheat combined with static stretching and Deep heatcombined with static stretching for improving flexibilityof plantar flexors muscles. But no study has been donecomparing the efficacy of these two treatmenttechniques, which signifies the need of the presentstudy.The aims and objectives of the study were;1. To evaluate the effectiveness of superficial heat withStatic Stretching towards improving plantar flexorsflexibility in females wearing high heel footwears.2. ToevaluatetheeffectivenessofDeepheatwithStaticStretching towards improving plantar flexorsflexibility in females wearing high heel footwears.3. To compare the effectiveness amongst the twogroupsoffemaleswhowereadministeredtheabovementioned therapies.METHODOLOGYStudy design: Cohort Comparative StudySample size: 40 individualsSampling method: Randomized samplingStudy Setting: Shree Devi College of Physiotherapy,MangaloreInclusion criteria1. Female wearing high heel footwears >2 Inches.2. Age: between 18 years to 30 years.3. IndividualwhohaveankledorsiflexionactiveROM(AROM) less than 10 Degrees with knee extensionExclusion criteria1. Individuals with Impaired sensation.2. Individuals with any orthopedic problem.3. Individuals those who are having neuromusculardisorder of hip, knee and ankle.4. Lower extremity malignancy.5. Individuals with ankle pathology. E.g. fractures.Tools used1) 360oUniversal Goniometer.2) Ultrasound, 1 MHz frequency, SL No. 2506,Ultrasonic Gel3) Moist pack12. Hasmukh patel 5th april--58-64.pmd 2/7/2013, 8:08 PM59
  • 66. 60 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Outcome MeasuresAROM Measurements for ankle dorsiflexion of bothlegs with knee extension was taken by using a UniversalGoniometer. (Fig. 2)The Measurement was taken Pre-treatment andPost-treatment i.e. after 3 weeks of intervention.PROCEDUREPrior to procedure individual those who met theinclusion criteria were assessed and evaluatedthoroughly by using the questionnaire. After signingthe consent form they were made to participate in study.40 Individuals of 18-30 years were randomlyassigned into two groups.Group A: Consisted of 20 Individual who wereadministered moist heat for 15 min to Achilles tendonfor 3 weeks.Group B: Consists of 20 Individual who wereadministered continuous ultrasound with frequencyof 1 MHz at an intensity of 1.5 W/Cm2for 7 min to theAchilles tendon for 3 weeks.Both the groups received 30 seconds of static stretchwith 4 repetitions performed 5 times per week for 3weeks.Superficial heat administered to Group A personsSuperficial heat was administered by hot packwhich was placed on subject’s Achilles tendon. Twolayers of terry cloth padding wereplaced between thehot pack and the subject. (Fig. 3)Deep heating for persons belonging to Group BUltrasonic gel, the coupling medium for treatmentwas applied to Achilles tendon followed by continuousultrasound with frequency of 1 MHz at an intensity of1.5 W/Cm2for 7 min by using Ultra sound machine intransverse manner. (Fig. 4)Staticstretchingtobeadministeredtoboththegroups:Calf stretch was performed for 20 seconds with theknee in full extension, followed by a 10-second rest.This sequence was repeated three more times, 5 daysper week for a period of 3 weeks. (Fig. 5)Fig. 1. Tools UsedFig. 4 Deep heat (Ultra sound)Fig. 3. Superficial heat (Moist pack)Fig. 2. Ankle ROM with knee extension12. Hasmukh patel 5th april--58-64.pmd 2/7/2013, 8:08 PM60
  • 67. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 61Following the recording of the above parameters,the obtained scores were tabulated and comparedamong both the study groups for ROM change.Ethical Consideration: Procedures followed were inaccordance with the ethical standards of HelsinkiDeclaration of 1975, as revised in 2000.12Statistical AnalysisAll participants received full treatments and therewere no drop outs.Data analysis was done by using SPSS 13.0 versionsoftware for present study. Unpaired t tests were usedto find out homogeneity of two groups for all theparameters at baseline and to compare the outcomemeasurement data between two groups. Paired t testswereconductedtodeterminewhetherankledorsiflexionROM was significantly different before and after theintervention. Each calculated t-value is compared witht-table value to test two tailed hypothesis at 0.05 level ofsignificance.RESULTSMean±SD of age for group A was 21.00±1.55 andfor group B was 21.10±1.68 and ‘t’calculated value was-0.195 at n1+n2-2 degree of freedom.Fig. 5. Static StretchingTable 1: shows descriptive statistics of age distribution among both groups.Descriptive StatisticsN Minimum Maximum Mean Std. DeviationGroup A 20 19.00 24.00 21.0000 1.55597Group B 20 19.00 25.00 21.1000 1.68273‘t’calculated value for right and left ankledorsiflexion ROM preintervention among both thegroups was 0.718 and 1.637 respectively at n1+n2-2degree of freedom. All the descriptive data for both thegroups was not significantly different, so both thegroups were homogenous for all possible confoundingfactors and were valid for comparison.Table 2: Pre and Post Intervention Comparison of both the Groups in terms of ankle dorsiflexion ROMVariable GROUP A GROUP BPre Post Change Pre Post ChangeRight ankle dorsiflexion ROM 7.31±0.59 11.20±0.90 2.90±1.37 7.18±0.56 11.69±0.64 4.25±0.85Left ankle dorsiflexion ROM 7.37±0.49 11.27±0.70 3.60±1.04 7.08±0.59 11.56±0.51 4.35±0.74Table 2 shows changes in terms of ankle dorsiflexion ROM of both sides pre and post intervention for both thegroups.12. Hasmukh patel 5th april--58-64.pmd 2/7/2013, 8:08 PM61
  • 68. 62 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Table 3: Paired ‘t’ test for outcome measures of both the groups‘t’calculated value in all these cases is statistically significant as it is above the ‘t’ tabulated value; hence boththe treatments were effective in improving Ankle dorsiflexion ROM.Table 4: Unpaired ‘t’ test for outcome measures of both the groupsBoth the groups showed improvement in ankledorsiflexion ROM postintervention. Mean±SD of pre-postdifferenceinrightankledorsiflexionROMforgroupA was 2.90±1.37 and for group B was 4.25±0.85 and‘t’calculated value was -3.73 at n1+n2-2 degree offreedom. Mean±SD of pre-post difference in left ankledorsiflexion ROM for group A was 3.60±1.04 and forgroup B was 4.35±0.74 and ‘t’calculated value was -2.61 at n1+n2-2 degree of freedom. ‘t’calculated value inall these cases is statistically significant as it is abovethe ‘t’ tabulated value of 1.96.DISCUSSIONNumber of clinical methods and techniques areavailable to improve flexibility, viz. therapeuticapplication of heat in form of superficial and deepheating modality, different stretching technique, preexercise warm up, etc. In stretching, static stretching isthe simplest, useful and most effective technique. Thisstudy consisted of 40 individuals, who were dividedinto2groups-GroupAandGroupB.GroupAconsistedof 20 individuals with mean age of 21.00 ± 1.55 andgroup B consisted of 20 individuals with mean age of21.10 ± 1.68. Group A was treated with superficial heat(moist heat pack) along with static stretching and groupB with deep heat (ultrasound) along with staticstretching for duration of 3 weeks. Ankle dorsiflexionROM with knee in extension was measured as anoutcome measure to evaluate the effect of superficialand deep heating on calf flexibility and thereby ondorsiflexion ROM. After retrieving the values, data wasstatistically compared using paired and unpaired ‘t’test for comparison within and between the groupsrespectively.The result demonstrated that the individuals treatedwithboth interventionsshowedimprovementinmeansof plantar flexors flexibility postintervention which wasevident from higher ‘t’ calculated value. Moreover12. Hasmukh patel 5th april--58-64.pmd 2/7/2013, 8:08 PM62
  • 69. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 63statistically when both groups were compared, GroupB showed more plantar flexor flexibility as it showedmuch greater improvement in dorsiflexion ROM ascompared to that in Group A and also the ‘t’ calculatedvalue was higher than ‘t’ tabulated value (1.96). Thiseffect of ultrasound can be attributed to the sufficientincrease in tissue temperature brought by it and hencethereby promoting greater relaxation of muscle ascompared to superficial heating modalities. Thesefindings are in line with those by David Draper (1993and 1998).13,14Moreover findings of Hendricson et al.(1984),15Wessling et al. (1987)16and Rather Aijaz et al.(2007)17also support the fact that ultrasound whencombined with static stretching as compared to staticstretchingaloneismoreeffectiveinimprovingsofttissueflexibility. Hence it is more suggestible to use acombination of ultrasound and static stretching toimprove soft tissue extensibility.Limitations of the study• The study was done on a small sample size.• Study was conducted for a short period of time.Scope of further studies• The study on the same treatment approaches withlarge treatment groups can be done.• The study of same treatment approaches with theinclusion of control group can be done.• Alongtermfollowupstudyshouldbedonetochecktherecurrencerateandtoknowthelongtermeffectsof interventions.CONCLUSIONThe individuals were treated with superficial heatalong with stretching and deep heat along withstretching for 3 weeks and were found to be effective inimproving the ankle joint ROM in both the groups.Statistically when both the groups were compared,group B individuals showed more improvement ascompared to group A. In conclusion both the treatmentprograms are highly significant and effective inimproving the ankle joint ROM, but ultrasound withdeep heating property is found to be more superior ascompared to moist heat pack with superficial heatingproperty in improving plantar flexors flexibility infemales wearing high heel foot wears.ACKNOWLEDGMENTSWe are thankful to all our subjects who participatedwith full cooperation. We are also grateful to authors/editors/ publishers of all those articles, journals andbooks from where the literature for this article has beenreviewed and discussed.REFERENCES1. BradAppleton, Stretching and Flexibility. Version:1.18, Last Modified 94/10/12.2. Kisner C, Colby LA. Therapeutic Exercise:Foundation and Techniques. Philadelphia, Pa: FADavis Co, 1985:172.3. Reynolds NL, Warrell TW. Chronic Achillesperitendinitis: etiology, pathophysiology andtreatment. J Ortho Sport Phys Ther.199; 13(4):171-176.4. Middleton JA, Kolodin EL: plantar fasciitis-heelpain in athletes. J Athl Train.1992; 27: 70-75.5. Millar AP: strains of posterior calf musculature(“tennis leg”). Am J Sports Med.1992; 7: 172-174.6. FranklinME,ChenierTC,BrauningerL,etal.Effectof positive heel inclination on posture, J OrthoSports Phys Ther. 1995; Feb: 21(2):94-9.7. Wearing high heel- Effect on body. Personal healthzone, February 2009.8. AL DALI Waleed A, OLUSEYE Kamaldeen A.Effect of high-heeled shoes and culturallyhabitual posture on calf muscle flexibility, Arabgulf journal of scientific research.1999; vol.17 (3): 326-339. Worrell TW, McCullough M, Pfeiffer a. Effect offoot position on gastrocnemius/soleus stretchingin subjects with normal flexibility. J Ortho SportsPhy Ther. 1994; 19: 352-356.10. Draper DO, Sunderland S. Examination of the lawof grotthus-draper: Does ultrasound penetratesubcutaneous fat in humans? J Athl Train 1993a;28: 246-250.11. FunkD,SwankA,AdamsK,etal.Efficacyofmoistheat pack application over static stretching onhamstring flexibility. J Strength Cond Res. 2001;15: 123-126.12. WMA Declaration of Helsinki - Ethical Principlesfor Medical Research Involving Human Subjects.59thWMA General Assembly Seoul, Korea, Oct2008. Hasmukh patel 5th april--58-64.pmd 2/7/2013, 8:08 PM63
  • 70. 64 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 113. Draper DO, Sunderland S, Kirkendall DT, RicardM. A comparison of temperature rise in humancalf muscles following applications of underwaterand topical gel ultrasound. J Orthop Sports PhysTher 1993;17: 247–251.14. David O. Draper, ChadAnderson et al. Immediateand Residual changes in dorsiflexion range ofmotion using an ultrasound heat and stretchroutine. Journal of Athletic Traning 1998;33(2):141-144.15. Hendricson A, Fredriksson K, Persson I, et al. Theeffect of heat and stretching on the range of hipmotion. J Ortho Sports Phys Ther. 1984; 13:110-11516. Wessling KC, DeVane DA, Hylton CR. Effects ofstatic stretch versus static stretch and ultrasoundcombined on triceps surae muscle extensibility inhealthy women. Phys Ther 1987; 67: 674-679.17. RatherAijaz Y, Pooja Chaudhary. Ultrasound andprolong long duration stretching increase tricepssurae muscle extensibility more than identicalstretching alone. Indian Journal of Physiotherapyand Occupational Therapy, vol. 1, no. 3 (2007-072007-09).12. Hasmukh patel 5th april--58-64.pmd 2/7/2013, 8:08 PM64
  • 71. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 65Influence of different Types of Hand Splints on FlexorSpasticity in Stroke PatientsEman Samir Fayez, Hayam Mahmoud SayedAssistantProfessorinDepartmentofPhysicalTherapyforNeuromuscularDisordersanditsSurgery, FacultyofPhysicalTherapy,CairoUniversity,EgyptABSTRACTObjective: The aim of this study is to evaluate the efficacy of each static and dynamic splint on handflexor spasticity and to compare between their effectiveness on hemiplegic patients.Design: Randomized controlled trial.Subject: 29 hemiplegic (stroke) patients (45-65 Y/o) with mild to moderate spasticity of upper limb. Theonset of stroke was from 6 month to one year before starting the study.Intervention: The patients were randomly assigned into two equal study groups of 15 (A and B). Theassessment were performed pre and post application of static splint for group A and dynamic splint forgroup B. The duration of splint application was one hour for both groups. All participants werereceiving designed program of treatment of hemiplegia after application of splint.Outcome measures: (1 The mean of active and passive range of motion for wrist extension usinggoniometer, and 2) Grip strength by using digital hand dynamometer.Keywords: Stroke ,Spasticity ,Static Splint And Dynamic Splint.INTRODUCTIONStroke, is defined as a cerebrovascular accident(CVA), it is the rapidly developing loss of brainfunctions due to disturbance in the blood supply to thebrain. As a result, the affected area of the brain is unableto function, leading to inability to move one or morelimbs on one side of the body, inability to understandor formulate speech, complications, and may lead todeath.1Spasticity caused by an upper motoneuronsyndrome is usually defined as a velocity-dependentincrease in muscle resistance against passivelengthening because of a supraspinal disinhibition ofboth tonic and phasic stretch reflexes. This muscle overactivity may result in muscle imbalance and shortening,leading to abnormal postures 4. Pain in the hemiplegicupper limb is also widely reported to be a complicationof spasticity.2Production of an effective powerful grip or even tomanipulate objects requires the wrist to be held in afunctional position of slight extension maintained byactivity of the wrist extensors4.The inability to open thehand when reaching for or releasing an object andlimitedgripisacommonfunctionalproblemafterstroke.Itmaybeduetoweaknessofthefingerextensormuscles,spasticity and stiffness of the finger and wrist flexormuscles. Grip can be limited not only because of aninability to activate finger flexors but also because ofweakness of the wrist extensors (extensor carpi radialislongus, extensor carpi ulnaris).3Splinting is commonly used by both physical andoccupational therapists to prevent joint deformities andto reduce muscle hypertonia of hemiplegic upper limbsafter stroke.4Orthoses and splints are commonly usedto improve and correct the position, range, quality ofmovement, and function of a person’s arm or hand 5.It is proposed that inhibition results from theapplication of splint can be due to altered sensory inputfrom cutaneous and muscle receptors during the periodof splint or cast application. Immobilization, applyinggentle continuous stretching of the spastic muscle atsubmaximal passive range of motion (PROM), is seento reduce spasticity by altering the threshold responsetostretchofthemusclespindleandGolgitendonorgansin the antagonist and agonist muscles. The effects ofneutral warmth and circumferential contact are alsothought to contribute to modification of spasticity seenfollowing casting.413. Eman Fayej cairo--65-69.pmd 2/7/2013, 8:08 PM65
  • 72. 66 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1The biomechanical effects of splinting relate tochanges in the length and extensibility of muscle andconnective tissue. Application of low-load prolongedstretch to the contracted tissues at the end of theiravailable range allows histological changes to occur inthe tissues in response to the position imposed6.It wassuggested that the increase in passive ROM seen afterremoval of casts in hemiplegic and cerebral palsy clientsresults from the lengthening of connective tissueelements along with addition of sarcomeres to themuscle fiber5.The types of splint designs commonly used aredynamic splint and static splint. The dynamic splintsdesigned to maintain wrist joint alignment withallowing movement at the wrist would improveperformance while maintaining activation of theforearm muscles that control the wrist. In addition, thedynamic splints would preserve and perhaps enhancegrip and manual dexterity skills7. Otherwise staticsplints are designed to be rigid for controlledimmobilization of the involved joint for improvedfunction8.In a study comparing muscle activation patternsduring perturbed balance when static and dynamicankle splints were worn, investigators reported thatstatic splints decreased muscle activation in anklemusculature7. In contrast, dynamic splints allowedactivation of ankle muscles while improving balancefunction. In addition, proximal muscles in the trunkand thighs were more active with the static splints thanwith the dynamic splints, suggesting increased muscleactivation proximal to the joint, which is fixed orimmobilized during static splint conditions 6.Many studies concluded the effects of dynamicsplints on upper limb in hemiplegic patients that theycould reduce swelling, improve wrist posture, andreduce wrist and finger flexor spasticity9. Other studyrecommended that daily use of static splint in post-stroke upper limb spasticity over an extended period isassociated with reduction of spasticity and pain, andwith an increase in wrist PROM8.Also an overnight splint-wearing regimen with theaffected hand in the functional position does notproduce clinically beneficial effects in adults withacquired brain impairment10.For optimal efficacy,therapies aimed to improving function should addressboth muscle shortening and muscle over activity;measures to relax overactive muscles should becombined with physical treatment to lengthen them9.Therefore, the goal of the current study is to evaluateand compare between the short term efficacy ofdynamic and static splints on hand flexor spasticity instroke patients.MATERIALS AND METHODSubjectsTwenty nine stroke patients (17 women, 12 men)were recruited from outpatient departments in KingFahadHospitaloftheUniversity.Subjectswererequiredto meet the following inclusion criteria:(1) post strokehemiplegia with duration ranged from 6 months toone year before the study; (2) upper-limb mild tomoderate spasticity (Modified Ashwarth Scale 1+ to 3at the wrist), and (3) age between 45 and 65 years .Exclusion criteria were : (1)cognitive impairment, (2)major contracture affecting muscles of the spastic armat the time recruitment; (3) Joint pathology of the upperlimb (eg, previous fractures, articular blocks); (5)Patients under antispastic drug . Informed consent wasobtained for all patients separately . Subjects werearranged randomly into two groups; group I (G1) andgroup II (G2). Group I consisted of 14 patients (9 malesand 5 females) and group II consisted of 15 patients (8males and 7 females).INSTRUMENTATIONHand digital dynamometer was used to measurethegripstrengthofaffectedhand.Goniometerwasusedto measure active and passive range of motion of wristextension. Two types of splints were used in this study.The static splint made from a low-temperature,nontoxic, biodegradable material produced from astrictly controlled cotton tissue, the splint held the handin the functional resting position (wrist positionedbetween at 30 degree extension), thumb in abduction 2.The dynamic splint was costumed made fromthermoplastic material and allowed 30 degrees ofmovement at the wrist and the fingers were free 9.INTERVENTIONAll patients of both groups were evaluated at thebeginning and at end of one-hour period of splintapplication. Patients of G1 were wearing static splintfor one hour while, patients of G2 were wearingdynamic splint for one hour .Changes occurring withstatic splint were then compared with changesoccurring with dynamic splint. Because the way inwhich the splint is fitted to the arm may be important,the fitting was performed by the same trainedinvestigator.All assessments were performed in a quietroom while the patient was sitting with the shouldersrelaxed and arms resting comfortably on chair’s armsupport.13. Eman Fayej cairo--65-69.pmd 2/7/2013, 8:08 PM66
  • 73. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 67OUTCOME MEASUREThreeoutcomemeasureswererecorded,whichwereactive range of motion, passive range of motion andgrip strength .These measures were obtained before andafter application of static and dynamic splints in bothstudy groups.Clinical and instrumental outcome goniometricmeasurements of wrist extension from full flexion ofthe patient were obtained in degrees to calculate theactive and passive range of motion. Each patient wasthen cued to start grip strength using digitaldynamometer, elbow flexed 90 degree with hand andforearm in mid position while rested on the table. Forstatistical analysis, mean of 3 consecutivemeasurements were taken to reduce possiblemeasurement errors, the number of repetitions givenwere according to standardized methods establishedduring previous studies 2, 9.STATISTICAL ANALYSISForparametricdata(AROM,PROM,gripstrength)differences of the changes occurring after wearing staticand dynamic splints for 1-hour period of time weremeasured and compared using 2-tailed paired t tests.Statistical analysis was performed using SPSS with levelof statistical significance at Pd”0.05.RESULTSThis study was performed to evaluate the effectof each static & dynamic splints on hand flexorspasticity in stroke patients. There were not statisticalsignificant differences between both groups beforetreatment, Demographic characteristics of both groups,were shown in Table, 1.Table 1: Demographic Data and Clinical Data of theStudy PopulationComparison Group I Group II P valueMean ±SD Mean ±SDAge(year) 63.5 ± 8.1 60.83 ±6.5 0.693#Height(cm) 170.3±5.13 173.9±8.4 0.432#Weight(kg) 83±13.4 85.5±10.6 0.649#Male 9 8 -Female 5 7 -Duration of 8.6 7.9stroke(months)#: Not significant.Comparison between pre and post-application ofstatic splint in group I, the results revealed that therewerestatisticalsignificantimprovementingripstrengthand active ROM, while there was highly significantimprovement of passive ROM, after application of staticsplint; data were shown in Table, 2.Table 2: Comparison of G.S, AROM and PROM meanvalues before and after static splint application forgroup1.Variables Pre Post P valueMean ±SD Mean ±SDGrip strength 3.96 ± 0.61 4.9 ± 0.83 0.003*AROM 55.24± 6.65 60.7 ± 3.5 0.001*PROM 101.66±5.6 115.63±6.36 0.0001**AROM: Active Range Of Motion; PROM: PassiveRange of Motion; SD: standard deviation; *: significant;**: highly significant.Comparison between pre and post-application ofstatic splint in group I, the results revealed that therewerestatisticalsignificantimprovementingripstrengthand active ROM, while there was highly significantimprovement of passive ROM, after application of staticsplint; data were shown in Table, 3.Table 3: Comparison of G.S, AROM and PROM meanvalues before and after dynamic splint application forgroup2.Variables Pre Post P valueMean ±SD Mean ±SDGrip strength 4.8 ± 0.53 5.53 ± 0.49 0.001*AROM 57.01± 7.76 70.52 ± 9.6 0. 01*PROM 116.33±12.5 135.56±16.7 0.001**AROM: Active Range Of Motion; PROM: PassiveRange of Motion; SD: standard deviation; *: significant;**: highly significant.Comparison between G1 and G2, regarding activeROM, passive ROM and grip strength, the resultsrevealed that dynamic splint had significantimprovement in wrist AROM and PROM whencompared to results of static splint. However, patientswho wore dynamic splint had improvement in gripstrength when compared with those of static splint butthis improvement was not statistically significant, datawere shown in Table, 4 and figure, 1.13. Eman Fayej cairo--65-69.pmd 2/7/2013, 8:08 PM67
  • 74. 68 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Table 4: Comparison between static and dynamic splint mean values of both groups pre and post splintVariables Pre (Mean ±SD) P value Post (Mean ±SD) P valueGroup I Group II Group I Group IIGrip strength 3.96 ± 0.61 4.8 ± 0.53 0.14 4.9 ± 0.83 5.53 ± 0.49 0.13AROM 55.24±6.65 57.01± 7.76 0.32 60.7 ± 3.5 70.52 ± 9.6 0.05*PROM 101.66±5.6 116.33±12.5 0.17 115.63±6.36 136.56±16.7 0.001*AROM; Active Range of Motion, PROM; PassiveRange of Motion; SD: standard deviation; *: significant..DISCUSSIONThis study was designed to investigate the shortterm efficacy of dynamic and static splints on handflexor spasticity in stroke patient and compare betweenthem by changes in degrees of active and passive rangeof motion and grip strength. The result showed thatpatient with spastic hand in both groups haddemonstrated improvement after application of bothtypes of splints .However; the dynamic splint hadsignificant improvement in wrist AROM, PROM & gripstrength compared with static splint.Because dynamic splints have moving parts thatallow the individual a range of voluntary controlledmovement, it has been proposed that their use mayprevent contractures while allowing opposingantagonistmuscleforcetocountertheforceofthespasticmuscle16.Muscle activation patterns of the upper extremitymuscles of ten children with CP were compared duringreaching with and without a hand-positioning device.Results suggested more normalized muscle activationwith the device application16.In contrast, another studyusing static splints that immobilize wrists reporteddecreased muscle activation, which over time may leadto disuse atrophy in the wrist muscles and overuse ofmore proximal muscles.17In contrast, dynamic wristsplints that provide wrist support for more optimalhand function allowed some movement, may notproduce this additional strain on proximal muscles19.These finding agree with (Assunta,et al,2005)2thatstudied the effect of volar static splint in post strokespasticity of the upper limb .The author found that therewas an increase in wrist PROM after application of acustom volar static splint for 2 to 3 hours a day in post-stroke spasticity of the upper limb . The results of thecurrent study come in accordance with (Jean , et al,2000)7that studied the short term effects of dynamiclycra splints on upper limb in hemiplegic patients , thestudy reported reduction in wrist and finger flexorspasticity when lycra garments were worn over 3 hours.Our results disagree with (Natasha, etal 2003)6thatstudied the effect of splinting the hand in the functionalposition after brain impairment, the study indicatedthat subjects with acquired brain impairment who wereparticipating in routine motor training and upper-limbstretches did not showed detectable or importantchanges in wrist flexor extensibility after wearing asplint daily for 4 weeks.Also , the current results counteract with (Turtonand Britton 2006)11that found that application of anintensive 4-week splinting program to preventcontractures in the arm after stroke did not increase theextensibility of the wrist and long finger flexor musclesin adults after stroke, this trial evaluating stretchpositioning in theupper limb, reported a loss of 13° ofwrist extension range at 8 weeks.RECOMMENDATIONFurther investigation is necessary to determineefficacy of the different splints over time and in differentfunctional activities to more clearly understandsplinting use for spastic hand in hemiplegic patient.CONCLUSIONThe study findings suggested that spastic hand inhemiplegic patient may experience improvement inPROM , AROM and hand grip strength as a result ofstatic and dynamic splint application , but better resultswere found when dynamic splint were worn duringthe same time of application.REFERENCES1. Donnan GA, Fisher M, Macleod M, Davis SM.Stroke. Lancet 2008; 371 (9624): 1612–1623.2. Assunta Pizzi, Giovanna Carlucci, CatusciaFalsini, etal. Application of a volar static splint inpoststroke spasticity of the upper limb. Arch PhysMed Rehabil 2005; 86:1855-1859.3. Ruth Turk, Jane H. Burridge, Ross Davis, etal.13. Eman Fayej cairo--65-69.pmd 2/7/2013, 8:08 PM68
  • 75. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 69Therapeutic Effectiveness of Electric Stimulationof the Upper-Limb Poststroke Using ImplantedMicrostimulators. Arch Phys Med Rehabil 2008;89:1913-1922.4. KatzR,RymerWZ.Spastichypertonia:mechanismand measurement. Arch Phys Med Rehabil 1989;70:144-155.5. Wilton JC: Splinting and casting in the presenceof neurological dysfunction. In: WIlton JC, Handsplinting: principles of design and fabrication.London: WB Saunders 1997; 168-197.6. PatriciaA. Burtner, Janet L. Poole, Theresa Torres,etal. Effect of wrist hand splints on grip, pinch,manual dexterity, and muscle activation inchildren with spastic hemiplegia: A PreliminaryStudy. J HAND THER 2008; 21:36–43.7. Collins K, Oswald P, Burger G, Nolden J.Customized adjustable orthoses: Their use inspasticity, Arch Phys Med Rehab 1985;66:397-8.8. Langlois S, Pederson L, MacKinnon J: The effectsof splintingon the spastic hemiplegic hand: reportof a feasibility study. Canadian J Occup Ther 1991;58(1):17-25.9. Neeman R, Neeman M: Rehabilitation of a post-stroke patient with upper extremity hemipareticmovement dysfunction by orthokinetic orthoses, JHand Ther 1992; 3(5):147-155.10. Natasha A. Lannin, Sally A, Horsley, etal.Splinting the Hand in the Functional Position afterBrain Impairment: A Randomized, ControlledTrial. Arch Phys Med Rehabil 2003; 84:297-302.11. Jean-Michel Gracies, Jeno Emil Marosszeky, RogerRenton, etal. Short-term effects of dynamic lycrasplints on upper limb in hemiplegic patients. ArchPhys Med Rehabil 2000 ;( 81):1547-1555.12. Lannin NA, Cusick A, McCluskey A, etal. Effectsof splinting on wrist contracture after stroke: arandomized controlled trial. Stroke 2007; 38(1):111-116.13. Patricia A. Burtner, Jennifer Bradley Anderson,Michelle Lee Marcum, etal. A comparison of staticand dynamic wrist splints usingelectromyography in individuals withrheumatoid arthritis. J HAND THER 2003 ;(16):320–325.14. Stern EB, Yterberg SR, Krug HE, Mullin GT,Mahowald ML. Immediate and short-term effectsofthreecommercialwristextensororthosesongripstrength and function in patients with rheumatoidarthritis. Arthritis Care Res 1996 ;(9):42–50.15. TurtonAJ,BrittonE.Apilotrandomizedcontrolledtrial of a daily muscle stretch regime to preventcontractures in the arm after stroke. Clin Rehabil2005 ;( 19):600–612.16. Feldman P.Upper extremity splinting and casting.In: Glenn MB,Whyte J (eds). The PracticalManagement of Spasticity in Children and Adults.Malvern, PA: Lea & Febiger 1990; pp 59–166.17. Reid DT, Sochaniwskyj A. Influences of a handpositioning device on upper extremity control ofchildren with cerebralpalsy. Int J Rehabil Res 1992;(15):15–29.18. Bulthaup S, Cipriani DJ, Thomas JJ. Anelectromyography study of wrist extensionorthoses and upper extremity function. Am JOccup Ther 1999 ;(53):434–440.19. Jansen CWS, Olson SL, Hasson SM. The effect ofuse of a wrist orthosis during functional activitiesonsurfaceelectromyographyofthewristextensorsin normal subjects. J Hand Ther 1997 ;(10):283–289.13. Eman Fayej cairo--65-69.pmd 2/7/2013, 8:08 PM69
  • 76. 70 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Interferential Current Therapy versus Narrow BandUltraviolet B Radiation in the Treatment of Post HerpeticNeuralgiaIntsar Salim.WakedLecturerofPhysicalTherapy,DepartmentofPhysicaltherapyforSurgery,FacultyofPhysicalTherapy,CairoUniversity,Egypt.ABSTRACTObjective: To compare the efficacy of interferential current therapy versus narrow band ultraviolet Bradiation in the treatment of post herpetic neuralgia.Subjects: Forty nine patients suffering from distressing post herpetic neuralgia. assigned randomlyinto 2 groups; interferential group and narrow band ultraviolet B group. Intensity of pain was recordedbefore and after therapy using numerical rating scale.Results: The results of this study showed no significant difference in pain intensity post treatmentbetween both groups in acute and subacute neuralgia as p value > 0.05 while there was significantdifference between both groups in established neuralgia as p value< 0.05.Conclusion: The study concluded that interferential current and narrow band ultraviolet B wereeffective in acute and subacute neuralgia, while only interferential is effective in established neuralgia.Keywords: Interferential Current Therapy, Narrow Band Ultraviolet B Radiation, Numerical Rating Scale, Postherpetic neuralgia.INTRODUCTIONHerpes zoster ( HZ ) infection is caused by areactivation of the latent varicella zoster virus thatcauses chicken pox. It appears predominantly in olderadults whose immunity for the virus has waned. Post-herpeticneuralgia(PHN)isdescribedassharp,burning,aching,orshootingconstantlypresentinthedermatomethat corresponds with the herpes rash1.Pain in HZ evolves in three phases: acute, subacute,and chronic. The acute phase occurs with the onset ofthe herpetic rash and lasts for less than 30 days, thesubacute phase lasts for 1-3 months after the onset ofthe rash, and the chronic phase, or PHN, lasts for 3months or longer after the onset of the rash2.Post herpetic neuralgia (PHN) is a common,debilitating complication of herpes zoster that has amajor impact on patients’ quality of life. It can causeinsomnia, fatigue, depression. Predictors of PHN aregreater age, acute pain and rash severity, prodromalpain, the presence of virus in peripheral blood, as wellas adverse psychosocial factors3.The treatment of PHN is medically challenging andoften frustrating in some situation as the exactmechanism of neuralgia is poorly understood andmultiple and complex pathophysiology is postulatedrequiring poly pharmacy, which itself leads to manyside effects4.Interferential current (IFC) is a commonelectrotherapeutic modality used to treat pain. IFCtherapy is the application of alternating medium-frequency current (4,000 Hz) amplitude modulated atlow frequency (0–250 Hz). Despite IFC’s widespreaduse, information about it is limited. A review of theliterature reveals incomplete and controversialdocumentation regarding the scientific support of IFCin management of post herpetic pain5.The inflammatory response plays a major role inthe pathogenesis of acute zoster pain and PHN.Ultraviolet B radiation (UVB) may affect the course ofPHNthroughitssuppressingeffectontheinflammatoryresponse in the acute zoster attack, thus decreasing theneuronal damage contributing to PHN 6.The purpose of this study was to evaluate theefficacy of interferential current therapy versus narrowband ultraviolet B radiation in the treatment of post –herpetic neuralgia.14. Instar cairo--70-75.pmd 2/7/2013, 8:08 PM70
  • 77. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 71PATIENTS AND METHODSubjectsForty nine patients (24 male, 25 female) withdistressing post herpetic neuralgia were recruited fromdepartment of dermatology and the study conductedin outpatient department of physical therapy- El-Mataria Teaching Hospital after approval of theinstitutional ethical committee. The history & clinicalexamination were done for all patients. Subjects whofulfilled the following criteria were eligible forenrollment in the study; (1) age ranged from 50 to 80years, (2) elapsed time since the beginning of pain lessthan 6 months. Patients were excluded if they had (1)disseminated zoster, (2) malignancy, (3) diabetes, (4)pregnancy (5) pacemakers (7) Patients were takingimmunosuppressive medication. The patients wererandomized into two groups of equal number. (1)interferential group and (2) narrow band ultraviolet B (nbUVB) group. Pain was assessed by numerical ratingscale before starting of the treatment and at the end ofthe therapeutic period for all patients.At the time of this study, Human Research EthicsCommittee had not been established in the faculty ofphysical therapy, but the study was approved by thedepartmental council of physical therapy for surgeryand all patients signed an informed consent at the firstvisit to the physical therapy clinic .Outcome measuresMeasurement of pain intensity by Numeral RatingScaleNumeral Rating Scale (NRS) is a common andpractical method for assessing pain severity. It is themost widely used pain rating scale in clinical practice.There is evidence, which supports the validity andreliability of the NRS in younger. and older patients.The reliability of the NRS is acceptable and it has ahigh internal consistency, with a Cronbach á range of0.86 to 0.88 7.The NRS is an 11-point pain scale, where patientsare requested to quantify the intensity of their pain on ascale from zero to 10 (from 0 = no pain to 10 = worstpain imaginable). The NRS scale can also be usedvisually with both words and numbers along a verticalor horizontal line. Patients are asked to express anumber that relates best to their pain intensity8.Treatment proceduresInterferential current Therapy (IFC)Description of apparatusSONOSTIM ( Class 1-type BF, Norm: 601-1) was acombined unit used to introduce interferential currentfor group 1. This unit introduced a quadripolar IF aswell as bipolar mode. The unit was provided with twooutput channels for interferential currents.Treatment parametersThe parameters used were; frequency 250 Hz, apulse duration 120ì, 30 minutes. The treatment wasgiven for 3 sessions per week for 5 weeks. Intensity ofthe impulse varied according to the patient’s tolerance9.Electrodes placement• The dermatome that was affected by the shingles isthe treatment path for electrotherapy. Each channelhas one electrode that emits electricity and the otherelectrode is the ground.• One electrode, from channel 1, was placed directlybeside the origin point where the dermatome exitsthe spinal cord. The other electrode for channel 1was placed about 2/3rds of the way down thedermatome.• On channel 2 one electrode was placed betweenthetwoelectrodesofthefirstchannelapproximately1/3rd down, and the other electrode from channel2 was placed at the distal end of the dermatome,.This electrode placement now covers the entiredermatome 5.NarrowBandUltravioletBRadiationTherapy(nUVB)Narrow band UVB apparatus (Waldmann - UV100L) was used to introduce nbUVB (311-312nm) topatients in group 2. The starting dose was 0.21 J/cm2and gradually increasing the dose by 10 mJ/cm2eachsession to a maximum dose of 100 mJ/cm2. (as long asthere is no adverse effects reported such as persistenterythema, burn, itching)10.Patientswereinstructedtoexposetheinvolvedbodypart while the rest of the body was covered usingclothing. Patients were instructed to wear protectivegoggles to avoid damage of the cornea. Treatmentsessions were repeated three times a week.Statistical AnalysisData were coded and entered to a statistical packageof social science (SPSS, version 16). Mann-Whitney Utest was used to assess the difference in sex, type ofpain, type of neuralgia, affected dermatome as well asthe intensity of pain in acute, subacute and establishedneuralgiabetweenbothgroups,whilewilcoxontestwasused to assess the intensity of pain within each group.All p values less than 0.05 were considered to bestatistically significant.14. Instar cairo--70-75.pmd 2/7/2013, 8:08 PM71
  • 78. 72 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1RESULTSA total of 49 patients was screened for eligibility,and 47 subjects fulfilled the inclusion criteria. Threesubjects of 47 reported poor adherence to the treatment,(a participant with poor adherence to the programdefined as missing more than three consecutive sessionsor more than 20% of all sessions) and excluded fromthe study, and their data were not used in the statisticalanalysis. A total of 44 subjects completed the study andwere initially randomized into two groups of equalnumber. IF group (n=22), and nbUVB group (n=22).Table (1) presents the characteristics of the patientscompleting the study. Both groups were comparable atthe baseline regarding to the demographic and clinicalcharacteristics.Table 1: Demographic and clinical characteristicsVariables IF group nbUVB group P valuesAge (years) (mean ±SD) 60.90±7.19 59.90±8.39 0.673*Duration of pain (day) 103.05±62.00 98.50±68.84 0.819*(mean±SD)Type of neuralgia (%) Acute 5(22.7%) acute 7(31.8%) 0.633*Subacute 5(22.7%) subacute 4(18.2%)Established 12(54.5%) established 11(50%)Sex (Male - Female) Male 10(45.5%) Male 11(50%) 0.765*Female 12(54.5%) Female 11(50%)Affected dermatome Cervical 3(13.6%) Cervical 5(22.7%) 0.891*Thoracic 7(31.8%) Thoracic 5(22.7%)Lumbar 2(9.1%) Lumbar 1(4.5%)Rt upper limb 6(27.3%) Rt upper limb 6(27.3%)Lt upper limb 4(18.2%) Lt upper limb 5(27.7%)Type of pain ( %) Continuous burning 8(36.4%) Continuous burning 7(31.8%) 0.591*Intermittent burning 6(27.3%) Intermittent burning 5(22.7%)Continuous stabbing 5(22.7%) Continuous stabbing 6(27.3%)Intermittent stabbing 3(13.6%) Intermittent stabbing 4(18.2%)Intensity of pain Acute 8.00±.8366 Acute 8.00±1.11 0.932*(median±SD)Subacute 8.00±.8366 Subacute 8.50±0.577 0.190*Established 8.00±.866 Established 8.00±0.894 0.558** No significant differences SD; standard deviationMeasurements of pain intensityIn table (2); Theresultsshowedsignificantreductionin pain intensity post treatment in IF group whatevertype of neuralgia ( acute, subacute, chronic) as p value<0.05. In nbUVB group; the results showed significantreduction of pain intensity post-treatment in acute andsubacute neuralgia as p value <0.05 however nosignificant difference in established neuralgia as pvalue > 0.05..Table 2: pain intensity within both groups pre and post treatment.Acute neuralgia Subacute neuralgia Established neuralgiapre post pre post pre postIF Group 8.0±0.83 2.0±1.14 8.0±0.83 3.0±0.84 8.0±0.87 2.0±0.94P value 0.043** 0.041** 0.002**NBUVB 8.0±1.11 3.0±0.899 8.0±0.57 3.5±0.96 8.0±0.89 7.5±1.00P value 0.018** 0.039** 0.55** No significant difference * * Significant difference14. Instar cairo--70-75.pmd 2/7/2013, 8:08 PM72
  • 79. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 73IF group nbUVB groupPercentage of improvement in acute neuralgiaIF group nbUVB groupPercentage of improvement in subacute neuralgiaIF group nbUVB groupPercentage of improvement in established neuralgia14. Instar cairo--70-75.pmd 2/7/2013, 8:08 PM73
  • 80. 74 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1In table (3); The results showed no significantdifference in pain intensity post treatment between bothgroups in acute and subacute neuralgia as p value >0.05 but significant difference between both groups posttreatment as regard to established neuralgia as p value<0.05.Table 3: Comparison of pain intensity between bothgroups post treatmentIF Group NBUVB P valueAcute neuralgia 2.0±1.14 3.0±0.899 0.442*Subacute neuralgia 3.0±0.84 3.0±0.96 0.439*Established neuralgia 2.0±0.94 7.5±1.00 0.001*** No significant difference * * Significant differenceDISCUSSIONPostherpetic neuralgia is the major chroniccomplication and is a difficult management problem.The aim of this study was to compare the effects ofinterferential current therapy versus narrow bandultraviolet B radiation in the treatment of post herpeticneuralgia. A prospective study of forty nine subjectswas carried out. Subjects were divided into two groups;IFgroupthatreceivedinterferentialtherapyandnbUVBgroup that received narrow band UVB sessions.Outcome measures were assessed using numericalrating scale to assess pain intensity pre and posttreatment.The results of the study showed that there wassignificant reduction in pain intensity post treatmentin IF group in acute, subacute and chronic neuralgia asp value <0.05. This support the efficacy of interferentialfor minimizing pain and this may be attributed toanalgesic effects of interferential therapy.The analgesic effect of interferential therapy can beexplained in part by Wednesky inhibition of Type Cnociceptive fibres, although other mechanisms arecertainly involved. ‘Pain gate’ theory, proposed byMalzack and Wall11remains central to this explanation.Another system that helps to reduce pain is the‘descending pain suppression mechanism’, which ismediated by the endogenous opiates12.Number of previous studies demonstrated theeffectiveness of inferential current therapy in order toreduce neuropathic pain. Babu and Murali;13andBurchiel;14analyzed analgesic effects of IFC in chronicand acute neuropathic pain. Natarajan;15also foundpositive results of interferential currents in diabeticneuropathy and post-herpetic neuralgia. Nabila; et al;9concluded that Interferential therapy is an effective,easy to use therapy with minimal side effects in patientssuffering from trigeminal neuralgia that not respondingto conventional treatment.In a study compared IF with transcutanous electricalnerve stimulation (TENS) Cheing and Hui-Chan;16confirmed the analgesic effects of IF and TENSin their study and concluded that both TENS and IFincreased the heat pain threshold to a similar extentduring stimulation. However, the post-stimulationeffect of IF lasted longer than that of TENS.As regard to the efficacy of nbUVB; the results ofstudy showed that there was significant reduction ofpain intensity in acute and subacute neuralgia howevernon significant differences in chronic neuralgia. Theimprovement in acute and subacute neuralgia may beattributed to the anti-inflammatory effect of UVB. UVBmay affect the course of PHN through its suppressingeffect on the inflammatory response in the acute zosterattack thus decreasing the neuronal damagecontributing to PHN17.Langerhanscell(LCs)playanimportantroleinPHNas several molecules that sensitize cutaneousnociceptors are released by LCs. And the langerhansmay be activated in acute PHN. UVB radiationsuppresses antigen presentation of LCs in differentways. It stimulates keratinocytes and mast cells tosecrete immunosuppressive cytokines such as IL-10,TNF-á, IL-4, PG-E2, á-MSH or CGRP, which inhibit theantigen-presenting function of LCs. Furthermore, itcauses depletion of the LCs in the epidermis 18, whichmay also explain the improvement induced by UVB inPHN.Also UVB modifies the T-cell response to persistentVZV particles in nerve fibers, which might be involvedin the pathogenesis of PHN. UVB induces a shift from aTh-1 immune response to a Th-2 response in differentways19.Two studies correlate with the results of this study.Jalali et al;20who reported 58.33 and 83.33% completepain relief at 1 month and 3 months follow up,respectively.And concluded that UVB phototherapy inthe acute stage of zoster rash might reduce the incidenceand severity of PHN. Treatment after 3 months does notseem to have a significant beneficial effect. Also El-Nabarawy; 10who used nbUVB for 17 patients withpost herpetic neuralgia and the results showed morethan 50% improvement was achieved in 6 (35.29%) and8 (47.06%) patients, at the end of therapy and after 314. Instar cairo--70-75.pmd 2/7/2013, 8:08 PM74
  • 81. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 75months follow up, respectively. And concluded thatnbUVB may provide a potential tool in the managementof PHN.To the best of our knowledge, there is no studycomparing the efficacy of interferential therapy versusnarrow band ultraviolet B radiation. The results of thisstudy showed no significant difference in pain intensitypost treatment between both groups in acute andsubacute neuralgia as p value > 0.05 but significantdifference in established neuralgia as p value< 0.05.This confirm the efficacy of both interferential andnbUVB for acute and subacute neuralgia, while onlyinterferntial is effective in established neuralgia. Thelimitations of our study were no control group includedand no period of follow-up. Further studies includingcontrol group and follow-up are needed to furthervalidate our findings.Conflict of interestThere is no interest of conflict with any organization,and this research is not fundedACKNOWLEDGEMENTSWe express our gratitude to all those who havecontributed in completing this research work, especiallyall the subjects who willingly agreed to participate inthis study.REFERENCES1. De Benedittis G, Besana F, Lorenzetti A “A newtopical treatment for acute herpetic neuralgia andpost-herpetic neuralgia: the aspirin/diethyl ethermixture. An open-label study plus a double-blindcontrolled clinical trial”. Pain; (1992); 48 (3):383–390.2. Dworkin RH, Portenoy RK. Proposedclassification of herpes zoster pain. Lancet1994;343:1648.3. Johnson RW, Whitton TL. Management of herpszoster (shingles) and postherpetic neuralgia.Expert Opin Pharmacother (2004);5:551-9.4. Fashner J, Bell AL. Herpes zoster and postherpeticneuralgia: prevention and management. Am FamPhysician. (2011) Jun 15;83(12):1432-1437.5. Kitchen S, Palmer S, Martin D,. Interferentialcurrent for pain control. In: KitchenS ed.Electrotherapy Evidence-based Practice. 11th ed.Edinburgh, Scotland: Churchill Livingstone;2002:287–298.6. EL-Ghor AA, Norval M. Biological effects ofnarrow-band (311nm TL01) UVB irradiation: areview. J Photochem Photobiol B 1997;38:99-106.7. Lara-Munoz C, De Leon SP, Feinstein AR, PuenteA, Wells CK: Comparison of three rating scales formeasuring subjective phenomena in clinicalresearch, Use of experimentally controlledauditory stimuli. Arch Med Res 2004, 35(1):43-48.8. Hartrick CT, Kovan JP, Shapiro S: The numericrating scale for clinical pain measurement: a ratiomeasure? Pain Pract 2003, 3(4):310-316.9. Nabila S; Muhammad H; Faisal Y; Rukhsana B;Efficacy of interferential current on trigeminalneuralgia. 2012; NEURALGIAMC Vol. 19 - No.2;33 – 35.10. El-NabarawyE.Theuseofnarrowbandultravioletlight B in the prevention and treatment ofpostherpetic neuralgia (A pilot study). Indian JDermatol;2011;56:44-7.11. Kloth, L. Interference current. In: ClinicalElectrotherapy Nelson, R.M., Currier, D.P. (Ed.) Ch9, 183-207, Appleton and Lange, 1987. Norwalk,Connecticut, USA.12. Watson, J. Pain mechanisms: a review. 3.Endogenous pain mechanisms Aust J. Physiother1982, 28 (2), 38-4513. Babu R, Murali R. “Arachnoid cyst of thecerebellopontine angle manifestingascontralateral trigeminal neuralgia: case report”,Neurosurgery 2010; Jun; 28(6): 886-7.14. Burchiel KJ. “A new classification for facial pain”,Neurosurgery 2001; Nov; 53(5):1164-6.15. Natarajan, M “Percutaneous trigeminal ganglionballoon compression: experience in 40 patients”.Neurology (Neurological Society of India)(2001)’;48 (4):330–2.16. Cheing GL, Hui-Chan CW. Analgesic effects oftranscutaneous electrical nerve stimulation andinterferential currents on heat pain in healthysubjects. J Rehabil Med. 2003 Jan;35(1):15-9.17. Misery L. Langerhans cells in the neuron-immuno-cutaneous system. J Neuroimmunol 1998;89:83-7.18. Shreedhar V, Giese T, Sung VW, Ullrich SE. Acytokine cascade including prostaglandin E2, il-4, IL-10 is responsible for UV-induced systemicimmunosuppression. J Immunol 1998;160:3783-9.19. Schwarz T. Mechanisms of UV-inducedimmunosuppression. Keio J Med 2005 ; 54:165-71.20. Jalali MH, Ansarin H, Soltani-Arabshahi R. Broad-band ultraviolet B phototherapy in zoster patientsmay reduce the incidence and severity ofpostherpetic neuralgia. PhotodermatolPhotoimmunol Photomed. 2006 Oct;22(5):232-7.14. Instar cairo--70-75.pmd 2/7/2013, 8:08 PM75
  • 82. 76 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Effect of the Duration of Play on Pain Threshold and PainTolerance in Soccer PlayersShahid Raza1, C.S. Ram2, Jamal Ali Moiz31Physiotherapist,CentreforPhysiotherapyandRehabilitationSciences,JamiaMilliaIslamia,2Director,DepartmentofPhysiotherapyITSParamedicalcollege,Ghaziabad,3AssistantProfessor,CentreforPhysiotherapyandRehabilitationSciences,JamiaMilliaIslamiaABSTRACTBackground: The athletes capacity to tolerate pain is one of the most important features of sportingsuccess. Research suggest that a verity of pain suffers can benefit from exercise. Duration of play mayincrease in pain threshold and pain tolerance in soccer players.Objective: The purpose of this study was to evaluate the effect of pain threshold and pain tolerance onparticipation in playing soccer.Design: This was a same subject pre-test post-test trial.Setting: The study was conducted at Siri Fort Sports Complex and Jawaharlal Nehru Stadium (SportsAuthority of India) New Delhi.Participants: Thirty healthy male district level soccer player (aged 17-22 years) participated in thestudy.Measurements: A gross pressure device was used to induce pain, and to measure pain threshold andpain tolerance. It consisted of a sphygmomanometer and rubber coated steel cleat. Cleat along withshin guard was placed of the medial surface of the tibia approximately in the middle portion. Pain wasinduced by inflating the sleeve at 10 mmHg every 10 seconds. The subjects were asked to inform whenthey first sense pain. The pressure was noted as pain threshold reading. Pressure was further increasedtill the subject cannot endure it readings were noted as pain tolerance and pressure was released. Thereadings were taken before, between and after the game.Results: Compared with three readings of pain threshold and pain tolerance a repeated measure ofANOVAshowed a significant difference.Abonferroni test was used for post hoc pair wise comparisonamong all three conditions showed a significant difference among three possible pairs.Limitations: Further work is needed to determine whether sex differences in pain coping mechanismexist before, during after competition.Conclusion: The present data suggest that changes in pain threshold and pain tolerance in soccerplayer depend on the duration of play. The result of this study proves that the participation in game toimprove the pain threshold and pain tolerance in soccer players.Keywords: Soccer, Pain Threshold, Pain Tolerance Introduction.INTRODUCTIONThe athlete’s capacity to tolerate pain is among themost important features of sporting success.Researchers contended that the pain tolerance is theCorresponding author:Jamal Ali MoizAssistant Professor,Centre for Physiotherapy and Rehabilitation Sciences,Jamia Millia Islamia (Central University),New Delhi-110025,India, E-mail: +91 (011) 26980544, Fax: +91 (011) 26980544most critical differentiator between successful andunsuccessful athletes in endurance sports. The abilityto tolerate pain is often inherent in competitive sportssuccess.Performingphysicalskillsattheoptimalefforts,particular when the movement involves contact withother participants, virtually maintaining other effortand skilled performance after experiencing pain duringthe contest, and after rehabilitation.1Dramatic anecdotes of dancers or athletes whocontinue strenuous exercise in the face of severe injuriesand later report that they felt no pain have contributedto the notion that exercise can increase pain tolerance.15. Jamal ali Moitz--76-80.pmd 2/7/2013, 8:08 PM76
  • 83. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 77Such anecdotal evidence has been linked to theory todata which indicate that exercise releases endorphinsand that endorphins reduce pain. This proposedlinkage has, intern, led to a belief that exercise-inducedanalgesia is an established phenomenon.2Ronalds Melzack,3founder of pain gate theory haddescribed pain in his own words in the following ways“ it is not a fixed response to a noxious stimulus ;itsperceptionismodifiedbypastexperiences,expectationsand even by culture. It has a protective function,warning us that something biologically harmful ishappening. But anyone who has suffered prolongedpain would regard it as “Evil”, punishing affection thatis harmful in its own right”.It has been reported by Raithel that most painmanagement programmers prescribe some kind ofexercise regimen, some include aerobic exercise, othersinclude resistance exercise, and still others use acombination of aerobic and resistance exercise.Research has been conducted into whether aerobicexercise, such as cycling and running , is associatedwith an analgesic effect, and has indicated that aerobicexercise at a sufficient intensity (>70% of maximumaerobic capacity) has been associated with increases inpain threshold.4The Literature regarding whether or not exercise –induced analgesia is an established phenomenon inhumans is equivocal. Haier et al (1981)5have reportedchanges in pain threshold following exercise, whileothers have not. a number of investigators have studiedchanges in pain threshold using a dental pulpstimulation. Pertovara et al. (1985)6al investigatedchanges in dental pain threshold during exercise atdifferent intensities and found that dental painthreshold tends to increase with increasing workload.The experiments are typical studies investigatingpost-exercise analgesia. Their emphasis was not onsupporting the casual role of exercise in the analgesiceffect, but instead focused on whether the analgesiceffect is mediated by release of endorphins. However,while these studies appear to support the analgesiceffect of exercise, a causal interpretation is limited bythe failure to include a no exercise control group.7Willium P. Margan(1984)8examined the “effectivebeneficence of vigorous physical activity” andconcluded that distraction, release of monoamine aswell as endorphins during vigorous physical activities,act synergistically to produce the analgesic effect.Ashley Grossaman and John R. Sutton(1984) 9investigated the relationship between the endorphinrelies and their role in exercise and found that theendorphin concentration in the blood increasesconsiderably with exercise and play an important rolein regulation of ventilation especially at higher intensityexercise , where they appear to inhibitory.Another study by Conard Droste (1990)10onexperimental pain threshold and plasma beta –endorphine level dosages does not correlatesignificantly with pain threshold, though short term,exhaustive physical exercise can evoke transient painthreshold. This exercise induced elevation in painthresholddoesnothowever,appeartobedirectlyrelatedto plasma endorphine level.Maria Gurevich (1994)11and colleagues found thatsubmaximal exercise intensity produces analgesiasuggesting the possibility of using moderate exercisein therapeutic intervention. Another study by Mark HAand Kenith Russel (1994)1confirmed that resistiveaerobic exercises can result in greater pain tolerance.Though the growing body of research suggest that avariety of pain sufferer can benefit from exercise, and agreater reliance upon exercise as an effective , healthyand less intrusive pain management alternatives, oradjunctive, to pharmacological analgesics can be laid.However relatively little research has been devoted toexamining the effectiveness of exercise on influencingthe person’s threshold and tolerance of pain,particularly acute.PURPOSEThe purpose of this study was to evaluate the effectof pain threshold and pain tolerance on participationin playing soccer.HYPOTHESISDuration of play will increase the pain thresholdand pain tolerance in soccer players.METHODSubjectsAtotalnumberof30healthymaledistrictlevelsoccerplayers were selected for the study from Siri Fort sportscomplex and Jawaharlal Nehru stadium (sportsauthority of India) New Delhi. Ethical approval wasobtained from the university ethical committee prior torecruiting subjects. The mean age of the selected sample15. Jamal ali Moitz--76-80.pmd 2/7/2013, 8:08 PM77
  • 84. 78 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1was 18.6 +1.4 ranging from 17to 22 years of age. Aninformed consent was taken from all the participantsafter describing in detail the procedure and purpose ofthe study to all of them. The subjects were selectedaccording to the following inclusion and criteria.Inclusion criteria• Age group between 16 to 25 years• Healthy district level soccer players• Only malesExclusion criteria• Subjects taking pain killers or muscle relaxant drugs• Any recent or previous injury• Non co-operative persons• Those subjects whose pain tolerance exceeded morethan 300 mmHg(maximum rereading for thesphygmomanometer) during pre-testDESIGN OF THE STUDYA same subject pre-test post test design was selectedfor testing the hypothesis. A baseline reading was takenprior to start of the game, a second reading of thedependent variable were taken during the half time ofthe game and final reading immediately after the gamewas over. Only one subject was selected formeasurement of dependent variable during a singlegame. These readings were then compared to find outthe effect of independent variables. The outcomemeasure or dependent variables, selected for this studywere pain threshold and pain tolerance.Instrument and tool• Sphygmomanometer• Rubber coated steel football cleat• Soccer shin guard• Digital stopwatch to record timePROCEDUREBefore the warm-up a baseline measurement of painthreshold and pain tolerance was taken from theselected subject. The selected subject has been giveninstructions regarding not to exercise, not to smoke, notto consume alcohol or caffeine at least two hours beforethe game. The subjects were made to lye supine on theground to make them comfortable and also to ensurethat they cannot see the sphygmomanometer readingsto avoid giving any visual feedback. A gross pressuredevice was used to induce pain, and measure painthreshold and pain tolerance. It consisted of asphygmomanometerandrubbercoatedsteelcleatalongwithin the shin guard was placed on the medial surfaceof the tibia approximately in the middle portion. Thesleeve of the sphinomanometer was fastened aroundthe shin guard and was inflated.Pain was induced by inflating the sleeve at 10mmHg every 10 seconds, which compressed the steelcleat against the shin causing pain. The subjects wereasked to inform when the first sense the pain. thepressure reading of the mercury column of thesphygmomanometer was noted as pain thresholdreading. The pressure was increased further till thesubject cannot endure it. At this point again thesphygmomanometer readings were noted as paintolerance and pressure was released.Methods of instruction was standardized by givingthe subjects the following commands “ this apparatus,using pressure for investigation of sensitivity to painyou have to say “start” as soon as you are not able tobear the pain . These readings were taken before gameagain during half time and after the end of the game.DATA ANALYSISData analysis was done using SPSS software.Demographic data of patient including age , sex weredescriptively summarised. A repeated measure ofANOVA was performed to analysed the difference inpain threshold and pain tolerance. An alpha level of0.05 was used to determine statistical significance. Allpossible pair wise post hoc analysis was conducted onthe significant dependant variable in order to comparedifference among duration of game.RESULTSA total thirty (n=30) district level soccer player withmean+ SD age 18.6+14 years were selected for theanalysis. Before warm-up, prior to the game, during thehalf time of the game and at the end of the game bothpain threshold and pain tolerance are summarised inmean and standard deviation in table 1.15. Jamal ali Moitz--76-80.pmd 2/7/2013, 8:08 PM78
  • 85. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 79To find out the difference among all the threereadings of pain threshold and pain tolerance arepeated measure of ANOVA shows statisticallysignificant difference among all the three readings ofboth pain threshold (F=17.05,p<0.0001)and paintolerance (F=19.69, p<0.0001). A bonferonnin post hocpair wise comparison shows significant differenceamong three pairs before game vs. between game (painthreshold p=0.02,pain tolerance =0.001) before gamevs. after game (pain threshold p<0.0001, pain tolerancep<0.0001) and between game vs. After game (painthreshold p=0.033, pain tolerance p=0.019) which ispresented in figure 1.DISCUSSIONThe results of this study suggest that competitionmodulate pain threshold and pain tolerance responsesto noxious stimuli. Soccer player exhibits higher painthreshold and pain tolerance during and after the gamecompared to before the game.We believe that the stress component of competitioncontributes to the pain inhibition associated withphysical exertion. In soccer scoring chances are rare, adefensivemistakeinsoccer,forexample,maycarrymoreimportance and cause a higher degree of anxiety and adefensive mistake in a basketball game. If a defensivemistake in a basketball game results in a basket for theopposition, many opportunities to make up the deficitare likely to occur. Soccer is a “player’s game,” duringa game, athletes are expected to make their owndecisions concerning what to do in every situation.Athlete, who participated in soccer or basketball,however experienced similar levels of analgesia priorto game situations. The study provides evidence thatthe competitive aspects of competition and its physicalstressors aroused the SIA mechanism. Much of theexisting research on anxiety in sports is too focused onthe characteristics of the athlete, while ignoring thecharacteristics of the environment in which thebehaviour took place. Situational variables have beenshown to effect emotions elicited by the variouscompetitive environment.12Winning experiences, social context, coaching style,and the nature of sports all play a role in athlete painresponse to meaningful competition and shouldtherefore be considered in athletes who claim to feel nopain following an injury. Exercise induced analgesiais only produced in humans following high level ofexercise with a work load of at least 74% aerobiccapacity. Each testing session was not aerobicallychallenging for the participants, and therefore wasunlike to lead to significant changes in pain thresholdand pain tolerance due to exercise.13Athletes display a rise in pain threshold (analgesia)in response to athletic completion as compared withnon competitive testing session. Hormonal levels insoccer players, in game compared to before. Cortsol hasbeen identified as a reliable marker of stress. Bothanalgesia and elevated cortisol levels measured beforegames suggest that game situations can be consideredas reliable stressors. Many outside factors alsocontribute to overall physiological status of a playerincluding conditioning activities, practice schedules,academic demands, and physiological stressors, inaddition to completion. Such factors consistently affectan athlete’s overall level of stress and confoundpossible cortisol elevations in anticipation of practice.14Research suggests that environmental stress is anatural triggers of the inhibition of pain sensation. Itfollows the athletes experienced both analgesia priorto the game and elevated cortisol level due to the stressof athletic competition. Stress is believed to activate theendogenous opoid system which will cause theobserved analgesic response.15Cortsol “the stresshormone” is the dominant form of glucocorticiods inhumans. ACTH and â-endorphine have roles in theregulation of stress; Both ACTH and â-endorphine haveroles in the regulation of stress; ACTH stimulates theadrenal which releases cortisol and â-endorphinebindsto opoid receptors which produce analgesia. Thus, theanalgesic findings from the study could be due to thestress elicited from comparative situations, which inturn caused analgesia and subsequently higher painthreshold and pain tolerance. The study supports theTable 1. Results of pain threshold and pain tolerance at before game, between game and after gameBGM+SD BTM+SD AFM+SD ANOVA BonferroniF P BF Vs.BT BFVs.AF BTVs.AFPain threshold 151+20.6 158.5+21.8 164+25.84 17.05 0.000 0.002 0.000 0.033Pain tolerance 188.2+27.9 200.2+28.6 209.5+30 19.69 0.000 0.001 0.000 0.019Significant at p<0.05; BF= before game; BT= between game; AF= after game15. Jamal ali Moitz--76-80.pmd 2/7/2013, 8:08 PM79
  • 86. 80 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1hypothesis that the duration of play increase painthreshold and pain tolerance in soccer players. 14Competition can be considered a stressor significantenough to evoke analgesia in athletes. The study foundthat the soccer players have higher pain threshold andpain tolerance after the game compared to before andbetween games.CONCLUSIONThe present data suggest that changes in painthreshold and pain tolerance in soccer player dependon the duration of play. The changes may be related tostress mechanism that involves within the competition.The result of this study proves that the participation ingame to improve the pain threshold and pain tolerancein soccer players.ACKNOWLEDGEMENTSThe authors wish to acknowledge the co-operationof all the participants who participated in this study.The authors extend their thanks to M.S. Basins, seniorPhysiotherapist, Sports Authority of India, for his co-operation throughout this study process.Conflict of InterestThe authors have no conflict of interest to declare.REFERENCES1. Anshel M H , Russell KG. Effect of aerobic andstrength training on pain tolerance, pain appraisaland mood of unfit males as a function of painlocation. Journal of Sports Sciences (1994); 12:535-547.2. Wendy J. Padawer and Fredric M. Levine Exercise-induced analgesia: fact or artifact? Pain(1992);48:131-1353. Melzack R, Wall PD. Pain mechanisms: a newtheory. Science (1965); 150 (3699):971–9.4. Raithel KS.Chronic pain and exercise therapy,Physician and Sports Medicine (1998);17203-105. Haier RJ, Quaid K, Miller JS. Naloxone alters painperception after jogging. Psychiatr. Res.(1981);5:231-2326. Modification of dental pain and cutaneousthermal sensitivity by physical exercise in men.Brain Research. (1985);360:33-407. Bartholomew JB, Lewis BP, Linder DE, Cook DB.Post exercise analgesia: replication and extension.Journal of Sports Science. (1996); 14:329-3348. Morgan PW affective benefits of vigorous physicalactivity. Medicine Science in Sports and exercise.(1998);17(1):94-1009. Grossman A, Sutton JR. Endorphins: What theyare? How are they measurement? What is theirrole in exercise? Medicine Science in Sports andExercise (1984);17(1)74-81.10. Droste C, Greenlee MW, Schrech M, Roskamm H.Experimental pain threshold and plasma beta-endorphin level during exercise. Medicine Sciencein Sports and Exercise. (1990);23(3):334-34211. Gurevich M, Kohn PM, Davis C. Exercise inducedanalgesia and role of reactivity in pain sensitivity.Journal of Sports Sciences (1994);12:549-559.12. Darlene Hartline, Randalph,Kesler M.Management of common MusculoskeletalDisorders. 2nd edition, J.B Lippincott, New York2000.13. Pertovara A, Huopaniemit, Virtanen A, JohnssonG, The influence of exercise on dental painthreshold and the release of stress hormones.Physical Behavior (1984);33(6),923-92614. Stern berg WF, Brokat C, Kass L, Alaboyadjian A,Grecely RH. Sex dependent components of theanalgesia produced by athletic competition. Pain(2001);2(1) 65-74.15. Koltyn KF.Analgesia following exercise a review.Sports Medicine (2000); 29(21) 85-98.15. Jamal ali Moitz--76-80.pmd 2/7/2013, 8:08 PM80
  • 87. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 81Neuromuscular Electrical Stimulation Versus IntermittentPneumatic Compression on Hand Edema in StrokePatientsEman S.M.Fayez1, Hala Ezz Eldeen21Assistant Professor in Department of Physical Therapy for Neuromuscular Disorders and its Surgery, Faculty ofPhysical Therapy, Cairo University, 2Professor in Department of Cardiopulmonary Rehabilitation and Geriatrics.Faculty of Physical Therapy, Cairo UniversityABSTRACTObjective: the purpose of this study was to evaluate and compare between the effect of application ofneuromuscular electrical stimulation and intermittent pneumatic compression on reducing hand edemain stroke patients.Subjects: Thirty stroke patients of both sexes (18 females and 12 males).They assigned randomly into2 study groups each one composed of 15 patients.Method: Group I received intermittent pneumatic compression therapy and group II receivedneuromuscular electrical stimulation three times per week for twelve weeks. The patients were assessedfor hand volume by using the volumetric measurement and by hand held dynamometer to measurehand grip strength before and after the end of treatment period.Results : The results of this study revealed that application of intermittent pneumatic compressiontherapy had a significant effect on reducing hand edema in stroke patients than receiving neuromuscularelectrical stimulation .While hand function measured by hand grip strength was improved moresignificantly with receiving neuromuscular electrical stimulation than the group who receivedintermittent compression therapy.Conclusion: Application of intermittent pneumatic compression therapy was more effective in reducinghand edema than neuromuscular electrical stimulation while application of neuromuscular electricalstimulation resulting in greater improvement in hand grip strength and hand function.Keywords: Stroke, Hand Edema, Hand Function, Neuromuscular Electrical Stimulation and IntermittentPneumatic Compression TherapyINTRODUCTIONIn hemiplegic patients, swelling of the affected handis a recognized phenomenon. The mechanism ofswelling is uncertain, but it had many predisposingfactors as immobility, dependency, impaired venousreturn and paralysis of the sympathetic control ofvasculature.1Edema in paretic hand may be attributed to acombination of dependency and insufficient musclepump resulted from hemiplegia that will hampervenous return in the affected limb which in turn willincrease the capillary filtration resulting in edemawhich can be the main mechanism of hand edema inthat cases.3-4Pain and disfigurement resulted from edema whichin chronic cases may predispose to contractures. Thiscombined with the increased weight of the limb, whichmay interfere with the rehabilitation of the limb andaffect hand function 5.Handedemafollowingstrokeisassociatedwithpainand stiffness, which can lead to a decrease in activemotion and disuse. The most widely acceptedexplanationisduetoincreasevenouscongestionrelatedto prolonged dependency and loss of muscle pumpingfunction in the paretic limb6.In stroke rehabilitation neuromuscular electricalstimulation (NMES) can be used to modulate neuralactivity to either regain voluntary muscle contraction16. Eman Fayej cairo--81-86.pmd 2/7/2013, 8:08 PM81
  • 88. 82 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1ortopreventabnormalmusclereactionduetoweaknessand spasticity7 .It was found that application of (NMES)had a significant effect in reducing hand edema poststroke because it produce an active muscle pumpresulted in removing excess fluid 8-9. Others studied theapplication of intermittent pneumatic compression(IPC) in treating hand edema following stroke but theyfound that (IPC) had a limited role in reducing edema ifit used solely1. The aim of this study was to evaluateand compare between effect of application of (NMES)and (IPC) on reducing hand edema and improvinghand function in stroke patients.MATERIAL AND METHODSubject selection• Thirty patients of both sexes (18 females and 12males) who were diagnosed as stroke and referredby a neurologist. All of the participants complainedfrom wrist and hand edema. The mean age was54±7 years. They were selected from the out-patientclinic of the faculty of physical therapy, CairoUniversity. CT was performed for all patients toconfirm the diagnosis. All patients had grade 1 to 2of spasticity according to the modified AshworthScale10.Subjects were excluded if they had majorcognitive impairment, heart failure, myocardialinfarction, lymphedema, or trauma, . The patientswere assigned into 2 groups equal in number groupI which composed of 15 patients (10 females and 5males ) and they received (IPC) .Group II composedof 15 patients (8 females and 7 males ) and theyreceived (NMES).EquipmentsVolumeter which is used to objectively measure thevolume of body parts by using the fluid displacementmethod1. Hand digital dynamometer was used tomeasure the grip strength in affected hand to measurethe impact of treatment on hand function12. Vasotrain447, Enraf-Nonius apparatus for application of (IPC).The 2-channel Respond Select II electrical stimulator(Texas, USA) was used for application of (NMES) .ProceduresAll patients received the same standard physicaltherapy treatment designed for stroke patients, for 30min on 3 days each week for 12 weeks, respectively.Group I patients received (IPC) therapy as follows, astockinet layer was applied to the hemiplegic limb toabsorb moisture and a full arm-inflatable sleeve wasapplied over this and attached to the compressionpump. The pressure levels were set as an intermittentcompression manner which composed of a pressure of80-120 mmHg for 40 seconds as compression phaseand a pressure of 40 mmHg for 20 seconds as deflationphase 1.Each patient in both study groups receivedtreatment once a day, 3 sessions weekly for 12 weeks.The patients in (group II) were given (NMES). Thesurface electrodes were applied on hand flexor musclegroup. This stimulation pattern will be administered tothis muscle group for approximately 20 minutes.Electrodes will then be repositioned and applied to theextensor muscle group for approximately 20 minutes.The stimulation was at a frequency of 30 Hz, with apulse width of 300 ìs. The amplitude of the current wasadjusted to the maximal tolerance of the patient, in arange up to 90 micro ampere , with a duty cycle of 5second on and 5 second off. The total stimuli were 180cycles during the treatment session. Patients werefocusing on the movement induced by (NMES) duringthe treatment. Treatment lasted for 30 min., 3 days perweek for 12 weeks.The outcome data were measured as follows thevolumeter was placed on a horizontal stable surfaceand filled with tap water to the level of the spout. Thepatient was asked to lower his hand into the volumeter.This made the water to displace from the spout to becollected into a graduated glass container. The collectedwater in the graduated container which referred topatient’s hand volume was measured. For measuringhand grip strength each patient was instructed to startgrip strength measures by using digital dynamometer,while elbow flexed 90 degree with hand and forearm inmid position and rested on the table.The measurements were repeated three times andan average measure was taken for the hand volumeand hand grip strength.Statistical analysisThe data were descriptively analyzed bycalculating: Mean ± Standard deviation. Student t. testwas used to compare the mean of pre and post studymeasurements of hand volume and hand grip strengthin each group .The statistical significance differencewas determined with P value d”0.05.Unpaired t.testwas used to compare these findings between studygroups. Pairson correlation was used to measure therelationship between hand volume and hand gripstrength in each group.16. Eman Fayej cairo--81-86.pmd 2/7/2013, 8:08 PM82
  • 89. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 83RESULTSI – Anthropometric characteristics of both groups:Table (1) Anthropometric characteristics of the patients in the two groups represented in table (1)Comparison Group I Group II P valueMean ±SD Mean ±SDAge 47.5 ± 6.1 48.3 ±4.5 0.693Height 170.3 ±5.13 173.9 ±8.4 0.432Weight 83 ±13.4 85.5 ±10.6 0.649Male 5 - 7 -Female 10 - 8 - -BMI 23.7 ±4.1 25.6 ±2.8 0.635II – Comparison between the pre, and post hand, wrist volume and grip strength in group I.Table (2) shows comparison between the pre, and post hand, wrist volume and grip strength in group I. There was asignificant decrease in hand and wrist volume. Also, there was a significant increase in hand grip strength in groupI who received (IPC)Mean hand SD (cm³) Mean hand grip SDvolume (cm³) strength (Newton) (Newton)Pre 469.50 13.329 4.33 1.49Post 421.40 19.687 6.65 2.41P value 0.0001** 0.0475***highly significant * significantIII– Comparison between the pre, and post hand , wrist volume and grip strength in group II.Table (3) shows comparison between the pre, and post hand, wrist volume and grip strength in group II. There wasa significant decrease in hand and wrist volume. Also, there was a highly significant increase in hand grip strengthin group II who received (NMES)Mean hand SD (cm³) Mean hand grip SDvolume (cm³) strength (Newton) (Newton)Pre 464.67 15.562 5.13 1.51Post 447.00 14.938 7.35 1.91P value 0.0032* 0.0001****highly significant * significantIV– comparison between the pre, and post values of hand, wrist edema and hand grip strength in both studygroupsTable (4) reveals the pre, and post values of hand, wrist edema and hand grip strength in both study groups. There wasstatistically significant decrease in hand volume in group I who received (ICP) when compared with group II whoreceived (NMES). While there was statistically significant improvement in hand grip strength in group II when comparedwith group I.Table (4) comparison between the pre, and post values of hand, wrist edema andhand grip strength in both study groupsMean hand P value Mean hand grip P valuevolume (cm³) strength (Newton)Group I Group II Group I Group IIPre 469.50 464.67 0.4060 4.33 5.13 0.1185Post 421.40 438.00 0.0356* 6.65 7.35 0.0008****highly significant * significant16. Eman Fayej cairo--81-86.pmd 2/7/2013, 8:08 PM83
  • 90. 84 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1V- Correlation between hand volume and hand grip strength in both study groups:Table (5) There was a statistically significant correlation between hand volume and hand grip strength in group I.While there was none statistically significant correlation between hand volume and hand grip strength in group II.Group I R P value Group II R P valueHand Hand grip Hand Handgripvolume strength volume strength421.40 6.65 -0.6301 0.0118 438.00 7.35 -0.3979 0.1588**highly significant * significantFigure (4) Correlation between hand volume and hand grip strength in both study groupsDISCUSSIONEdema of the hand is one of the complications thatcan developed after stroke. The etiology of edemaformation might be due to dependency and loss ofmuscle pump efficiency due to hemiplegia will hamperthe return of blood in the veins of the affected limb20.Because there was great contradictions about theeffect of both IPC and NMES on reduction of edema instroke patients’ hand . So, this study was conducted tohelp in determination the most effective modality withmore prolonged effects on the edema of the hand instroke patients. The study was performed on 30 strokepatients (18 females and 12 males) complicated withhand and wrist edema. Group I received therapy, whilegroupIIreceived(NMES).Bothgroupsunderwenttheirprograms 3 times a week for 12 weeks. The collecteddata included values of hand, wrist volumes and handgrip strength which were measured before and afterthe treatment program.LookingforgroupI,showedreductionofmeanvalueof hand volume from the statistical analysis of data ofgroupIshowedimprovementofhandedemaafterthreemonths of treatment.These results can be attributed to the evidence that(IPC) increases venous velocity, reduces edema,enhances fibrinolytic activity and reduces the damagingeffect of white cell activity13.It can also be due to the increased venous andlymphatic return as a result of external pressure on alimb. This external compression not only moves thelymph and fluids along, but also it may spread theintercellular edema over a larger area, enabling morelymph and venous capillaries to become involved inremoving the plasma proteins and water 21.The mechanism of improving hand edema by theuse of intermittent pneumatic compression therapy canalso be explained as intermittent high pressurecompression allows limb salvage in patients withhemostasis and limb-threatening ischemia who are notcandidates for revascularization.14.The results of this study agree with (Armstrong andNguyen 2001)19who reported that pneumaticcompression is an effective tool for the reduction ofedema.On the other hand there was contradiction with(Roper et al,1999)1in his previous study for thetreatment of the edematous stroke hand withintermittent pneumatic compression (IPC)using apressure of 50 mmHg, applied with 30 sec inflationand 20 sec deflation duty cycle treatment compriseddaily for 1 month. This study showed no influenceneither on edema reduction nor upper limb function. Itseems that good results in our study were obtainedbecause we used higher pressure levels (a pressure of80-120 mmHg for 40 seconds as compression phase I16. Eman Fayej cairo--81-86.pmd 2/7/2013, 8:08 PM84
  • 91. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 85and a pressure of 40 mmHg for 20 seconds ascompression phase II, deflation) and longer treatmentperiods (session period was 30 minutes, one session aday, 3 days weekly for 12 weeks).Concerning group II neuromuscular electricalstimulation, their data showed reduction hand volume.However the reduction in hand edema in group II maybe resulted from production of an active muscle pumpwhich cause removing excess fluid during applicationof neuromuscular stimulation induced contraction ofthe paralyzed muscles7.Also, application ofneuromuscular stimulation resulted in increasedmuscle bulk and strength. This will also lead to greatercapillary density and therefore improved local bloodsupply and tissue condition17. Neuromuscular electricalstimulation had also been reported to modulate edemaby reducing capillary permeability22.The results of the present study were in accordancewith Gad e al16who reported that application ofneuromuscular electrical stimulation can improveselected hand functions and impairment of chronicstroke survivors.This finding was also supported by previous study,which reported reduction in hand volume due tocompression and squeezing of venous and lymphaticvessels caused by skeletal muscles contraction thatresults from the electrical stimulation. These repetitivecontractions may promote reabsorption of leakage fluidand proteins with subsequent edema reduction11.Our results demonstrated that there was asignificant increase in hand grip strength as anindicator of hand function 12in both groups but thisimprovement was significantly higher in group II thanin group I. These results may be attributed to improvingstrength, voluntary movement, force production, andfunctional skill abilities in the upper extremity resultedfrom application of neuromuscular electricalstimulation15.Thus the present study revealed (IPC) was moresignificantly effective than NMES in reducing handedema in stroke patients .Perhaps, this differenceresulted from increased venous and lymphatic flow dueto application of external compression was higher thanthat caused by muscle pumping due to electricalstimulation. Although NMES had an effect on reducingcapillary permeability this effect didn’t cause edemareduction as compression therapy.RECOMMENDATIONIt is recommended to use intermittent compressiontherapy in conjunction with neuromuscular electricalstimulation especially in patients who have been failedin controlling their hand edema with standard therapymodalities. Further studies needed to compare betweendifferent types of current stimulation and thesummation effect of both therapy modalities.REFERENCES1. Roper TA, et al. Intermittent compression for thetreatment of the edematous hand in hemiplegicstroke: a randomized controlled trial, Age andaging; 1999; 28:9-13.2. Boomkamp k., et al: post stroke hand swelling andedema: prevalence and relationship withimpairment and disability. Clinical rehabililtation;2005; 19:552-559.3. Wang JS, et al: Neuromuscular electric stimulationenhances endothelial vascular control andhemodynamic function in paretic upperextremities of patients with stroke. Arch Phys MedRehabil; 2004; 85:1112-1116.4. Leibovitz A, et al. Edema of the paretic hand inelderly poststroke nursing patients. Arch GerontolGeriatr. ; 2007; 44:37-42.5. Faghri PD, The effects of neuromuscularstimulation-induced muscle contraction versuselevation on hand edema in CVApatients. J HandTher; 1997; 10:29-34.6. Chae J. A critical review of neuromuscularelectrical stimulation for treatment of motordysfunction in hemiplegia.Asst Technol; 2000; 12:33-49.7. Maram J, et al. Neuromuscular stimulation afterstroke: from technology to clinical deployment.Expert. Rev. Neurother, 2009; 4-9.8. Ashworth MS and Tardieu .Their ClinicalRelevance for Measuring Spasticity in Adult andPediatric Neurological Populations. PhysicalTherapy Reviews; 2002; 1: 53-62.9. Griffin JW, et al .Reduction of post traumatic handedema: A comparison of high voltage pulsedcurrent, intermittent pneumatic compression andplacebo treatments. Phys Ther; 1996; 70; 5:279-285.10. Alan S. et al. Arm functions after Stroke .Anevaluationofgripstrengthasameasureofrecoveryand a prognostic indicator. J Neurol, Neurosurg,and Psychiatry; 1989; 52:1267-1272.11. Vowden K .The use of intermittent pneumaticcompression in venous ulceration. Br. J. Nurs. ;2001; 10; 8: 491-509.16. Eman Fayej cairo--81-86.pmd 2/7/2013, 8:08 PM85
  • 92. 86 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 112. Bemellen V, et al .Intermittent high-pressurecompression in homeostasis. Arch Surg; 2001;136:1280-1285.13. Ziling L and Tiebin Y.Long term effectiveness ofneuromuscular electrical stimulation forpromoting motor recovery of the upper extremityafter stroke. J Rehabil Med; 2011; 43:506–510.14. Gad al. A home based self administeredstimulation program to improve selected handfunctions of chronic stroke. Neuro Rehabilitation;2003; 18:215–225.15. Chae J, Yu D. A criical review of neuromuscularelectrical stimulation for treatment of motordysfunction in hemiplegia. Asst Techno; 2000; 12:33-49.16. Winsor T. et al .The effect of venous compressionon the circulation of the extremities. Arch PhysMed Rehab; 1999; 34: 559-565.17. Armstrong DG, Nguyen HC .Improvement inhealing with aggressive edema reduction afterdebridement of foot infection in persons withdiabetes. Arch Surg.; 2001; 135:1405-1409.18. Boomkamp KH et al, Post stroke hand swellingand edema: prevalence and relationship withimpairment and disability .Clinical Rehabilitation;2005; 19:552-559.19. Wilkerson J External compression for control oftraumatic edema. Phys Sports Med.; 2001;13(6):97-106.20. Bettany JA,etal Influence of high voltage pulseddirect current on edema formation followingimpact injury. Phys Ther; 1990; 70(4):219-224.16. Eman Fayej cairo--81-86.pmd 2/7/2013, 8:08 PM86
  • 93. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 87A Combination Approach using Manual Therapy andExercise in the Treatment of Shoulder ImpingementSyndromeAnnamma Mathew1, Abedi Afsaneh21Assistant Lecturer, College of Allied Health Sciences, Gulf Medical University, Ajman, UAE2Physiotheapist, Gulf Medical College Hospital and Research Center, Ajman, UAEABSTRACTThe purpose of this case study was to compare the effectiveness of traditional physical therapyinterventions of using therapeutic modality and exercise versus a combined approach usingmobilization with movement and exercises in the treatment of shoulder impingement syndrome. Atotal of 5 patients diagnosed with shoulder impingement syndrome were selected from the hospital.Patients then participated in the programs, which were held twice a week for two months. Mainoutcome measures included 24-hour pain (VAS), shoulder active range of motion (AROM), and shoulderfunction (SPADI). Repeated-measures analysis indicated significant decreases in pain, improvedfunction, and increases in AROM. The MWM had a higher percentage of change from pre- to post-treatment on pain measures pain (VAS): 0.6 to 0.2 following 4 session treatment, higher percentage ofchange on the SPADI and in AROM.Thisstudysuggeststhatperformingglenohumeralmobilizationswithmovement(MWM)incombinationwith a supervised exercise program may result in a greater decrease in pain and improved functionalthough studies with larger samples and discriminate sampling methods are needed.Keywords: Exercise, Glenohumeral Mobilization, Mobilization with Movement.Corresponding author:Mrs. Annamma MathewCollege of Allied Health SciencesGulf Medical UniversityAjman, UAEEmail: researchdivision2@gmail.comINTRODUCTIONShoulderimpingementsyndrome,themostcommondiagnosis of shoulder dysfunction1, is often de-scribedas shoulder pain exacerbated by overhead activities.Primaryshoulderimpingementoccurswhentherotatorcuff tendons, long head of the biceps ten-don,glenohumeral joint capsule, and/or subacromial bursabecome impinged be-tween the humeral head andanterior ac-romion. Primary impingement may be dueto intrinsic factors: rotator cuff weak-ness2, chronicinflammation of the rota-tor cuff tendons and/orsubacromial bursa, rotator cuff degenerativetendi-nopathy, and posterior capsular tight-nessleading to abnormal anterior/supe-rior translation ofthe humeral head. It may also be due to extrinsic factors:possession of a curved or hooked acro-mion, acromialspurs, or postural dysfunction. Secondary shoulderim-pingement is defined as a relative de-crease in thesubacromial space due to glenohumeral joint instabilityor abnor-mal scapulothoracic kinematics. Commonlyseen in athletes engaging in overhead throwingactivities, second-ary impingement occurs when therota-tor cuff becomes impinged on the poste-rior-superior edge of the glenoid rim when the arm is placedin end-range ab-duction and external rotation. Thisposi-tioning becomes pathologic during excessiveexternal rotation, anterior cap-sular instability, scapularmuscle imbal-ances, and/or upon repetitive over-loadof the rotator cuff musculature. Physical therapy hasbeen found to be effective in reducing pain anddisability in patients with shoulder impingement.Effective interventions include therapeutic exercisesfocusing on strengthening the rotator cuff and scapularstabilizing musculature3, stretching to decreasecapsular tightness, scapular taping techniques, andpatient education of proper posture.17. JAYAKUMARI--87-89.pmd 2/7/2013, 8:08 PM87
  • 94. 88 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1CASE PRESENTATIONThe present study was conducted on five femalepatients, aged 32-45 (mean 39.8 years) with chiefcomplaint of intermittent catching pain on shoulder,complaint of night pain and unable to sleep on involvedside, who were diagnosed as having shoulderimpingement syndrome. The effect of treatment wasassessed based on the following dependent variables:pain intensity measured with VAS scale; pain-activeROM measured with a standard goniometer for flexionandabduction;andameasurementofshoulderfunctionassessed with the Shoulder Pain and Disability Index(SPADI)4-5. These traditional interventions includedTENS, posterior capsule stretching, postural correctionexercises, and an exercise program focusing on rotatorcuff strengthening and scapular stabilization. A manualtherapy approach to treating shoulder dysfunction isthe Mulligan concept of mobilization with movement(MWM)6. The goal of per-forming MWM is immediateand sus-tained improvement in joint pain and mobility.Mulligan’s techniques6entail having the physicaltherapist apply an accessory mobilization to aperipheral joint while the patient simultaneouslygenerates active movement. This procedure wasrepeated for a total of 3 sets of 10 repetitions as long aspain-free motion was sustained; if pain commencedduring any repetition of any set, the technique wasterminated. This technique involved the therapistapplying a sustained posterior accessory glide to theglenohumeral joint while the subject simultaneouslyactively flexed the shoulder to the pain-free endpointand applied a gentle overpressure force using thecontralateral arm. Total abolition of pain during thetechnique was mandatory; if the patient started toexperience pain during active motion, the therapistwould investigate different force planes and/or gradesof force until pain-free motion was restored.Table 1. Baseline demographics and pre-treatmentmeansDVs Mobilisationwith MovementVAS 6/10Flexion 900Abduction 800SPADI 48.6%Age 39.8 yearsVAS = visual analog scale;SPADI = Shoulder Pain and Disability Index.The study shows, significant decrease in pain (VAS):0.6 to 0.2 following 4 session treatment spread over 3weeks and increases in function (SPADI): 0.48 to 0.25.2and Abduction ROM: 96 to 166 within 8 sessiontreatment following 5 weeks, compared to traditionalintervention, which was done without manual therapytechnique.Table 2. Changes after treatmentDVs Exercise MWMVAS 3/10 2/10Flexion 15001700Abduction 16201670SPADI 34.2% 15%MWM = mobilization with-movement group;VAS = visual analog scale;SPADI = Shoulder Pain and Disability Index.The MWM (mobilization with movement) had ahigherpercentageofchangefrompre-topost-treatmenton pain measures pain (VAS 6/10 to 2/10) followingfour session treatment, and a higher percentage ofchange on the SPADI and in AROM.DISCUSSIONThe purpose of this case study was to describe theeffect of exercise therapy combined with manualtherapy in treatment of patients with shoulderimpingement.Itappearsthatthecombinedinterventionofmanualtherapyandexercisesforfiveweeksprovidedsignificant reductions in pain measures in subjects tothose received only modality and exercise alone. It isimportant to note that the patients underwenttraditional physiotherapy for an extended period withminimal improvement. Where as in patients who hadundergone physical therapy intervention of manualtherapy and exercise their end of treatment assessmentscore reflected improvement in the symptoms such assignificant difference in the VAS, SPADI and AROM.Thus the combined treatment of manual therapy andexercises has proven to be effective in management ofshoulder impingement syndrome.CONCLUSIONIn summary, the physical therapy inter-ventions ofManual therapy base on MWM in combination withan exercise program resulted in decreasing pain andimproving function compared to traditional physicaltherapy intervention.17. JAYAKUMARI--87-89.pmd 2/7/2013, 8:08 PM88
  • 95. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 89REFRENCES1. Millar AL, Jasheway PA, Eaton W, et al. Aretrospective, descriptive study of shoulderoutcomes in outpatient physical therapy. J OrthopSports Phys Ther 2006;36:403-14.2. McClurePW,MichenerLA,KardunaAR.Shoulderfunction and 3-dimensional scap-ular kinematicsin people with and without shoulderimpingement syndrome. Phys Ther 2006;86:1075-1090.3. BellingSAK,JorgensenU.Secondaryimpingementin the shoulder. Scand J Med Sci Sports 2000;10:266-278.4. WilliamsJW,HollemanDR,SimelDL.Mea-suringshoulder function with the shoulder pain anddisability index. J Rheumatol 1995;22:727-32.5. LudewigPM,BorstadJD.Effectsofahomeexerciseprogram on shoulder pain and functional statusin construction workers. Occup Environ Med2003;60:841-849.6. Mulligan BR. Manual Therapy Nags, Snags,Mwm, etc, 4th editon. Wellington, NZ: Plane ViewSeries Ltd, 1999.17. JAYAKUMARI--87-89.pmd 2/7/2013, 8:08 PM89
  • 96. 90 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Musculoskeletal Pain among Computer UsersShweta Keswani1, Lavina Loungni1, Tiana Alexander1, Hebah Hassan1, Shatha Al Sharbatti2,Rizwana B Shaikh3, Elsheba Mathew41MBBS students, College of Medicine, Gulf Medical University, Ajman, UAE2Professor and Head, 3Assistant Professor, 4Professor, Department of Community Medicine, College of Medicine,Gulf Medical University, Ajman, UAEABSTRACTObjective: The objective was to assess muscle pain as an effect of utilizing computers for more than fivehours and identify the variables associated with the occurrence of pain and the measures taken toprevent.Methods: It is a descriptive study conducted on 249 subjects in different private organizations in UAE.All those who mentioned wrist, back or neck pain without any pre-existing musculoskeletal problemsamong those who work on computer for more than 5 hours were included in the study. Questionnaireswere distributed to all those who satisfied the inclusion criteria in each of the offices identified.Results: A significant association was noticed between age and wrist pain and no significant associationwas observed between gender, onset of pain and wrist pain. Higher frequency of back pain was noticedin older age group compared to younger. Neck pain was found to be higher among participants between60-69 years of age. The incidence of pain in the wrist was more in men than in women and a similarpattern was seen in hand and back pain too. Our study shows a positive relation between sleep hoursand musculoskeletal pain.Conclusion: We concluded that wrist, neck and back pain is more prevalent in younger age groups andit increases as the duration of computer use increases. Pain was a problem in majority of peopleworking on computer for more than 5 hours.Keywords: Musculoskeletal pain, Computer users, Duration of computer useCorresponding author:Shatha Al SharbattiProfessor and HeadDept. of Community MedicineGulf Medical UniversityAjman, United Arab EmiratesP O Box: 4184Email: shatha_alsharbatti@yahoo.comINTRODUCTIONMusculoskeletal disorders affect all age groups andfrequently cause disability, impairments, andhandicaps. They consist of a variety of different diseasesthat cause pain or discomfort in the bones, joints,muscles, or surrounding structures, and can be acuteor chronic, focal, or diffuse. In one study among Detroitresidents who kept track of daily health symptoms in adiary, musculoskeletal symptoms constituted the mostfrequent category of health symptoms1.Musculoskeletal disorders (MSDs) are highlyprevalent; because of their association with aging, theyare likely to become more prevalent as the populationages throughout the world. While many of thesedisorders are not devastatingly disabling to affectedindividuals, their prevalence is so great that moremobility and other limitations are accountable to thesedisorders than to any other type. While much of thesubstantial cost of these disorders is due to the medicalcare and medications and other treatments required bypatients, the preponderance of costs is due to work loss,which is a frequent consequence of these disorders. Notonly do MSDs cause personal suffering and loss ofincome, but they also cost businesses and affect nationaleconomies. Any worker can be affected, yet MSDs canbe prevented by assessing work tasks, putting in placepreventive measures, and checking that these measuresstay effective.Most work-related MSDs are cumulative disorders,resulting from repeated exposure to high or low18. JAYAKUMAR--90--95.pmd 2/7/2013, 8:08 PM90
  • 97. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 91intensity loads over a long period of time. However,MSDs can also be acute traumas, such as fractures, thatoccur during an accident2.These disorders mainly affect the back, neck,shoulders and upper limbs, but can also affect the lowerlimbs. Some MSDs, such as carpal tunnel syndrome inthe wrist, are specific because of their well-defined signsand symptoms. Others are nonspecific because onlypain or discomfort exists without evidence of a clearspecific disorder3. Different groups of factors maycontribute to MSDs, including physical andbiomechanical factors, organizational and psychosocialfactors, individual and personal factors .These may actuniquely or in combination.An integrated management approach is necessaryto tackle MSDs. This approach should consider not justthe prevention of new disorders, but also the retention,rehabilitation and reintegration of workers who alreadysuffer from MSDs4. Individuals with musculoskeletalcomplaintsshouldbeevaluatedwithathoroughhistory,a comprehensive physical examination, and, ifappropriate, laboratory testing. The initial encountershould determine whether the musculoskeletalcomplaint is (1) articular or nonarticular in origin, (2)inflammatory or noninflammatory in nature, (3) acuteor chronic in duration, and (4) localized or widespread(systemic) in distribution5. The present study wasconducted to assess the musculoskeletal problemsamong computer users and rationalize the variablesthat play a part in the occurrence of the pain and, toassess the knowledge of face such problems and, toevaluate the measures taken to tackle and preventmusculoskeletal problems.MATERIALS AND METHODThis descriptive study was conducted in thefollowing settings viz. Ajman chamber of commercebuilding, Alco Shipping Services (Ajman), TNT branch(Deira), Ocean View Real Estate (Dubai), OmanInsurance (Ajman branch), AMB constructions, GulfChain, GMU and GMCHRC. Total 249 employees inthe above settings participated in the study and thedata was collected from 2009 March to 2010 January.We selected all those people who mentioned wrist, backor neck pain without any pre-existing musculoskeletalproblems and those who work on computer for 5 hoursor more. All those who had previous musculoskeletalproblems, and who work less than 5 hours on thecomputer were excluded. A questionnaire was used fordata collection including variables like Age, Sex,Nationality, Smoking status, Alcohol status, Diabetes,People with Wrist, Back and Neck pain.The questionnaires were distributed to differentoffices, selecting one office at a time to those who usedthe computer for 5 hours or more and the completedquestionnaires were collected within two – three days.The whole process was repeated in all the abovementioned offices. The data from the questionnaire wasthenenteredinanexcelsheetandanalyzedusingPASW18.0 version.RESULTSTable- 1. Distribution of wrist pain according to gender, age and duration of computer useVariables Group Wrist painYes NoNumber Percent Number PercentGender Male 82 61.2 73 63.5Female 52 38.8 42 36.5Age group 20-29 61 45.5 46 40.030-39 47 35.1 34 29.640-49 16 11.9 15 13.050-59 10 7.5 13 11.360-69 —- —- 07 6.0Duration of computer use < 5 hrs 14 43.8 18 56.35-7 hrs 26 40.0 39 60.07-9 hrs 55 59.8 37 40.2> 9 hrs 39 65.0 21 35.018. JAYAKUMAR--90--95.pmd 2/7/2013, 8:08 PM91
  • 98. 92 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Table 1 shows distribution of the study subjects bywrist pain and gender. Higherfrequency of wrist pain was noticed among femaleswhen compared with males. Nosignificant association was noticed between wristpain and gender (P>0.05). Distribution of the studiedsample by wrist pain and age shows a higher frequencyof wrist pain was noticed in younger age groupscompared with older ones. Statistically significantassociation was found between age and wrist pain(P<0.05). Distribution of the studied sample by wristpain and duration of computer use for the onset of painshows higher frequency of wrist pain was noticedamong worker after working for more than 5 hours. Nosignificant association was noticed between wrist painand duration for the onset of pain. (p>0.05)Table 2. Distribution of Back pain according to gender, age, and duration of computer useVariables Group Back painYes NoNumber Percent Number PercentGender Male 113 61.1 42 65.6Female 72 38.9 22 34.4Age group 20-29 81 43.8 26 40.630-39 54 29.2 27 42.240-49 25 13.5 06 9.450-59 20 10.8 03 4.760-69 05 2.7 02 3.1Duration of computer use < 5 hrs 17 53.1 15 46.95-7 hrs 50 76.9 15 23.17-9 hrs 66 71.7 26 28.3> 9 hrs 52 86.7 08 13.3Higher frequency of back pain was noticed amongfemales compared with males. Nosignificant association was noticed between wristpain and gender (P>0.05). Higher frequency of backpain was noticed in 50-60 years of age group. Nosignificant association was found between age andback pain (P>0.05). Higher frequency of back pain wasnoticed among worker after working for more than5hours. Significant association was noticed betweenwrist pain and duration for the onset of pain. (p<0.05)(Table 2).Table- 3. Distribution of neck pain according to gender, age and duration of computer useVariables Group Neck painYes NoNumber Percent Number PercentGender Male 114 61.6 41 64.1Female 71 38.4 23 35.9Age group 20-29 80 43.2 27 42.230-39 62 33.5 19 29.740-49 20 10.8 11 17.250-59 16 8.6 7 10.960-69 7 3.8 —- —Duration of computer use < 5 hrs 19 59.4 13 40.65-7 hrs 45 69.2 20 30.87-9 hrs 69 75.0 23 25.0> 9 hrs 52 86.7 08 13.318. JAYAKUMAR--90--95.pmd 2/7/2013, 8:08 PM92
  • 99. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 93Table 3 - Shows distribution of neck pain by gender.Higher frequency of neck pain was noticed among thestudied females compared with males. No significantassociation was noticed between wrist pain and gender.(P>0.05)Higher frequency of neck pain was noticed in 60-69years age group. Statistically no significant associationwas found between age and neck pain. Higherfrequency of neck pain was noticed in 60-69 years agegroup. No significant association was found betweenage and neck pain.Higher frequency of neck pain was noticed amongworker after working for more than 5 hours. Significantassociation was noticed between neck pain andduration for computer use. (p<0.05). Lowest frequencyof headache was noticed in more than 60 years agegroup. Significant association was found between ageand headache. Higher frequency of headache wasnoticed among the studied females compared withmales.Significant association was noticed betweenheadache and gender. (P<0.05). Highest frequency ofheadache was seen in the age group 30-39 years.Significant association was noticed between headacheper week and age group. (P<0.05). The higher frequencyof headache was noticed to be twice per week for malesand four times per week for females. Significantassociation was found frequency of headache andgender. Higher frequency of headache was observedamong participant who had neck pain. No significantassociation was found between headache and neckpain (P>0.05). Lower frequency of wrist pain wasnoticed when ergonomic facilitates were available atwork place however no significant association wasfound between availability of ergonomic facilities atwork place and wrist pain (P>0.05). No significantassociation was found between availability ofergonomic facilities at work place and back pain(P>0.05). Lower frequency of neck pain was noticedwhen these facilitates were available at work place.Significant association was found between availabilityof ergonomic facilities at work place and neck pain(P>0.05). No Significant association was found betweenavailability of break in between work and wrist pain(P>0.05). Lower frequency of back pain was noticedwhen these breaks were available between work.Significant association was found between availabilityof break in between work and back pain. (P<0.05). NoSignificant association was found between availabilityof break in between work and neck pain (P>0.05).Significant association was found between neck painand sleep hours. (P>0.05). Higher frequency of peoplewith wrist pain had complained of work affecting sleep.Significant association was found between wrist painand work affecting sleep (P<0.05). Higher frequency ofpeople with back pain had complained of workaffecting sleep. Significant association was foundbetween back pain and work affecting sleep (P<0.05).No Significant association was found between neckpain and work affecting sleep (P>0.05). No Significantassociation was found between change in postureduring work and wrist pain (P>0.05). Lower frequencyof back pain was noticed when change in postureapplied during work No Significant association wasfoundbetweenchangeinpostureduringworkandbackpain (P>0.05). No significant association was seenbetween weight gain and breaks between work hours(P>0.05). Higher frequency of diabetics had back pain,but there is no significant association between the two(P>0.05).Higher frequency of diabetics had neck pain, butthere is no significant association between the two(P>0.05). Highest frequency of moderate wrist pain wasobserved with alcohol consumption. There is nosignificant association between alcohol consumptionand severity of pain. Highest frequency of moderateback pain was observed with alcohol consumption.There is no significant association between alcoholconsumption and severity of pain. Highest frequencyof moderate neck pain was observed with alcoholconsumption. There is no significant associationbetween alcohol consumption and severity of pain.Lower frequency of wrist pain was noticed whenchange in posture applied during work.Significant association was found between changein posture during work and back pain.(P<0.05). Significant association was found betweenchange in posture during work, neck pain and jobsatisfaction (P>0.05). Lower frequency of neck painwas noticed among job satisfied participants. Nosignificant association was found between neck painand job satisfaction (P>0.05). Higher job satisfactionwas noticed when facilities are available. Significantassociation was found between facilities and jobsatisfaction (P<0.05).18. JAYAKUMAR--90--95.pmd 2/7/2013, 8:08 PM93
  • 100. 94 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Figure 1: Showing distribution of study sampleaccording to nationalityThis chart shows the distributions of our studysample to gender. Female population was seen to behigher than the male population. (Fig-3)Figure 4: Showing distribution of study sampleaccording to duration on computerThis chart shows the distribution of our sampleaccording to nationality. The highest frequencies werefound to be Indians and the lowest were Iranians.(Fig-1)Figure 2: Showing distribution of study sampleaccording to age groupThis chart shows the distribution of our studysample according to age. The highest frequencies wereseen in the age groups 20-29 and 30-39 whereas thelowest frequencies were in the higher age groups.(Fig-2)Figure 3: Showing distribution of study sampleaccording to genderThis chart shows the distribution of our studysampleaccordingtothedurationoncomputer.Agreaterfrequency was found among the sample working formore than 5 hours on the computer. (Fig-4)Figure 5: Showing distribution of musculoskeletalpain among the study sampleChart showing the distribution of musculoskeletalpain among the studied sample. It was seen that backand neck pain has a greater frequency while wrist painwas lower. (Fig-5)Figure 6. Distribution of the study sample withfrequency of exercise and musculoskeletal disorders18. JAYAKUMAR--90--95.pmd 2/7/2013, 8:08 PM94
  • 101. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 9541% of population who exercised twice a monthsuffered from wrist pain whereas approximately 37%of the population who exercised 4 times a monthsuffered from back and neck pain.(Fig-6)DISCUSSIONAs the continuing use of machines and computersincreases in today’s world there is a need for the generalmasses to be educated about the increasing incidenceof musculoskeletal disorders. Many people have thetendency to overlook all these hazards as trivial and donot get it checked and hence end up with a series ofmechanically restricting injuries.MSD ranks first in prevalence as the cause ofchronic health problems, long term disabilities andconsultations with a healthy professional and rankedsecond for restricted activity all day and use ofprescription medications and drugs. Hence society hascome up with the intervention of ergonomics amongthe working masses.There were many factors that we had to take intoconsideration for the completion of our study. Thesewere Age, Nationality, Sex, Duration of work, Sleephours, Pain intensity, Exercise, Diet, Smoking /Alcoholetc.Average duration of computer use in our study was5 hours. This was in accordance with Bureau of LabourStatistics which said that average time of employeesworking on computer is 35 hours per week6.Through our study showed that there was a higherincidence of pain among the males and femalesalthough affected were not so severe. The incidence ofpain in wrist to be more in men (61%) than in women(39%) and a similar pattern was shown in the handand back pain too. This was not in confirmation withthe other studies that we had gone through on MSDs. Astudy done in Europe found a higher prevalence ofdisorders in women (45%) than men (39%). Thisdifference could have occurred in the study as they useda larger population for their study whereas our samplesize was comparatively smaller. Our study shows apositive relation between sleep hours andmusculoskeletal pain similar results was seen in a studyby the psychosomatic research7.CONCLUSIONFrom our study we concluded that wrist, neck andback pain is more prevalent in younger age groups andit increased as the duration of computer use increased.The variables, age, duration of computer use, facilitiesat work place, sleep hours, diabetes and job satisfactiondid play a part in occurrence of pain. The result showedthat the commonest complaints were back pain andneck pain. Wrist pain was the least complained whenoperating on a computer system. Pain was more severein people working for more than 5 hours. The result ofthis study can help in preventing occupational injuryassociated with the use of computer with emphasis ongood posture, work station ergonomics.REFERENCES1. OSHA [Online]. European Agency for Safety andHealth at Work, 2010 [cited 2010 September 20].Available from URL: Gerr F, Marcus M, Ensor CBS, et al. Aprospectivestudy of computer users: Study design andincidence of musculoskeletal symptoms anddisorders. Am J Ind Med 2002;41:221-35.3. Pillinger J, Rutherford. Computer and neck pain.Health News 2003;39:12-4.4. European Agency for Safety and Health at Work[Onine]. Research on work-related low backdisorders, 2000 [cited 2010 September 20].Available from URL: Uhlenberg P. International handbook ofpopulation aging, 1stedition. New York, Springer,2009;772.6. USDeprtmentogLabour[Onine].Bureauoflabourstatistics, 2007 [cited 2010 September 20].Available from URL: Akerstedta T, Knutssonb A, Westerholmc P, et al.Sleep disturbances, work stress and work hours:A cross-sectional study. J Psychosom Res2002;53(3):741-8.18. JAYAKUMAR--90--95.pmd 2/7/2013, 8:08 PM95
  • 102. 96 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1A Report of Body weight Supported Overground Trainingin Acute Traumatic Central Cord SyndromeAsir John Samuel1, John Solomon2, Senthilkumaran3, Nicole Dsouza41Lecturer, Alvas College of Physiotherapy, Moodabidri, India, 2Associate Professor, Department of Physiotherapy,Manipal College of Allied Health Sciences, Manipal University, Manipal, India, 3Associate Professor, Department ofPhysiotherapy, Manipal College of Allied Health Sciences, Manipal University, Manipal, India, 4Neurophysiotherapist,Parkinsons Disease & Movement Disorder Society, Mumbai, IndiaABSTRACTStudy design: Acase report of a patient with Traumatic Central Cord Syndrome (TCCS)Objective: To analyse the benefits of BWSOT in early ambulation and gait performance.Setting: Tertiary care, University teaching hospital.Methods: A 25-year old man with TCCS at the C4 level, grade B on the American Spinal InjuryAssociation (ASIA) Impairment Scale (AIS) participated in BWSOT. Following the immobilizationphase, he underwent two BWSOT sessions per day (20 minutes each), six days a week, for three weeks.AIS motor score, 10-m walk test, Walking Index for Spinal cord Injury-version II (WISCI-II), Spinal cordIndependenceMeasure-versionIII(SCIM-III)andFunctionalIndependenceMeasure(FIM)wererecordedat the time of initiating of BWSOT and at the end of three weeks. He received regular physiotherapy andoccupational therapy during the entire hospital stay.Results: Three weeks of BWSOT resulted in an increase in all the outcome measures. At the time ofinitiating BWSOT,AIS motor score, 10-m walk test, WISCI-II, SCIM-III and FIM were 45/100, 3 min 14sec, 3/20, 30/100 and 60/126 and by the end of three weeks, they were 68/100, 1 min 41 sec, 17/20,50/100 and 72/126 respectively.Conclusion: BWSOT may allow therapists to initiate gait training programs at an earlier stage amongthose with stable TCCS with promising outcomes.Keywords: Spinal Cord Injury, Central Cord Syndrome, Overground Training, Gait Training, Rehabilitation,Locomotor Training.Corresponding author:D. A. Asir John SamuelLecturer,Alvas college of Physiotherapy, Moodabidri - 574 227,South Canara District, Karnataka, India.Contact No. +91 9481939806Email: asirjohnsamuel@gmail.comINTRODUCTIONTraumatic Central Cord Syndrome (TCCS) is themost common incomplete Spinal Cord Injury (SCI) withthe incidence varying from 15.7% to 25%.1As the lowerlimbs (LL) are less affected, early gait training can beinitiated.However,poortrunkcontrolisamajorobstaclein achieving this goal. This can be overcome bystabilizing the trunk using a body weight supportedapproach.To date, only a limited number of studies havecomparedthebenefitsoftaskspecificactivitieslikebodyweight supported treadmill walking and BWSOT inincomplete SCI. However, the use of BWSOT has notbeen documented in incomplete TCCS.CASEREPORTA 25-year-old male presented with severe neck painand quadriplegia after sustaining a fall from a heightof 15m. He was managed conservatively and referredto the Neuro Rehabilitation Unit within 24 hours ofinjury. The patient was examined at the time of referralby a qualified physiotherapist. His vitals were stable.Neurological examination revealed normal higherfunctions and cranial nerves. His tone was flaccid inthe upper limbs (UL) and increased in the LL at thistime. Sensory and muscle power evaluation revealed asensory and motor level of C4 with sacral sparing.American Spinal Injury Association Impairment Scale(AIS), motor score was 10/100 comprising 0/50 for ULand 10/50 for LL. Using AIS he was graded as AIS B.Deep tendon reflexes were absent in the UL and brisk19. Asir John--96--98.pmd 2/7/2013, 8:08 PM96
  • 103. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 97in the LL. He had a flaccid bladder for which he wascatheterized.His cervical spine x-ray showed no bonyabnormalities. Magnetic Resonance Imaging showedan area of increased signal intensity on the T2-weightedimages of the sagittal sections of the cervical cord.He was immobilized with a Philadelphia collar fortwo weeks during which time he received conventionalphysiotherapy. By the end of 4thweek ASI motor scoreimproved to 45/100 with normal sensation below thelevel of lesion bringing him to AIS grade C. As trunkhas not improved compared to lower limbs, we lookedfor the method to make him walk which providesupports to trunk. Hence we devised Body weightsupported overground training (BWSOT) system.Fig 1 shows the BWSOT which consists of overheadsuspension system and harness to support a percentageof the patient’s body weight as the patient walks on aparallel bar and progressively decreasing the amountof body weight supported as the gait pattern improves.The body weight unloading is high in the beginning oftraining and decreased gradually. The harness wasattached to an overhead suspension, usually a systemcomposed of ropes and pulleys (rope-and-pulleysystem) connected to a counterweight. A counterweightwas used to dynamically unload part of the patient’sbody weight.sessions per day (20 minutes each), six days a week, forthree weeks. Baseline and at the end of 3 weeks trainingof AIS motor score, 10-m walk test, WISCI-II, SCIM andFIM were recorded and showed improved in all theoutcome measures. By 8thweek he was able to walkwith minimal pelvic support, Fig 2. At the time ofdischarge he was graded on AIS as AIS D with normalbladder function.Fig. 2. Ambulation at the time of discharge.Fig. 1. Gait training using BWSOT with pelvic support (a)anterior view and (b) posterior view.Informed consent was obtained from the patientprior to initiating therapy. He performed two BWSOTDISCUSSIONThis case study highlights three important findings.First, BWSOT found to accelerate the improvementsresulted in improved muscle power, gait speed, andfunctional independence. Second, this set up uses a19. Asir John--96--98.pmd 2/7/2013, 8:08 PM97
  • 104. 98 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1simple and inexpensive device which can be used insmall set up. Third, it reduces the risk of secondarycomplications. Improvements seen in muscle power,gaitandfunctioncouldbeduetothenormalneurologicalrecovery process due to the decrease in cord edema.2However; the addition of BWSOT initiated within threeweeks of injury could have augmented the observedchanges.In developing countries, the uses of cost effectivemethods, which produce significant results with regardto patient outcomes are important. This simple andinexpensive device appears to play a vital role inimproving the quality of rehabilitation and also infacilitating early mobilization which would in turnprobably be cost-effective.Cervical cord injuries have a higher risk ofsecondary complications.3Early mobilization and gaittrainingusingtheBWSOTmayhavearoleinpreventingthese complications. However, larger studies with longterm follow up will be required to test this hypothesis.CONCLUSIONThis case highlights the importance of BWSOT inearly rehabilitation of patients with stable TCCS ininitiation of gait training programs, as early as threeweeks post injury.ACKNOWLEDGEMENTThe authors express special thanks AbrahamSamuel Babu, MPT, FCR, (PhD) for content review.Conflict of InterestThe authors declare no conflict of interest and haveno disclosures.REFERENCES1. McKinley W, Santos K, Meade M, Brooke K:Incidence and outcomes of spinal cord injuryclinical syndromes. J Spinal Cord Med 2007, 30:215-224.2. Uribe J, Green B, Vanni S, Moza K, Guest J, LeviA.Acute traumatic central cord syndrome-experience using surgical decompression withopen-door expansile cervical laminoplasty. SurgNeurol. 2005; 63:505–510.3. Sekhon HS, Fehlings M G. Epidemiology,Demographics, and Pathophysiology of AcuteSpinal Cord Injury. Spine 2001; 26: S2-S12.Table 1: Outcome of the patient following BWSOTWeeks ASIA MS 10-m WT WISCI-II SCIM-III FIM1 10/100 NA 0/20 10/100 50/1264 45/100 3 min 14 sec 3/20 30/100 60/1267 68/100 1 min 41 sec 17/20 50/100 72/126Abbreviations: ASIA MS, America Spinal cord Injury Association Motor Score; WT, Walk Test; WISCI-II, Walking Index for Spinalcord Injury-version II; SCIM-III, Spinal cord Independence Measure-version III; FIM, Functional Independence Measure.19. Asir John--96--98.pmd 2/7/2013, 8:08 PM98
  • 105. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 99Effects of Ischemic Compression on the Trigger Points inthe Upper Trapezius MuscleBhavesh H. Jagad, Karishma B. JagadLecturer, Shri K. K. Sheth Physiotherapy College, Rajkot, Gujarat, IndiaABSTRACTBackgroundandPurposeofTheStudy:Amyofascialtriggerpointhasbeendescribedasahyperirritablespot, usually within a taut band of skeletal muscles or in the muscles fascia. The myofascial triggerpoint in the upper trapezius is most commonly found at the midpoint of the upper boarder of themuscle.The objective of the study is to determine the effectiveness of ischemic compression for the treatment ofmyofascial trigger points in upper trapezius.Method: 30 subjects were randomly assigned to either treatment group (group 1) or a control group(group 2). Subjects in group 1 received ischemic compression on the primary trigger point followed bystretching of the upper trapezius muscle. Subjects in group 2 received active neck exercise followed bystretching. All the patients of group 1 and 2 received treatment for 7 days. Pressure Pain Threshold(PPT) measured by pressure algometer was used to measure trigger point sensitivity and VisualAnalogue Scale(VAS) was scored as a measure of pain intensity on day 1 and day 8 in both the groups.Results: In the treatment group (group 1) significant improvement was evident in the pressure painthreshold values (t=7.02, p<0.05), however no such improvement was found in the control group(group 2). Comparison between the two groups also showed significant difference in the pressure painthreshold measurement.Significant improvement was noted in the visual analogue scale score of group 1 (T=120, p<0.001) andgroup 2 (T= 66, p<0.001) both; however greater improvement was noted in treatment group (group 1).Conclusion: Ischemic compression technique is highly effective in reducing the trigger point sensitivityand pain intensity in the trapezius muscle.Keywords: Ischemic Compression, Upper Trapezius, Trigger Point.INTRODUCTIONNeck pain is very commonly shown by most peopleto be in the region of the back of the neck and betweenthe bases of the neck to the shoulder, primarilyindicating the region of the trapezius muscle1. Abouttwo thirds of people will experience neck pain at sometime.2,3Prevalence is highest in middle age with womenbeing affected more the men. The prevalence of neckpain varies widely between studies, with mean pointprevalence of 13% (range 5.9 – 38.7%) and mean lifetimeprevalence of 50% (range 14.2 – 71.0%). In someindustries neck related disorders account for as manydays of absenteeism as low back pain4,5.The myofascial trigger point in the trapezius is mostcommonly found at the midpoint of the upper border ofthe muscle. It has been described as a hyperirritablespot, usually within a taut band of skeletal muscles orin the muscles fascia. The spot is painful oncompression and can give rise to characteristics referredpain, tenderness and autonomic phenomena.6There ispain with passive or active stretching of the musclesand limited range of motion.6,7Several trigger point treatment methods have beenstudied for effectiveness. These methods includeinjection or dry needling8,9, spray and stretch10,transcutaneous electrical nerve stimulation(TENS)31,41,42, and post isometric relaxation43. Injectionand spray and stretch are reported as the most commonforms of therapy for trigger points.6,11,12,13,14Ischemic compression has been studied by severalauthors to treat myofascial pain, fibromyalgia andparaesthesias. It is a non invasive technique and does20. Karishma--99-104.pmd 2/7/2013, 8:08 PM99
  • 106. 100 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1not produce muscle soreness. However due todifference in study population and outcome measuresused to assess the effectiveness, there is lack of rigorousevidence for use of ischemic compression in clinicalpractice. The objective of the study is to determine theeffectiveness of ischemic compression for the treatmentof myofascial trigger points in upper trapezius.MATERIALS & METHODSubjectsThe study was conducted in Shri K. K. ShethPhysiotherapy College, Rajkot, India. 30 volunteersubjects who participated in the study were selectedfrom the patients attending OPD department of thecollege.EXCLUSION CRITERIA-History of orthopedic surgery to neck or back-Cardiovascular or neurological conditions-Clotting disorders and-Treatment of myofascial pain or trigger points at thetime of the study.INCLUSION CRITERIA-A palpable tender spot in the neck or upper back-Reproduction of the subject’s pain upon palpation-A jump sign characterized by patient vocalization orwithdrawl5, 7INSTRUMENTATIONThe pressure algometer was used in the study tomeasure pressure pain threshold as an index of triggerpointsensitivity.Itisareliabletechnique,demonstratinghigh interrater and intrarater reliability.15,16,17Figure-1Form, and Assessment Form.METHODAn experimental study was conducted to study theeffectiveness of ischemic compression on the triggerpoints in trapezius muscle. Each subject was randomlyassignedtotreatmentgroup(group1)andcontrolgroup(group 2).The subject was required to complete the informedconsent form. Then the subject was asked to mark avisual analogue scale with the average pain intensityfor their pain over past 24 hours. The subjects werethen acquainted with the sensation of pressurealgometer on an unaffected part of the body beforetesting for pressure pain threshold of primary triggerpoint. The pressure algometer was placedperpendicular to the area to be tested, increasing thepressure steadily at the rate of approximately 1 Kg/sec.Examiner palpated the region of trapezius and markedall the trigger points that matched the inclusioncriteria with a non permanent marker. Pressure painthreshold was measured for each marked trigger point.The trigger point with the lowest pressure painthreshold was considered as primary trigger point andwas marked with Reynolds permanent marker.Figure-2 Placement of Algometer for Measurementof PPTA Visual Analogue Scale was used to measureintensity of the subject’s pain.Other materials used include Reynolds Marker,Kodak C875 Zoom Digital Camera, Paper, Pen, ConsentGroup 1 - With the patient in comfortable sittingposition on an armless chair and both feet firmlyplanted on the floor, gradual pressure was applied tothe primary trigger point using the right thumb withthe left thumb reinforcing it from the top. The patientwas asked to side bend the neck to the opposite side inorder to place mild stretch on the primary trigger point.Pressure was gradually increased to produce localizeddiscoloration as well as symptoms in the target area.The same pressure was held till the patient reported20. Karishma--99-104.pmd 2/7/2013, 8:08 PM100
  • 107. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 101easing of local and referred pain followed by a releaseof 10 seconds. The same sequence of ischemiccompression was repeated three times per session withthe pressure of ischemic compression increasing as thepatient’s tolerance increased.7,18Ischemic compressionwas followed by sustained stretch to the uppertrapezius. The stretch was maintained for 30 secondsfollowed by rest of 10 seconds. The procedure wasrepeated 5 times per session.Group 2 - The patients were asked to perform activeneck flexion, neck lateral flexion, neck extension andneck rotation while seated near the edge on an armlesschair with both the feet firmly planted on the floor. Thepatients performed these exercises 10 times each.Sustained stretch to the upper trapezius was given inthe same manner as described above.All the patients of group 1 and 2 received treatmentfor 7 days. No treatment was given on the 8thday todetermine the short term effects of the interventionwithout confounding effects from the treatment justcompleted. On day 8, the therapist again obtainedmeasurements for each subject A Pressure PainThreshold measurement of primary trigger point and avisual analogue scale score for the average painintensity for the past 24 hours were recorded.RESULTSWilcoxon signed rank test, wilcoxon sum rank testand student’s T test were used to analyze the data. Thepaired and unpaired t-tests were performed using SPSSstatistics 17.0Table 1. Gender distribution of 30 subjects whoparticipated in the study.Gender Group 1 Group 2Male count% 533% 533%Female count% 1067% 1067%Total 15 15Table 2. Mean age of subjects in group l and group 2Group 1 Group 2Mean age(Years) 28.73 29.53There was no significant age difference seen acrosstwo groupsPretreatment and post treatment means and SD ofPPT value and VAS score of each group are shown inchart2andchart3respectively. Thescoresreflectgreaterimprovement for group 1 than for group 2 on all thevariables.Chart-1 Raw score Means for Pre-treatment andPost-treatment PPT of group 1 and group 2Chart-2 Raw score Means for Pre-treatment andPost-treatment VAS of group 1 and group 2Table 3. Calculated and Observed ‘t’ values for difference of PPT withinand between group 1 and group 2CALCULATED OBSERVEDGroup 1 (t14) 6.910 2.15 P<0.001 Highly significantGroup 2 (t14) 1.871 2.15 P>0.05 Not significantBetween Groups 1&2 (t28-) 6.40 2.05 P<0.001 Highly significantTable 4. T value calculated by Wilcoxon Signed Rank Test for group 1 and group 2VAS T value Probability (P)Group 1 120 <0.01Group 2 66 <0.0120. Karishma--99-104.pmd 2/7/2013, 8:08 PM101
  • 108. 102 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Table-5 ‘z’ value calculated by Wilcoxon Rank SumTest for between group comparisonScore ‘z’ value Probability (P)VAS 3.44 <0.0003DISCUSSIONPoint prevalence of neck pain is nearly 13%19,20andlifetime prevalence is 50%.21In females, the fiber-typedistribution pattern of trapezius is similar to male butthe mean cross-sectional area of the fibers isconsiderably smaller. The significantly smaller cross-sectional fiber area, which indicates a lower functionalcapacity, may be of importance in the development ofneck and shoulder dysfunction in females.22Researchers also found that shoulder abduction torqueand trapezius EMG amplitude were significantlylower in the women with myalgia compared withthose without the muscle pain.23Higher incidence ofneck pain in female population can be accounted forthe higher number of female subjects in the presentstudy.Garvey et al found injection of a local anesthetic,injection of a local anesthetic plus steroid,acupuncture (dry needling), and acupressure withvapocoolant spray to be effective in relieving pain.8This conclusion is also supported by authors likeRubin D (1981)12Imich D et al (2002)24and Hong C(1994)9. Garvey et al reported that the acupressure plusvapocoolant spray was the most effective at relievingpain. This led them to propose that relief is likely due tomechanicalstimulationofthetriggerpointbytheneedleor the acupressure, not the injection of a particularsubstance. Hong C also suggested that, localvasodilatation and removal of metabolites along withmechanical disruption of abnormal functioning ofcontractile elements or nerve endings is responsiblefor trigger point inactivation by injection method.However the treatment involves invasive procedureand to the varying degree produces post injectionsoreness and muscle necrosis.When ischemic compression is used on the triggerpoints, local chemistry changes due to blanching of thenodules followed by hyperemia when the compressionis released. This flushes out the muscle inflammatoryexudates and pain metabolites, breaks down thescar tissue, desensitizes the nerve endings and reducesthe muscle tone. Thus the ischemic compression hasessentially the same mechanism of action on thetrigger point as the injection therapy. Howeverischemic compression is a non invasive technique thatdoes not produce post treatment soreness orhemorrhage.Stretching of the affected muscle is believed bysome -authors to be an integral part of trigger pointtherapy.6,10,13,14,25Techniques like post isometricrelaxation, strain/ counter strain, reciprocal inhibition,passive stretching of the affected muscle and ‘spray-stretch have been found to be effective in reducing thepain intensity and trigger point sensitivity.7,18,26Simons(1981) hypothesized that stretching a muscle releasesthe locked actin and myosin heads, allowing the ATPto form. The ATP allows the sarcoplasmic reticulum toreturntonormal andcirculation toimprove.27Howeverthe stretch works better when there are nerve impulsesfrom the skin being sent to the brain and inhibitingthe reflex pathway that produces trigger point activityand pain messages. These conflicting skin impulsesare most viewed as a sustained stretch to a specificpoint in the muscle and it gets right to the tight orrestricted area in a muscle. The conclusion would seemto be that stretching alone is not enough but that as anadjunct to ischemic compression it is helpful.The present study demonstrates significantimprovement in pain intensity and pain threshold ingroup 1 treated with ischemic compression andtrapezius stretching compared to group 2 treated withactive neck exercises and trapezius stretching. Researchin 1993 by Hong et al lends credibility to the statementthat ischemic compressionissuperior toother physicalmedicine modalities for treating trigger points. Similarresult has been obtained by Jamie Dearing (2007)28CONCLUSIONThe results of this study indicate that ischemiccompression is highly effective in the short termmanagement of trigger point in the upper trapezius byreducing the trigger point sensitivity and average painintensity.Limitations And Future SuggestionsThe study did not examine effectiveness relative toany other outcome such as functional limitation ordisability.The long term effects of the ischemic compressionon the trigger point sensitivity needs to be investigatedfurther.The study includes a small sample sizeThe duration of pain relief associated with the20. Karishma--99-104.pmd 2/7/2013, 8:08 PM102
  • 109. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 103control of contributing factors to the development oftrigger point needs to be investigated.REFERENCES1. Jennifer Chu, Neck Pain- Trapezius, Chu2. Makela M et al, Prevalence, Determinants, AndConsequences Of Chronic Neck Pain In Finland,Am J Epidemiol 1991; 134: 1356-1367.3. Cote P et al, The Saskatchewan Health and BackPain Survey: The Prevalence of Neck Pain andRelated Disability in Saskatchewan Adults, Spine1998; 23:1689-1698.4. Fejer R et al, The Prevalence Of Neck Pain InThe World Population: A Systematic CriticalReview Of The Literature, Eur Spine J 2006;15: 834-848.5. Peter D Aker, Anita R Gross et al, ConservativeManagementofMechanicalNeckPain:SystematicOverview and Meta-Analysis, BMJ 1996; 313:1291-1296.6. Travell JG et al, Myofascial Pain and Dysfunction:The Trigger Point Manual, The Upper Extremities,Baltimore, Md: Williams & Wilkins, 1983: 5-90.7. Siobahn Maguire, Myofacial Therapy AndPodiatry: A Literature Review http://p o d i a t r y . c u i t i n . e d u . a u /encyclopedialmyofascial/#intro8. Garvey TA et al, A Prospective, Randomized,Double-Blind Evaluation Of Trigger-PointInjection Therapy For Low-Back Pain, Spine, 1989,14: 962-964.9. Hong C, Lidocaine Injection Versus DryNeedling To Myofascial Trigger Point: TheImvortance Of The Local Twitch Response, Am JPhys Med Rehabi1, 1994,·74: 262-263.10. Jaeger B et al, Quantification Of Changes InMyofascial Trigger Point Sensitivity With ThePressure Algometer Following Passive Stretch,Pain, 1986, 27:203-210.11. Grosshandler SL et al, Chronic Neck and ShoulderPain: Focusing On Myofascial Origins, PostgradMed, 1985,77: 149-158.12. Rubin D, Myofacial Trigger Point Syndromes: AnApproach To Management: Arch Phys MedRehabil, 1981 Mar; 62(3): 107-110.13. Fricton JR, Management of myofascial painsyndrome. In: Fricton JR, Awad EA, eds.,Advances in Pain Research and Therapy, NY:Raven Press; 1990, 17: 325-346.14. McClaflin RR, Myofascial Pain Syndrome:Primary Care Strategies for EarlyIntervention,Postgrad Med, 1994, 96: 56-73.15. Reeves JI et al, Reliability Of The PressureAlgometer As A Measure Of Myofascial TriggerPoint Sensitivity, Pain, 1986, 24: 313- 321.16. Fischer AA, Documentation of Myofascial TriggerPoints, Arch Phys Med Rehabil, 1988, 69: 286-291.17. StuartCathcart etal,ReliabilityOfPainThresholdMeasurement In Young Adults: The InternetJournal Of Pain, Symptom Control And PalliativeCare, 2005, 4.18. Leon Chaitow, Integrated treatment of myofascialtrigger points, n d e x . p h p ? o p t i o n = c o mcontent&task=view&id=361&itemi19. Bovim G et al, Neck Pain in The GeneralPopulation, Spine 1994, 19:1307-1309.20. Van der et al,TheAssociations Of Neck Pain WithRadiological Abnormalities Of The Cervical SpineAnd Personality Traits In A General—Population. J Rheumatol1991, 18: 1884-1889.21. Peter D et al, Conservative Management OfMechanical Neck Pain: Systematic Overview AndMeta-Analysis, BMJ, 1996, 313: 1291-1296.22. R. Lindman et al, Fiber type composition of thehuman female trapezius muscle: Enzyme-histochemical characteristics, Am J Anat, 2005,190: 385-39223. KristenJ.Light,ExertionProvokesPainInMyalgiaPatients, BioMechanics Archives, 2008.24. Irnich D et al, Is Acupuncture At Distant PointsReally Superior To Dry Needling Of Trigger PointsIn Chronic Neck Pain?, pain, 2002, 83: 991-992.25. Fricton JR, Clinical Care For Myofascial Pain, DentClin North Am, 1991, 35: 1-28.26. Lewit D et al, Myofascial Pain: Relief by Post-Isometric Relaxation, Arch Phys Med Rehabil,1984, 65: 452—456.27. Simons D, Myofacial Trigger Points: A Need forUnderstanding, Arch Phys Med Rehabil, 1981, 62:97-99.28. Jamie Dearing, An Examination Of Pressure PainThresholdAt Myofacial Trigger Points FollowingMuscle Energy Technique Or IschemicCompressionTreatment,Chiropractic,Osteopathyand Physiotherapy Annual Conference, 2007, 4:14.29. Fricton JR, Myofascial Pain Syndrome:Characteristics and Epidemiology. In: Fricton JR,Awad EA, Advances in Pain Research andTherapy, Vo117, NY: Raven Pres; 1990: 107-127.30. Simons DG, Muscular Pain Syndromes, In: FrictonJR, Awad EA, eds. Advances in Pain Researchand Therapy, Vol17, New York, NY: Raven Press;1990: 1-41.20. Karishma--99-104.pmd 2/7/2013, 8:08 PM103
  • 110. 104 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 131. Han SC et al, Myofascial Pain Syndrome andTrigger-Point Management, RegAnesth, 1997, 22:89-101.32. Travell JG et al, Letter to The Editor, Pain, 1981, 10:106—109.33. Travell JG, Myofascial Trigger Points: ClinicalView, In: Bonica JJ, Albe-Fessard D, Eds.,Advances In Pain Research and Therapy, NY:Raven Press; 1976, 1: 919-926.34. Nice Det al, IntertesterReliabilityOf JudgementsOf The Presence Of Trigger Points In ..T.. )patientsWith Low Back Pain, Arch Phys Med Rehabil,1992, 73: 893-898.35. Graff-Radford SB et al, Effects Of TranscutaneousElectrical Nerve Stimulation On Myofascial Pain AndTrigger Point Sensitivity, Pain, 1989, 37: 1-5.36. Melzack R, Prolonged Relief Of Pain By Brief,Intense Transcutaneous Somatic Stimulation, Pain,1975, 1: 357-373.37. Hameroff SR et al, Comparison Of Bupivacaine,Etidocaine, And Saline For Trigger-Point Therapy,Anesth Analg, 1981, 60: 752-75520. Karishma--99-104.pmd 2/7/2013, 8:08 PM104
  • 111. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 105Prevalence of Upper Limb Dysfunction in Subjects withChronic non Specific Neck Pain in Bangalore City,KarnatakaKinchuk DB1, Soumya G2, Payal D31Student, MSc. Clinical Physiotherapy, International School of Physiotherapy, a Collaborative Programme of GokulaEducation Foundation and Coventry University, Bangalore, Karnataka, 2Lecturer, International School of PhysiotherapyGEF - CU Collaborative Programme Bangalore, 3Lecturer, International School of Physiotherapy GEF - CU CollaborativeProgramme Bangalore.ABSTRACTStudy design: Cross sectional studyObjective: To find out the prevalence of upper limb dysfunction in subjects with non specific neck pain.Summary of the background data: Non specific neck pain is highly prevalent in women particularlyof working age. Upper limb disorder and disability/ dysfunction are one of the most important factorsthat have been discovered in the management outcome for nonspecific neck pain. Single Arm MilitaryPress (SAMP) test has been used to measure the level of upper limb dysfunction in neck pain population.With a high prevalence of non specific neck pain in India either due to their occupation or age itbecomes important to quantify the rate of upper limb dysfunction in Indian population in their workingenvironment so that further measures can be taken to address upper limb dysfunction in the course ofmanagement of non specific neck pain.Method: Seventy two (72) subjects fulfilling the inclusion criteria and exclusion criteria were taken upforthestudy.Theupperlimbdysfunctionwasmeasuredforallthesubjectsforboththehands.Descriptivestatistical analysis was carried out for this study. Results on continuous measurements are presentedon Mean SD (Min-Max) and results on categorical measurements are presented in Number (%) withlevelofsignificancesetat0.05.Thecomparisonbetweenthecategoricalmeasurementshasbeenanalyzedusing one sample t- test.Results: Of the 72 subjects 93.1% had upper limb dysfunction as determined by the test scores. Themean and standard deviation of SAMP score for the right hand was 20.44 ± 5.25 and for the left handit was 18.49 ± 4.49. The comparison between the mean scores of right and left upper limb was done toshow a cumulative finding using one sample t- test and it was found to be statistically significant (p <0.001).Conclusion: Upper limb dysfunction has been found to be highly prevalent in subjects with non specificneck pain working women in Bangalore city, India.Keywords: Ischemic Compression, Upper Trapezius, Trigger Point.INTRODUCTIONNon specific neck pain is a common occurrence ingeneral population and the incidence appears to berising1,2.Most of the working aged women have beencomplaining of neck pain to the physicians 3,4and thefrequency has increased since past two decades 5,6.Women are found to be having lower strength of theirneck muscles when compared to men 7,8,9,10.There is evidence to understand the relationshipbetween the neck pain and upper limb dysfunction assummarized by McLean et al.11. Any mechanicalloading of the articular structures results in a protectivespasm that invariably restricts the upper limb inperforming its functions. Static positioning of the upperlimbs during working like using computers could leadtodeconditioningoftheupperlimbeventuallyreducingthe strength and endurance 12.The Single Arm Military Press (SAMP) test, whichis strength and endurance performance based outcomemeasure, is more valid and reliable tool than DASH toquantify the level of upper limb dysfunction 13. UKStudies have found 67% of the population sufferingfrom non specific neck pain having problems regardingupper limb functions14.21. Kinchuk Dolma--105-109.pmd 2/7/2013, 8:08 PM105
  • 112. 106 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Despite the high prevalence of neck pain in India,limited literature is available regarding the presence ofupper limb dysfunction among neck pain population.Thus, the present study intends to find out theprevalence of upper limb dysfunction among subjectswith non specific neck pain by evaluating the strengthand endurance of upper limb using SAMP test.MATERIALS AND METHODMethods Of Data CollectionMethod of sampling : Convenience samplingType of the study : Cross sectionalSample size : 72 (seventy two)Inclusion criteria• Mechanical/non specific neck pain• Chronic pain (i.e., should have had pain more than3 months)• No disabling pain at the time of study• Working women (age 30-55 years)• No previous physiotherapy treatment taken• English speakingExclusion criteria• Traumatic neck pain e.g., whiplash associateddisorder• Old/recent trauma to the shoulder, elbow and hand• Acute neck pain (less than 3 months)• Cervical spondylosis• Radiculopathy• Neurogenic pain• Any other systemic illness• Psychological disordersProcedure of data collectionA cross sectional study on 72 symptomatic subjectswith non specific neck pain was carried out in variousinstitutions in Bangalore city, India. The institutionsincluded primary and secondary school, privateworkplace, private hospitals and clinical diagnosticcentres. An ethical clearance for Research study wasobtained from M S Ramaiah Medical College andHospital, Bangalore, Karnataka, India. Approval forconducting the study was taken from the Principals ofthe respective institutions. All the participants wereprovided with a copy of the detailed informed consentform. Purpose of the study was explained and a writteninformed consent was obtained from the subjects.Seventy two women of age ranging between 30 to 55years fulfilling the inclusion criteria and exclusioncriteria were taken up for the study. Following a formalintroduction, a brief demographic data of the subjectsparticipating in this study was noted. The procedure ofthe SAMP test was explained and demonstrated. Thistestrequiredthesubjectstocompleteasmanyrepetitionsof the SAMP technique as possible within 30 secondsusing a 3kg weight [see figures (1) and (2)] with boththe upper limbs separately. All participants wereinstructed to do the test as fast as possible but couldstop and start at anytime during the 30 seconds, thoughthe timing continues. This was one time performedtechnique and the cut off number of repetitions was 25,the number of repetitions subjects were able to do wasdocumented.MEASURESTo assess the baseline dysfunction of upper limb insubjects with neck pain a performance based outcomemeasure was used viz., Single Arm Military Press(SAMP) test. This SAMP test has a cut off point i.e. 25.This means that the scoring less than 25 was consideredto be having upper limb dysfunction amongst thesubjects and a score of 25 and above meant the subjectdid not have upper limb dysfunction.MATERIALS REQUIREDA set up was organized taking the participantsprivacy into consideration in the various workinginstitutions for the study. Three kilogram dumbbell anda stop watch along with documentation sheet werearranged.STATISTICAL METHODDescriptive statistical analysis has been carried outfor the present study. Results on continuousmeasurements (i.e. Age and score of right and left upperlimb) are presented on Mean ± SD (Min-Max).Percentage enumeration has been carried out forcategorical measurements (presence of upper limbdysfunction) as significance is set 0.05. The comparisonbetween the categorical measurements has beenanalyzed using one sample t- test. The followingassumptions on data are made, Assumptions: 1.Dependent variables should be normally distributed,2. Samples drawn from the population should berandom, and 3. Cases of the samples should beindependent.21. Kinchuk Dolma--105-109.pmd 2/7/2013, 8:08 PM106
  • 113. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 107RESULTSThe basic demographic characteristics of the studypopulation: All the seventy two subjects were workingsymptomatic females of middle age ranging from 30 -55 years (Mean 40.09 ± 7.029 SD), right hand dominant.Table 1: mean and standard deviation (MIN-MAX) ofage.Age (years) Mean ± SD30- 55yrs 40.09 ± 7.029Table 1. Shows the mean and standard deviation of the age ofthe subjects who participated in the study.Table 2: SAMP score of right upper limb inpercentage.Right Total numberSAMP Score of subjects% of % ofsubjects subjectswith score with score(d”24) (e”25)57 15 72(79.2%) (20.8) (100.0%)Table 2. Shows the Percentage of scores of right upper limb ofthe subjects who participated in the study. Out of 72 (100%)subjects 57 (79.2%) of them had a score less than equal to 24and 15 (20.8%) of them had score more than equal to 25.Fig.1. Start position for SAMP test showing (a) anterior view and (b) lateral viewFig. 2. Finish point for SAMP test showing (a) anterior view (b) lateral view21. Kinchuk Dolma--105-109.pmd 2/7/2013, 8:08 PM107
  • 114. 108 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Table 3: SAMP score of left upper limb in percentage.Left Total numberSAMP Score of subjects% of % ofsubjects subjectswith score with score(d”24) (e”25)65 7 72(90.3%) (9.7%) (100%)Table 3. Shows the Percentage of scores of left upper limb ofthe subjects who participated in the study. Out of 72 (100%)of the subjects 65 (90.3%) had score less than equal to 24 and7 (9.7%) had scores more than equal to 25.Table 4. Comparison of Mean score between rightand left upper limb.Mean Std. Error pValue(One samplet- test)Score Right Total 20.44 0.619 <0.001(N = 72) (SD ± 5.25)Score Left Total 18.49 0.53 <0.001(N = 72) (SD ± 4.49)Total 1.09 0.03516(72) (SD± 0.29)Table 4. Shows the Mean and Standard Deviation of the scoresin right and left upper limb of the study population. Since onlyone group of subjects were there, one sample t- test has beenused to compare the Mean between the scores of right and leftupper limb. With Standard of error 0.619 and for right and leftupper limb respectively the p value is <0.001.Table 5. Percentage enumeration of upper limbdysfunction in subjects after combining both right andleft scores.Total CombinationScoreUpperlimb NoDysfunction DysfunctionPresent of Upper LimbTotal Count 72 67 5(100%) (93.1%) (6.9%)Table 5. Shows the Percentage of presence of upperlimb dysfunction of the subjects who participated inthe study. 67 persons that accounts for 93.1% of thetotal subjects had upper limb dysfunction and 5 personsthatamountto6.9%ofthetotalsubjectshadnoobservedupper limb dysfunction.DISCUSSION/CONCLUSIONInthepresentstudy72workingwomenfromvariousoccupations with chronic non specific neck pain weretaken up. These subjects were evaluated for their upperlimb dysfunction using SAMP test as an outcomemeasure. The ones who performed repetitive action lessor equal to twenty four (d”24) were considered to haveupperlimbdysfunctionandtheoneswhooutperformedthis test twenty five or more (e”25) times wereconsideredtobenothavinganyupperlimbdysfunction.The results suggests that middle aged workingwomen with chronic non specific neck pain presentswith upper limb dysfunction with the percentageprevalence of 93.1% (67 subjects) and without upperlimb dysfunction percentage prevalence of 6.9% (5subjects) after combining the mean scores of both rightand upper limb (Refer Table 5). This finding is inaccordance with the literature that concluded thatwomen older than 37 years of age independent ofoccupation were susceptible of acquiring chronic neckpain which could probably result in upper limbdysfunction 15,16,17Studies have shown that with increase in age therewill be a steady drop in SAMP test score11and theassessment of work and non work related factorsparticularly in women is essential18. Since the presentstudy was just to find the prevalence of upper limbdysfunction in non specific neck pain population, noother outcome measures were used other than SAMPtest. This study suggests performing a detailedbiomechanical and functional analysis of the specificarea of problem (neck) as well as associated part (upperlimb) of the musculoskeletal system, in order to planout a rehabilitative protocol / strategy for any workingindividual with neck pain.Further studies can be done by• Considering larger subjects with similar condition.• Comparing upper limb dysfunction in dominantand non dominant hand.• Further validating the clinical use of SAMP test asan outcome measure of upper limb dysfunction/disability.ACKNOWLEDGEMENTI would like to extend my gratitude towards ourCourse Coordinator Prof. Savita Ravindra, CourseDirector Dr. Sudha Suresh, Associate prof communitydepartment Dr. Nanda Kumar B.S., internet searchenginesGoogleScholar,PubMedCentral,Mendeley,mycolleagues and parents and the subjects who willinglyparticipated in my study21. Kinchuk Dolma--105-109.pmd 2/7/2013, 8:08 PM108
  • 115. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 109REFERENCES1. Hakala P, Rimpela A, Salminen JJ, Virtanen SM,Rimpela M. Back, neck, and shoulder pain inFinnish adolescents: national cross sectionalsurveys. BMJ. 2002; 325:743.2. Bot SD, Waal JM, Terwee CB, Windt DA, SchellevisFG, Bouter LM, Dekker J. (2005) Incidence andprevalence of complaints of the neck and upperextremity in general practice. Ann Rheum Dis.2005; 64(1):118-123.3. Rekola K. Health service utilization formusculoskeletal disorders in Finnish primaryhealth care. Acta Univ Oul. 1993; D259:53-59.4. Mantyselka PT. Patient pain in general practice.1998 Kuopio, Finland. Kuopio UniversityPublications.5. Ferrari R, Russell AS. Regional musculoskeletalconditions: neck pain. Best Pract Res ClinRheumatol. 2003; 17:57–70.6. IhlebaekC,BrageS,EriksenHR.Healthcomplaintsand sickness absence in Norway, 1996-2003.Occup Med (Lond). 2007; 57;43–9.7. Staudte HW, Duhr N. Age- and sex-dependentforce-related function of the cervical spine. EurSpine J. 1994; 3:155–161.8. Ylinen J, Takala EP, Nykanen M, Hakkinen A,Malkia E, Pohjolainen T, Karppi SL, KautiainenH, Airaksinen O. Active Neck Muscle Training InThe Treatment Of Chronic Neck Pain In Women.JAMA. 2003; 289(19):2509-16.9. Taimela S, Takala EP, Asklöf T, Seppälä K. Activetreatment of chronic neck pain: a prospectiverandomized intervention. Spine. 2000; 25(8):1021–1027.10. Bernard B. Musculoskeletal disorders andworkplace factors- A critical review ofepidemiologic evidence for work-relatedmusculoskeletal disorders of the neck, upperextremity, and low back. Cincinnati (OH): UnitedStates Department of Health and Human Sciences,National Institute for Occupational Health andSafety. 1997; 2.1—2.90.11. McLean SM, Taylor J, Balasoobramanien T,Kulkarni M, Patekar P, Darne R, Jain V. Measuringupper limb disability in non-specific neck pain: Aclinical performance measure. InternationalJournal of Physiotherapy and Rehabilitation. 2010;1(1):44-52.12. Frank AO, De Souza LH, Frank CA. Neck painand disability: a cross-sectional survey of thedemographic and clinical characteristics of neckpain seen in a rheumatology clinic. InternationalJournal of Clinical Practice. 2005; 59(2):173-182.13. McLean S. Conservative management of non-specific neck pain: Effectiveness of treatment,predictors of treatment outcome and upper limbdisability. PhD dissertation, University of Hull;Hull. 2007.14. McLean SM, Moffett JK, Sharp DM, Gardiner E.An investigation to determine the associationbetween neck pain and upper limb disability forpatients with non-specific neck pain: A secondaryanalysis. Manual Therapy. 2011; 16:434-439.15. Daffner SD, Hilibrand AS, Hanscom BS, BrislinBT, Vaccaro AR, Albert TJ. Impact Of Neck AndArm Pain On Overall Health Status. Spine. 2003;28(17):2030-2035.16. Cassou B, Derrienmic F, Monforz C, Norton J,Touranchet A. Chronic neck and shoulder pain,age and working conditions; longitudinal resultsfrom a large random sample in France. OccupEnviron Med. 2002; 59:337-544.17. Andersson IH, Ejlertsson G, Leden I, RosenbergC. Chronic pain in a geographically-definedgeneral population: Studies on differences in age,gender, social class, and pain localization. ClinicalJ Pain. 1993; 9:174-82.18. Fredriksson K, Alfredsson L, Köster M,ThorbjörnssonCB,ToomingasA,TorgénM,KilbomA. Risk factors for neck and upper limb disorders:results from 24 years of follow up. Occup EnvironMed. 1999; 56:59–66.21. Kinchuk Dolma--105-109.pmd 2/7/2013, 8:08 PM109
  • 116. 110 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Randomized Controlled trial of Group Versus IndividualPhysiotherapy Sessions for Genuine Stress Incontinencein WomenKomal Soni1, Harshit Soni2, Dhaval Desai1, Chintan Shah1, Hasmukh Patel31(Lecturer), 2(Tutor), SPB Physiotherapy College, Surat, 3Clinical Therapist, U. N. Mehta Institute of Cardiology &Research Centre, AhmedabadABSTRACTBackground: Pelvic floor muscle exercises are used since 1948 as first-line treatment for management ofgenuine stress incontinence in women. This pelvic floor muscle exercises can be deliveredsimultaneously to a group of women or individually on a one to one basis.Objective: The purpose of this study was to compare the effects of group physiotherapy and individualphysiotherapy sessions on the severity of incontinence & quality of life in patients with genuine stressincontinence.Materials and Methods: 40 women with chronic genuine stress incontinence were randomized intoGroup A - where women were delivered the pelvic floor muscle exercises in a group of 10 (n=20) &Group B - where pelvic floor muscle exercise on a conventional one to one basis, the individual approach(n=20) were administered. Outcome measures which included VAS for measuring severity ofincontinence & Kings health questionnaire for assessing quality of life were taken at baseline & at theend of 3 months intervention program.Results: Both the group A and group B showed improvement in severity of incontinence and quality oflife postintervention when compared with preintervention measurement and tcalculated value forpre-postintervention measures was statistically significant as it was above the t tabulated value.Moreover, Mean±SD of pre-post change in VAS for groupAwas 2.02±0.46 and for group B was 1.94±0.43and Kings Health Questionnaire scores for group A was 30.09±5.3 and for group B was 21.51±6.73.tcalculated value for pre-post changes was statistically not significant as it was below the t tabulatedvalue of 2.576.Conclusion: Both group and individual physiotherapy pelvic floor muscle exercises for women withgenuine stress incontinence are equally effective. One may choose anyone of it to gain benefits.Keywords: Genuine Stress Incontinence, Pelvic Floor Muscle Exercise, Group Physiotherapy, IndividualPhysiotherapy.Corresponding author:Komal Soni543, Jalaramnagar, GHB, Ganeshpura, Amroli,Surat - 394107,Gujarat, India, Mobile No: 9904157300E-mail: sonikomal10@gmail.comINTRODUCTIONGSI (Genuine stress incontinence); also known asStress urinary incontinence is defined as an involuntaryloss of urine that occurs during physical activity, suchas coughing, sneezing, laughing, or exercise.1GSI isfound to be commonest, with its prevalence beinggreatest in 5thdecade of life.2WHO’s 1st InternationalConsultation on Incontinence estimated that bladderproblems affects approximately 200 million peopleworldwide, with 10 to 30% of women between the agesof 20 and 55 years, and in up to 40% of older women.3Although not a life-threatening condition, GSIcauses various physical, psychological & sexualproblems for millions of women & their families. GSIthus has a negative impact on Quality of Life (QoL) &most affected domains are physical health & mobility.4Hence the need for the effective management of thiscondition is vital, not only for the relief of symptomsbut perhaps more importantly, for the prevention ofrecurrent episodes of leakage, personal suffering, andlost work productivity.Studies have found out that women withurinary incontinence have a significant reduction of22. komal soni--110-115.pmd 2/7/2013, 8:08 PM110
  • 117. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 111pelvic floor function & following a 4-month pelvic floormuscle exercise (PFME) training period, incontinenceof both stress type and with an urge component can bealleviated in most of the women.5NICE 2006 guidelinesfor the management of women with GSI have alsooutlined the evidence for the use of both pelvic floormuscle training & bladder retraining as first-linetreatmentsforwomenwithGSI.6Usedsince1948,PFMEwhenemployedinthetreatmentofGSImaybeexpectedto give a significant improvement or cure about 50%with exercises usually having a long lasting effect.7,8This PFME can be given on a one to one basisas with the conventional ‘individual approach’ or canbe given simultaneously to a group of women; a ‘groupapproach’. Promoting incontinence in group sessionsis suggested as an effective means to educate women &to encourage active self-management.Approximately20% of Women’s Health Physiotherapists use groupapproach.9Despite this there has been few RandomizedControl Trials comparing the effectiveness of groupintervention against individual approach whichsignifies the need of the present study. Thus the aim ofthe study was to compare the effectiveness of pragmaticgroup approach versus individual treatment sessionson the severity of incontinence & QoL in patients withGSI.MATERIALS AND METHODIn this Experimental study, total of 40 subjects whowere sent to Bombay Maternity and Surgical Hospital,Surat were assessed for their eligibility based on thecriteria for the study and following that they wererandomlyassignedtoGroupA&GroupB.Aftersigningthe written informed consent (to participate in the studyand to allow reproduction of their photographs) theywere made to participate in study and baselinemeasurements were recorded.Group A: Consisted of 20 females who wereadministered PFME in a group of 10 for 3 weeks.Group B: Consisted of 20 females who weredelivered PFME individually on a one to one basis for 3weeks.Inclusion criteria1. History of chronic (between 2 years to 5 years) GSIwith positive cough stress test.2. Age group of 30 to 55 years.3. Females who have undergone full-term vaginaldelivery.Exclusion criteria1. Pregnancy.2. Participation in Physiotherapy program for GSI inthe past 12 months.3. Disease of central nervous system (e.g. MS, CVA) oracute mental illness & dementia.4. History of pelvic malignancy or pelvic surgery.5. Vaginal or bladder grade 2 and 3 prolapses.Outcome Measures• VisualAnalogue Scale (VAS) for measuring severityof incontinence• King’s Health Questionnaire (KHQ) for measuringQoLExercise RegimensGroup intervention for female urinary incontinence(Group A) (Figure 1 & 2)Group met for nine, one-hour long sessions over athree months period. Group sizes were planned to be10 women in a group.Session 1Introduction to anatomy of lower abdomen & pelvicfloor, explanation of normal PFM & bladder function,teaching and practice of PFME’s recruiting both fast &slow twitch fibers, encouraged to maintain contractionfor 3-5 seconds, repeat 10 times.Session 2Discussion to motivate patient, PFME practice &progression to 10 seconds with 10 repetitions plus upto10 fast repetitions (2 sets) targeted for both slow & fasttwitchfibers.PFME’sduringdaytodayactivitiestaught.The therapist instructed subjects to use the “stressstrategy”.Session 3PFME in standing position with different footpositions taught.Session 4PFME’s progressed to 15 seconds with 10 repetitionsplus 10 fast contractions (3 sets). Lighthearted quiz toreinforce knowledge gained.Session 5PFME’s progressed to include the ‘step’ & ‘lift’exercise & adoption of variety of postures.Session 6Recruitment of transverse abdominus along withPFME taught.22. komal soni--110-115.pmd 2/7/2013, 8:08 PM111
  • 118. 112 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Session 7, 8 & 9PFME’s in different postures to 20 seconds with 10repetitions plus 10 fast contractions (3 sets). Themaximum exercise prescription possible by session 9was 60 repetitions (3 sets of 20 seconds).Patients were asked to perform their respectiveexercises taught at every session twice a day at home.Pelvic floor exercise booklet explaining the aboveprocedures was given to patient in prior.In Individual treatment (Group B), once a week 30minute long session was delivered over a three monthsperiod. The line of treatment progressed on the samelines as described for group sessions. (Figure 3 & 4)Following the recording of the above parameters,the obtained scores were tabulated and comparedamong both the study groups.Ethical Consideration: Procedures followed were inaccordance with the ethical standards of HelsinkiDeclaration of 1975, as revised in 2000.10Statistical AnalysisAll participants received full treatments and therewere no drop outs.Data analysis was done by using SPSS 13.0 versionsoftware. Unpaired t tests were used to find outhomogeneity of two groups for all the parameters atFigure 1 & 2 – Delivery of Group Physiotherapy Sessions (GROUP A)Figure 3 & 4 – Delivery of Individual Physiotherapy Sessions (GROUP B)22. komal soni--110-115.pmd 2/7/2013, 8:08 PM112
  • 119. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 113baselineandtocomparetheoutcomemeasurementdatabetween two groups. Paired t tests were conducted todetermine whether VAS and KHQ scores weresignificantly different before and after the intervention.Each calculated t-value is compared with t-table valueto test two tailed hypothesis at 0.01 level of significance.RESULTSTable-1. Demographic Data for both the groupsGROUPA GROUPBMean±SD Range Mean±SD RangeAge (years) 42.0±4.96 34-52 42.5±6.0 33-51BMI 27.01±1.02 25.01-29.14 26.74±1.02 24.89-28.14Duration of 39.25±7.18 26-57 38.5±8.88 27-54the symptoms(months)Parity 2.35±0.67 1-4 2.5±0.97 1-4‘t’calvalueatn1+n2-2degreeoffreedomforage,BMI,duration of symptoms and parity was 0.243, -0.693, -0.249 and 0.496 respectively. Also the ‘t’ cal value atn1+n2-2 degree of freedom among both the groups forvarious preintervention measures like VAS, KHQ, KHQvariables viz. general health perception, incontinenceimpact, role limitations, physical limitations, sociallimitations, personal relationships, emotions, sleep/energy, severity measures for incontinence was -0.921,-1.313, 0.000, -0.190, -0.305, -1.46, -2.53, -1.792, -0.384, -0.545 and -1.646 respectively. Hence, all the descriptivedata for both the groups was not significantly different,so both the groups were homogenous for all possibleconfounding factors and were valid for comparison.Graph 1: Comparison of pre-post Mean VASbetween both the groupsTable-2: Comparison of KHQ Scores between two groupsGROUP A GROUP BVariables Pre Post ‘t’ cal value Pre Post ‘t’ cal valueKHQ Mean 52.43±7.78 22.34±5.05 17.01 47.05±9.50 25.54±4.04 9.57General Health Perception 57.5±18.31 25.0±11.47 12.36 57.5±12.07 27.5±7.90 9.00Incontinence Impact 54.99±22.36 28.33±12.21 5.81 53.32±23.3 26.66±14.05 4.00Role Limitations 53.33±12.79 26.66±8.37 10.46 51.66±16.57 28.32±8.05 6.33Physical Limitations 54.16±11.93 24.99±8.55 8.81 48.33±5.27 28.32±8.05 9.00Social Limitations 55.27±14.24 17.22±11.09 9.12 41.10±14.85 25.55±9.14 3.67Personal Relationships 40.83±16.64 14.99±7.45 7.21 29.99±13.14 18.32±5.27 2.83Emotions 54.99±11.66 23.88±9.02 12.07 53.32±10.20 31.1±4.68 7.74Sleep/Energy 38.33±16.31 15.41±7.29 7.75 34.99±14.59 20.82±7.08 3.97Severity Measures 62.49±15.64 24.58±8.32 15.25 53.33±11.25 23.33±6.57 10.30As evident from graph 1 and table 2, ‘t’ calculatedvalueofpre-postinterventionVASandKHQscoreswereabove the ‘t’ tabulated value of 2.576 and hence werestatistically significant, so both the treatments wereeffective in improving the severity of incontinence andQoL.22. komal soni--110-115.pmd 2/7/2013, 8:08 PM113
  • 120. 114 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Graph 2: Comparison of mean Pre-post change ofVAS between both the groupsMoreover, both the strategies being equally effective,group therapy can be considered as a convenient optionasitmaybemorecosteffective,butthecost-effectivenessof group therapy needs to be assessed. The findings ofstudies done by LA Hill et al. (2007)13and SE Lamb etal. (2009)14showed cost-effectiveness of group therapyand hence gave preference towards it.As seen from our study, while considering QoL itcan be seen that some domains of QoL like physicallimitations, social limitations and personalrelationshipsshowedimprovementbetteringroupthanindividual sessions. This can be attributed to betterdelivery of information in group sessions and hencehigh level of satisfaction associated with group therapyas suggested by B Aston et al. (2007).15Previous worksdone by Frances Griffiths et al. (2009)16showed thatwomen who had preference for individual therapywhen given group sessions exhibited their experienceof group sessions as good but also stated that for groupsessions, its effectiveness lies in its proper designing. Ifthe designing of group therapy is not proper thanembrassement associated with group sessions may leadto failure in delivery of effective treatment.Hence, both the treatments being equally effective,either one can be used for benefit of the patients. Butfactors should be sought that can predict theeffectiveness of therapy and thus better select thosepatients most likely to benefit from specific treatmentprogram.Limitations of the Study1. This study only included women with GSI betweenage group of 30-55 years as GSI is most common inthat age women & also a big age difference inwomen receiving group therapy may lead toimproper delivery of exercise to patient.2. This study only included a smaller population asstudy sample & also the time duration chosen waslimited, thus giving only short-term benefits.Future Implications1. Study can be explored for both the sex and for allage groups & all types of incontinence to know theeffects of these exercise interventions.2. In future study, a larger population can be studiedthus giving more standardized results.3. In future studies, electromyography could be usedconcurrently to provide additional information onmuscle activation associated with the Pelvic FloorMuscle Exercises.TABLE 3 - Comparison of pre-post change in KHQscores between two groupsVariable GROUPA GROUPB ‘t’ calPre-Post change Pre-Post change valueKHQ 30.09±5.30 21.51±6.73 1.63General Health Perception 32.5±11.75 30±10.54 0.56Incontinence Impact 26.66±20.51 26.66±21.08 0.00Role Limitations 26.66±12.56 23.33±11.65 0.00Physical Limitations 29.16±14.17 20.00±10.54 2.30Social Limitations 38.05±15.42 15.55±7.76 3.30Personal Relationships 25.83±15.74 11.66±11.25 3.00Emotions 31.1±9.26 22.22±9.07 1.50Sleep/Energy 22.91±13.21 14.16±12.45 0.80Severity Measures 37.91±11.93 30.0±11.24 0.80As shown in graph 2 and table 3, ‘t’ calculated valueof pre-post intervention change in VAS and KHQ scoreswere below the ‘t’ tabulated value of 2.576 and hencewere statistically not significant (except for sociallimitations and personal relationships), so both thetreatments were equally effective in improving theseverity of incontinence and QoL.DISCUSSIONFollowing a 3 months intervention with GroupPhysiotherapy sessions & Individual Physiotherapysessions, the women showed significant reduction inseverity of incontinence & improvement in QoL.However there were no significant differences foundbetween the two groups treated individually or ingroup, thus suggesting that both individual & groupphysiotherapy sessions are equally effective inmanagement of women with GSI. These findings are inline with the findings of previous studies done by SaraDemain et al. (2001),9Janssen et al. (2001)11& FlaviaCamargo et al. (2009).1222. komal soni--110-115.pmd 2/7/2013, 8:08 PM114
  • 121. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 115CONCLUSIONThis study concluded that both theapproaches – group and individual are equally effectiveto reduce severity of incontinence & improve quality oflife in women with GSI. However factors should be sortfor each specific patient so that they can benefitmaximum from the intervention.ACKNOWLEDGMENTSWe are thankful to all our subjects who participatedwith full cooperation, extended thanks to Mrs. DhartiHingarajia for her valuable help. We are also grateful toauthors/ publishers of all those articles, journals andbooks from where the literature for this article has beenreviewed and discussed.REFERENCES1. Stress Incontinence – medlineplus. Available at: Minassian VA, Stewart WF, Wood GC. Urinaryincontinence in women: variation in prevalenceestimates and risk factors. Obstet Gynecol. 2008Feb;111:324-31.3. Hunskaar S, Burgio K, Diokno AC, etal. Epidemiology and natural history of urinaryincontinence. Urology October 2003;62(4):16-23.4. Rehab Ali Mohamed, Ahmed Mahmoud Mostafa– The impact of urinary incontinence on qualityof life of women attending family practice centerat Fanara village – Ismailia governorate.Availablefrom: Marianne Gunnarsson, Pia Teleman , AndersMattiasson , Jonas Lidfeldt , Christina Nerbrand ,Göran Samsioe . - Effects of Pelvic Floor Exercisesin Middle Aged Women with a History of NaiveUrinary Incontinence: APopulation Based Study.Eur Urol. 2002 May;41(5):556-61.6. NICE guidelines for management of women withurinary incontinence (NICE 2006), Journal of theAssociation of Chartered Physiotherapists inWomen’s Health, Autumn 2007;101:37-43.7. H. Cammu & M. Van Nylen - Pelvic floor muscleexercises in genuine urinary stress incontinence.Int Urogynecol J, September 1997;8(5):297-300.8. Chantale Dumoulin, Marie-Claude Lemieux –Physiotherapy for persistent postnatal SUI: arandomized controlled trial. American College ofObstetricians & Gynecologists, September2004;104(3):504-10 .9. Sara Demain, Jan Fereday Smith, Louise Hiller,Krysia Dziedzic – Comparison of group &individual Physiotherapy for female urinaryincontinence in primary care. Physiotherapy, May2001;87(5):235-42.10. WMA Declaration of Helsinki - Ethical Principlesfor Medical Research Involving Human Subjects.[59thWMA General Assembly Seoul, Korea, Oct2008].Available from: C. C. M. Janssen, A. L. M. Lagro-Janssen & A. J. A.Felling – the effects of physiotherapy for female UIindividual compared with group treatment. BJUInternational(2001); 87:201-6.12. Flávia de Oliveira Camargo,A n d r e a M o u r a R o d r i g u e s ,Raquel Martins Arruda, Marair Gracio FerreiraSartori, Manoel João Batista Castello Girão andRodrigo Aquino Castro - Pelvic floor muscletraining in female stress urinary incontinence:comparison between group training andindividual treatment using PERFECT assessmentscheme; Int Urogynecol J, December2009;20(12):1455-62.13. L. A. Hill, J. Fereday Smith, J. C. Knights, A. J.Williams, S. E. Lamb, J. Pepper, M. Clarke –bladdersbehavingbadly:arandomizedcontrolledtrial of group versus individual intervention inmanagement of female urinary incontinence.Journal of the Association of CharteredPhysiotherapists in Women’s Health, Autumn2007;101:30-36.14. SE Lamb, J Pepper, R Lall, EC Jørstad-Stein, MDClark, L Hill, and J Fereday-Smith - Grouptreatments for sensitive health care problems: arandomised controlled trial of group versusindividual physiotherapy sessions for femaleurinary incontinence. BMC WomensHealth(2009);9:26.15. B. Aston & S. Moulder – Is group treatmentacceptable in the management of women withpelvic floor dysfunction? Journal of theAssociation of Chartered Physiotherapists inWomen’s Health, Autumn 2007; 101:37-43.16. Frances Griffiths, Jo Pepper, Ellen C Jorstad-Stein, Jan Fereday Smith, Lesley Hill & Sarah ELamb-Groupversusindividualsessionsdeliveredby a physiotherapist for female urinaryincontinence: an interview study with womenattending group sessions nested within arandomised controlled trial. BMC Women’sHealth 2009;9:25.22. komal soni--110-115.pmd 2/7/2013, 8:08 PM115
  • 122. 116 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1A Study of Electromyographic Changes in Muscle PostExercise Induced Muscle SorenessManish Rajput1, Ankita Samuel1, Chhavi Gupta1, Sumit Kalra21Student BPT, Banarsidas Chadiwala Institute of Physiotherapy,2Assistant Professor, Banarsidas Chadiwala Institute of PhysiotherapyABSTRACTAim and objective: To analyze electromyographic changes in muscle post Exercise Induced MuscleSoreness (EIMS).Methodology: 80 subjects(age group 21-30yrs, BMI 18-29kg/m2) free of any musculoskeletal/Neuromuscular/psychological disorder, took part in the study.After checking for leg dominancy andcalculation of BMI, the subjects were asked to perform one single squat up to 900 of hip and knee flexionwhile an EMG of the Rectus Femoris and Vastus Medialis Obliqus (both parts of quadriceps muscle)was recorded simultaneously.Another EMG reading was taken in the similar manner after confirmingthe development of muscle soreness on a graphic pain rating scale following the exercise protocol.Results: The mean value of peak EMG of Rectus Femoris pre exercise is 508.69mV (microvolt) and postexercise induced muscle soreness is 686.60 mV. The mean of peak EMG amplitude of Vastus MedialisObliqus came out to be as 379.81 mV pre exercise and 472.70 mV post exercise induced muscle soreness.The p value for RF pre and post was 0.000 and for VMO pre and post was 0.034.Conclusion: The conclusion drawn from the study is that there is a significant increase in peak EMGamplitude of the muscles (RF and VMO) post exercise induced muscle soreness.Keywords: Exercise Induced Muscle Soreness (EIMS), RF, VMO, EMGINTRODUCTIONAt one time or another, each one of us must haveexperienced muscle soreness following everydayactivities that are not associated with participation insports or in formal exercise programs for e.g.: downhillwalking etc. Although muscle soreness usually occursin less physically trained individuals, most people,including elite athletes can experience this soreness aswell.Sincethesorenessisexperiencedinthetimeperiodfollowing any strenuous work, it is termed as exerciseinduced muscle soreness (EIMS).Exercise-induced muscle soreness is a commonoccurrence in daily routine. It can be classified as acuteor delayed onset muscle soreness.1-4. Acute onset occursduring exercise and may last four to six hours post-exercise before subsiding. Delayed onset musclesoreness (DOMS) typically appears approximately 12hours after activity and may last for several daysfollowing exercise.1,2It is perhaps one of the mostcommon and recurrent forms of sports injury.2All forms of exercise, if carried out vigorouslyenough, can become painful. But only one form ofexercise, eccentric exercise5, 6, if we are unaccustomedto it, leaves us stiff and sore the next day. In eccentricexercise the contracting muscle is lengthened; inconcentric exercise it shortens. These eccentric actionsproduce micro-injury to the active muscle fibers, 7-10exhibiting muscular soreness, loss of joint range ofmotion, swelling, and decreased force production.8, 11-16The muscle soreness usually manifests as a dull,aching pain combined with tenderness and stiffness.Clinical signs of muscle soreness include increases inplasma enzymes12, 14, 16muscular fiber degeneration, 17and the protein degradation18that accompanies thedegeneration to favor sarcomere disruption as thestarting point for the damage. As well as damage tomuscle fibers there is evidence of disturbance of musclesense organs and of proprioception.19Accompanying the muscle soreness is muscleweakness”20, 21which persists long after the muscle23. Manish--116-120.pmd 2/7/2013, 8:08 PM116
  • 123. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 117soreness has receded, prolonged strength loss, areduced range of motion, and elevated levels of creatinekinase in the blood. These are taken as indirectindicators of muscle soreness, and biopsy analysis hasdocumented damage to the contractile elements.22A measure to quantify muscle soreness is a Graphicpain rating scale33which is a 12 cm line between nopain and unbearable pain. Pain was quantified bymeasuring the distance (to the nearest 1/2 cm) from theextreme left to the mark made by subjects to describetheir perception of pain. The length was multiplied bytwo, yielding scores from 0 = no pain to 24 = unbearablepain.Electro-myography (EMG) is the study ofmuscle function that involves recording the actionpotentials (or electrical currents) that activate skeletalmuscle fibers23, 24.After fatiguing muscle with exercise, there is adecrease in maximal force production, which has beenobserved as early as l hour after exercise. The surfaceelectromyographic (EMG) activity is modified duringmuscleFatigue(Big1and-Ritcgie, 1981).TheEMGpowerspectrum is shifted towards the lower frequencies asexemplified by the fall in mean power frequency (MPF)during static contractions as well as during dynamicexercise. The EMG spectrum from eccentric, concentricmuscle contractions under human were studied as afactor of mechanical damage of muscle fiber andfunctional change of metabolic tissue. The primarypurpose of the study was to examine the relationshipbetween DOMS in after exercise and EMG change induring exercise. A secondary purpose was to examinetheir relationship to local muscle fatigue and perceivedscale of DOMS. We hypothesized that if exercise-induced muscle soreness is associated with musclefatigue then the localized DOMS to muscle contractionswould be accompanied by attenuated response in indexof muscle fatigue.The quadriceps Femoris muscle plays an importantrole in explosive and powerful actions of the leg duringsport and daily activities. Eccentric contraction iscommonly used during training programs which oftenleads to fiber injury and muscle soreness. The dominantleg was chosen as there is enough evidence that injuriesare most common on the dominant limb.25AIMS AND OBJECTIVETo study the electromyographic changes in musclepost exercise induced muscle soreness.H1- (EXPERIMENTAL HYPOTHESIS)There is significant change in EMG analysis ofquadriceps muscle post exercise induced musclesoreness.H0- (NULL HYPOTHESIS)There is no significant change in the EMG analysisof quadriceps muscle post exercise induced musclesoreness.METHODOLOGYResearch design- comparativeNumber and Source of subjects80 (male) college going students took part in thestudy.Inclusion Criteria1. Body Mass Index(BMI)26should be within the rangeof 18-29 kg/m22. Asymptomaticmalesubjectsbetweenagegroup21-3027years.3. Not involved in unaccustomed eccentric muscleaction over past 6 months.28Exclusion Criteria1. History of lower limb injury , surgery or anyimplant282. All contraindications to EMG3. Anyvisibledeformityoftheupperlimb/lowerlimb4. Obesity5. Athletes6. A diagnosed case of any musculoskeletal/neurological/ psychological/ cardio-pulmonarydisorder and psychiatric diseaseInstrumentation1. Neurotrac EMG machine2. Weighing machine3. Measuring tape4. Football5. Barbell6. Ice pack23. Manish--116-120.pmd 2/7/2013, 8:08 PM117
  • 124. 118 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1VariablesDependent Variable1. Peak value of EMG amplitude2. Graphic pain rating scale(GPRS)33Independent Variable1. Height2. WeightPROCEDURE80 subjects volunteered for the study, out of which61 subjects were fulfilling the inclusion criteria and 19were excluded. The subjects who were fulfilling theinclusion criteria were explained about the topic of theresearch and its advantages and disadvantages. Afterclearing their doubts regarding the study, a writtenconsent was obtained from them.The subjects were asked to kick a ball to check forleg dominancy29and their body weight and height wasmeasured for calculating the body mass index. Thedominant leg was then prepared for the recording ofthe EMG. The skin was carefully prepared by rubbingwith abrasive gel and alcohol. All standard precautionsweretakenbeforerecordingEMGactivityofthemuscle.The EMG activity of Vastus Medialis Obliqus (VMO),and Rectus Femoris (RF) (both parts of QUADRICEPS)was recorded with surface electrodes (5mm disk self-adhesive electrodes) placed approximately in parallelwith the muscle fibers over the muscle bellies, based ona modification of standard proposed by Zipp30. Thedistances and angles were measured for optimalelectrode placement.31The subjects were asked to perform a single 2secdown and a 2sec up squat while the EMG was recordedsimultaneously. After this the subjects were requestedto perform squat exercises, specifically chosen to inducefatigue in the knee extensors (quadriceps) (WilliamRetailer et al). An intermittent exercise protocol(NavragB. Singh et al)32was used and subjects were requestedto start in an upright position with feet shoulder-widthapart and with weights (approx. 40% body weight)carried on a barbell over the shoulders, squat down toapproximately 90° knee flexion, and return to their startposition. Each set of squat exercises consisted of eightrepetitions and a 30 s rest period was provided betweensets. Each subject performed a minimum of 11 sets ofsquat exercises with the final set including continuoussquats as long as participants could complete an entirerepetition. The exercises were terminated when subjectsindicated that they were unable to perform the exercisefurtherThe subjects were then required to fill up GraphicPain Rating Scale33after 8hrs of the exercise session toassess for the induction of DOMS. Those in whichDOMS were established were again asked to perform a2sec down and 2sec up squat and the EMG wasrecorded. After recording the subjects were given icepacks and were advised to take ice packs at home twicedaily for next five days for the treatment of the musclesoreness.Thesubjectswerespecificallynotallowedtoperformany vigorous physical activities or quadriceps musclestretching or any form of treatment for muscle sorenessduring the entire experimental period34.RESULTThe Mean, standard deviation and two tailed PairedT-test values were obtained with the help of SPSSsoftware (version16)The mean value of peak EMG amplitude of RectusFemoris (RF) pre exercise is 508.69mV (microvolt) andpost exercise induced muscle soreness is 686.60 mVwhereas for Vastus Medialis Obliqus (VMO) it cameout to be as 379.81 mV pre exercise and 472.70 mV postexercise induced muscle soreness.The two tailed p value for RF pre and post is 0.000and for VMO pre and post was 0.034. (Table 1&2)The mean percentage for RF pre is 43% and post is57% (Graph.1)The mean percentage for VMO pre is 45% and postis 55% (Graph.2)Graph-1 Mean percentage of EMG of RF23. Manish--116-120.pmd 2/7/2013, 8:08 PM118
  • 125. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 119Graph-2Mean & standard deviation of RF CONCLUSIONThe p value for pre n post exercise induced musclesoreness EMG recordings is less than 0.05 for both RF& VMO, which by conventional criteria is consideredto be extremely statistically significant. Thus theexperimental hypothesis for the study holds true i.e;there is significant change in the peak EMG amplitudeof the muscle post exercise induced muscle soreness.The percentage increase in peak EMG activity of RFis 14 %( Graph.1)The percentage increase in peak EMG activity ofVMO is 10 %( Graph.3)A reduction in force output by an injured partof a muscle may lead to compensatory recruitment froman uninjured area of a muscle, or from other muscles35.This leads to a marked increase in EMG activity(hyperactivity), altered EMG ratios and increased forceproduction of the compensating muscles.FUTURERESEARCH1. The EMG of the non-dominant leg can be recordedafter post exercise induced muscle soreness2. A comparison can be carried out by recording theEMG activity at the origin and insertion of themuscle.3. The same study can be carried on females.REFERENCES1. Isabell,W.E.,E.Durrant,W.Myrer,andS.Anderson.1992. The effects of ice massage, ice massage withexercise, and exercise on the prevention andtreatment of delayed onset muscle soreness. J AthlTrain. 27(3):208-217.2. Prentice, W.E. 2009. Arnheim’s Principles ofAthletic Training. 13th ed. Mcgraw-Hill, NewYork. 273pp.3. .Gulick, D.T., I.Kimura, M.Sitler, A.Paolone, andJ.Kelly. 1992. Various treatment techniques onsigns and symptoms of delayed onset musclesoreness. J Athl Train. 31(2):145-152.4. Kuligowski, L.A., S.M. Lephart, F.P. Giannantonio,and R.O. Blanc. 1998. Effect of whirlpool therapyon the signs and symptoms of delayed-onsetmuscle soreness. J Athl Train. 33(3):222-228.5. Armstrong RB. Mechanisms of exercise-induceddelayed-onset muscular soreness: a brief review.Med Sci Sports Exerc. 1984; 16:529-538.6. Clarkson PM, Nosaka K, Braun B. Muscle functionafter exercise-induced muscle damage and rapidadaptation. Med Sci Sports Exec. 1992; 24:512-520.Graph-3 Mean percentage of EMG of VMOGraph-4 Mean & standard deviation of VMOTable-1 p value for RF pre-postPaired DifferencesPre-post (RF) 95% ConfidenceInterval ofthe DifferenceLower Upper T Sig(2-tailed)-266.11 -89.69 -4.03 .000Table-2 p value for VMO pre-postPaired DifferencesPre-post (RF) 95% ConfidenceInterval ofthe DifferenceLower Upper T Sig(2-tailed)-178.57 -7.21222 -2.16 .03423. Manish--116-120.pmd 2/7/2013, 8:08 PM119
  • 126. 120 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 17. Armstrong RB, Ogilvie RW, Schwane JA. Eccentricexercise-induced injury to rat skeletal muscle. JAppl Physiol. 1983; 54:80-93.8. Friden J, Sjostrom M, Ekblom B. Myofibrillardamage following intense eccentric exercise inman. Int J Sports Med. 1983; 4:170-176.9. Kuipers H, Drukker J, Frederik PM, Geurten P, vanKranenburg G. Muscle degeneration after exercisein rats. Int J Sports Med. 1983; 4:45-51.10. Smith LL. Causes of delayed-onset musclesoreness and the impact on athletic performance:a review. J Appl Sport Sci Res. 1992; 6:135-141.11. ClarksonPM,TremblayI.Exercise-inducedmuscledamage, repair, and adaptation in humans. JApplPhysiol. 1988; 65:1-6.12. NosakaK,ClarksonPM.Effectofeccentricexerciseon plasma enzyme activities previously elevatedby eccentric exercise. Eur J Appl Physiol. 1994;69:492-497.13. Rodenburg JB, Steenbeek D, Schiereck P, Bar PR.Warm-up, stretching and massage diminishharmful effects of eccentric exercise. Int J SportsMed. 1994; 15:414-419.14. Saxton JM, Donnelly AE. Light concentric exerciseduring recovery from exercise-induced muscledamage. Int J Sports Med. 1995; 16:347-351.15. Smith LL. Acute inflammation: the underlyingmechanism in delayed onset muscle soreness?Med Sci Sports Exec. 1991; 23:542-551.16. Takahashi H, Kuno S, Miyamoto T, et al. Changesin magnetic resonance images in human skeletalmuscle after eccentric exercise. Eur J Appl Physiol.1994; 69:408-413.17. McCullyKK,FaulknerJA.Injurytoskeletalmusclefibers of mice following lengthening contractions.J Appl Physiol. 1985; 59: 119-126.18. Thompson HS, Scordilis SP. Ubiquitin changes inhuman biceps muscle following exercise-induceddamage. Biochem Biophys Res Commun. 1994;204:1 193-1198.19. U. Proske and D. L. Morgan. Muscle damage fromeccentric exercise: mechanism, mechanical signs,adaptation and clinical applications. Journal ofPhysiology (2001), 537.2, pp.333–34520. Newham, D.J., Jones, D.A. and Edwards, R.H.T.Large delayed plasma creatine kinase changesafter stepping exercise Muscle Nerve 1983, 6, 380-38521. New ham, D.J., Jones, D.A. and Clarkson, P.M.Repeated high-force eccentric exercise: effects onmuscle pain and damage J Appl Physiol 1987, 63,1381-138622. J Sports Med Phys Fitness. 1994 Sep; 34(3):203-16.Exercise-induced muscle pain, soreness, andcramps. Miles MP, Clarkson PM.23. Basmajian & deluca: A fundamental EMGtextbook. Definition Muscles Alive (2 - p. 1)24. DE LUCA, C.J. The use of surfaceelectromyography in biomechanics. J. Appl.Biomech. 13:135 – 163. 1997.25. Kieran O’Sullivan et al, The relationship betweenprevious hamstring injury and the concentricisokinetic knee muscle strength of Irish Gaelicfootballers, BMC Musculoskeletal Disorders 2008,9:30 doi:10.1186/1471-2474-9-3026. Heatherk.Vincen,PhD,KelleyM.Lamb,BS,Timi.Day, PT, Susan M. Tillman, PT, Kevin R.Vincent,MD, PhD, Steven Z. George, PT, PhD.Morbid Obesity is Associated with Fear ofMovement and Lower Quality of Life in PatientswithKneePain-Relateddiagnosis.Volume2,Issue8, August 2010, pg713-72227. Dawn T. Gulick, Michael Sitler, Albert Paolone,John D. Kelly. Journal ofAthletic Training Volume31 * Number 2 * June 199628. Michelle A. Cleary; Michael R. Sitler; Zebulon V.Kendrick.DehydrationandSymptomsofDelayed-Onset Muscle Soreness in Normothermic Men.Journal of Athletic Training 2006;41(1):36–4529. Cameron M, Adams R, Maher C: Motor controland strength as predictors of hamstring injury inelite players of Australian football. PhysicalTherapy in Sport 2003, 4:159-16630. ZIPP, P. Recommendations for the standardizationof lead position in surface electromyography. Eur.J. Appl. Physiol. 50:41–54, 1982.31. STENSDOTTER, A.-K., P. W. HODGES, R.MELLOR,G.SUNDELIN,andC.HA¨GER-ROSS.Quadriceps Activation in Closed and in OpenKinetic Chain Exercise. Med. Sci. Sports Exec., Vol.35, No. 12, pp. 2043–2047, 200332. Singh NB et al.philos transact A MATHphys.sci.2010 jun 13;368(1920)2783-98[PMID-20439273]33. CraigR.Denegar,PhD,ATCDavidH.Perrin,PhD,ATC,Effect of Transcutaneous Electrical NerveStimulation, Cold, and a Combination Treatmenton Pain, Decreased Range of Motion, and StrengthLoss Associated with Delayed Onset MuscleSoreness, Volume 27 * Number 3 * 1992 * Joumalof Athletic Training(pg no.200-206)34. Philippou, M. Maridaki, G. Bogdanis, A. HalapasAnd M. Koutsilieris [Department of ExperimentalPhysiology, Medical School, National andKapodistrian University of Athens, Goudi,Athens; Department of Sports Medicine andBiology of Physical Activity, Faculty of PhysicalEducation and Sport Science, National andKapodistrian University of Athens, Dafni,Greece](in vivo 23: 859-866 (2009)35. Edgerton VR, Wolf SL, Levendowski DJ, et al.Theoretical basis for patterning EMG amplitudesto assess muscle dysfunction. Med Sci Sports Exec1996; 28 (6): 744-5123. Manish--116-120.pmd 2/7/2013, 8:08 PM120
  • 127. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 121Effect of Pelvic Floor Muscle Strengthening Exercises inChronic Low Back PainManisha RathiAssociate Professor, Padmashree Dr. D. Y. Patil College of Physiotherapy, Pimpri, PuneABSTRACTLow back pain (LBP) is a condition of localized pain to the lumbar spine. The pelvic floor muscle (PFM)have an important role in proper muscular activation for lumbar stabilization and also in unloadingthe spine. It was hypothesized that PFM exercise could be of benefit for patients with chronic LBP.Afterethical approval, a randomized controlled trial was carried out on 30 females with chronic LBP. Patientswere randomly allocated into two groups: an experimental and a control group. The control group wasgiven conventional physiotherapy treatment including modality and exercises; and the experimentalgroup received PFM strengthening with conventional therapy for 5 times per week upto 4 weeks. Painintensity and functional disability by Oswestry Disability Index were measured before and afterintervention . In both groups pain and functional disability were significantly reduced followingtreatment (p < 0.01). Also the significant difference was found between the two groups (p > 0.05). Itseems that the PFM exercise combined with conventional treatment was effective over conventionaltreatment alone in females with chronic LBP.Keywords: Pelvic floor muscle, LBP.INTRODUCTIONLow back pain (LBP) is a condition of localized painto the lumbar spine with or without symptoms to thedistal extremities whose etiology is commonlyunknown. 1More than 80% of the population willexperience an episode of LBP at some time during theirlives. 2For most, the clinical course is benign, with 95%of those afflicted recovering within a few months ofonset.3Some,however,willnotrecoverandwilldevelopchronic LBP (ie, pain that lasts for 3 months or longer).Recurrences of LBP are also common, with thepercentage of subsequent LBP episodes ranging from20% to 44% within 1 year for working populations tolifetime recurrences of up to 85%. 4In the United Statesit is the most common cause of job-related disability, aleading contributor to missed work, and the secondmost common neurological ailment — only headacheis more common.Lower back pain may be classified by the durationof symptoms as acute (less than 4 weeks), sub acute (4–12 weeks), chronic (more than 12 weeks).6Causes oflower back pain are varied. Most cases are believed tobe due to a sprain or strain in the muscles and softtissues of the back.8Others may have pain from theirsacroiliac joint, where the spinal column attaches tothe pelvis, called sacroiliac joint dysfunction. Physicalcauses may include osteoarthritis, rheumatoid arthritis,degeneration of the discs between the vertebrae or aspinal disc herniation, a vertebral fracture (such as fromosteoporosis), or rarely, an infection or tumor. In thevast majority of cases, no noteworthy or serious causeis ever identified. If the pain resolves after a few weeks,intensive testing is not indicated.9It has been suggested that the overall mechanicalstability of the spinal column, especially in dynamicconditions and under heavy loads, is provided by thespinal column and the precisely coordinatedsurrounding muscles. 10The spinal stabilizing systemof the spine was primarily suggested by Panjabi (1992),consisting of three subsystems: the spinal columnproviding intrinsic stability; spinal muscles,surrounding the spinal column, providing dynamicstability; and the neural control unit evaluating anddetermining the requirements for stability andcoordinating the muscle response11,12. Under normalconditions, the three subsystems work in harmony andprovide the needed mechanical stability 13,14Among various documented risk factors for LBPsuch as smoking 15obesity 16, pregnancy 17, physicalactivity18,mentalhealth19,recentresearchdonebySmithet al. 2009 and Hodges et al., 2007 has focused on therelationship between LBP and respiratory disorders,24. Manisha Rath-121-125.pmd 2/7/2013, 8:08 PM121
  • 128. 122 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1incontinence and gastrointestinal problems from theAustralia.20A longitudinal study on women’s healthreported that women with pre-existing incontinence,gastrointestinal problems and breathing disorderswere more likely to develop LBP than women withoutsuch problems. 21This was considered to be a result ofchanges in control of the trunk muscles followinginvolvement with incontinence, respiratory andgastrointestinal problems. Changes in morphology andaltered postural activity of the trunk muscles includingmuscles of respiration and continence which providemechanical support to the spine and pelvis has beenshown to be related to the development and occurrenceof LBP (Hides et al., 2001, Cholewicki et al., 2005).Apart from the role of pelvic floor muscle (PFM) inpatients with urinary and faecal incontinence, the PFMhave also an important role in proper muscularactivation for lumbar stabilization and also inunloading the spine (Sapsford and Hodges, 2001,Sapsford et al., 2001). The pelvic floor forms the base ofthe abdominal cavity and during different tasks thatelevate intra-abdominal pressure, muscles mustcontract to maintain continence and contribute topressure increases (Gilpin et al., 1989). In a smallexperimental trial of healthy subjects, strong voluntaryabdominal muscle contraction caused PFM activity atthe same intensity as maximal PFM’s effort (Sapsfordand Hodges, 2001). Morkved et al. (2007) haveinvestigated the effect of group training duringpregnancy in prevention of lumbopelvic pain. Self-reportedsymptomsoflumbopelvicpain,sickleave,andfunctional status were measured on 301 healthynulliparous women who were randomly allocated intoa training group (148) or a control group (153). Thecontrol group received daily PFM training at home, andthe training group was given weekly group trainingover 12 weeks including aerobic exercises, PFM andadditional exercises, and information related topregnancy. They reported that at 36 weeks of gestationwomen in the training group were significantly lesslikely to report lumbopelvic pain and had significantlyhigher scores on functional status but there was nodifferenceinsickleaveduringpregnancy.However,theyconcluded that a 12-week specially designed trainingprogram during pregnancy was effective in preventinglumbopelvic pain in pregnancy.Sapsford et al. (2001) investigated the co-activationpattern of the pelvic floor and the abdominal musclesvia needle electromyography (EMG) for the abdominalsand surface EMG for the pelvic floor. They found thatthe abdominals contract in response to a pelvic floorcontraction command and that the pelvic floor contractsin response to both a “hollowing” and “bracing”abdominal command. The results from this researchsuggest that the pelvic floor can be facilitated by co-activating the abdominals and vice versa.However, very few published evidence was foundto assess the function of PFM in patients with LBP or toevaluate the effect of PFM exercises in the treatment ofsuch patients. The need to carry out this study was toinvestigate the effect of PFM exercise in the treatment ofpatients with chronic Low back pain specially infemales . As PFM has an important role in lumbar spinestability, and lumbar instability was suggested to beone of the causes for LBP, it was hypothesized that PFMexercise could be of benefit for patients with chronicLBP.MATERIALS AND METHODThis experimental study was carried out inPhysiotherapy OPD of Dr. D. Y. Patil College ofPhysiotherapy, Pune. Ethical approval was taken fromInstitutional Ethical Committee. 30 married femaleswith chronic low back pain fallowing in the age groupbetween 20 to 40 years were selected and divided byrandom allocation into two groups- group A with 15females and group B with 15 females. Pregnant females,females with any Urogenital Dysfunction like UVProlapsed, Pelvic Inflammatory disease, Nerve injuryto pelvic floor muscle, any pathology of spine, lowerlimb were excluded from the study. Informed consentwas obtained from all the females. Females from GroupAreceivedconventionalphysiotherapytreatmentwhichincluded Short wave diathermy or Interferentionaltherapy , Abdominals and back extensors strengtheningexercises,Stretchingexercisesalongwithcorestabilizers(Transverse abdominals and multifidus) for 5 timesper week upto 4 weeks.Females from Group B received conventionalphysiotherapy treatment as mentioned above alongwith pelvic floor muscle strengthening exercises for 5timesperweekupto4weeks.PelvicFloorstrengtheningexercises were given initially in supine position. Beforestarting, patients were instructed to evacuate theirbladder, relax as much as possible, not to hold breathingand concentrate only at pelvic floor muscles. Patientwas instructed to contract pelvic floor muscles, holdthe contraction for 5 seconds and then relaxation for 5seconds. She was further instructed to repeat thecontraction for 10 times. As the strength was increasing,contraction time was increased and relaxation time was24. 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  • 129. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 123reduced from time to time. All the pelvic floor exerciseswere repeated 3 times in a day(21).Pain was assessed by using Visual Analogue Scaleand Functional Disability was assessed by OswestryDisability Index on the 1stday of visit to thephysiotherapy department and at the end of 4 weeks.RESULTSGraph 1 :- Showing pre and post score of VAS ingroup A and Bwas 24.07 + 3 .24 . This difference showed significantimprovement in reduction in pain as p < 0.05 withCI at 95%.DISCUSSIONPresentstudyshowedtheeffectofpelvicfloormusclestrengthening exercises in chronic Low back ache. Thisstudy showed that PFM exercise combined withconventional physiotherapy treatment had asignificant effect over the conventional physiotherapyprogram alone in the treatment of patients with chronicLow back pain .A study done by Eliasson et al. (2008) concludedthat the prevalence of urinary incontinence and signsof PFM dysfunction were greatly increased in the LBPgroup compared with the reference group. It appearsthat LBP is a risk factor for urinary incontinence andassessment of PFM function may be of value whentreating patients with LBP. Evidence suggest that theexercise of the abdominal muscles may be beneficial inmaintaining PFM coordination, support, endurance,and strength. Hence these exercise has the potential tobe useful in the rehabilitation of persons withsymptoms of PFM dysfunction. A few studies bySapsford et al., 2001 and Neumann and Gill, 2002 havedemonstrated the synergy between abdominal musclesand PFM in healthy volunteers. EMG activity of PFMand abdominal muscles showed that during voluntaryactivity of PFM all abdominal muscles were activatedat different levels. The PFM seems to be an integral partof trunk and lumbopelvic stability in addition tocontributingcontinence.Astherearethestrongevidencesupports the co-contraction of PFM and abdominalmuscles, the results of the present study showed theconsistentresultthattheseco-contractionshaveaneffecton patients with chronic LBP and reducing disability.One of the functions of PFM is to unload the spine.Thestaticpressurecreatedbyarigidabdominalcylindercan act to support the upper part of the body andtherefore unload the spine. This involves abdominal,dorsal, diaphragmatic and PF muscles( Grillner et at1978). Studies also indicates that the co-activation ofall these muscle is an essential prerequisite fordeveloping appropriate IAP, thus supporting the spine.When strengthening of the PFM occurs, the load on thelumbar spine decreases. This may be the cause forreliving LBP in the present study.Sapsford et al 2001 suggested that recruitment ofabdominal muscles function in association withvoluntary contraction of PFM may be affected by spineGraph 2 :- Showing Pre and Post score of OswestryDisability Index in Group A and Group BThe Graph 1 showed that the mean difference inpain in patients who received PFM strengtheningexercises along with conventional therapy was3.8 + 0.96 whereas differences in pain at VAS in groupA was 2.867 + 0 .83 . This difference showed significantimprovement in reduction in pain as p < 0.05 withCI at 95%.The Graph 2 showed that the mean difference inODI in patients who received PFM strengtheningexercises along with conventional therapy was19.73 + 3.58 whereas differences in ODI in group A24. Manisha Rath-121-125.pmd 2/7/2013, 8:08 PM123
  • 130. 124 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1position. Placing the lumbar spine in flexion orextension would change the length-tension propertiesof the abdominal muscles and may have an influenceon their response to PFM contraction. As Sapsford et al.(2001) highlighted that increase in TransverseAbdominals activity with PFM activity wassignificantly greater compared with External Obliqueand Rectus Abdominal in lumbar extension. It wassuggested that a neutral or extended lumbar spinepositionispreferableforPFMexercise.Inaddition,thesefindings indicate that contraction of the PFM may beused to initiate contraction of the abdominal muscles.A RCTby Richardson et al., 1999 indicates that specifictraining of the Transverse Abdominals can assist withthemanagementofLBP.Theresultsoftheirinvestigationrevealed that this could be best achieved by contractionof the PFM with the spine positioned in either a neutralor extended position. In the present study patients wereinstructed to perform PFM exercise in supine position (Neutral Position). This can results in improvement inLBP by strengthening transverse abdominals.CONCLUSIONThis study showed significant improvement inchronic low back pain in females after giving pelvicfloor strengthening exercises with conventional therapythan the conventional therapy alone.LIMITATIONSObjective outcome measures such as muscle activityand muscle thickness using EMG or ultrasound wasnot done. Also the measurement of pain intensity andfunctional disability was done in subjective way in thepresent study.ACKNOWLEDGEMENTThe author acknowledges the Dr. D. Y. PatilVidyapeeth, Pimpri, Pune for financial support of thisstudy.Conflict of interestThe authors declare no conflict of interest.REFERENCES1. Rubin DI. Epidemiology and risk factors for spinepain. Neurol Clin. 2007;25(2): 353-371.2. Carey TS, Garrett J, Jackman A, McLaughlin C,Fryer J, Smucker DR. The out- comes and costs ofcare for acute low back pain among patients seenby primary care practitioners, chiropractors, andorthopedicsurgeons:theNorthCarolinaBackPainProject. N Engl J Med. 1995;333(14):913-917.3. van Tulder M, Koes B, Bombardier C. Low backpain. Best Pract Res Clin Rheumatol. 2002;16(5):761-775.4. Richardson C, Jull G, Hodges P, Hides J.Therapeutic exercise for spinal segmentalstabilization in low back pain. ChurchillLivingstone, Edinburgh; 1999.5. “Lower Back Pain Fact Sheet.”.. Retrieved2008-06-16.6. Bogduk M (2003). “Management of chronic lowback pain”. Medical Journal of Australia 180 (2):79–83.7. Floyd, R., & Thompson, Clem. (2008). Manual ofstructural kinesiology. New York, NY: McGraw-Hill Humanities/Social Sciences/Languages.8. Atlas SJ (2010). “Nonpharmacological treatmentfor low back pain”. Journal of Musculoskeletal9. Eliasson K, Elfving B, Nordgren B, Mattsson E.Urinary incontinence in women with low backpain. Manual Therapy. June 2008;13(3):206-212.10. Panjabi MM. The stabilizing system of the spine.Part 1. Function, dysfunction, adaptation andenhancement. Journal of Spinal Disorders1992;5:383–9.11. Samuelsson EC, VictorAFT, Tibblin G, SvardsuddKF. Signs of genital prolapse in a Swedishpopulation of women 20 to 50 years of age andpossible related factors. American Journal ofObstetrics and Gynecology 1999;180:299–305.12. Bergmark A. Stability of the lumbar spine. A studyin mechanical engineering. Acta OrthopaedicaScandinavia Supplement. 1989;230:1–5413. Barr KP, Griggs M, Cadby T. Lumbar stabilization:core concepts and current literature, Part 1.American Journal of Physical Medicine andRehabilitation. 2005;84:473–48014. Mikkonen P, Leino-Arjas P, Remes J, Zitting P,Taimela S, Karppinen J. Is smoking a risk factorfor low back pain in adolescents? A prospectivecohort study. Spine. 2008;33:527–53215. Mirtz TA, Greene L. Is obesity a risk factor for lowback pain? An example of using the evidence toanswer a clinical question. Chiropractic andOsteopathy. 2005;13:216. Mohseni-Bandpei M, Fakhri M, Ahmad-Shirvani M, Bagheri Nessami M, Khalilian A,Shayesteh-Azar M, et al. Low back pain in 110024. Manisha Rath-121-125.pmd 2/7/2013, 8:08 PM124
  • 131. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 125Iranian pregnant women: prevalence and riskfactors. Spine Journal. 2009;9:795–80117. Hartvigsen J, Christensen K. Active lifestyleprotects against incident low back pain in seniors:a population based 2-year prospective study of1387 Danish twins aged 70–100 years. Spine.2007;32:76–8118. Strine TW, Hootman JM. US national prevalenceand correlates of low back and neck pain amongadults. Arthritis and Rheumatism. 2007;57:656–66519. Smith MD, Russell A, Hodges PW. Doincontinence, breathing difficulties, andgastrointestinal symptoms increase the risk offuture back pain?. The Journal of Pain.2009;10:876–88620. Hodges PW, Sapsford R, Pengel L. Feedforwardactivity of the pelvic floor muscles precedes rapidupperlimbmovements.AustralianPhysiotherapyAssociation Conference, Sydney; 2002,21. J Laycock , D. Jerwood (2001) Pelvic Floor muscleassessment: The PERFECT Scheme,Physiotherapy December 2001, volume 87, no. 1224. Manisha Rath-121-125.pmd 2/7/2013, 8:08 PM125
  • 132. 126 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Comparing Hold Relax - Proprioceptive NeuromuscularFacilitation and Static Stretching Techniques inManagement of Hamstring TightnessAli Ghanbari1, Maryam Ebrahimian2, Marzieh Mohamadi3, Alireza Najjar-Hasanpour41Rehabilitation School, Shiraz University of Medical Sciences, Iran, 2Rehabilitation School, Shiraz University of MedicalSciences, Iran, 3Rehabilitation School, Shiraz University of Medical Sciences, Iran, 4Student Research Committee,Rehabilitation School, Shiraz University of Medical Sciences, IranABSTRACTIntroduction: Hamstring tightness may result in several conditions of the knee and spine such asanterior knee pain and low back pain. Stretching is a preventive and therapeutic technique in thesesituations. The aim of this study is to compare the effectiveness of static stretching and hold-relax PNFon increasing the extensibility of hamstring muscles.Method & material: 51 male subjects in the age range of 18 to 30 entered to the study and randomlyassigned to one of the three groups of static stretching, hold-relax PNF and control. The extensibility ofhamstring was assessed byActive Knee Extension Test (AKET). The treatments in both static stretchingand PNF groups were applied for six sessions during the study.Findings: At the end of the treatment period, we found a significant difference in hamstring extensibilityamong the study groups. Hamstring extensibility was significantly larger in both treatment groupscompared to the control group (p<0.001). Moreover, the subjects in PNF group showed significantlygreater hamstring extensibility compared with the static-stretch group (p=0.015).Conclusion: The present study suggests that hold relax - PNF is more effective than static stretching inincreasing the hamstring extensibility. Therefore, application of this technique and education of thatmay be more useful for either patients with hamstring contracture or athletes.Keywords: Hamstring Extensibility, Static Stretching, Proprioceptive Neuromuscular Facilitation (PNF), HoldRelaxCorresponding author:Marzieh MohamadiRehabilitation School of Shiraz University of MedicalSciences, Abiverdi Street, Chamran Boulevard,Shiraz, Iran.Email: mohamadipt@yahoo.comPhone No.: 987116271551, Fax: 98711627249INTRODUCTIONThe two-joint hamstring muscle group is the kneeflexor and hip extensor. The complete range of kneeflexion rarely occurs in activity daily living; thereforethe complete contraction and stretching of this musclegroup is rare. In this type of muscles, failure may beoccur under rapid and stressful situations(1).Hamstring tightness may result in severalconditions of the knee and spine. The Resultant flexionmoment following hamstring tightness may causeanterior knee pain owing to excessive patellofemoralforces(1-2). Furthermore, decrement in rang of kneeextension may result in plantar fasciitis due toabnormal loading on forefoot(3). In patients withhamstring tightness, anterior pelvic tilt is decreasedduring trunk forward bending(4); therefore mobility inlumbar vertebrae would be increased(4), and lead to lowback pain(4-6). Because of these problems, it is importantto consider the length of the hamstring muscle group.Stretching is a preventive and therapeutictechnique(7-8)which is applied musculotendinousstructures in order to change their length, improve jointrangeofmotion,reducestiffness,improveperformance,decrease risk of injuries, improve posture and promoterelaxation(8-10). There are different types of stretching25. marzeih iran-126-130.pmd 2/7/2013, 8:08 PM126
  • 133. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 127techniques including static, active, passive,proprioceptive neuromuscular facilitation (PNF) andballistic(7, 10-11). Static stretching is the most common formof stretching technique because of its safety,effectiveness and easy performance(10). PNF stretchinginvolves active muscle contraction and neuromuscularreflexes which decrease the resistance againststretching(10, 12).In spite of many research studies performed on theissue of stretching, there are still disagreements aboutthe most effective and safe method, intensity, durationand frequency of stretching(10, 13). Several studies havefocused on comparing the different methods ofstretching. Some of these studies have found that PNFstretching and static stretching were equally effectivein improvement of muscle extensibility(7, 13-14). Othershave shown that PNF is more effective than staticstretching(9, 15). On the contrary, Davis et al reported thatstatic stretching is more effective(16).The controversy around this issue was a motive forconducting the present study. One limitation of theprevious studies, comparing the different techniquesof stretching, was that the intervention was appliedonly for one Session. In this study, we aimed to comparethe effectiveness of several sessions of static stretchingand hold-relax PNF on increasing the extensibility ofhamstring muscles.MATERIAL & METHODSubjectsWe recruited a convenience sample of 51 malesubjects in the age range of 18 to 30, who were thestudents of a local university. Exclusion criteria weremusculoskeletal or neuromuscular disorders, a historyof fracture or dislocation in lower extremity and activeparticipation in sports or exercise activities thatrequired regular hamstring stretching. We definedactive participants as those who were involved inregular exercise activities in at least 2 sessions during aweek.PROCEDUREAfter signing a consent form, the subjects wererandomly assigned to one of the three groups of staticstretching,hold-relaxPNFandcontrol.Atthebeginningof the first session, the extensibility of hamstring wasassessed for every participant. We used Active KneeExtension Test (AKET) for this purpose. The subject liedin supine position with his hip and knee in 90 degreeflexion and ankle in plantar flexion. Then, he was askedto extend his knee as far as he could and in this position,popliteal angle was measured by a goniometer. Tomeasurethisangle,along-armgoniometerwasutilized.One arm was located on the line connected the greatertrochanter and the lateral femoral condyle.The otherarm was along the line from the lateral malleolus to thelateral condyle of tibia.After the initial measurement, the subjects in eitherof the two intervention groups (i.e. static stretching andPNF groups) received the treatments as following:Static stretching groupThe subject was supine with his hip in 90 degree offlexion. Therapist passively extended the subject’s kneeup to a point where the subject reported a mild tomoderate stretching sensation without any pain. Thetherapist held this position for 30 seconds and thenrepeated the procedure three times with 10 seconds restbetween successive stretches.PNF groupThe subject was supine with his hip in 90 degree offlexion. The Therapist extended the subject’s knee untilthe subject felt a very mild stretching sensation in hishamstringmuscles.Then,thetherapistaskedthesubjectto flex his knee against the resistance applied by thetherapist’s hand. The subject was asked to use a forcearound 50% of his maximal strength. No movementwas allowed to occur in the knee joint so that anisometric form of contraction was gained in hamstringmuscles. The subject holds the contraction for 8 secondsand then, on the command of the therapist relaxed thehamstrings muscle. Immediately after the musclerelaxation the therapist stretched the hamstring musclesup to a point where the subject reported a mild tomoderate stretching sensation without any pain andhold this position for 30 seconds. The therapist repeatedthis procedure three times in every session.The treatments in both static stretching and PNFgroups were applied for three sessions in one week withone day rest between two sessions. The treatmentscontinued for two successive weeks, and thus everysubjectreceived6sessionsoftreatmentduringthestudy.At the end of the last session, the popliteal angle wasmeasured again in the similar way as that of the firstsession.25. marzeih iran-126-130.pmd 2/7/2013, 8:08 PM127
  • 134. 128 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1The subjects in the control group received notreatment during a two weeks period. At the end of thesecond week, the therapist measured the popliteal anglesimilar to what he did for the other two groups.Statistical analysisDue to non-normal distributions of the study data,we used Kruskal-wallis test with Bonferroni correctionto compare the hamstring extensibility among the threestudy groups.FINDINGSThe mean age of the subjects and the mean angle ofknee extension at the baseline of the study werecompared by Kruskal-wallis andANOVAtests (Table1).There were no significant differences between the threegroupsinthisregard.Attheendofthetreatmentperiod,we found a significant difference in the angle of kneeextension among the study groups (Table2).Apost hoctestusingMann-WhitneytestwithBonferronicorrectionshowed significant differences in pair wisecomparisons of the study groups. Since there were threepairs of comparison, the alpha level was set on 0.0167(á level =.05/3= .0167). The angle of knee extensionwas significantly larger in both treatment groupscompared to the control group (p<0.001). Moreover, thesubjects in PNF group showed significantly greaterangle compared with the static-stretch group (p=0.015).Muscle, fascia, capsule and tendon are the primarylimiting factors of joint movement. Therefore, it isnecessary to consider the muscle spindle and Golgitendon organ in the ability of muscles to lengthen inresponse to stretch, as well as the passive structures.PNF stretching techniques focus on active componentsand static stretching address the passive componentswhich limit the range of motion(17).Instaticstretching,theinversemyotaticreflexresultsin muscle relaxation and further stretch and range ofmotion. In hold relax – PNF, the neural inhibitionreduces reflex activity(13). An inhibitory interneuronreduces á-motoneuron activity of antagonist muscle(8)which results in muscle relaxation and decreasedresistance to stretch(13).Our study found that hold relax – PNF was moreeffective in increasing hamstring extensibility. Theprevious studies on this issue, have found no differencebetween these two methods of stretching(7). Thediscrepancy between our study and the previous onescould be explained by several issues. The subjects onour study were relatively young (i.e. 18-30), comparedto the Feland’s study which were on 55 to 79 years oldpeople. Feland et al, has stated that PNF stretching intheyoungerpatientsismoreeffectivethaninolderones.This is due to the age-related neurophysiologic andmusculoskeletal changes such as motor neuron deathand increased collagen of the skeletal muscle, in olderpeople(13). In the O’Hora’s study that was on 21 to 35years old people, the results was similar to our study(15).Another explanation for the disagreement betweenthis and the previous studies, could be that weperformed the intervention techniques in severalsessions, while, other studies used the techniques inonly one session(7-8, 13, 15). Probably, the effects of thestretching techniques have been accumulated duringthe six sessions of our study. We may propose that, ifthere is a real difference between the two techniques ofstretching, one session of treatment might not beenough in detecting that small difference. When thetreatment effects are accumulated during severalsessions, then, the difference between the twotechniques get larger and hence statistically significant.The superiority of PNF technique on static stretchingobserved in our study may be due to the different effectsof these techniques on the blood flow of muscles(11, 18).The resultant muscle relaxation following PNFtechniques can cause changes in blood flow. PNFtechnique increase motor activity that can affectvascular function. The muscle activation may increaseTable1: The mean age of the subjects and the meanangle of knee extension at the baseline of the study.Group PNF Static stretch control P.Valuenumber 17 17 17Age 23.59±2.26 22.71±2.56 22.06±1.29 0.117Angle ofknee extension 150.29±6.98 147.47±8.69 152.18±8.08 0.231DISCUSSIONThis study showed significant increases in thehamstring extensibility in both static stretching andhold relax – PNF technique groups in comparison withthe control group.Table2: The comparison of the angle of knee extensionafter treatment among the study groupsGroup Mean Median P.Valuedifference differencePNF 4.59±1.94 5 <0.001Static stretch 3±1.22 3control 0±0.5 025. marzeih iran-126-130.pmd 2/7/2013, 8:08 PM128
  • 135. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 129the release of vasoactive substances which results invascular dilation(18). On the other hand, the muscleextension due to static stretching decreases muscleblood flow(11, 19)because of two physical changes: 1)longitudinal extension of blood vessels with the muscleextension and 2) the increase of intramuscular pressureduring the stretching(19). Hyperactivity or hyperemiacan affects the muscular temperature(20). During theexercise, muscle temperature increase from 35 to 40degrees due to elevation in plasma ATP. The increasedtemperature of collagen will increase tissue elasticity(21).CONCLUSIONThe present study suggests that hold relax – PNF ismore effective than static stretching in increasing thehamstring extensibility. Therefore, application of thistechnique and education of that may be more useful foreither patients with hamstring contracture or athletes.ACKNOWLEDGEMENTThis work was based on the dissertation of theAlireza Najar Hasanpour at Shiraz University ofMedical Sciences (SUMS), faculty of rehabilitationsciences. The authors are thankful to Miss YasamanKhademolhoseini and the Rehabilitation ResearchCenter staff. Financial support from the SUMS 88-4649grant made this research possible.Conflict of InterestTheauthorsdeclarethatthereisnoconflictofinterestREFERENCES1. Morgan-Jones R, Cross T, Cross M. Hamstringinjuries. Critical Reviews in Physical andRehabilitation Medicine. 2000;12(4):277-82.2. Piva SR, Goodnite EA, Childs JD. Strength aroundthe hip and flexibility of soft tissues in individualswith and without patellofemoral pain syndrome.J Orthop Sports Phys Ther. 2005;35(12):793-801.3. Harty J, Soffe K, O’Toole G, Stephens MM, editors.The role of hamstring tightness in plantarfasciitis2004: JBJS (Br).4. Norris CM. Back stability: integrating science andtherapy: Human Kinetics Publishers; 2008.5. McGill S. Low back disorders: evidence-basedprevention and rehabilitation: Human KineticsPublishers; 2007.6. Hoskins WT, Pollard HP. Successful managementof hamstring injuries in Australian Rulesfootballers: two case reports. Chiropr Osteopat.2005;13(1):4.7. Puentedura EJ, Huijbregts PA, Celeste S, EdwardsD, In A, Landers MR, et al. Immediate effects ofquantified hamstring stretching: Hold-relaxproprioceptive neuromuscular facilitation versusstatic stretching. Physical Therapy in Sport. 2011.8. Schuback B, Hooper J, Salisbury L. A comparisonof a self-stretch incorporating proprioceptiveneuromuscular facilitation components and atherapist-applied PNF-technique on hamstringflexibility. Physiotherapy. 2004;90(3):151-7.9. Rashad AK, El-Agamy MI. Comparing TwoDifferent Methods of Stretching on ImprovementRange of Motion and Muscular Strength Rates.World. 2010;3(4):309-15.10. Armiger P. Stretching for Functional Flexibility:Wolters Kluwer Health/Lippincott, Williams, &Wilkins; 2010.11. Gremion G. The effect of stretching on sportsperformance and the risk of sports injury: a reviewof the literature. Schweiz Z Med Traumatol.2005;53(1):6-10.12. Colby LA, Kisner C. Therapeutic Exercise:Foundations and Techniques. FA Davis; 2007.13. Feland JB, Myrer J, Merrill R. Acute changes inhamstring flexibility: PNF versus static stretch insenior athletes* 1,* 2,* 3,* 4. Physical Therapy inSport. 2001;2(4):186-93.14. YuktasirB,KayaF.Investigationintothelong-termeffects of static and PNF stretching exercises onrange of motion and jump performance. Journalof Bodywork and movement therapies.2009;13(1):11-21.15. O’Hora J, Cartwright A, Wade CD, Hough AD,Shum GLK. Efficacy of Static Stretching andProprioceptive Neuromuscular FacilitationStretch on Hamstrings Length After a SingleSession. The Journal of Strength & ConditioningResearch. 2011;25(6):1586.16. Davis DS, Ashby PE, McCale KL, McQuain JA,Wine JM. The Effectiveness of 3StretchingTechniques on Hamstring Flexibility UsingConsistent Stretching Parameters. The Journal ofStrength & Conditioning Research. 2005;19(1):27-32.17. Weng M-C, Lee C-L, Chen C-H, Hsu J-J, Lee W-D,Huang M-H, et al. Effects of Different StretchingTechniques on the Outcomes of Isokinetic Exercisein Patients with Knee Osteoarthritis. TheKaohsiung Journal of Medical Sciences. [doi:10.1016/S1607-551X(09)70521-2]. 2009;25(6):306-315.25. marzeih iran-126-130.pmd 2/7/2013, 8:08 PM129
  • 136. 130 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 118. Escobar-Hurtado C, Ramírez-Vélez R.Proprioceptive neuromuscular facilitation (PNF)and its impact on vascular function. ColombiaMédica. 2011;42(3):373-378.19. Otsuki A, Fujita E, Ikegawa S, Kuno-MizumuraM. Muscle Oxygenation and Fascicle LengthDuring Passive Muscle Stretching in Ballet-Trained Subjects. International journal of sportsmedicine. 2011;32(07):496-502.20. Barão VAR, Gallo AKG, Zuim PRJ, Garcia AR,Assunção WG. Effect of occlusal splint treatmenton the temperature of different muscles in patientswith TMD. Journal of Prosthodontic Research.2011;55(1):19-23.21. Lounsberry NL. Therapeutic Heat: Effects ofSuperficial and Deep Heating Modalities onHamstring Flexibility the osprey journal of ideas& inquiry. 2008 All Volumes (2001-2008): 138.25. marzeih iran-126-130.pmd 2/7/2013, 8:08 PM130
  • 137. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 131Reliability and Feasibility of Community Balance andMobility Scale (CB&MS) in Elderly PopulationNagaRaju1, Arun Maiya2, Manikandan31MPT, Department of Physiotherapy, Manipal College of Allied Health Sciences, Manipal, Karnataka,2Associate Dean and Head of Physiotherapy Department, Manipal College of Allied Health Sciences,Manipal, Karnataka, 3Associate Professor, Department of Physiotherapy, Manipal College of Allied Health Sciences,Manipal, KarnatakaABSTRACTThe objective was to determine the reliability and feasibility of Community Balance and Mobility Scale(CB&MS) as a screening instrument for identifying balance dysfunction in elderly population in anIndian situation. An observational study was conducted in community and old age homes residingelderly population, involving 33 elderly individuals aged 60 years and above, selected by conveniencesamplingmethod.CB&MSandComputerizedStaticPosturographymeasureswereusedforassessment.Intraclass Correlation Coefficient and spearmans correlation coefficient were used for analysis. Resultsshowed high test-retest reliability (0.985) but no correlation with velocity moment measure ofComputerized Static Posturography. Our findings demonstrated that CB&MS is reliable and feasibleand hence could be applicable in the community for assessing balance and mobility of young oldelderly population.Keywords: Test -Retest Reliability, Balance, Challenging Tasks, Community Setting.INTRODUCTIONAgeing, in its broadest sense is the continuous andirreversible decline in the efficiency of variousphysiological processes2.The average life expectancyis around 60 years now and the way health care facilitiesare expanding with better income levels and access tomedicare, the life expectancy may rise between 70 and75 by 20208.India had the second largest number ofelderly (60+) in the world.The size of India’s elderlypopulation aged 60 and above is expected to increasefrom77millionin2001to179millionin2031andfurtherto 301 million in 2051. The proportion is likely to reach12 per cent in 2031 and 17 per cent in 2051 17.A decline in all the major systems for example,cardiovascular, metabolic, respiratory, andneuromuscular contributes to weakness, fatigue, andslowing of movement that have been the hallmarks ofaging14.Older adults have impaired balance recovery due toan age-related decline in the ability to rapidly andefficiently contract the muscles of the lower extremities.These physiologic changes of normal aging mayincrease the risk of falls13.This led to increase in thenumber of older persons with disability9.Among community-dwelling older people over 64years of age, 28-35% fall each year. Of those who are 70years and older, approximately 32%-42% fall each year.Older people who are living in nursing homes fall moreoften than those who are living in the community.Approximately 30-50% of people living in long termcare institutions fall each year, and 40% of themexperienced recurrent falls20. Balance disturbancesfrequently cause elderly people to seek medical adviceand admission to hospitals and residential homes3.Although a number of procedures have beendescribed to assess balance, many of these techniquespresent difficulty in application due to cost, subjectivity,specificity of assessment or other problems6. In spite oflaboratory measures of balance offer greater precisionand potential to detect subtle or sub clinical balanceimpairments, Clinical and Functional tests of balance(static and dynamic) share the advantages of ease ofadministration, low cost and more directly interpretablefunctional relevance16.Computerized Posturography is the gold standardtool to evaluate postural sway and quantify balance. Itis simple and efficient tool and offers technology for theobjective assessment and comprehensivedocumentation of postural control7. Amplitude and26. Naga Raju--131-135.pmd 2/7/2013, 8:08 PM131
  • 138. 132 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1velocity of anterior-posterior and medial-lateral swayduring standing in different positions are measuredusing Posturography. The general census is thatcomputerized measures have a greater precision andpotential to detect sub clinical balance impairments1.RoleofPosturographyinelderlypopulationtodetectbalance impairments has gained importance in therecent years. However the balance measures wereassessed in clinical set up where the elderly individualdoes not encounter barriers that challenge his balanceabilities. This necessitates the assessment of balance incommunity environment.CB&MS is a tool used to measure balance andmobility of individual in the community setting. Thescale has been used and found to be valid and reliablein high functioning patients with traumatic braininjury10. This scale has not been tested for its usefulnessin Indian elderly population and no literature isavailable to correlate this scale with the postural swaymeasures of Posturography. Our study aims to find thereliability and feasibility of CB&MS and its correlationwith postural sway measures using StaticPosturography.MATERIAL AND METHODAn observational study with convenience samplingmethodwasconductedatdepartmentofPhysiotherapy,MCOAHS, Manipal, India. The sample size for thestudy was estimated from the previous existing study,consisted of 33 (20 males and 13 females) elderlypersons aged above 60 years and were able tounderstand and follow commands. Subjects who hadacute illness on the day of assessment, foot ulcers, acutelabyrinthine disorders, functional hearing & visualdeficits, cognitive impairments and non-cooperativeparticipants were excluded from the study.PROCEDUREThe study protocol was presented and approvalwas obtained to conduct the study by the ethicalcommittee of Manipal University. Elderly subjects inthe age group of 60 years and above were identifiedfrom the community and old age homes after whichthey were screened for inclusion and exclusion criteria.The selected subjects were explained about the studyand informed consent was obtained for theirparticipation. The subjects were assessed for thefollowing measures as explained below.Community Balance and Mobility Scale (CB&MS)An 8 meter track with duct tape was made which isof 5cm width on the floor with a perpendicular startline and finish line. Markings done at 1m, 2m, 4m and6m with a tape perpendicularly. A 40cm bare spot wasplaced for item 3 and 4 after 6m mark. The visual targetfor items 8 and 11 was placed at the 4m mark, atindividual’s eye level and 1m from the outside edge ofthe track. Individuals were advised to wear comfortableclothes. All items (total 13) were scored in the first trailafter explaining each one task and ensuring rest periodsin between tasks as required.The set up resembles asInitial evaluation using CB&MS was done andrevaluation was done after a period of one week fordetermining the test –retest reliability.Postural sway amplitude and velocityAfter measuring the height, weight and age, subjectswere instructed to stand with normal base of supporton the force platform of Posturography machine witharms folded in front of chest. Subjects were instructedto stand relaxed on force platform, bare foot, with thehead in a straight head position. They were asked tofocus on specific point (2 m distance) at their eye levelduring eyes open conditions and the timer is started.After 30 seconds, the timer is stopped and the subject isrested for two minutes.The same procedure is repeated with subjectstanding with normal base- eye closed for 30 seconds,tandem stance –the heel of one foot touches great toe ofother foot, the foot position according to convenience ofpatient (eyes open and eyes closed) and both right andleft single leg stance while opposite leg flexed at kneefor 20 seconds. Two minutes of rest was given inbetween each position. The subjects who did not standfor 30 seconds in normal stance eyes open and eyesclosed and 20 seconds in remaining testing positionseven after two trials, the test is stopped and noted downas unable to test. After all the testing positions weredone, velocity moment noted down from the computer.These readings were used to correlate with CB&MS andTinetti POMA balance subscale measures.Data analysisData was analyzed using SPSS version 16.Test retestreliability of CB&MS was analyzed using IntraclassCorrelation Coefficient. Concurrent validity of CB&MSwith posturography measure (Velocity Moment) was26. Naga Raju--131-135.pmd 2/7/2013, 8:08 PM132
  • 139. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 133analyzed using Spearman’s correlation coefficient. Thelevel of significance was kept at P value less than orequal to 0.05.RESULTSDescriptive statistic on the anthropometrics data,balance subscale of Tinetti POMA and CB&MS totalscores of the study subjects is shown in table 1.Table 1: Demographic characteristics, median CB&MSand POMA scores of elderly subjects (n=33)Variables Male FemaleGender 20 13Age in years (Mean + SD) 66.25+7.25 68.00+5.68Height in cms (Mean + SD) 164.58+ 5.44 149.89+ 4.32Weight in kgs (Mean + SD) 60.03+ 11.61 51.07+7.26CB&MS score(Median , IQR) 50.50 (43.25+57.00) 40.00 (34.50+46.00)Balance subscaleof Tinetti POMA 16(16+16) 16(16+16)Above table suggests that study group populationconsist predominately males, scored higher in CB&MSthan females. It also shows all the all subjects scoredfull on the balance subscale of Tinetti POMA.Phase1: Test-retest reliability of CB&MSTable 2: Intra-class correlation coefficient (ICC) valuesfor test –retest CB&MS in elderly subjects (n=33).Item No Item name ICC valueI Unilateral stance right 0.871Unilateral stance left 0.910II Tandem walking 0.994III 1800Tandem pivot 0.960IV Lateral foot scooting :Right 0.981Lateral foot scooting :Left 0.953V Hopping forward: Right 0.976Hopping forward: Left 0.960VI Crouch and walk 0.959VII Lateral dodging 0.934VIII Walking& looking :Right 0.939Walking& looking :Left 0.969IX Running and controlled stop 0.860X Forward to back ward walking 0.944XI Walk ,look & carry: Right 0.983Walk ,look & carry: Left 0.981XII Descending stairs 0.889XIII Step ups × 1 step: Right 1.000Step ups × 1 step: Left 0.973Total 0.985scoreAbove table shows high test-retest reliability of bothtotal score and individual items.Phase 2: Correlation of CB&MS total score withposturography velocity moment in different positionsTable 3: Correlation of CB&MS total score withposturography velocity moment in different positionsPosturography Correlation p valueconditions withCB&MSr valueNormal stance eyes open(NSEO) 0.078 0.672Normal stance eyes closed(NSEC) -0.033 0.859Tandem stance eyes open(TSEO) -0.092 0.617Tandem stance eyes closed(TSEC) 0.307 0.087Single leg stance Rt eyes open(SL rt EO) 0.556 0.001Single leg stance Lt eyes open(SL lt EO) 0.049 0.791Single led stance Rt eyes closed(SL rt EC) 0.308 0.086Above table displays significant low positivecorrelation of CB&MS total score with posturographysingle leg stance right side in eyes open condition. Inaddition to that it also shows negative correlation withnormal stance eyes closed and tandem stance eyes openbut not statistically significant.Table 4: Correlation of individual items of CB&MSwith posturography velocity momentItem Item Posturography r value P valueNo name conditionsI Unilateral stance (Left) SL lt EO 0.406 0.021III 180 Tandem pivot SL rt EO 0.500 0.004IV Lateral foot scooting (Left ) SL rt EO 0.542 0.001V Hopping forward NSEC -0.423 0.016SL rt EO 0387 0.029VI Crouch and walk SL rt EO 0.492 0.004IX Running with controlled stop SL rt EO 0.389 0.028Table shows significant positive correlation ofindividual item of CB&MS with posturography velocitymoment except hopping forward with normal stanceeyes closed showed negative correlation.DISCUSSIONThe study participants were young-old with fullscore in Tinetti POMAbalance subscale, which impliesparticipants were highly functional. Males scoredsignificantly higher in CB&MS than females.Our phase 1 results showed high test-retestreliability of CB&MS in elderly subjects suggesting thatit could be a reliable tool to assess balance and mobilityfunction in them. CB&MS is simple and feasible test as26. Naga Raju--131-135.pmd 2/7/2013, 8:08 PM133
  • 140. 134 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1it does not require any special equipment to beperformed in the community setting. Uneven surfacesin community could be utilized since people wouldhave accommodated to that specific environment. Thisalso leads to evaluation in actual real life setting insteadofclinicalsetting.Allsubjectscompletedthetestwithoutany adverse events and hence it is safe to be used inyoung old elderly population.CB&MS has items which represents the underlyingmotor skills necessary for function within thecommunity. For example Single leg stance is necessaryduring stance phase of gait cycle and for publictransportation.,etc.In spite of being healthy elders, subjects could notattain full score in CB&MS. A number of factors couldhave contributed to the decrease in successfulperformance and not attaining full score in CB&MS.First, the tasks were challenging as certain items aretime scored, in which (item no I-right and left, VI, VII-right and left, IX,X,XI-right and left ,XIII-right and left)they have to complete the tasks within the time limit inorder to attain full score. Second, the complexity of taskswhich include hopping forward, crouch and walk,running with controlled stop, and lateral dodgingwhich requires good strength ,balance andcoordination. These observations were supported byearlierstudydonebyScottJ.Butcheretal2004.Althoughnot tested in this study, the fact that women tend tohave lower muscle strength than men15could explaintheir lower performance on these items in the 60 to 72year age category (table1). Slow speed of performance,particularly for item 7(lateral dodging), could also beattributed to slowness in reaction time with increasingage5. A decrease in speed has previously been attributedtoage-relatedreductioninmusclefibresize,particularlyin type II fibres, which are primarily responsible forspeed of movement20.We observed that the subjects were motivated,enthusiastic and enjoyed the part of the test, whichcould be due to dynamic and challenging tasksinvolved in the scale. This might be the reason foradherence to retest evaluation of our study except nineparticipants who could not attend the retest due topersonnel problems.The average time taken to complete the testadministration was approximately 30 minutes.This ismorecompared toother assessment measuresinelderlywhich could be explained by the progressive difficultyin task items. Some of the items were scored based onduration, which requires the subject to complete theminimum time of 45 seconds (SLS).Some items need tobe performed four (Lateral dodging) or five (Step ups)times and walk for seven consecutive steps (tandemwalking) which further increased the assessment time.Rest periods given in between tasks could also haveincreased the test duration.In our phase results, we did not find any correlationbetween items of CB&MS and Posturography measureswhich could be explained by the difference inmeasurement surface, environment and non-familiarization of Posturography. Posturographymeasures were taken on force platform in well designedand organized laboratory setting as against to CB&MSwhich was performed in real setting.Poor correlation between CB&MS andPosturography could also be attributed to the differentcomponents of balance being assessed by two tests, thatis Posturography measures static balance while,CB&MS measures dynamic balance and mobility tasks.LIMITATIONOur results were restricted to young-old elderlypopulation and hence cannot be generalized to old-old. However, we would like to recommend furtherstudies to test the feasibility of CB& MS in old-oldsubjects.CONCLUSIONCB&MS showed excellent test –retest reliabilityhenceitcouldbefeasibleinthecommunityforassessingbalance and mobility of young-old elderly population.REFERENCES1. Alan H Feiveson , E Jeffrey Metter ,Williams HPaloski .member IEEE (2003). A statistical modelfor inter predating computerized dynamicposturography data.IEEE transactions onBiomedical Engineering.Vol49, no 4. 300-309.2. Balcombe NR, Sinclair A (2001). Ageing:definitions, mechanisms and the magnitude of theproblem. Best Pract Res Clin Gastroenterol. 15:835-849.3. Bischoff ,Hannes B.Stahelin et al(2003).Identify acut off point for normal mobility.Acomparison ofthe timed ‘U…....,Age and aging .32;3;proquestmedical library pg 315.4. Faber MJ, Bosscher RJ, vanWieringen PCW (2006).Clinimetric properties of the Performance-Oriented Mobility Assessment.Phys Ther.86:944–954.26. Naga Raju--131-135.pmd 2/7/2013, 8:08 PM134
  • 141. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 1355. Fozard JL, Vercruyssen M, Reynolds SL, HancockPA, Quilter RE(1994).Age differences and changesin reaction time; Baltimore Longitudinal Study ofAging. J Gerontol.49;P179-89.6. Gary Kamen ,Carylon pattern ; C. DFuke Du;Steven sison(1998) :An accelerometry basedsystem for the assessment of balance and posturalsway.Gerontology.44,1;proquestmedicallibrary;pp.40.7. Goidie PA.Bach TM Evans OM (1982) :Forceplatform measures evaluating postural control:reliability and validity. APMR.70;510-517.8. Governance in India: vision 2020.9. Harada N.W, Chiu V , Damron –Rodriquez J, et al(1995) .screening for balance and mobilityimpairment in elderly individuals living inresidential care facilities. Phys Ther .75:462-469.10. Howe JA, EL Inness, AVenturini J I Williams andMC Verrier (2006): The community balance andmobility scale – a balance measure for individualswith traumatic brain injury, the clinicalrehabilitation.20; 885.11. Inui N (1997). Simple reaction times and timing ofserial reactions of middle-aged and old men.Percept Mot Skills.84; 219-25.12. Kauranen K, Vanharanta H (1996): Influences ofaging, gender, and handedness on motorperformance of upper and lowerextremities.Percept Mot Skills.82; 515-25.13. Maki BE, McIlroy WE(1996). Postural control inthe older adult. Clin Geriatr Med Nov.12(4):635–658.14. Payton OD, Poland JL (1983): Aging process:Implications for clinical practice. PhysTher. 63: 41–48.15. PinciveroDM,GoelhoAJ,CampyRM(2003).Kneefiexor torque and perceived exertion; a gender andreliability analysis. Med Sci Sports Exerc.35;1720-1726.16. Sadashiv Ram Aggarwal, Deepak Kumar (2006):Lower extremity muscle strength and balanceperformance in Indian community dwellingelderly men aged 50 years and above; IndianJournal of Physiotherapy and OccupationalTherapy. Vol. 0, No. 017. The 2001 census: Aging population of India –ananalysis of the 2001 census data.18. Tinetti, M.E(1987). Factors associated with seriousinjury during falls by ambulatory n u r s i n ghome residents. J Am Geriatr Soc. 35(7): p. 644-8.19. Tinetti,M,et al (1988):Identifying mobilitydysfunction in elderly patients :standardneuromuscular examination or direct assessment.JAMA.259:119.20. Vandervoort A (2002). Aging of the humanneuromuscular system. Muscle Nerve .25; 17-25.26. Naga Raju--131-135.pmd 2/7/2013, 8:08 PM135
  • 142. 136 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Core Stability Training with Conventional BalanceTraining Improves Dynamic Balance inProgressive Degenerative Cerebellar AtaxiaKhan Neha Tabbassum1, Nayeem-U-Zia2, Harpreet Singh Sachdev3, Suman K41Student (M.P.T Neurology), Dept. of Rehabilitation Sciences, Hamdard University, New Delhi, 2Lecturer, Dept. ofRehabilitation Sciences, Jamia Hamdard, New Delhi, 3Consultant physiotherapist, Neurology Dept.,A.I.I.M.S., New Delhi, 4Co- Guide, Associate Professor, Neurology Dept., IHBAS hospital, New DelhiABSTRACTBackground and Purpose: Disorder of balance and gait is the commonest feature found in Cerebellarataxia patients. Purpose was to see the effect of Core stability training along with balance training ondynamic balance in progressive degenerative Cerebellar Ataxia.Methods: 20 subjects of progressive Degenerative condition (18 SCA subjects and 2 olivopontocerebellaratrophy) were systematically assigned in two groups, group A (n=10) in core and balance training andgroup B (n=10) in balance and relaxation training. Treatment was given 1 hour per session for eachgroup, 3 days a week for 4 weeks. The outcomes of the study were measured by Balance EvaluationSystem Test (BESTest) and Modified falls efficacy scale (MFES).Results: Core stability training group showed significant improvement on BESTest at follow upcompared to conventional balance training group. There was no statistical difference found in theMFEscale among the two groups but the results were clinically significant till follow up for core stabilitytraining group.Conclusion: Core stability training can be included as an adjunct to conventional balance training inimproving dynamic balance in patients with progressive degenerative Cerebellar ataxia.Keywords: Cerebellar Ataxia, Core Stability Training, Dynamic Balance, FallsINTRODUCTIONCerebellar ataxia indicates dysfunction of thecerebellum.Ataxia literally means ‘without order’. Theterm ataxia refers mainly to inaccuracy of movementtowards a target, to rhythmic limb movements eitherduringasustainedpostureorwhenthepatientattemptsto reach a target, inability to perform smooth alternatemovements and loss of coordination of muscle groupsin multi joint movements.1Patients with degenerative cerebellar lesions showglobal impairment of balance with greater instabilityin anterior- posterior direction than medio- lateraldirections.2, 3important factor contributing to instabilityisdecreasedkneeandankleflexionwhentestedthroughperturbations 3. Individuals with cerebellar ataxia showmore co-contraction modes of muscles resulting instiffness of muscles of major joints e.g. knee stiffnessand result in impaired coordination during feedbackand feed forward postural control4Studies revealcerebellar gait ataxia is more related to balance deficitsthan voluntary leg coordination deficits.5Systems approach describes, dynamic balance is aresult of interaction of the individual, task &environment. Ankle, hip, suspensory and steppingstrategieskeepcentreofgravityoverthebaseofsupport,anticipatory postural adjustments occur before theactual disturbance, volitional postural movements areunder conscious control are the motor components ofbalance that support postural orientation & automaticpostural reactions.6The muscles stabilizing lumbar spine form the coremuscles. This muscular control is required aroundlumbar spine to maintain functional stability.7Corestability is defined as the ability of the lumbopelvic-hipcomplextopreventbucklingofthevertebralcolumnand return it to equilibrium following perturbation.8Core stability (spinal stabilization)techniquesincorporated in Low Back Pain subjects have found toimprove the stability of spine by improving the co-contraction of trunk muscles, recovery in the size ofmultifidus muscle, also resulted in motor learning byretaining appropriate coordination of deep and27. Neha Tabussam--136-140.pmd 2/7/2013, 8:08 PM136
  • 143. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 137superficial muscles for gaining spinal stability9,10,11.Core strengthening improves dynamic postural controlin rehabilitation of athletic injury.12The purpose of this study was to determine whetherthe addition of Core stability training to conventionalbalance training in patients with Progressivedegenerative cerebellar ataxia has any benefit ondynamic balance as compared with conventionalbalance training alone. Dynamic balance is a problemin patients with Progressive Degenerative CerebellarAtaxia. The trunk muscles form the basis of core whichacts as the powerhouse for force production and co-ordinated limb movements during locomotion.13CoreStability training it is aimed to create awareness ofmuscle contractions around the spine which haveeventually weakened due to chronic nature of disease.2,3Also in progressive degenerative Cerebellar Ataxia thesynergies required for maintaining Dynamic Balanceare altered.4The synergies can be strengthened throughtraining of Core muscles.14If the study reveals positiveeffects of core stability training on dynamic balance,treatment protocols can be developed to improvedynamic balance with ease in every clinical setting.METHODA sample of 20 subjects with progressivedegenerative Cerebellar ataxia (18 subjects were SCAand 2 were olivopontocerebellar atrophy) participatedin the study. Out of 20, 15 were male whereas 5 werefemale. 18 subjects suffered from SCA’s (type 1, 2, 3)and two from olivo-ponto cerebellar atrophy.Asampleof convenience was taken.Subjects in group A were treated with core stabilitytraining which included back stabilization exercises,single leg slides, leg loading, facilitation of Transversusabdominis, bridging, Pelvic floor exercises anddiaphragmatic Breathing while balance trainingincluded turning, walking sideways, heel to toewalking, sit to stand, heel lifts, toe lifts, single legstanding ,leg swings, stair climbing. Subjects in GroupB treated with balance training and relaxationtraining15, 16,17,18,19at Institute of Human Behaviour andAllied Sciences Hospital, Delhi.Subjects with Progressive degenerative ataxia ofcerebellar origin diagnosed by neurologist, age rangefrom 18-50, MMSE score e” 24,Chronic cases havingsymptoms more than a year, SARA score 15-23,20Subjects should be able to walk minimum distance of10 meters with or without walking aid were includedin the study.20Subjects diagnosed as Afferent/ sensory ataxia, anyotherneurologicalororthopaedicdisorderaffectinggaitor balance, severe Low back pain, Already undergoingphysiotherapy intervention for last 3 months,Uncorrectable visual or hearing loss, Subjects unwillingto follow the exercise regime were excluded. It was aprospective repeated measure experimental groupdesign. Instrument used for exercise regime waspressure biofeedback device16, 21(Chattanooga group).A duly signed consent form was obtained from thesubjects. A detailed assessment of every subject wasdone using neurological evaluation form. All thesubjects were assessed for inclusion and exclusioncriteria. The mini mental status examination was done.Demographic data of the subjects were collected.Subjects were assigned systematically into two groups– group A experimental and group B conventionaltreatment groups.The treatment sessions for both the groups weregiven for 1 hour per day, 3 times per week for 4 weeksThe performance of the two groups was examined onthe following scales: Dynamic Balance was tested onBalance Evaluation System Test(BESTest)22and for fearof Falls Modified Falls efficacy scale (MFES) 23wasused..Theoutcomesweretaken3timesduringtreatmentfirst before treatment, second immediately after the 4weeks of treatment and third after a month’s follow up.The treatment was given n the physiotherapydepartment of the IHBAS hospital. The study wasreviewed by the ethical board of Jamia HamdardUniversity, New Delhi.DATA ANALYSISThe data was analysed using SPSS software version15. Independent T-test was used to see the differencebetween the effects training between group A andB.Effectiveness of treatment within the groups wasmeasured using repeated measureANOVA. The resultswere checked at P<0.05 level of significance.RESULTSThe change in the Dynamic Balance and Fear of fallswas measured at three levels of the treatment phases,initially at pre treatment, then post treatment and lastat follow upBETWEEN GROUPThe Mean ± SD values for BESTest in experimentalgroup after 1 month of treatment was 63.50 ± 15.757and conventional group was 50.00 ± 11.981.Thisdifference in values was statistically significant p=0.045.The Mean ± SD values for experimental group from preintervention to Follow Up was 55.60 ± 17.602 the resultwas statistically significant (P=0.024) and conventionalgroup was 40.10 ± 9.327.This difference in values wasstatistically significant (p=0.024), indicating that the27. Neha Tabussam--136-140.pmd 2/7/2013, 8:08 PM137
  • 144. 138 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1experimental group showed more improvement inBalance than the conventional group. Although therewas no statistically significant improvement in thescores at post treatment (p=0.433) and at follow up(p=0.154) after treatment.Table. 1.1 Comparison between pre, post and followup scores of experimental and conventional groups onBESTest scaleDependent Experimental Conventional P valuevariables Mean±SD Mean±SDPre BESTest total 35.60 ± 12.616 38.10 ± 10.503 0.636Post BESTest total 63.50 ± 15.757 50.00 ± 11.981 0.045*Follow up BESTest total 55.60 ± 17.602 40.10 ± 9.327 0.024*Table 1.2 Comparison between pre, post and follow upscores of experimental and conventional groups onMFE ScaleDependent Expt Conv P valuevariables Mean±SD Mean±SDPre MFES 52.80 ± 20.137 59.10 ± 14.395 0.431Post MFES 77.80 ± 30.724 68.80 ± 17.725 0.433Follow Up MFES 78.50 ± 32.857 59.90 ± 21.957 0.154DISCUSSIONThe key findings that emerged from the study werethat core stability training is effective in improvingDynamic balance in progressive degenerative cerebellarataxia. Core stability training group showed significantimprovement on BESTest till follow up compared toconventional balance training group. There was nostatistical difference found in the MFEscale among thetwo groups but the results were clinically significant atfollow up for core stability training group.Liebenson found trunk stabilization exercisesresulted in reduction of low back pain, by increasingthe kinaesthetic awareness necessary to maintain safeneutral spine which is ideal for rehabilitation.24NicoleL et al. studied on dynamic balance testing amongyoung healthy adults and found that core strengtheningimproves dynamic postural control duringrehabilitation of athletic injury.12The diaphragm servesas the roof of the core; stability is augmented on thelumbar spine by contraction of diaphragm andincreasing intraabdominal pressure.13Pelvic floormusculature is co activated with the Transversusabdominis contraction.13The results found this study are supported by thework of Paul W. Hodges which provided the rationaleof core stability training, that stability of spine dependson both the muscle activation and CNS control.14Thecore stability training results in motor learningsequentially through skill learning, precision training,activation in variety of contexts, integration of skillsinto tasks that includes coordination of deep andsuperficial trunk muscles is maintained in functionalcontext balance.14Konin JG et al. al described diagonalorientation of core muscles resemble a serape,producing a serape effect connecting the stability forupper and lower extremities and maintaining muscularcontrol around the spine and maintaining functionalstability.25In this study the pressure biofeedback was used forcore training including abdominal hollowing a basicexercise taught initially and then hollowing associatedwith lower limb movements. It activated TransversusAbdominis (TrA) muscle, which is important muscleformingcore.26Itisfoundthatthepatientwithcerebellarataxia uses restricted synergies i.e. stiffening of pelvis,knees, and ankles during challenging tasks.27It has alsobeen found that practice could lead to transition fromco-contraction to reciprocal patterns on the basis ofuncontrolled manifold (UCM) hypothesis.28This studyincluded patients with chronic progressive disease, asabovestudymentionedthatthesepatientsuserestrictedsynergies to maintain balance. Practice of core trainingalong with lower limb activities provided in this studymighthavehelpedpatientstodevelopreciprocalmusclepattern rather than the stiffening of the joints.28resultingin reduction of synergies and their strengthening whichare essential for dynamic balance control.28The rationale behind the fact that patients did notreturn to pre treatment level or their condition did notdecline due to progression of disease, is that the naturalprogression of degeneration in Cerebellar ataxia is 0.6-2.5 points 1 year as found on SARA scale depending ongenotypes (data of EUROSCAnatural history. ThomasKlockgether, 2008).5Long term effects of intensiveexercise training have been proven in research onprogressive degenerative cerebellar disease even aftera year of training.29There was no statistical significance in improvementof the falls score at post treatment (p=0.433) and atfollow up (p=0.154).However experimental groupshowed clinical improvement in falls score. Whenbaselines (fig.1.2) were compared for both the groups itcan be observed that the difference for improvementwas more in Experimental group than the conventionalgroup.The results obtained may be attributed to the 1)gender differences, in experimental group there were 3females and conventional group there were 2 females,because the females were seen to have less confidencethan males of same severity.23, 302) Considering agedifferences, in conventional group 3 patients were ofage45yearsandabove,whileinexperimentaltherewere4 patients having age 45years and above. 3) Considering27. Neha Tabussam--136-140.pmd 2/7/2013, 8:08 PM138
  • 145. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 139disease severity, in conventional group 4 subjects wereabove 16 scoring of SARA scale, while in experimentalthere were 5 subjects scoring more than 16. The abovefactors may be the possible causes of difference of MFEsscore at pre treatment level that led to no statisticalsignificance even though the experimental groupimproved more than conventional group.CONCLUSIONThe results obtained show that the core stabilitytraining improves dynamic balance. However it wasseen that although there was clinical improvement ofscores on MFEScale, but no statistical significance wasobserved. Thus it is concluded that in rehabilitation ofdynamicbalanceinpatientswithprogressiveCerebellarataxia, core stabilization programme can be includedas an adjunct to conventional balance training.LIMITATIONS OF STUDY1. Thesubjectsincludedinthisstudyweremoderatelydisabled (rated on SARA scale). The results of thisstudy cannot be generalized to severely disabledpatients.2. Scale for measurement of fear of falls taken wassubjective.3. The sample size was smaller.ACKNOWLEDGEMENTSSincere thanks to Physiotherapy Dept. IHBAS, JamiaHamdard, New Delhi.REFERENCES1. M.Halliet.Hand book of ClinicalNeurophysiology.Elsevier2003; 1: 498.2. Ganesan Mohan, Pramod Kumar Pal,Kumar R.Sendhil, Kandavel Thennarasu, B.R. Usha.Quantitative evaluation of balance in patients withspinocerebellar ataxia type 1:Acase control study.Parkinsonism and Related Disorders 2009; 15:435–439.3. Maaike Bakker, John H.J. Allum, Jasper E. Visser,Christian Grüneberg, Bart P. van de Warrenburg,Berry H.P. Kremer, et al. Postural responses tomultidirectional stance perturbations in cerebellarataxia. Experimental Neurology 2006; 202: 21–35.4. Asaka T, Wang Y, Fukushima J, Latash ML.Learningeffectsonmusclemodesandmulti-modepostural synergies. Exp Brain Res. 2008 Jan;184(3):323-38.5. Susanne M.Morton, AmyJ.Bastain. Relativecontributions of balance and voluntary leg-coordination deficits to cerebellar gait ataxia. J.Neurophysiol 2003;89:1844-18566. Darcy Ann Umphred PT PhDFAPTA.Neurological Rehabilitation. 5thEd.7. DeLisa, JoelA.; Gans, Bruce M.; Walsh, Nicolas E.;Bockenek et al. Physical Medicine &Rehabilitation: Principles and Practice, 4th EditionLippincott Williams & Wilkins20058. John D. Willson, MSPT, Christopher P. Dougherty,DO, Mary Lloyd Ireland, MD, and Irene Mc ClayDavis, PhD, PT Volume 13,. J Am Acad OrthopSurg 2005;13:316- 325.9. Gardner-Morse MG, Stokes IA. The effects ofabdominal muscle co activation on lumbar spinestability. Spine (Phila Pa 1976). 1998 Jan 1;23(1):86-91.10. Libenson.C Spinal stabilization training. Journalof bodywork and movement therapy 1997; 1(2):87-90.11. Danneels LA, Vanderstraeten GG, Cambier DC,WitvrouwEE,BourgoisJ,DankaertsWetal..Effectsof three different training modalities on the crosssectional area of the lumbar multifidus muscle inpatients with chronic low back pain. Br J SportsMed. 2001 Jun; 35(3):186-91.12. JNicole L. Kahle, BS; Phillip A. Gribble. CoreStability Training in Dynamic Balance TestingAmong Young, HealthyAdults.Athletic Training& Sports Health Care 2009; 1(2):13. Akuthota V, Nadler SF. Core strengthening. ArchPhys Med Rehabil 2004; 85(3 Suppl1):S86-92.14. Hodges PW. Core stabilization exercises inChronic Low Back Pain. Orthopaedic Clinics ofNorth America2003; 34:245-254Mario-UbaldoManto, Massimo Pandolfo. The Cerebellum andits disorders. Cambridge 2002.15. Jull GA, Richardson C, Toppenberg R, ComerfordM and Bui B: Towards a measurement of activemuscle control for lumbar stabilization. Australianjournal of physiotherapy 1993;39: 187-19316. Richardson C, Jull G, Toppenberg R, ComerfordM. Techniques of active lumbar stabilization forspinal protection:Apilot study.Australian Journalof Physiotherapy 1992; 38(2): 105-11217. Clinical sports medicine 3 Ed; Mc Graw HillProfessional. Brukner and Khan.18. Shirley Sahrmann. Treatment and Diagnosis ofMovement Impairment Syndromes, Mosby,19. Zampieri C, Di Fabio RP. Balance and eyemovement training to improve gait in people withprogressive supranuclear palsy: quasirandomizedclinical trial. Phys Ther. 2008;88:1460–147320. Ilg W, Synofzik M, Brötz D, Burkard S, Giese MA,Schöls L. Intensive coordinative training improvesmotor performance in degenerative cerebellardisease. Neurology. 2009 Dec 1; 73(22):1823-30.27. Neha Tabussam--136-140.pmd 2/7/2013, 8:08 PM139
  • 146. 140 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 121. Sullivan.P, Towmey.L, Allison.G. Alteredabdominal muscle recruitment in patients withchronic low back pain following a specific exerciseintervention. Journal of Sports Physical Therapy,1998; 27(2):114-124.22. Horak FB, Wrisley DM, Frank J.The BalanceEvaluation Systems Test (BESTest) to differentiatebalance deficits. Phys Ther. 2009 May; 89(5):484-98.23. Hill KD, Schwarz JA, Kalogeropoulos AJ, GibsonSJ.Fearoffallingrevisited.ArchPhysMedRehabil.1996 Oct; 77(10):1025-9.24. C. Libenson. Spinal stabilization training. Journalof bodywork and movement therapy 1997; 1(2):87-90.25. Konin JG, Beil N, Werner G. Functionalrehabilitation. Facilitating the serape effect toenhance extremity force production. AthlTherToday 2003;8:54-626. Carolyn Richardson, Gwendolen Jull, RowenaToppenber, Mark Comerford. Techniques of activelumbar stabilization for spinal protection: A pilotstudy. Australian Journal of Physiotherapy 1992;38(2): 105-11227. Tadayoshi Asaka, Yun Wang. Feed forwardpostural muscle modes and multi-modecoordination in mild cerebellar ataxia. Exp BrainRes 2011; 210:153-163.28. Tadayoshi Asaka, Yun Wang, E, JunkoFukushima, E Mark, L. Latash. Learning effectson muscle modes and multi- mode posturalsynergies. Exp Brain Res 2008; 184:323-338.29. WinfriedIlgPhD, DorisBrötzPT,SusanneBurkardPT, Martin A. Giese PhD, Ludger SchölsMD,*,Matthis Synofzik MD. Long-term effects ofcoordinative training in degenerative cerebellardisease.2010; 25 (13):2239–2246200099730. Hill K. Studies of balance in older people. [PhD].The University of Melbourne, 1998.27. Neha Tabussam--136-140.pmd 2/7/2013, 8:08 PM140
  • 147. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 141Restoration of Normal Length of Upper Trapezius andLevator Scapulae in Subjects with Adhesive CapsulitisPandit Niranjan Hemant1, Mhatre Bhavana Suhas2, Mehta Amita Anil31Physiotherapist - Mumbai Cricket Association, Cricket Centre, Wankhede Stadium, D Road, Churchgate,Mumbai, - Jaslok hospital & Research Centre, 15 - Dr. Deshmukh Marg, Pedder Road, Mumbai,2Associate Professor, P.T School and Centre, Seth Dhurmal Bajaj Orthopaedic Centre, 3Professor and Head, P.T School andCentre, Seth Dhurmal Bajaj Orthopaedic Centre, Seth G.S.Medical College and KEM hospital, Parel, MumbaiABSTRACTStudy Design: Prospective clinical trial of subjects with Adhesive CapsulitisObjective: To find the effect of restoration of length of the shortened upper trapezius and levatorscapula muscle with muscle energy technique and sustained passive stretching techniques along withMaitland joint mobilization for glenohumeral joint as compared to Maitland joint mobilization aloneon range of motion and scapular position at rest in subjects with unilateral adhesive capsulitis.Background: The glenohumeral hypomobility in adhesive capsulitis causes excessive scapular motionto compensate for the reduced gleno-humeral motion. The resulting tightness of upper trapezius andlevator scapula causes an altered scapular position at rest. Restoring normal length of upper trapeziusand levator scapulae will help to restore an optimal length-tension relationship and scapular positionresulting in better improvement of glenohumeral range of motion.Methods and measures: 60 male subjects with unilateral adhesive capsulitis were divided into groupI and group II of 30 each. Baseline outcome measures assessed were shoulder ROM of flexion, abductionand external rotation and resting position of the scapula using the Lennie test. Group I received MuscleEnergy Technique (MET) for upper trapezius and levator scapula along with Maitland joint mobilizationfor the glenohumeral joint. Group II received Maitland mobilization for the gleno-humeral joint.Outcomes were reassessed at 6 weeks.Results: The results showed statistically significant improvement ROM in both groups withimprovement being more in group I as compared to group II. However scapular position showedstatistically significantly improvement only in group I with no improvement in group II.Conclusion: Adding muscle energy techniques to the treatment of adhesive capsulitis gives betteroutcomes compared to treating with joint mobilization alone.Keywords: AdhesiveCapsulitis,Muscle EnergyTechniques,Upper Trapezius,Levator Scapula,Joint MobilizationINTRODUCTIONAdhesive capsulitis is a condition causing painfuland restricted motion of the glenohumeral joint.Normally the entire glenohumeral joint in the restingposition (arm dependent at the side) is surrounded bya large, loose capsule that is taut superiorly and slackanteriorly and inferiorly (redundant folds or axillarypouch) 1. Hyaluronic acid with water is the lubricantbetween the collagen fibres that allows the free glidingto occur 2.The pathogenesis of adhesive capsulitisinvolves the entire capsule with more involvement ofthe antero-inferior axillary folds which are shrunkenand fibrosed3,4.The impairments are pain and loss of active andpassive mobility of the glenohumeral joint. Abnormalscapular motion, such as excess elevation and increasedoutward rotation of the scapula during elevation of thearm, is generally thought to be a compensation strategyfor a limited glenohumeral motion, muscle imbalanceand pain 3. In a trial of ten patients with unilateral frozenshoulder syndrome for 3 months early scapular lateralrotation of the frozen shoulder during elevation of thearm using an electromagnetic tracking device wasdocumented 5.Research supports the view that patients sufferingfrom frozen shoulder syndrome compensate for28. Niranjan Pandit-141-147.pmd 2/7/2013, 8:08 PM141
  • 148. 142 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1impaired glenohumeral motion via the use of accessorymusculature i.e. increased trapezius muscle activity 6.The upper trapezius and levator scapulae areconsidered to be postural muscles and hence undergoshortening in response to stress or overuse 7. Thescapula on the involved side is usually elevated,laterally rotated and abducted 2. Studies on treatmentof adhesive capsulitis concentrate on treatingglenohumeral joint. But little attention is paid tonormalize scapular static and dynamic mechanicswhich are essential for normal glenohumeral rhythm.Hence the focus of this study was to find the effect ofrestoration of length of the shortened upper trapeziusand levator scapula muscle with muscle energytechnique and sustained passive stretching techniquesalong with Maitland joint mobilization forglenohumeral joint as compared to Maitland jointmobilization alone on pain scores, range of motion andscapular position at rest in subjects with unilateraladhesive capsulitis.We begin with the null hypothesis that there is norelation between combining muscle energy techniquesfor upper trapezius and levator scapula and Maitlandjoint mobilizations for glenohumeral joint as comparedto treating glenohumeral joint alone with Maitland jointmobilization.MATERIALS AND METHODOLOGY• Prospective clinical trial of 60 male subjects withadhesive capsulitis from the outpatient departmentof physiotherapy at Seth G.S. Medical college &K.E.M. hospital Mumbai.Inclusion criteria• Patients with unilateral adhesive capsulitis.Exclusion criteria• Bilateral adhesive capsulitis• Dorsal spine scoliosis as spine was taken as themidline reference• Associated pathology of the cervical spine.• Post fracture stiffness• Rotator cuff tendinosis or tears• Shoulder instability• Complex regional pain syndrome• Neurovascular neoplastic or infectious conditionsof or around shoulder• Adhesive capsulitis along with neurologicalconditions like hemiplegiaThe material used• Universal goniometer• Vernier caliper• Wrist watch• Skin markers• Manual therapy table• 10 centimeter visual analogue scale (VAS)• Assessment proforma.Informed consent was obtained from subjects priorto their inclusion in the study. Approval was takenfrom Ethics Committee for Research on Human subjects(ECRHS) of K.E.M. Hospital Mumbai.The following outcome measures were assessed onday 1 and at the end of 6 weeks (18thtreatment session).• Flexion,abductionandexternalrotationROMusinggoniometer.• Position of the scapula on the thorax at rest usingthe Lennie test 8(Fig 1)Markers were put on the skin overlying the affectedand non-affected scapulae for the superiorangle, root of the scapular spine and inferior angle.Three measurements of scapular position in thefrontal plane were obtained for both sides.• Midline to superior angle distance• Midline to root of the spine of scapula distance• Midline to inferior angle distance.• In addition, height difference between scapulae(defined as difference between the vertical positionsof the inferior angles of the affected and the non-affected scapula) was measured with the caliperusing the midline marks corresponding to the twoinferior angles.Subjects were divided into group I and group II of30 each and assigned alternately into groups i.e. evennumbers into group I and odd numbers in Group II.GroupIreceived:Muscleenergytechniquesforupper28. Niranjan Pandit-141-147.pmd 2/7/2013, 8:08 PM142
  • 149. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 143trapezius and levator scapulae along with Maitlandjoint mobilization• Muscle Energy Technique for upper trapezius andlevator scapula 7: (Fig 2)Subject performed a sub-maximal isometriccontraction in supine position for the respective muscleagainst resistance commencing with the muscle at theresistance barrier and maintained it for 10 seconds.Following relaxation, muscle was stretched beyond thebarrier till a new barrier was reached and stretch wasmaintained for 30 seconds. The sequence was repeated3 times for upper trapezius and levator scapula.• Maitland joint mobilization: (Fig 3)• Anteroposterior (AP), posteroanterior (PA) andinferior glide• Grade 3 and 4 Maitland joint mobilizations for thegleno-humeral joint.• 3 sets of 30 oscillations per minute per glide 9.Group II received: Maitland joint mobilization.• Maitland joint mobilization: (Fig 3)• Anteroposterior (AP), posteroanterior (PA) andinferior glide• Grade 3 and 4 Maitland joint mobilizations for thegleno-humeral joint.• 3 sets of 30 oscillations per minute per glide9.Both groups were given hydrocollator packs for theshoulder joint for 10 minutes in sitting position beforetreatment10.Home exercise program 11Both the groups were given home exercise programwith the following exercises:1) Shoulder girdle retraction and depression(scapularsetting).2) Wand exercise to improve shoulder flexion andshoulder rotation with both hands.3) Active assisted shoulder extension in standing.The subjects were asked to repeat each exercise tentimes twice a day.They were told to take hot packs at home beforeexercising to reduce pain and relieve spasm.Data analysis and results56 patients completed the study. Two subjects ineach group were lost to follow up before 6 weeks. Sothere data was not taken into consideration in statisticalanalysis. For the values of shoulder range of motionand scapular position, paired “t” test (pre-post withingroup comparison) and unpaired “t” test (inter-groupcomparison) was used.Table 1: Baseline values of the two groups - unpaired ‘t’ test.The baseline mean values for the parameters did not show a statistically significant difference (p > 0.05).Variables Group I Group II p value SignificanceMean SD Mean SDROMFlexionActivePassive 102.86112.14 13.5013.57 98.93108.57 12.3510.35 0.26090.2731 NSAbductionActivePassive 78.9388.75 14.3012.22 73.7585.36 10.8510.09 0.13270.2622 NSExternal rotationActivePassive 7.1414.46 7.266.98 4.8212.14 4.615.17 0.15880.1632 NSScapular positionSA 6.3368 0.2099 6.2829 0.1700 0.2955 NSIA 7.2882 0.3194 7.2261 0.2593 0.4276 NSI I’ 0.9811 0.1765 0.9779 0.1734 0.9576 NSNS – Not Significant, SA – Superior angle, IA – Inferior Angle, I I’ – Difference in Inferior angle levels28. Niranjan Pandit-141-147.pmd 2/7/2013, 8:08 PM143
  • 150. 144 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Analysis of scapular position changeTable 2. Inter-group comparison of reduction of distance of Superior and Inferior Angle from midline andDifference between Inferior anglesMean SA Pre SA Post IA Pre IA Post II’ Pre II’ PostGroup I 6.3368 6.2418 7.2882 6.7500 0.9811 0.3836Group II 6.2829 6.2821 7.2261 7.2175 0.9779 0.9729t- value # 1.05 1.39 0.79 6.43 0.05 15.66p- value 0.2955 0.1697 0.4276 0.0001 0.4276 0.0001* - Results analysed using paired t test# - Results analysed using unpaired t testThese results indicate that only treatment receivedby group I was effective in bringing about change in thescapular position (p < 0.05) while no statisticallysignificant effect was seen in scapular position byintervention given in group II (p > 0.05).Analysis of abduction range of motionTable 3. Intergroup comparison between abduction ROM before and after treatment.Mean Active Pre Active Post Passive Pre Passive PostGroup I 78.93 110.54 88.75 121.07Group II 73.75 100.00 85.36 111.79t – value # 1.52 2.70 1.13 2.81p – value 0.1327 0.0091 0.2622 0.0068* - Results analysed using paired t test# - Results analysed using unpaired t testShoulder ROM of abduction showed extremelystatistically significant improvement within both thegroups post treatment (p < 0.05). In inter- groupcomparison, group I showed more highly statisticallysignificant improvement in abduction as compared togroup II (p < 0.05).Analysis of flexion range of motionTable 4 – Intergroup comparison between flexion ROM before and after treatment.Mean Active Pre Active Post Passive Pre Passive PostGroup I 102.86 137.86 112.14 146.96Group II 99.64 114.82 108.57 125.89t - value 1.13 6.21 1.10 6.42p - value 0.2609 0.0001 0.2731 0.0001* - Results analysed using paired t test# - Results analysed using unpaired t testShoulder ROM of flexion showed extremelystatistically significant improvement within both thegroups post treatment (p < 0.05). In inter- groupcomparison, group I showed more highly statisticallysignificant improvement in flexion as compared togroup II (p < 0.05).28. Niranjan Pandit-141-147.pmd 2/7/2013, 8:08 PM144
  • 151. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 145Analysis of external rotation range of motionTable 5 – Intergroup comparison between external rotation ROM before and after treatment.Mean Active Pre Active Post Passive Pre Passive PostGroup I 7.14 35.54 14.46 43.57Group II 4.82 23.04 12.14 33.75t – value # 1.42 4.46 1.41 4.71p - value 0.1588 0.0001 0.1632 0.0001* - Results analysed using paired t test# - Results analysed using unpaired t testShoulder ROM of external rotation showedextremely statistically significant improvement withinboththegroupsposttreatment(p<0.05).Ininter-groupcomparison, group I showed more highly statisticallysignificant improvement in external rotation ascompared to group II (p < 0.05).DISCUSSIONBoth the groups showed a significant improvementshoulder range of motion. Intergroup comparisonindicates that group I showed significant improvementpost treatment at the end of 6 weeks (18thsession) ontheabovementionedoutcomewhencomparedtogroupII. However, the improvement of scapular position posttreatment was seen only in group IScapular position improvement was seen secondaryto the treatment of the upper trapezius and levatorscapula muscle using muscle energy technique couldbe attributed to the therapeutic effects of muscle energytechniques. Many authors have proposed that METtechniques facilitate stretching by producingneurological reflex muscle relaxation 7followingisometric muscle contractions mediated by Golgitendon organs. Connective tissue elongation is timedependent, and if a constant stretching force is loadedon the tissue, the tissue will respond with slowelongation or creep causing greater deformation i.e.there is viscoelastic or muscle property change 7.Myofascial structures have two distinct connectivetissue arrangements: elastic ‘parallel’ fibres, arrangedparallel to the muscle fibres, and the stiffer ‘in series’fibres that lie perpendicular to muscle fibres and foundmainly at the tendinous junctions. Passive stretchingwould elongate the parallel fibres but have little effecton the ‘in series’ fibres; however, the addition of anisometric contraction would place loading on thesefibres to produce viscoelastic or plastic change aboveand beyond that achieved by passive stretching alone.LiteraturesuggeststhatMETmethodsproduceagreaterchange in stretch tolerance 7than passive stretching bydecreasing an individual’s perception of muscle pain.Stretching and isometric contraction stimulate jointmuscle and joint mechanoreceptors and proprioceptors,and it is possible that this may attenuate the sensationof pain.The above mentioned mechanisms contributed toreduce over activity and increased length of the uppertrapezius and levator scapula muscle. This wasreflected on the scapular position in Group I on theLennie test. Literature supports the view that abnormalcompensatory scapular movements in patients withshoulder stiffness can be reduced. In a particular study,it was demonstrated that with simple motor controlinstruction, the subjects reduced the amount of scapularelevation and retained relative timing and control 12.The primary role of mobilization is to restore jointplay and facilitate joint movement by restoringarthrokinematics. The neurophysiologic effect is basedon the stimulation of the peripheral mechanoreceptorsand inhibition of nociceptors.The biomechanical effectis based on breaking up adhesions in the capsule,collagen fibre realignment and improving interfibreglide 2. A multiple-subject case report concluded thatthere seems to be a role for intensive mobilizationtechniques in the treatment of adhesive capsulitis 13.Hence there was increase in ROM of the shoulder overa period of 6 weeks.The underlying basis for the use of hot packs is theability of heat to elevate pain threshold, alter nerveconduction velocity and change in muscle spindle firingrate 10.Thus the null hypothesis was rejected and theexperimental hypothesis was proved.CONCLUSIONRestoring length of upper trapezius and levatorscapula is essential when treating patients withadhesive capsulitis. While assessing patients withadhesive capsulitis attention needs to be given toassessment of abnormal scapular position. Treatment28. Niranjan Pandit-141-147.pmd 2/7/2013, 8:08 PM145
  • 152. 146 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1should be focused on treating the glenohumeral jointalone but also incorporate techniques to restore alteredscapular mechanics.Limitations of the studyThe study did not take into account the strength ofmuscles like middle and lower trapezius, rhomboids,serratus anterior.Also the influence of other muscles which becometight in adhesive capsulitis like pectorals, subscapularis,and teres major on glenohumeral range of motion wasnot taken into account.Implication for future studiesStudying the EMG activity before and postintervention for the upper trapezius and levatorscapula would be helpful in understanding themechanism of improvement in the length of thesemuscles post MET.Interest of conflict: We, Pandit N, Mhatre B andMehta A state that there is no conflict of interests withother people or organizations about our work.Upper trapeziusFig. 2. Muscle energy techniquesLevator scapulaACKNOWLEDGEMENTSWe are heartily thankful to the staff of PT Schooland Centre, KEM hospital, who supported us from thepreliminary stages of the project.Fig. 1. Lennie test28. Niranjan Pandit-141-147.pmd 2/7/2013, 8:08 PM146
  • 153. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 147Fig. 3. Glenohumeral mobilizationAnteroposterior glide Posteroanterior glideInferior glideREFERENCES1. Norkin C. and Levangie P. 3rd edition. JaypeeBrothers 2001.2. Donatelli R.A. Physical therapy of the shoulder,3rd edition; Churchill Livingstone 1997.3. Reeves B. Arthrographic changes in frozenshoulder and post traumatic stiff shoulders. ProcSoc Med 59:827, 1966.4. Neviaser J. S. Adhessive capsulitis of the shoulder:Astudyofthepathologicalfindingsinperiarthritisof the shoulder. JBJS Am. 1945;27:211-222.5. Vermeulen H.M. Stokdijk M. Eilers P.H.C. MeskersC.G.M. Rozing P.M. Vliet Vlieland T.PM.Measurement of three dimensional shouldermovement patterns with an electromagnetictracking device in patients with a frozen shoulder.Ann. rheum. Dis. 2002;61:115-1206. Jiu-Jenq Lin.Ying-Tai Wu. Shwu-Fen Wang. Shiau-Yee Chen. Trapezius muscle imbalance inindividuals suffering from frozen shouldersyndrome. Clin Rheumatol 2005;24:569–575.7. Chaitow L. Muscle energy techniques, 3rd edition;Churchill Livingstone 2006.8. Sobush D. C. Simoneau G.G. Deitz K.E. LeveneJ.A. Grossman R.E. Smith W.B. The Lennie Test formeasuring scapular position in healthy youngadult females: A reliability and validity study,JOSPT Vol. 23 No. 1 Jan 1996.9. Maitland G.D. Peripheral manipulation, 3rdedition.10. Michlovitz S. Thermal agents in rehabilitation. 3rdedition FA Davis Co. Philadelphia 199011. Kisner C. and Colby L. Therapeutic exercise, 5thedition 2007.12. 15 Babyar S. R. Excessive scapular motion inindividuals recovering from painful and stiffshoulders: Causes and treatment strategies, PhysTher. 1996;76:3.226-238.13. Vermeulen H.M. Obermann W.R. Burger B.J. KokG.L. Rozing P.M. van den Ende C.HM. End-rangemobilization techniques in adhesive capsulitis ofthe shoulder joint: A multiple-subject case report.Phys Ther. 2000;80:12.1204-1213.28. Niranjan Pandit-141-147.pmd 2/7/2013, 8:08 PM147
  • 154. 148 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Comparison of VMO/VL Ratio in Patello-Femoral PainSyndrome (PFPS) Patients: A Surface EMG StudyNishant H NarConsultant Physiotherapist Wockhardt Hospital, RajkotABSTRACTBackground: PFPS describes anterior and retro patellar knee pain in the absence of other pathology.PFPS is one of the most common disorders of the knee accounts for 25% of knee injuries in sportsmedicine clinics. Prevalence rate is 20% in USA students and morbidity is directly related to activity ofpatients. EMG studies of normal subject have revealed that VMO /VL ratio is about 1:1 (power CM et al)Objective: To study the VMO/VLratio during ECCENTRIC, CONCENTRIC, ISOMETRIC exercise andQ-angle in PFPS patients and control groups.Materials & Method: SUBJECTS; 25 diagnosed with PFPS and 25 asymptomatic control were recruitedfor study. EMG activity of VMO VL was recorded by surface electrodes.EMG data were analyzed inthree activities for both groups, ISOMETRIC, CONCENTRIC and ECCENTRIC exercise. Outcomemeasure was EMG MUAP amplitude and Q-angle.Results: Results showed that VMO/VL ratio is lower in PFPS subjects. And static and dynamic Q-angle is higher for PFPS groups.Conclusion: There was significant difference in VMO/VL ratio and Q-angle in both groups.Keywords: VMO, Surface EMG, Q-angle.INTRODUCTIONPFPS describes anterior or retro patellar knee painin the absence of other pathology. PFPS which is one ofthe most common disorders of the knee accounts for25% of all knee injuries treated in sports clinics. [1]Female patient are particularly more affected thanmale [2].Incidence rate is 7% and 10% in young maleand female.[2]Prevalence rate is 20% in students in USA andmorbidity is directly proportional to activity of Patients[3]InonestudydonebyWinslowetal1995outof16,748patients presenting with sports related musculoskeletalproblems, 11.3% had an anterior knee pain. Incidenceof PFPS in general population is reported in somestudies to be high as one in four with proportionincrease in athletes. (Levine 1979, Outbridge 1984)In orthopedics sports medicine, the most commonreasons for anterior knee pain are, [4]OveruseMal-alignmentTraumaStudies on the natural history of PFPS report that ingeneral it is a benign condition that may improve orpersist over time serious disability is uncommon. PFPSis a condition of both malalignment and musculardysfunction.Rehabilitation exercises can restore PF jointhomeostasis although the anatomical malalignment ofPFPS may not be corrected. [5]Symptoms of anterior knee pain are brought on byoveruse stress; PFPS is an ideal condition forprerehabilitation. [6]Total or near total recovery was noted in 22% at 16years ( Noman et al 1998)70 % at 3 years (Kanmus et al 1994), 81% at 12 years( jensssen et al 1990), 85% at 11 years (Karlsson et al1996 ).29. Nishant--148-153.pmd 2/7/2013, 8:08 PM148
  • 155. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 149The basic origin and exact pathogenesis of PFPS areunknown but many predisposing factors have beenproposed including[7]Acute trauma, knee ligament injury, instability,overuse, immobilization, overweight, malalignment ofextensor mechanism.Inmanycases,howevertherearenoobviousreasonsfor the symptoms, there is no clear association betweenseverity of the symptoms and the radiologic andarthroscopic findings.Some theories for the origin of non- traumaticgradual onset of PFPS are [8]Neuromuscular imbalance of VMO VL, Tightnessof lateral retinaculum, Hamstrings , Iliotibial band,Overpronation of subtalar joint.Several authors have exposed the theory thatabnormal patellar alignment is the root of pain [8]Patients usually complain of insidious onset ofvague, activity related pain coupled with evidence ofwasting of Vastus medialis.[9]EMG studies of normal subjects have revealed thatVMO/VL activity ratio is about 1:1,Whereas EMG recording in patients havingPFPS has shown that the ratio of VMO/VL is le than1:1. [10] [11].Controversy exist in the literature as to the normalrelationship between the timing of EMG activity of theVMO and VL and whether this difference in populationwith PFPS.[12, 13]Manyrehabilitationstrategieshaveimplementedforpatients with PFPS. In general the goals of patellafemoral rehabilitation are to maximize quadricepsstrength while minimizing the patella femoral jointreaction force and stress.[14, 15]Recently EMG biofeedback is also useful method toactivate VMO muscle. Selina Lm Yip et al concludedthat EMG biofeedback + exercise programme isbeneficial than alone exercise in PFPS patients.[16]Other investigators [17, 18]have examined VMO andVL EMG levels in the patients with PFPS, but have notused control groups. Approximately 70% of patellafemoral disorder will improve with conservativemanagement.Also in outpatient department the cases of PFPS isincreasing day by day, and so the clinical assessmentand treatment of the condition are extremelychallenging because of the multiple forces affecting thepatella femoral joints.MATERIALS AND METHODOLOGYSTUDY DESIGNCross sectional studySTUDY SETTINGThis study was conducted at Physiotherapy Instituteof Ahmedabad. All the patients were referred fromOrthopedic Out patient Department of V.S Hospital,Ahmedabad.SAMPLE SIZE: 25 Subjects in each groupSUBJECTS: Male and Female with clinicaldiagnosis of PFPS who were referred to physiotherapyOPDINCLUSION CRITERIA1) Age between 25-40 year2) Anterior knee pain more than 1 month3) Knee pain atleast 2 of the following activitiesAscending stairsDescending stairsSquattingKneeling4) Diagnostic tests were positive for PFPS5) Subjects willing to participate in studyEXCLUSION CRITERIA1) Any trauma around knee joint2) Any previous surgery around knee joint3) Neurological disorder4) Skin abrasion around knee5) Previous physiotherapy taken in past 6 months forknee29. Nishant--148-153.pmd 2/7/2013, 8:08 PM149
  • 156. 150 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1MATERIALS USED IN STUDYElectrode, electrode gel, goniometer, measure tape,micro pore, plinth, consent form, Pencil, Papersassessment charts and recording sheets.APPARATUS USED IN STUDYEMG Machine with Neuro Perfect Plus SoftwareComputer System with printerOUTCOME MEASURESEMG amplitudeQ- Angle: static and dynamicPROCEDURETwenty five subjects diagnosed with PFPS on thebasis of clinical examination and referred fromorthopedic OPD, and 25 asymptomatic controls wererecruited for the study. Subjects were selected on thebasis of inclusion and exclusion criteria. Detailedassessment of patients with diagnostic tests for PFPSand radiological examination was done. All subjectswereprovidedwritteninformedconsent.Thenpatient’sdata was entered to EMG programme (Neuro Perfectplus Software) in computer. Then EMG surfaceelectrodeswithgelwereplacedovertheselectedmuscle.Micropore tape was used to adhere the electrodes onskin.EMG parameters were SWEEP -10ms, SENSITIVITY100micro volts, LOW CUT 100Hz, HIGH CUT 5 KHz,PULSE/ SEC- 1, PULSE WIDTH-0.02msVMO placed over the muscle belly approximately 4cm superior to and 3 cm medial to the superomedialpatellar border and oriented 55 degrees to vertical. [19](Fig 2)EMG amplitude was recorded during ISOMETRIC,CONCENTRIC and ECCENTRIC exercises.EMG MUAP Amplitudes were identified fromindividual trials and averaged over the 5 repetition.After that electrodes were removed and placed forVL muscle and MUAP amplitude was recorded duringabove described three exercises.The electrode for VL was placed 10 cm superior and6-8 cm lateral to the superior border of the patella, andoriented 15 degrees to vertical. [19](Fig 1)Averaged EMGAmplitude was taken for both VMOand VL and then VMO/VL ratio was calculatedmanually.Static and Dynamic Q-angle was measured for bothgroups. For static Q-angle measured with knee in fullextension with subject in supine position. ASIS (anteriorsuperior iliac spine), centre of patella and tibialtuberosity was marked with pencil. The angle formedby the intersection of line from ASIS to centre of patellawith centre of patella to tibial tuberosity was measuredin degrees with universal goniometer. [Fig-3]Dynamic Q-angle was measured with staticquadriceps contraction in supine position with kneeextended. Procedure of measurement was same as forstatic Q-angle.VL electrode placementFig. 1. VMO electrode placementFig. 2. Q-angle measurement29. Nishant--148-153.pmd 2/7/2013, 8:08 PM150
  • 157. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 151RESULTSIn this study all the tests were performed manuallyas well as with the use of Graph pad software.To analyze the value of static and dynamic Q-anglewithin the groups for control and PFPS groups pairedt-test was used, as the data is normally distributed.To analyze the static Q-angle between groups mann-whitney U-test was used as the data is non parametric.To analyze the dynamic Q-angle between groupsmann-whitney U- test was used as the data is nonparametric.To analyze the value of VMO/VL ratio betweencontrol and PFPS groups during isometric exerciseunpaired t-test was used, as the data is normallydistributed.To analyze the value of VMO/VL ratio betweencontrol and PFPS groups during concentric exerciseunpaired t-test was used, as the data is normallydistributed.To analyze the value of VMO/VL ratio betweencontrol and PFPS groups during eccentric exerciseunpaired t-test was used, as the data is normallydistributed.Table-1 Age distribution of both group patientsGroups Mean SDControl 32.56 5.324Experimental 33.12 4.825The mean age of the control group was 32.56 ± 5.324and in the PFPS patients, the mean age was 33.12 ±4.825 No significant difference was seen across the twogroups.Fig. 3Table 2. Comparison of static and dynamic Q-angle in PFPS patientsQ-angle mean SD Test used t-value p-value significanceStatic 16.12 2.789 paired t-test t=3.663 P=0.0006 ExtremelysignificantDynamic 19.52 3.709Here the paired t-test was used as the data is normally distributed. Mean value for static and dynamic Q-anglewere respectively 16.12 ± 2.789 and 19.52 ± 3.709. t=3.663 and p=0.0006 so the difference was extremely significantat 95% confidence interval.Table -3 Comparison of static and dynamic Q-angle in control groupQ-angle mean SD Test used t-value p-value significanceStatic 14.36 3.390 paired t-test t=0.8088 P=0.4272 Not significantDynamic 15.12 3.321Here the paired t-test was used as the data is normally distributed. Mean value for static and dynamic Q-anglewere respectively 14.36 ± 3.390 and 15.12 ± 3.321. t=0.8088 and p=0.4272 so the difference was not significant at95% confidence interval.Table -4 Comparison of static Q-angle in PFPS and control groupsQ-angle mean SD Test used U-value p-value significancePFPS 16.12 2.789 Mann whitney U= 210 P=0.0475 Considered significantU testControl 14.36 3.390Here the Mann Whitney U test was used as the data is non-parametric. Mean value of static Q-angle for controland PFPS groups respectively were 16.12 ± 2.789 and 14.36 ± 3.390. Difference was significant at 95% confidenceinterval.29. Nishant--148-153.pmd 2/7/2013, 8:08 PM151
  • 158. 152 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Table -5 Comparison of dynamic Q-angle in PFPS and control groupsQ-angle mean SD Test used U-value p-value significancePFPS 19.52 3.709 Mann whitney U= 120.50 P=0.0002 Extremely significantU testControl 15.12 3.321Here the Mann Whitney U test was used as the data is non-parametric. Mean value of static Q-angle for controland PFPS groups respectively were 19.52 ± 3.709 and 15.12 ± 3.321. Difference was significant at 95% confidenceinterval.Table 6. Comparison of VMO/VL ratio during ISOMETRIC exercise in PFPS and controlGroups mean SD Test used t-value p-value significanceControl 0.9260 0.0482 Unpaired t-test t=5.136 P=0.0001 Extremely significantExperimental 0.8124 0.0995Here the un paired t-test was used. Mean value of VMO/VL in control group was 0.9260 ± 0.0482 and PFPSgroup was 0.8124 ± 0.0995. t=5.136 and p < 0.0001. so the difference was extremely significant at 95% confidenceinterval.Table 7. Comparison of VMO/VL ratio during CONCENTRIC exercise in PFPS and control groupsGroups mean SD Test used t-value p-value significanceControl 0.9484 0.0300 Unpaired t-test t=4.976 P=0.0001 Extremely significantExperimental 0.8336 0.1113Here the un paired t-test was used. Mean value of VMO/VL in control group was 0.9484 ± 0.0300 and PFPSgroup was 0.8336 ± 0.1113. t=4.976 and p < 0.0001. so the difference was extremely significant at 95% confidenceinterval.Table -8 Comparison of VMO/VL ratio during ECCENTRIC exercise in PFPS and control groupsGroups mean SD Test used t-value p-value significanceControl 0.9505 0.0374 Unpaired t-test t=7.457 P=0.0001 Extremely significantExperimental 0.8126 0.0844Here the un paired t-test was used. Mean value ofVMO/VL in control group was 0.9505 ± 0.0374 andPFPS group was 0.8126 ± 0.0844. t=7.457 and p < the difference was extremely significant at 95%confidence interval.Graph 1. Comparison of mean of VMO/VL ratiobetween control and experimental groupsCONCLUSIONThis is a cross sectional study comparing the VMO/VL ratio and Q-angle in PFPS and control groups on 50total subjects.There was a statistically significant difference inVMO/VL ratio between control and PFPS subjectsduring ISOMETRIC, CONCENTRIC and ECCENTRICexercise, so null hypothesis was rejected andexperimental hypothesis was accepted.There was a statistically significant difference instatic and dynamic Q-angle in both groups. Static anddynamic Q-angle value was higher in PFPS patients.ACKNOWLEDGEMENTSI would like to thank Dr Nehal shah (PG teacher)and I am grateful to all my patients for their kindcooperation and willingness to participate in this study,without whom this study would not have materialized.29. Nishant--148-153.pmd 2/7/2013, 8:08 PM152
  • 159. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 153Conflict of Interest : NilREFERENCES1. Baquie P, Brukner P: Injuries presenting to anAustralian sports medicine centre: A 12-monthstudy. Clin J Sport Med 1995;7:28–312. Fulkerson JP, Arendt EA: Anterior knee pain infemales. Clin Orthop 372: 69–73, 20003. Wilk KE ,Davies GJ, Mangine et al: patella femoraldisorder, A classification system and clinicalguidelines for non-operative rehabilitation ,jorthop physiotherapy 1998,28 : 307-22.4. Powers CM , Mortensons , Nishimoto d,Simon D :criterion relaterd validity of clinical measurementto determine medial/lateral component of patellaorientation, J orthop sports phys ther 1999; 29 :372-3775. Salaki N,Luo Z-P,Rand JA,An K-N: The influenceof weakness in thei. vastus medialis oblique muscle on the patellafemoral joint: an vitroii. biomechanical study.clin biomech 2000;15:335-339.6. Mirzabeigi E,Jordan C,Groneley JK et al: Isolationof vastus medialis oblique muscle during exercise.Am J Sports Med 1999; 27: 50-537. Natri A, Kannus P, Jarvinen M. Which factorspredict the longterm outcome in chronicpatellofemoral pain syndrome? A 7-yr prospectivefollow-up study. Med Sci Sports Exerc 1998; 301572-7.8. Blond L, Hansen L. Patellofemoral pain syndromeinathletes:a5.7yearretrospectivefollow-upstudyof 250 athletes. Acta Orthop Belg 1998;64:393-4009. Garrick JG: Anterior knee pain (chondromalaciapatella). The physian and sports Medicine, 1989,17: 75-84.10. Powers CM, Landel DR perry J:timing andintensity of vastus muscle activity duringfunctional activities in patients with and withoutpatellofemoral pain.Phys Ther,1996,76:946-95511. Miller JP,Sedory D,Croce RV:vastus medialisobliquus and vastus lateralis activity in patientswith and without patellofemoral pain syndrome.Jsports Rehabil,1997a,6:1-10.12. Voight M, Weider D. Comparative reflex responsetimes of the vastus medialis and the vastuslateralis in normal subjects and subjects withextensor mechanism dysfunction. Am J SportsMed 1991;10:131-7.13. Witvrouw E, Sneyers C, Lysens R, Victor J,Bellemans M. Reflex response times of vastusmedialis oblique and vastus lateralis in normalsubjects with patellofemoral pain syndrome. JOrthop Sports Phys Ther 1996;24:160-5.14. Braddom R. Physical medicine and rehabilitation.In: Casazza B,Young J, editors. Musculoskeletaldisorders of the lower limbs 2nd ed. Philadelphia:WB Saunders; 2000. p 834-7.15. Bechman M, Craig R, Lehman RC. Rehabilitationof patellofemoral dysfunction in the athlete. ClinSports Med 1989;8:841-60.16. Selina Lm Yip et al; Biofedfback supplementationto physiotherapy programme for rehabilitation ofpatellofemoral pain syndrome: ClinicalRehabilitation, Vol. 20, No. 12, 1050-1057 (2006)17. Wild J , franklin T,woods W.patellar pain andquadriceps rehabilitation : an EMG study.Am Jsports Med .1982; 10:12-1518. Moller B, krebs B, Tidermand Dal c,aaris k,isometric contractions in the patella femoral painsyndrome.arch orthop trauma a surg,1986: 105:24-2719. Lam PL,Ng GYF: Activation of quadriceps muscleduring semisquatting with different hip and kneepositions in patients with anterior knee pain. AmJ Phys Med Rehabil,2001,80:804-80829. Nishant--148-153.pmd 2/7/2013, 8:08 PM153
  • 160. 154 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1A Study to Check Added effects of Electrical Stimulationwith Task Oriented Training in Hand Rehabilitationamong Stroke PatientsParas JoshiAssistant professor, Shree K K Sheth Physiotherapy College, RajkotABSTRACTBack ground: stroke patients are having variety of disable functions, including limited hand functionswhich has key role to do activities of daily living.Objective: To determine the added effects of electrical stimulation combined with task oriented trainingin stroke patients.Methods: 30 subjects were selectively divided in to two groups. Group A received Eletrical stimulationwith Task oriented training while Group B received only task oriented training. Outcome measureswere grip strength, Box and Block test, 9 hole peg and ROM.Findings: statistical significant difference found for all the variables used in methods in between thegroups.Conclusion: Electrical stimulation with task oriented training improves hand functions more effectivelycompared to only task oriented training in stroke patients.Keywords: Electrical Stimulation, Task Oriented Training, Hand RehabilitationINTRODUCTIONStroke is an acute onset of neurological dysfunctiondue to an abnormality in cerebral circulation withresultant sign and symptoms that correspond toinvolvement of focal areas of the brain. The termcerebrovascular accidents (CVA) are usedinterchangeably with stroke to refer to thecerebrovascular conditions that accompany eitherischemic or hemorrhagic lesions. To be classified asstroke,focalneurologicaldeficitsmustpersistforatleast24 hours. 1Stroke is the third leading cause of death inindustrialized countries and the leading cause of adultdisability. Half of all stroke survivors are left with majorfunctional problems in their hands and arms.2Although initial neurological loss in arm is generallythought to be predictive factor for overall recovery ithas been reported that the recovery of the upperextremity function is independent of the overall level ofstroke severity. 3Numerous studies have suggested that electricalstimulation improve muscle strength motor controlrange of motion and reduced the spasticity of pareticlimb 4, 5Electrical stimulation of spastic wrist flexor muscleswas compared with passive stretch of wrist flexor byking who reported a significantly greater effect ofelectrical stimulation on flexor spasticity.6Howeveralfier10stated that “no direct stimulus must be allowedto reach spastic muscle” and he reported a reduction inflexor spasticity after electrical stimulation of extensormuscles.Electrical stimulation at wrist in combination withother rehabilitation strategies can result in increase gripstrength and improve motor function.7The exact mechanism underline the action ofelectrical stimulation has not been elucidated butneurophysiologic models produce arguments in favorof each strategy improvement in extensor musclestrength through electrical stimulation of extensor30. Paras Joshi--154-159.pmd 2/7/2013, 8:08 PM154
  • 161. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 155might provide sufficient power to overcome flexorspasticity.8Its central tenet is the idea that the interactingsystems within the CNS are organized around essentialfunctional tasks and the environment in which the taskis performed. Thus an understanding of tasks, theessential elements within each task, and theenvironment is key to understanding and promotingmotor control. This approach is also based on the theorythat action system within the CNS are organized tocontrol function9.Patients are instructed to practice those tasks thatpresent difficult for them, and to practice them invarying environments. Different strategies may be usedby the different individual and should be allowed ifthey achieve the desired functional outcome.11So the aim of this study was to check the addedeffects of electrical stimulation combined with taskoriented training in hand rehabilitation in strokepatients.METHOD AND MATERIALSStudy design: Experimental study.Sampling technique: Purposive samplingtechnique.Samples: A total of 30 subjects were included fromK K Sheth Physiotherapy center, Rajkot andsurrounding the city in 2 years framework.Prior to participation in study the subjects wereexplained about the procedure of physiotherapeutictreatment with therapeutic electrical stimulation of themuscle and task related training. Informed consent wasobtained from all the subjects.Inclusion Criteria• Unilateral ischemic stroke• Grade 4 or 5 Brunnstrom assessment scale• MMT of muscle around the shoulder and elbowjoint minimum grade 3• Above 40 years of age, both the sexesExclusion Criteria• Sensory impairment• Chronic stroke patients. (> 1 year of stroke)• Uncontrolled blood pressure• Severely impaired cognition and communication• Traumatic brain injury• Clinical evidence of limited joint range of motion ofwrist joint• Clinical evidence of shoulder subluxationThe 30 subject selected were randomly divided intothe group (group A and B of 15 each).Group AFifteen subjects received electrical stimulation alongwith task related training.Group BFifteen subjects received only task related training.Subjectswerekeptblindaboutthedifferenttreatmentprotocols for two groupsMeasurements for grip strength was taken by handheld dynamometer and hand functions were taken byBox and block test12, 9 hole peg test13, wrist extensionand radial deviation pre intervention(baseline) and postintervention (4thweek)Experimental procedureElectrical stimulation technique: The researcherhimself performed the electrical stimulation of wristextensor. Subjects were seated in straight backed chairwith the feet flat on the floor. Subject was seated next tothesupportedsurfaceandtheforearmrestonsupportedsurface. The wrist remains freely suspended at the edgeof the plinth to allow for movement due to electricalstimulation.The bipolar electrode placement was used to delivera motor level stimulus to the wrist and finger extension.One electrode was placed over the lateral epicondyle ofhumerus and active electrode was placed distally onwrist and finger extensor (extensor carpi radialis longusand bravis, extensor carpi ulnaris, extensor digitorumcommunis). The electrode skin coupling medium wasan electrolytic gel. To fix the electrodes elastic Velcrostraps were used.The stimulus was provided by an electricalstimulation (vectorstim) providing a maximum outputintensity of 50 MA. This stimulator operated on preprogrammed protocols which were enlisted in the usermanual provided by the manufacture. The researcherused protocol for the experimental group A protocol no14 (50 HZ) was employed for stimulation of wrist and30. Paras Joshi--154-159.pmd 2/7/2013, 8:08 PM155
  • 162. 156 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1finger extensor. The intensity was gradually increasedas per the tolerance of each subject, achieving themaximal intensity to produce motor response.Electrical stimulation parameters• type of current : short interrupted direct current(faradic)• waveform: monophasic• current modulation: surged• pulse duration: 0.7ms• inter pulse duration:19 ms (50 hz)• surge duration: 0.07ms• inter surge duration:3ms• on/off time:0.5 sec/3 sec (1:6)• intensity : as tolerated by patients• Duration of treatment: 30 min/dayTreatment was given for 5 days in a week to eachsubject for 4 weeks.TASK RELATED TRAINNINGSubjects were asked to identify daily activities thatcould be difficult to perform and that they would like toimprove.The four or more of the following tasks wereadministered / trained for the subjects.• manipulate tools for specific purpose ( tooth brush,comb ,knife, fork, coin, clothpin ,button)• Grasp and release the different objects, or differentshapes, sizes.• Transport an object from one place to another.• Subjects were asked to lift glass up and to lower itwithout loosing control at his wrist.Goalistopushtheglassalongthetablebyextendingwrist with forearm in mid position.• Subjects were asked to practiced picked uppolystyrene cup around the rim without deformingit between thumb and each finger.• Peg board exercises.Subjects performed their most difficult exercise for10 repetitions each. Unsuccessful attempt was notcounted; however a subject is advised to change theexercise if he/she is not able to do at al.Treatment was given for 5 times in a week for 4weeks.Paired an unpaired t tests were used for thestatistical analysis.FINDINGSTable I. Comparison of Strength scores within Group A and within Group BGroup Intervention N Mean Standard t- value Level ofPeriod Deviation significanceA Pre 15 7.84 1.62 8.98 SS SS at p < 0.05Post 15 9.46 1.50B Pre 15 7.79 1.62 8.93 SS SS at p < 0.05Post 15 8.81 1.40Graph 1. The female count in group A was 5 (33%)and that of the group B was 6 (40%). The male count ingroup A was 10 (67%) and that of the group B was 9(60%). The total count of females in this study was about11 (36%) and male was about 19(63%). The total countof male and female subjects in this study was about 30(100%).30. Paras Joshi--154-159.pmd 2/7/2013, 8:08 PM156
  • 163. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 157Table II. Comparison of Box ‘N’ Block and 9 Hole Peg Test Scores within Group A and within Group BGroup Variables Intervention N Mean Standard t- value Level ofPeriod Deviation significanceA Box ‘N’ Block Pre 15 16.53 2.41 17.83 SS SS at p < 0.05Post 15 19.27 2.219 Hole Peg Test Pre 15 2.04 .33 11.50 SS SS at p < 0.05Post 15 1.78 .30B Box ‘N’ Block Pre 15 16.80 2.24 7.17 SS SS at p < 0.05Post 15 18.47 2.039 Hole Peg Test Pre 15 2.08 .31 14.10 SS SS at p < 0.05Post 15 1.99 .31Table III. Comparison of Wrist Extension and Radial Deviation Scores within Group A and within Group BGroup Variables Intervention N Mean Standard t- value Level ofPeriod Deviation significanceA Wrist extension Pre 15 26.93 2.46 13.25 SS SS at p < 0.05Post 15 30.07 2.63Radial deviation Pre 15 5.80 1.01 11.37 SS SS at p < 0.05Post 15 7.87 .91B Wrist extension Pre 15 27.20 2.51 8.08 SS SS at p < 0.05Post 15 29.00 2.29Radial deviation Pre 15 7.13 1.06 4.58 SS SS at p < 0.05Post 15 7.73 .79Table IV: Comparison of Change in Strength, Box ‘N’ Block , 9 Hole Peg Test , Wrist Extension and Radial Deviationscores across the Intervention Period between Group A and Group BChange in Variable Group N Mean Standard t-value Level ofbetween Pre & Post Difference deviation significanceInterventionChange inStrength A 15 1.62 .69 2.81 SS SS at p < 0.05B 15 1.02 .44Change in Box‘N’ Block A 15 2.73 .59 3.83 SS SS at p < 0.05B 15 1.67 .90Change in9 Hole Peg Test A 15 .26 .08 7.67 SS SS at p < 0.05B 15 .08 .02Change in Wrist Extension A 15 3.13 .91 4.11 SS SS at p < 0.05B 15 1.80 .86Change in Radial Deviation A 15 2.07 .70 6.55 SS SS at p < 0.05B 15 .60 .50SS: Statistical significantGraph 1. The female count in group A was 5 (33%)and that of the group B was 6 (40%). The male count ingroup A was 10 (67%) and that of the group B was 9(60%). The total count of females in this study was about11 (36%) and male was about 19(63%). The total countof male and female subjects in this study was about 30(100%).DISCUSSIONWithin the two groups, both electrical stimulationcombined with task related activity ( groupA) and taskrelated activity alone (group B ) proved to be effective.This was reflected in the pre intervention and postintervention measurements of grip strength, box andblock test, 9 hole pack test and active wrist extensionand radial deviation range of motion.However between group comparisons of meanscores of wrist extension and radial deviation ( AROM), grip strength , box and block test , 9 hole peg test – subscores and total percentage showed that subjectsreceiving electrical stimulation combined with taskrelated training ( group A) had clinically and30. Paras Joshi--154-159.pmd 2/7/2013, 8:08 PM157
  • 164. 158 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1statistically significant improving in wrist extensionand radial deviation ( AROM) grip strength , box andblocktest,9holepegtest–subscoreandtotalpercentagewhen compared to subjects receiving task relatedtraining ( group B) across base line and 4thweek(table ) (p<0.05).Electrical therapy has been applied as a therapy inhumans with central nervous system (CNS) injuriesalthough there is no conclusive direction as to whichtechnique works the best for a given indication. Thereare convincing studies available to show that electricalstimulation can strengthen atrophied muscles, changein muscles property, increase the muscle bulk, andimprove the circulation and the change in themetabolism.10There is evidence that repetitive active movement,mediated by neuromuscular stimulation can enhancemotor relearning after CNS damage. The additionalcomponent of movement provides augmented sensoryfeedback and propioceptive afferent stimulation. Thereis reorganization of cortical representations for bodyparts basal upon the afferent input that they contributeas well as the amount of motor activation they undergo.With electrical stimulation there is evidence that itequally influence this reorganization. This can be highlyadvantageous in limbs that are impaired to such adegree that a voluntary movement could be impossible.Because of significant amount of hemiparesis that iscaused by stroke, the use of electrical stimulation togenerate movement provides the means of inducingpositive motor changes associated with motion.16Cauraugh14et al focused on less severely affectedsubjects, like those in the present trial spasticity werenot assessed; they reported improvement in sustainedcontraction of wrist extensor muscles and in function(box and block test) but no effect on motor control. Fromthe publication, it is not clearly whether there was nogain in motor control or no difference in gain. In a lettertrail function improvement was confirmed but theclinical relevance of this improvement was notdiscussed. In this study it seems that functionalimprovement can be clinically relevant for subjects.People with a brain injury have deficit in motorprogrammes, motor memory and associated feedbackand feed forward mechanism, which largely impedetheir functional performance. 14The motor relearningapproach promotes the regaining of normal motor skillthrough task oriented training with appropriatefeedback and the active participants of the patients. Inthisstudy,themotor relearningprogramwasstructuredin such a way that patient had ample opportunity togain this experience. First the patients were involved inidentifying their own problems in performance. Theseproblems are called the missing performancecomponent. The selection of task used for training wasmeant to target those missing performance componentstraining in the functional tasks followed through onthe same missing components. The incorporation ofthisstrategyturnedtheprogrammeintoaclientcenteredintervention. The training thus become moreanticipatory for the patients and hence was more self-initiated,targetedandeffective.15Limitationofthestudywas absence of control group; neither patients nor thetherapist were blinded.CONCLUSIONBoth electrical stimulation along with task orientedtraining and only task oriented training were useful toimprove hand functions.Electrical stimulation with task oriented trainingimproves hand functions more effectively compared toonly task oriented training in stroke patients.ACKNOWLEDGEMENTI am sincerely thankful to Dr Saralaben Bhatt,Principal K K Sheth Physiotherapy College, Rajkot fortheir guidance and supportREFERENCES1. Susan B. O’Sullivan, Thomas Schmitz. Physicalrehabilitation: assessment of treatment2. Hacke W, Kaste M,Olsen TS ,orgogozo JM,Bbogousslavsky j.empfehlumg der europaesschenschjaganfall initiative zur versorgumg andbehandlung des schlaganfalls.intensivmed2001;38:454-703. Wade DT, Langeton-hewer R et al; The hemiplegicarm after stroke :measurement and recovery . J.neurol. Neurosurg. Psychetric. 1983;46:521-244. Glanz M, Klawansky S ,et al; functional electricalstimulation In post of rehabilitation : a metaanalysis of randomized control trials .arch physmed rehabil 1996;77:549-535. JR de Kroon,J H Van der lee et al;theraputicselectrical stimulation to improve motor functionalabilities of the upper extremity after stroke clinicalrehabili .2002;16:350-606. King TI: The effect of neuro muscular electricalstimulation in reducing j occupation ther1996; 50:62-647. Joanna Powell, MCSP; A. David Pandyan,et al;Electrical Stimulation of Wrist Extensors in30. Paras Joshi--154-159.pmd 2/7/2013, 8:08 PM158
  • 165. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 159Poststroke Hemiplegia; Stroke. 1999; 30:1384-1389.)8. De Kroon JR, Ijzerman MJ, Lankhorst GJ, ZilvoldG.:electrical stimulation of upperlimb instroke:stimulation of extensors of the handvs.alternate stimulation of flexors 2004;83:592-6009. Green p:prombles of organization of motor system.In Rosan R,and Snell:Progress in theoreticalbiology. Academic press.San Diego 1972.p 30410. Alfieri V: Electrical treatment of spasticity Scand JRehabili med. 1982;14:177-8211. Horak ,F:Assumptions underlying motor controlfor neurologic rehabilition .In :contemporarymanagement of motor control problems.proceedings of the 2 step conference. APTA,Alexandri 199212. Desrosiers J, Bravo G, Hébert R, Dutil E, MercierL.ValidationoftheBoxandBlockTestasameasureof dexterity of elderly people: reliability, validity,and norms studies. Arch Phys Med Rehabil. 1994Jul;75(7):751-5.13. Mathiowetz, V., Kashman, N., et al. (1985). “Gripand pinch strength: normative data for adults.”Arch Phys Med Rehabil 66(2): 69-7414. Chronicmotordysfunctionafterstroke:recoveringwrist and finger extension by electro myographytriggered neuro muscular stimulation .Stroke 2000June ;30 (6) :1360-136415. Catherine M . Dean, Carol L. Richards et al .Taskrelated circuit training improves performance oflocomotor task in chronic stroke : a randomizedcontrolled pilot trial .arch phy med rehab2000;81:409-1716. N M Salback, N E Mayo et al.A task orientedintervention enhances walking distance andspeed in the 1 st year post stroke : a randomizedcontrolled trial.Clinical rehab 2004 ;18:509-51930. Paras Joshi--154-159.pmd 2/7/2013, 8:08 PM159
  • 166. 160 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Relationship of Cognition, Mobility and FunctionalPerformance to Fall Incidence in Recovering StrokePatientsParas Joshi1, Hardik Trambadi21Lecturer, Shree K K sheth physiotherapy college, Rajkot, 2Lecturer, Parul institute of Physiotherapy, VadodaraABSTRACTBackground: People with stroke are at risk of falls. The majorities of individual with stroke has somedegree of residual impairment, but regain walking ability and will be discharged home. Three quartersfell in the first six month after their discharge from hospital. Identify increased knowledge of incrementalrisk factors for falling and the assumption that some of the identified risk factors can be modified maylead to development of intervention to reduce number of fallsObjective: To explore the relationship between cognition, mobility and functional performance withrespect to fall incidence in recovering stroke patients.Methods: 110 subjects with stroke completed the study. Subjects were assessed on the basis of cognition,mobility and functional performance during 4th week after stroke incidence. Information regardingnumber of falls and characteristic of fall gained during a personal interview after six month fromstroke. Number of falls correlated with baseline scores.Findings: There is a significant good correlation found between cognition, mobility, and functionalperformance to number of falls in recovering stroke patients.Conclusion: Cognition, mobility and functional performance might contribute to fall risk and fallrelated injuries in recovering stroke patients.Keywords: Stroke, Fall Incidence, Cognition, Mobility, Functional Performance.INTRODUCTIONStroke is an acute onset of neurological dysfunctiondue to an abnormality in cerebral circulation withresultant sign and symptoms that correspond toinvolvement of focal areas of the brain. The termcerebrovascular accidents (CVA) are usedinterchangeably with stroke to refer to thecerebrovascular conditions that accompany eitherischemic or hemorrhagic lesions.1Stroke is the mostcommon cause of chronic disability.2People with strokeare at risk of falls.3,4The majority of individuals withstroke will have some degree of residual impairment,but will regain walking ability and will be dischargedhome following hospitalization. Although impairmentiscommon,mostpeoplewithstrokewillregainwalkingability; however poor balance and impaired gait canpersist. 5Studies reported that patients with stroke threequarters fell in the first six months after discharge fromhospital. Stroke patients in acute care and rehabilitationare at high risk of falling and remain a high-risk groupof the first few months after they are discharged tohome. 6-10Apart from age, osteoporosis, previousfractures, and falls are independent risk for hipfractures.10Side of the fracture is positively correlatedwith the side of hemi paresis. 11Patients with stroke have up to a 4 fold increasedrisk of hip facture because of their high incidence offalls.12It has been shown that stroke patients in additionhave reduced bone mass in their paretic extremities,that this development of hemi osteoporosis is extensiveand pronounced, and that begins early after strokeonset.13Furthermore, stroke has proved to be a factor for hipfracture among women in case control study14, andsubjects with previous strokes have been overrepresented in a sample of femoral neck fracturepatients.15Stroke has a relative high risk for falling. Increasedknowledge of incremental risk factors for falling andthe assumption that some of the identified risk factors31. paras joshi--160-164.pmd 2/7/2013, 8:08 PM160
  • 167. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 161can be modified may lead to development ofintervention to reduce number of falls.16,17Fall incidencerates between 23% and 50% have been reported instudies of people with chronic stroke (> 6 months poststroke). 18-21This rate is much higher than rates reportedfor older community dwelling adults without stroke(11%-30%). 22-24but lower than rates for people with subacute stroke (1-6 months post stroke) (25%).25Injury is afrequent consequences of falls in people with chronicstroke, with up to 28% reporting an injury.19Studies shown that cognitive deficit 18,21,26functionalimpairments26and impaired balance 7,26are related tofall history in people with acute stroke.25Andcognition18, balance impairment18and ADL19,21–increased fall risk in people with chronic stroke.The identification of fall- prone stroke patients is ofgreat importance. The issue has already been studiedto some extent, and a number of risk factors have beensuggested.27Postural sway8, increased motor response time tovisual stimuli28, and right ward orienting bias amongright hemisphere stroke patients29have been associatedwith an increased fall risk.A multi factorial case control study concluded thata history of falls, impaired decision making ability,perceptual impairment, restlessness, generalizedweakness and abnormal hemocritic level wereindependent fall risk factors among stroke patients inacute care.29,30Studies shown that 37% stroke survivors reportedat least one fall during the first six months after theirstroke. Among whom those fell, 37 percent suffered aninjury that require medical treatment, and 8 percentsuffered a fracture. Among those who fell, about halffell only once, but 12 percent fell more than five times.The study also found that 77 percent of patients fell athome.31Study showed that cognition, mobility andfunctional daily activity tend to decline after stroke. 31The purpose of this study is to correlate thecognition, mobility and functional performance to fallincidence in recovering stroke patients.OBJECTIVES OF THE STUDYTo explore the relationship between cognition,mobility and functional performance with respect tofall incidence in recovering stroke patients.HYPOTHESISNull hypothesis (H0): There will be no significantrelationship existing between cognition, mobility,functional performance with respect to fall incidenceamong recovering stroke patients.Alternate hypothesis (H1): There will be asignificant relationship existing between cognition,mobility, functional performance with respect to fallincidence among recovering stroke patients.MATERIALS AND METHODA Prospective observational study was used withpurposive heterogeneous sampling technique.One hundred and eighteen people with stroke wererecruited on a voluntary basis from vadodara city andsurrounding villages between oct 2009 to may 2011A written consent was sought from subjectsparticipating in the study.Selected one hundred and eighteen subjects met theestablished criteria and one hundred and ten (77 maleand 33 female) out them completed the study. Fivesubjects got an addition stroke and three of them weredied.Subjects who were already diagnosed as stroke byphysician participated in the study. Subjects of bothsexes and either side of paresis, fulfilling the criteriawere taken for the study.Inclusion Criteria1. Above 50 years of age.2. With ability to walk 8m (with assistive device, ifrequired).3. Deemed to be fit for the study and mentally stable.Exclusion Criteria1. Major musculoskeletal problems (e.g. amputationor recent joint replacement surgery).2. Neurological disorder in addition to stroke.3. More than one attack of stroke during study period.4. Perceptual disorders.5. Sever communication problem.EXAMINATIONPatients were assessed on the basis of cognition,functional performance and mobility during 4thweekafter stroke incidence.Cognition, Mobility and Functional performancewere assessed by Mini Mental Status Examination(MMSE), Performance Oriented Mobility Assessment(POMA) and Barthel Index respectively.31. paras joshi--160-164.pmd 2/7/2013, 8:08 PM161
  • 168. 162 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Patients and caretakers were asked to maintain thechart for recording the number of falls, side of fall andinjury if any during the study period.Patients were informed that a fall was defined ascoming to rest on the floor or another lower level butwas not due to seizures, stroke or myocardial infraction,or an overwhelming displacing force (e.g. earthquake.)Number of falls recorded between one month poststroke to six month post stroke (20 weeks).Information regarding number of falls andcharacteristic of falls were gained during a screeninginterview with the patient, six month after stroke.Assessment for the baseline score and interview forthe number and characteristics of falls were done bydifferent individuals.Numbers of falls were correlated with the baselinescoresFINDINGSTable 1. Gender distributionMales 77Females 33Subjects participated in the study with mean age of66.91±7.14. Pearson’s correlation coefficient was usedto determinetherelationship amongcognition,mobilityand functional performance in relation to occurrenceof falls. P value was kept at 0.01 for statisticalsignificance. SPSS software was used for the statisticalsignificance.Table 2. Variable analysisVariable N Mean Standard Pearson’s Correlation Level ofDeviation Coefficient significanceNumber of Falls 110 3.0 2.19 — —MMSE 110 23.57 2.47 -0.76 SS at 0.01statistically significantPOMA 110 21.73 4.33 -0.75 SS at 0.01statistically significantBI 110 74.25 8.15 -0.64 SS at 0.01statistically significantTable 3. Characteristics of subjects participated in the studyRight Side Hemiparesis, 45% Left side hemiparesis, 55%Using walking devices, 65% Independent Walking, 35%Fallers, 67% Non fallers, 33%Fall on hemiplegic side, 60% Fall on non hemiplegic side, 7%Reported serious injuries which required medical treatment, 17% Injuries required no medical intervention, 50%Reported Fracture because of fall, 11% Fall without fracture, 56%1 Fall during study period, 45% More than 1 fall, 22%DISCUSSIONMost of the patients with stroke are prone to fallincidence during recovery stage. The purpose of thisstudywastodeterminewhethercognition,mobilityandfunctional performance could explain falls inindividual with recovering stroke.It has been found that falls were common occurrencein recovering stroke patients. Most of the patientsreported at least one fall during study period. Subjectswho experienced fall, most of them fell on the pareticside.In addition, fall related injuries were common,although serious injury was less frequently reported. Ithas been found that most of the falls occurred in homeduring walking activities.In this study measure of cognition, functionalperformance and mobility were clearly able to explainfalls in this population or to discriminate between thosewho had fallen and had not fallen.It has been hypothesized that MMSE, POMA andBarthel Index score would be associated with fallincidence and be a risk factor for falls in recoveringstroke patients, and result supported the hypothesis.Someauthors32havesuggestedthattherecallmethodof information gathering can produce recall bias but toavoidthatpatientswereaskedtomaintainchartinterms31. paras joshi--160-164.pmd 2/7/2013, 8:08 PM162
  • 169. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 163of calendar and similar explanation was given to thecaregivers.Comparing age as a risk factor for fall, studiesshowed that fall incidence rate is much lower in oldercommunity dwelling adults without stroke (11%-30%)than rates for people with subacute stroke (25%)4.Reason behind that is pathophysiology of stroke thatchanges the mental state dramatically.2The scales which have been used for the study areeasily applicable to the patients within short time span,having good reliability33-35and found useful tool toidentify the subject who has more chances to fallfollowing hospitalization in this study. Howevercognition, mobility and functional performance are notthe only factors responsible for fall incidence, otherfactors needed to be rule out.LIMITATIONSThe clinical information (cognition, mobility andfunctional status) collected at the time of discharge mayhave been different at the time of fall. But the studyoutcome gave the predictive information about thefuture fall incidence (i.e. six month) with thesemeasures.During the 20 weeks time frame used for fall history,participants could have experienced on illness (e.g. flu,cold) or an exacerbation or worsening of an existingcondition (e.g. arthritis, dementia) that could havenegatively influenced their functional status at the timeof fall(s). In contrast, participants might have been inworse physical or mental condition at the time ofexamination that at the time of the fall(s).Fallers who had fractures (11%) must have hadreduce mobility and affected the mobility componentand functional performance (our baseline scores)With increasing age the cognition, functional statusand mobility level tend to decline, however stroke canworsen the mental status dramatically. Factors such asvestibular function, sensation, perception and homeenvironment have not been assessed in this populationin relation to fall risk.Clinical implicationCognition, mobility and functional status level areable to explain the number of falls.MMSE, POMA I and Barthel Index are easilyapplicable tools and can be applied within minutes.Patients with relative low scores can be advised to becareful or to take further inpatient rehabilitation. Hipprotectors can be given to the patients in order to avoidthe fall related injuries.Further recommendation1. Factors such as sensation, perception and homeenvironment can be included in this population.2. Combination of multiple risk factors can be checkedin relation to fall incidence.3. Correlation of the variables studied can be done instroke subjects with and without physiotherapyinterventions.CONCLUSIONMMSE, POMA and Barthel index are able to explainthe fall incidence in recovering stroke patients. There isa significant relationship between cognition, mobilityand functional performance to fall incidence.Cognition, Mobility and functional performance aresome of the factors responsible for falls in recoveringstroke patients, and might contribute to fall and fallrelated injuries.ACKNOWLEDGEMENTSincere thanks to Dr Praful Bamrotia for helping usin data collection.REFERENCES1. Susan B. O’ Sullivan, Thomas Schmitz. PhysicalRehabilitation: 5thEdition.2. Wolf, C: The impact of stroke. Br Med Bul. 2000;56: 275.3. Post stroke Rehabilitation Guideline panel: Poststroke Rehabilitation clinical practice Guideline.Aspen, Gaitherburg, MD, 1996.4. Jocelyn E Harris et al. Relationship of balance andmobility to fall incidence in people with chronicstroke, Physical therapy. 2005; 85: 150-158.5. Jorgense HS et al. Stroke. Neurologic andfunctional recovery- the cogenhagen stroke study.Phy med rehabil clin N Am. 1999; 10: 887-9066. Anne Forster, John young. Incidence andconsequences of falls due to stroke, a systemicinquiry, BMJ. 1995; 311: 83-86.7. Nyberg L, Gustafon Y. Patients falls in strokerehabilitation: A challenge to rehabilitationstrategies. Stroke. 1995; 26: 838-842.8. Sackely CM. Falls, sway and symmetry of weightbearing after stroke. Int. Disabil Stud. 1991; 13:1-4.9. ByersVetal.Predictiveriskfactorsassociatedwithstroke patients falls in acute care settings. JNeurosci Nurs. 1990; 22: 147-154.10. Tutuarima JA, Van der Mevlen Jhet al. Risk factorsfor falls of hospitalized stroke patients. Stroke.1997; 28: 297- 301.31. paras joshi--160-164.pmd 2/7/2013, 8:08 PM163
  • 170. 164 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 111. H.C. White: Archives of orthopeadic and Traumasurgery. 1998; 107: 345- 387.12. Anna Ramnemark, Mikael Nilson et al. Stroke, amajor and increasing risk factor for femoral neckfracture. Stroke. 2003; 31: 157- 168.13. Hamdy R C, Moore SW et al. Long term effects ofstroke on bone mass. Am J Phys Med Rehabil.1995; 74: 351-356.14. Grisso JA, Kelsey JL et al. Risk factors for falls as acauseofhipfractureinwomen.NEngliMed.1991;324: 1326- 1331.15. Gustasfron Y, Brannstrom B et al. A geriatricanesthesiologic program to reduce acuteconghesional state in elderly patients treated forfemoral neck fractures. J Am Geriatic Soc. 1991;39: 655- 662.16. Ramnemark A, Nyberg L et al. Progressivehemiosteoporosis on paretic side and increasedbone mineral density in non paretic arm the firstyear after sever stroke. Osteoporos Int. 1999; 9:269- 275.17. Cahit Ugur, Demet Gucuyener et al. Chracteristicsof falling in patients with storke. J NeurologyNeuro surgery Psychiatry. 2000; 69: 649- 651.18. Jorgensen L, Engstad Tet al. Higher incidences offalls in long term stroke survivors than inpopulationcontrols.Depressivesymptomspredictfalls after stroke. 2002; 33: 542- 547.19. Lamb SE, Ferrucci L et al. Risk factors for falling inhome dwelling older women with stroke. Thewomen’s health and aging study. Stroke. 2003; 34:494- 501.20. Hyndman D, Ashburn A, Stack E. Fall eventsamongpeoplewithstrokelivinginthecommunity.Circumstances of falls and characteristics offallers. Arch Phys Med. Rehabil. 2002; 83:165- 170.21. HyndmanD,AshburnA.Peoplewithstrokelivingin the community: attention deficits, balance, ADLability, and falls. Disabil Rehabil. 2003; 25:817- 822.22. Graafmans WC, Ooms Me et al. Falls in the eldery.Aprospectivestudyofriskfactorsandriskprofiles.Am J Epidemial 1996; 143: 1129- 1136.23. Bogle Thorbahn LD et al. Use of the Berg balancetest to predict falls in eldery persons. Phy. Ther.1996; 76: 576- 586.24. Tinnetti ME, Speechley M, Ginter SF. Risk factorsfor falls among eldery persons living in thecommunity. N Engl J M ed 1998; 319: 1701- 1707.25. Stalpheton T,AshburnA, Stack E.Apilot study ofattention deficits, balance control and falls insubacute stage following stroke. Clini Rehab. 2001;15: 437- 444.26. Tea sall R, MC Rac M et al. The incidence andconsequences of falls in stroke patients duringinpatient rehabilitation. Factors associated withhigh risk. Arch Phys Med Rehabil. 2002; 83:329- 333.27. Lars Nysberg, Yngve Gustafson. Fall predictionindex for patient in stroke rehabilitation. 1997; 28:716- 721.28. Mayo NE, Lorner Bitensky N, Kaizer F.Relationship between response time and fallsamong stroke patients undergoing physicalrehabilitation. Int J Rehabil Res. 1990; 13: 47- 55.29. Webster JS et al. Rightward orienting bias, wheelchair maneuring, and fall risk. Archy Phy MedRehabil. 1995; 76: 924- 928.30. Rapport LJ et al. Predictors of falls among righthemisphere stroke patients in the rehabilitationsetting. Arch Phys Med Rehabil. 1993; 74:621- 62631. MedlinePlus.AserviceoftheU.S.Nationallibraryof medicine and the national institute of Health.15thmay 2008.32. Peeel N. Validating recall of falls by older people.Accidental Analysis and Prevention. 2000; 32:371-372.33. Marjan J Faber, et al: Clinimetric properties of thePOMA, physical therapy 2006; 86: 944-954.34. Hsuch I P, Lee M, Hsieh C L. Psychometriccharacteristics of the barthel activities of dailyliving index in stroke patients. J formas Med assoc.2001; 100 (80): 526-532.35. Folstein MF et al. Mini mental state. A practicalmethod for grading cognitive state of patients forthe clinician, J psychiatr Res 1975; 12: 18931. paras joshi--160-164.pmd 2/7/2013, 8:08 PM164
  • 171. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 165Reliability of Modified Modified Ashworth Scale inSpastic Cerebral PalsyDivya Gupta1, Pooja Sharma21Post Graduate student, Amity Institute of Physiotherapy, Amity University Uttar Pradesh, 2Assistant professor, AmityInstitute of Physiotherapy, Amity University, Noida, Uttar Pradesh,ABSTRACTBackground & Objectives: In assessment of spasticity in the pediatric population, methods used inpractice are ordinal scales that lack reliability. Being a recent scale, Modified ModifiedAshworth Scalehas not been used in pediatric population as yet. This study aimed to assess inter- and intra-raterreliability of MMAS in assessing children with spastic cerebral palsy and also compare results withthose of AS and MAS.Methods & Materials: The study included 40 children with spastic CP with mean age 7.75 yrs.Functional levels of children were classified according to the Gross Motor Function ClassificationSystem. Spasticity in wrist, elbow and knee flexors was assessed according to the AS, MAS, andMMAS.Results: Interrater reliability and intrarater reliability of MMAS varied from moderate to good.Conclusions & Interpretations: The MMAS is a reliable tool in assessing children with spastic CP andso are AS and MAS.Keywords: Spasticity, Cerebral Palsy, Ashworth ScaleCorresponding author:Pooja sharmaAssistant professorAmityinstituteofphysiotherapy,Amityuniversity,NoidaE mail: psharma1@amity.eduINTRODUCTIONCerebral Palsy is defined as a non-progressive groupof disorders of movement and posture due to a defect orlesion of the immature brain.1It can be further definedas a group of disorders of development of movement,posture and coordination with varied etiologicalassociations and much phenotypic differences in theclinical presentation.2Of the many types and subtypesof CP, none of them has a known medical cure andtreatment is mainly symptomatic .3,4One of the majormanifestations of a sufficient intra-partum compromiseof fetal cerebral perfusion include abnormal tone.However a study on the Indian population concludedthat spastic quadriplegia constituted the predominantgroup ( 61%), followed by spastic diplegia (22%).5, 6, 7Spasticity may be defined as velocity-dependentincrease in muscle tone with exaggerated stretchreflexes.8,9The nature of spasticity has prompted in arange of assessment and management techniques.Different methods of spasticity assessment includeelectrophysiological tests, electromyography, dynamicflex meter, myometer, plasticity measurement system,and pendulum test and is kinetic dynamometer.However, they have limited clinical use. Methods mostcommonly used in clinical practice are the AshworthScale, the Modified Ashworth Scale, the Tardieu Scaleand the Modified Tardieu Scale.10When using clinicalmeasures to assess spasticity, one assesses theresistance to imposed passive movement when the limbis briskly stretched through the full range of availablemovement about a joint.10The Ashworth scale wascreated in the mid-1960s by Dr Bryan Ashworth as away of judging the effectiveness of anti-spastic drugs.11It is a 5-point ordinal scale and has been usedextensively since then to assess increase in muscle tonein a range of neurological disorders. The ModifiedAshworth Scale was created in 1987 by Bohannon andSmith who introduced a 1+ grade to increase thesensitivity of the original scale thus making it a 6-pointnominal scale.12With the MAS grades of ’1’, ’1+’ and’2’ having been questioned as hierarchical levels ofspasticity, recently the Modified Modified Ashworth32. Pooja Sharma-165-169.pmd 2/7/2013, 8:08 PM165
  • 172. 166 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Scale (MMAS) was created where grade ‘1+’ wasomitted and the grade ‘2’ redefined in the MAS.13Validand reliable assessment tools are a pre-requisite inestablishing baseline functions and monitoringdevelopmental gains and also to contributing to anincreasing body of evidence-based recommendationsfor CP. 14Reliability ofAS and MAS have been found tobe poor to good as assessed in patients with variousconditions.15,16, 17 18, 19with values of MAS being slightlyhigher. The existing data suggests that the reliability ofMMAS in patients with lower-limb muscle spasticity isvery good, and it can be used as a measure of spasticityover time.20 21. Although there are studies that concludeboth AS and MAS are not reliable for the assessment ofmuscle spasticity, however experience and trainingmay improve agreement between the raters.22,23,24Thereis a need to standardize methods to apply these scalesin clinical practice and research.25, 26, 27Being a recentscale, the Modified Modified Ashworth Scale has notbeen used in the pediatric population as yet. It providesclearly defined and distinct grades to rate spasticity.Also, the other two scales i.e. AS and MAS give arguableresults over their reliabilities in the same population.The present study aims to assess and the inter- andintra-rater reliability of the MMAS in three differentmuscle groups i.e. the wrist flexors, elbow flexors andknee flexors of children with spastic CP and alsocompare the results with those of the AS and the MASwhich have already been used in the population underconsideration.METHODOLOGYSubjects with spastic cerebral palsy belonging to agegroup 4 to 14 years were recruited from Special schoolsin Delhi and NCR whose informed consent had beenattained. All subjects with history of any orthopedicsurgery , botulinum toxin injection or those on oral orintrathecal myorelaxant drugs , mentally retarded wereexcluded. The procedure was explained to the subjectsand their parents. The functional level of participantswas classified according to the expanded and revisedGross Motor Function Classification System ( GMFCS -E & R ). Each subject was assessed by two raters in twodifferent sessions randomly . Both the raters arephysical therapists who are well-versed with theprocedure of the assessment and blinded to the resultsof each other. For the inter-rater reliability componentof the study, a 30-minute interval period is addedbetween the assessments. For the intrarater reliabilitycomponent of the study, one of the raters repeated theprocedure the next day. The measurements wereperformed in a quiet environment . Subjects wore looseand comfortable clothing which did not pose anyhindrance to the passive movements. Testingcommenced five minutes after the subjects had beenpositioned. One repetition was done per joint. Thescores for AS, MAS and MMAS were determinedaccording to the level of resistance during the passivemovement of the antagonistic muscles. The musclegroupstestedwerewristflexors,elbowflexors,andkneeflexors in the same order. Each test movement wasperformed over a duration of 1 second ( by counting“one thousand one”). A separate recording sheet wasused for each session of each subject. As passivestretching is considered to affect the measurementresults, measurements were repeated once on twodifferent days of the study. To minimize thedisadvantage of stretching of the spastic muscle, faststretching was avoided. The data obtained was laterstatistical analyzed using the SPSS software.Fig. 1. Testing wrist flexorsFig. 2. Testing elbow flexors32. Pooja Sharma-165-169.pmd 2/7/2013, 8:08 PM166
  • 173. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 167Patient positioned supine on a padded mat table.The patient’s shoulder was in mid-rotation, forearm inmid-pronation and hand was in functional positionwith the distal limb held vertical. Passive movementwas achieved by the rater grasping the hand justproximal to the MCP joints . Movement was from fullflexion to full extension over one second.26Patient positioned supine on a padded mat table.The patient’s shoulder was in mid-rotation, the forearmin mid-pronation and the hand was in functionalposition. The patient’s elbow was extended passivelyfrom a position of maximal possible flexion to maximalpossible extension over a duration of about one second.The lateral aspect of the forearm was grasped distallywhile applying a constant extensor rotational forceabout the elbow. While the elbow was extended, thearm was also stabilized proximal to the elbow.26The subject was in a seated position. The distal legwas suspended vertically with the foot off the floor. Thetrunk was stabilized by means of a padded strap drawncomfortably tight around the pelvis and the hip wasstabilized by means of a padded strap comfortably tightacross the proximal legs, half-way between the kneesand the hips. Passive movement was achieved by therater grasping the posterior aspect of the distal leg justproximal to the ankle and applying a constant extensorrotational force about the knee. Movement is from 90°flexion to full extension over 1 second.26RESULTSA total of 40 children were evaluated .AS, MAS, andMMAS scores were considered ordinal and a value of1.5 for MAS were assigned to ratings of 1+ to maintainequal intervals.TABLE 1 : Mean and standard deviation of age andGMFCS levelAge ( years ) GMFCS levelMean 7.775 2.375Standard Deviation 2.823 1.147TABLE 2 : Interrater reliability of A s,MAS AND MMAS in wrist flexors, ELBOW FLEXORSAND KNEE FLEXORSAs Wrist Elbow KneeFlexors Flexors Flexors(ICC) (ICC) (ICC)Single Measures .750 .757 .359Average Measures .857 .861 .528MASSingle Measures .397 .787 .738Average Measures .569 .881 .849MMASSingle Measures .336 .866 .605Average Measures .503 .928 .754TABLE 3: Intrarater reliability of AS , MAS ,MMAs inwrist flexors, elbow flexors AND KNEE FLEXORSAs Wrist ELBOW KneeFlexors Flexors Flexors(ICC) (ICC) (ICC)Single Measures .786 .890 .379Average Measures .880 .942 .550MASSingle Measures .630 .910 .692Average Measures .773 .953 .818MMASSingle Measures .874 .986 .735Average Measures .933 .993 .847DISCUSSIONThe results of the present study are in accordancewith the existing literature which demonstrate goodinter- and intra-rater reliability for AS, MAS has goodintra- and moderate inter-rater reliability, and MMAShas good intra- and moderate inter-rater reliability inwristflexors.22,23Fortheelbowflexors,allthethreescalesAS, MAS, and MMAS have good inter-and intra-raterFig. 3. Testing Knee flexors32. Pooja Sharma-165-169.pmd 2/7/2013, 8:08 PM167
  • 174. 168 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1reliability. AS is found to be moderately reliable withMAS and MMAS highly reliable in the knee flexors forlowerlimbs.Variousfactorsmayaffectthemeasurementresults of reliability. While investigating the reliabilityof scales, related joints, anatomical and biomechanicalcharacteristics of muscle groups as well as interraterand intrarater change and biological change should betaken into consideration. Low reliability results ofordinal scales are related to problems which occurduring the measurement of spasticity as well as theenvironment and general condition of the patient. Tominimize this, the measurements were performed in aquietenvironmentandscreenedfromotherpatientsandtherapists and one repetition was performed per joint.The error with repeated measurements taken ondifferent days would be probably due to systematicchanges in the participant status leading to change inthe tone. However, we considered it was important todocument test-retest variability of repeatedmeasurements by inclusion of an intervening timeperiod because in clinical practice, results from repeatedmeasurements are rarely compared without anintervening time interval. This interval has contributedto an underestimation of intrarater reliability scores inthis study because fluctuations of tone during a singleday as well are well established. For this, grading onthe second day was done at the same time of the day ason the first day. 24Tone is not static and may changewith time,17this factor may contribute to low agreementbetween the raters. It is therefore essential that repeatedmovements are kept to a minimum.25It is not surprisingthat the interrater reliability is higher than the intraraterreliability indicating that these scales should beinterpreted with caution and even the same rater haspossibilityofmakinganerror.Onepossiblereasoncouldbe the clinical environment in the hospital. 26Findingsof this study are consistent with the previous studiesshowing very good inter- and intra-rater reliabilityscores in elbow flexors for all the three scales AS, MAS,and MMAS; scores for MMAS being the highest. Thecurrent study does not observe any association betweenthe limbs, upper or lower, as well. This is probably dueto the fact that only one muscle group i. e. knee flexorswere investigated in the present study. Future studiesshould include more muscle groups to investigate theeffect of limb, upper or lower, on the reliability scores.The results of the present study are little variant fromthe previous studies due to the age of the populationincluded .Younger kids would be easier to move due tosmaller limbs but would be harder to test due to reasonsof adherence. Out of a total of 40, 10 subjects were inGMFCS level I, 14 in level II, 9 in level III, 5 in level IV,and 2 in level V. MMAS shows moderate interraterreliabilityinlevelIIforwristflexors,andmoderateinter-and intra-rater reliability in level III for knee flexors.Reliability of MMAS in levels I and II for all the musclegroups under study was good. It could not be assessedin groups IV and V owing to very small sample size.Hence future studies should assess the reliability witha large sample size of at least 40 in each level. The degreeof training and preparation to use the scales probablyexceeds the preparation of most clinicians using thescales.CONCLUSIONMMAS is a reliable tool in assessing spasticity inelbow flexors, wrist flexors and knee flexors of childrenas compared to AS and MAS in spastic CP.Conflict of interest - NilREFERENCES1. P O D Pharaoh, T Cooke, L Rosenbloom. Acquiredcerebral palsy. Arch Dis Child. 1989;64:10103-10116.2. Carr LJ, Reddy SK, Stevens S, Blair E, Love S.Definition & classification of cerebral palsy. DevMed Child Neurol. 2005; 47: 508-510.3. ReddihoughDS,CollinsKJ.Theepidemiologyandcauses of cerebral palsy. Australian Journal ofPhysiotherapy. 2003;49:7-12.4. Gad M, Bailik, Uri Givon. Cerebral palsy:Classification and etiology. Acta Orthopaedica etTraumatologica Turcica. 2009; 43: 77-80.5. Bax M, Tydeman C, Flodmark O. Clinical and MRIcorrelatesofcerebralpalsy:TheEuropeanCerebralPalsy study. JAMA. 2006; 296:1602-1608.6. Singhi PD, Ray M, Suri G. Clinical spectrum ofcerebral palsy in north India- an analysis of 1,000cases. J Trop Pediatr. 2002; 48:162-166.7. SrivastavaVK,LaisramN,SrivastavaRK.CerebralPalsy. Indian Pediatr. 1992; 29:993-996.8. Karen W Krigger. Cerebral palsy : an overview.Am Fam Physician. 2006; 73:91-100.9. Samuel R Pierce, Richard T Lauer, Patricia AShewokis, Joseph A Rubertone, Margo N Orlin.Test-Retest reliability of isokinetic dynamometerfor the assessment of the spasticity of the kneeflexors and knee extensors in children withcerebral palsy. Arch Phys Med Rehabil. 2006;87:697-702.10. Mutlu A, Livanelioglu A, Gunel MK. Reliability ofAshworth and Modified Ashworth Scales inchildren with spastic cerebral palsy. BMCMusculoskeletal Disorders. 2008; 9:44.11. Ashworth B. Preliminary trial of carisoprodol in32. Pooja Sharma-165-169.pmd 2/7/2013, 8:08 PM168
  • 175. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 169multiple sclerosis. Practitioner. 1964; 192:540-542.12. Bohannon RW, Smith MB. Interrater reliability ofmodified ashworth scale for muscle spasticity.Phys Ther. 1987; 67:206-207.13. Ansari NN, Naghdi S, Hasson S, Mousakhani A,Nouriyan A, Omidvar Z. Inter-rater reliability ofthe Modified Modified Ashworth Scale as aclinical tool in measurements of post-stroke elbowflexor spasticity. Neurorehabilitation. 2009;24:225-229.14. Kothari CR, Research Methodology; Methods andTechniques. New Age International Publishers,New Delhi, 2007.15. Brashear A, Zafonte R, Corcoran M, Jimenez NG,Gracies JM, Williams M, Chia-Ho Lee, Turkel C.Inter- and intrarater reliability of the AshworthScale and the Disability Assessment Scale inpatients upper-limb post-stroke spasticity. ArchPhys Med Rehabil. 2002; 83:1349-1354.16. Damiano DL, Quinlivan JM, Qwen BF, Payne P,Nelson KC, Abel MF. What does the AshworthScale really measure and are instrumentedmeasures more valid and precise? Dev Med ChildNeurol. 2002; 44:112-118.17. Gregson JM, Leathley M, Moore AP, Sharma AK,Smith TL, Watkins CL. Reliability of the ToneAssessment Scale and the Modified AshworthScale as clinical tools for assessing post strokespasticity. Arch Phys Med Rehabil. 1999; 80:1013-1016.18. FosangAL,GaleaMP,McCoyAT,ReddihoughDS,Story I. Measures of muscle and joint performancein the lower limb of children with cerebral palsy.Dev Med Child Neurol. 2003; 45:664-670.19. Clopton N, Dutton J, Featherston T, Grigsby A,Mobley J, Melvin J. Interrater and intraraterreliability of the modified ashworth scale inchildren with hypertonic. Pediatr Phys Ther. 2005;17:268-274.20. Ghotbi N, Ansari NN, Naghdi S, Hasson S.Measurement of lower-limb muscle spasticity:Intrarater reliability of Modified ModifiedAshworth Scale. J Rehabil Res Dev. 2011; 48:83-88.21. Fleuren JF, Voerman GE, Erren-Wolters CV, SnoekGJ, Rietman JS, Hermens HJ, NeneAV. Stop usingtheAshworth scale for the assessment of spasticity.J Neurol Neurosurg Psychiatry. 2010; 81:46-52.22. Ansari NN, Naghdi S, Hasson S, Fakhari Z,Mashayekhi M, Herasi M. Assessing the reliabilityoftheModifiedModifiedAshworthScalebetweentwo physiotherapists in adult patients withhemiplegia. Neurorehabilitation. 2009;25:235-24023. Ansari NN, Naghdi S, Moammeri H, Jalaie S. Acomparative study on the inter-rater reliability ofthe Ashworth scales in assessment of spasticity.Acta Medica Iranica. 2006; 44:246-250.24. Haas BM, Bergstrom E, Jamous A, Bennie A. Theinterrater reliability of the original and of themodified ashworth scale for the assessment ofspasticity in patients with spinal cord injury.Spinal cord. 1996; 34:560-564.25. Pandyan AD, Johnson GR, Price CIM, Curless RH,Barnes MP, Rodgers S. A review of the propertiesof limitations of the Ashworth and modifiedAshworth scales as measures of spasticity. ClinRehabil. 1999; 13:373-83.26. Blackburn M, van Vliet P, Mockett SP. Reliabilityof measurements obtained with the modifiedAshworth scale in the lower extremities of peoplewith stroke. Phys Ther. 2002; 82:25-34.32. Pooja Sharma-165-169.pmd 2/7/2013, 8:08 PM169
  • 176. 170 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Evaluation of Pulmonary Function Tests in PatientsUndergoing LaparotomyNahar P S1, Shah S H2, Vaidya S M3, Kowale A N41Assistant Professor, Department of Physiology, BJ Medical College, Pune, 2Assistant Professor, Department ofPhysiology, BJ Medical College, Pune, 3Professor and Head of the Department, BJ Medical College, Pune, 4Professor andHead of the Department, Government Medical College, KolhapurABSTRACTBackground: Postoperative pulmonary complications are the most common cause of postoperativemortalityandmorbidity.Inthisstudywetriedtoidentifypatientsathighriskofdevelopingpostoperativepulmonary complication.Objectives:1. To compare and evaluate preoperative and postoperative values of pulmonary function testsparameters.2. To study the effect of gender difference, site of surgery and body mass index on postoperativepulmonary function parameters.Methods: Pulmonary Function Parameters were recorded preoperatively one day prior to surgery andpostoperatively on 5th day. PFTs were recorded using RMS Helios spirometer and all the tests wereconducted according to ATS/ERS guidelines.Parameters recorded : TV,ERV,IRV,IC,VC,MVV,FVC,FEV1,FEV1/FVC,PEFR,PIFRStatistical analysis were carried out by using t testResults: We found statistically significant decrease in all the pulmonary function parameters inpostoperative period except that of FEV1/FVC. When we did intergroup statistical analysis, we foundmore decrease in PFT parameters in Male patients, Patients undergoing Upper abdominal surgery andin Obese patients.Conclusion: Thus after laparotomy there are Restrictive type of ventilatory changes due to pain, alteredpattern of ventilation and diphragmatic weakness.Male patients, patients undergoing upper abdominal surgeries & obese patients are high risk patientsfor pulmonary complications.Since these postoperative pulmonary changes can be easily diagnosed by spirometer, all patientsundergoing laparotomy should undergo preoperative and postoperative spirometry.Also prophylactic preoperative physiotherapy and postoperative deep breathing exercises, incentivespirometry and chest physiotherapy can be beneficial in patients of laparotomy.Keywords: Laparotomy, Pulmonary Function Tests, PostoperativeCorresponding author:Nahar PradeepDepartment of Physiology, B.J. Medical College, PunePhone numbers - 08237010726E-mail: pradeepnahar85@yahoo.comINTRODUCTIONNowadays, the scope of surgery has widenedtremendously. But along with this, the increased toll ofcomplications has also come into focus. Even in theface of good surgery, these post-operative complicationscan tilt the balance between success and failure, andamong these, post-operative pulmonary complicationsare especially notorious. Occurrence of these post-operative pulmonary complications can be easilydiagnosed by spirometry.Also these complications canbe prevented by simple pre-operative training andregular post- operative physiotherapy in high riskpatients.In this study, we hypothesized that after laparotomyin post-operative period there will be decrease inPulmonary function test (PFT) parameters. We alsobelieved that this decrease in PFT parameters is themajor culprit for post-operative pulmonary33. pradeep nahar--170-175.pmd 2/7/2013, 8:08 PM170
  • 177. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 171complications. In order to indentify the high riskpatients we also studied the effect of gender difference(Male, Female), site of surgery (Upper abdomen, Lowerabdomen) and BMI (Obese, Non obese) on post-operative PFT parameters.Aims and objectives1) To record various pulmonary function parameters(TV, ERV, IRV, VC, IC, MVV FVC, FEV1, FEV1/FVC,PEFRandPIFR)preoperativelyandpostoperativelyin patients undergoing laparotomy.2) To compare and evaluate alterations betweenpreoperative and postoperative values ofpulmonary function parameters.3) To study the effect of gender difference, site ofsurgery and Body Mass Index on postoperativepulmonary function parameters as compared totheir preoperative values.MATERIALS AND METHODThe study protocol was approved by theInstitutional Ethics Committee. Patients were selectedfrom those admitted to Surgery and Gynaecology wardof the Sassoon General hospital. 28 males and 22females of the age group 30-60 years undergoingplanned laparotomy were selected for the study. Thestudy protocol was explained in detail to the selectedpatients. All the patients willing to participate in thestudy were asked to fill an informed consent form.Pulmonary function parameters were recorded pre-operatively on one day prior to surgery and the post-operative readings were taken on fifth post-operativeday. The PFTs were measured using a computerizedportable RMS Helios 702(Chandigarh) spirometer(Photograph 1). This spirometer is automated and hasa flow sensor which converts the airflow signals todigital signals. Values obtained were in litres and theywerecomparedwiththeexistingdatabaseforthenormalhealthy Indian population depending on age, sex,height and weight. Patients with history of cardio-respiratory diseases, diabetes mellitus or hypertensionwere excluded from the study. Also patients who hadintra-operative complications, post-operativepulmonary, cardiac or surgical complications wereexcluded.The tests were conducted according to the AmericanThoracicSociety/European RespiratorySociety(ATS/ERS) task force guidelines. The pulmonary functionswere recorded in the sitting position and before thesubject had lunch. The subjects were instructed to wearloose clothes on the day of test. Name, age, sex, heightand weight were entered in the spirometer. Theprocedures of all maneuvers were demonstrated to thesubject using disposable mouthpiece.The Slow Vital Capacity (SVC) maneuver wasconducted in the following order:Subjectswereinstructedtobreathenormallythroughthe mouthpiece. After the three normal breaths, theywereaskedtotakedeepinspirationfollowedbyforcefulexpiration. And again they were asked to take threenormal breaths without removing the mouthpiece.Parameters recorded in this manoeuvre were Tidalvolume (TV) in litres, Expiratory reserve volume (ERV)in litres, Inspiratory reserve volume (IRV) in litres,Inspiratory capacity (IC) in litres, Vital capacity (VC) inlitres.The Forced Vital Capacity (FVC) maneuver wasconducted in the following order:Subjects were instructed to take slow and deepinspiration. Then subjects were instructed to hold themouthpiece in the mouth with lips pursed around itand asked to blow forcefully into the mouthpiece aslong as possible without hesitation and coughing. Thenwithoutremovingthemouthpiecefromthemouth,theywere instructed to inspire maximally through themouthpiece. Parameters recorded in this maneuverwere Forced vital capacity (FVC) in litres, Forceexpiratory volume in one second (FEV1) in litres, FEV1/FVC in %, Peak expiratory flow rate (PEFR) in litre persecond and Peak inspiratory flow rate (PIFR) in litreper second.The Maximum Voluntary Ventilation (MVV)maneuver was conducted in following order:Subjects were instructed to breathe in and out asrapidly and deeply as they can for a period of 15seconds through the mouthpiece. All the recordedmaneuver results were analyzed for acceptability andrepeatability. Three acceptable readings were taken andtheir mean values were calculated and analyzed.Statistical analysis was carried out by Student’s ttest SPSS software( version 11).FINDINGSWe found that post-operatively there is decrease inTV by 21.87%, ERV by 22.01%, IRV by 23.64%, IC by26.23%, VC by 25.54%, MVV by 26.28%, FVC by 26.32%,FEV1by 28.97%, FEV1/FVC by 3.48%, PEFR by 32.31%and PIFR by 41.73%. All these differences werestatistically significant except that in FEV1/FVC. (Table1, Figure 1)33. pradeep nahar--170-175.pmd 2/7/2013, 8:08 PM171
  • 178. 172 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Intergroup statistical analysis between Male andFemale patients showed that post-operative percentagedecrease was more in Male patients as compared tothat in Female patients. (Table 2, Figure 2)Intergroup statistical analysis between patientsundergoing upper abdominal surgery and patientsundergoinglowerabdominalsurgeryshowedthatpost-operative percentage decrease was more in patientsundergoing upper abdominal surgery. (Table 3,Figure 3)Intergroup statistical analysis between obese andnon obese patients showed that post-operativepercentage decrease was more in obese patients ascompared to the non obese patients. (Table 4, Figure 4)Table 1: Mean preoperative and postoperative values of pulmonary function parameters with postoperativepercentage decreaseParameter Mean SD Preoperative Postoperative mean p valuedifference (Percentage %)TV_PRE (in Lit.) 0.352 0.06 0.077 (21.87%) < 0.05*TV_POST (in Lit.) 0.275 0.04ERV_PRE (in Lit.) 0.763 0.18 0.168 (22.01%) < 0.05*ERV_POST (in Lit.) 0.595 0.15IRV_PRE (in Lit.) 2.580 0.26 0.610 (23.64%) < 0.05*IRV_POST (in Lit.) 1.970 0.21IC_PRE (in Lit.) 2.893 0.34 0.759 (26.23%) < 0.05*IC_POST (in Lit.) 2.134 0.28VC_PRE (in Lit.) 3.640 0.52 0.930 (25.54%) < 0.05*VC_POST (in Lit.) 2.710 0.30MVV_PRE (Lit/min.) 91.320 7.91 24.000 (26.28) < 0.05*MVV_POST (Lit/min.) 67.320 6.90FVC_PRE (in Lit) 3.230 0.42 0.850 (26.32) < 0.05*FVC_POST (in Lit) 2.380 0.36FEV1_PRE (in Lit.) 2.830 0.42 0.820 (28.97) < 0.05*FEV1_POST(in Lit.) 2.010 0.32FEV1/FVC_PRE (in %) 86.700 4.82 3.020 (3.48) > 0.05FEV1/FVC_POST (in %) 83.680 6.01PEFR_PRE (Lit/sec.) 6.072 1.31 1.962 (32.31) < 0.05*PEFR_POST (Lit/sec.) 4.110 1.04PIFR_PRE (Lit/sec.) 6.072 1.31 2.534 (41.73) < 0.05*PIFR_POST (Lit/sec.) 3.538 0.88Pre: PreoperativePost: Postoperative*< .05: statistically significantTable 2: Postoperative Percentage decrease in pulmonary function parameters in relation to the gender differenceParameters MALE, Postoperative FEMALE ,Postoperativepercentage decrease percentage decreaseTV 25.00 20.00ERV 24.44 18.64IRV 25.45 21.85IC 28.01 23.30VC 27.59 22.76MVV 28.15 23.61FVC 27.66 24.57FEV1 30.23 27.41FEV1/FVC 4.22 2.56PEFR 34.31 29.44PIFR 43.74 38.6033. pradeep nahar--170-175.pmd 2/7/2013, 8:08 PM172
  • 179. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 173Table 3: Postoperative Percentage decrease in pulmonary function parameters in relation to the site of surgeryParameters UPPER ABDOMAN, LOWER ABDOMAN,Postoperative Postoperativepercentage decrease percentage decreaseTV 26.47 20.00ERV 24.32 20.77IRV 25.09 21.40IC 29.65 22.02VC 29.47 21.85MVV 27.81 24.19FVC 29.79 23.05FEV1 32.35 26.19FEV1/FVC 3.69 3.28PEFR 35.96 28.87PIFR 45.70 37.90Table 4: Postoperative Percentage decrease in pulmonary function parameters in relation to the BMIParameters OBESE, Postoperative NON OBESE,percentage Postoperative percentagedecrease decreaseTV 23.52 19.44ERV 22.97 21.51IRV 24.80 22.48IC 28.32 23.50VC 26.40 24.86MVV 27.98 24.53FVC 28.52 24.08FEV1 30.85 27.11FEV1/FVC 4.50 2.34PEFR 35.57 28.91PIFR 43.80 39.58DISCUSSIONTo the best of our knowledge no one has studied allthe PFT parameters as a whole in postoperative periodas we did. Few authors have studied some parametersin laparotomy patients. Beecher HK [2]found a greaterdecrease in TV, ERV, IRV and VC as compare to ourstudy. This may be due to the fact that their studymeasured PFT parameters on 2ndpostoperative daywhile ours was on 5thpostoperative day. Similar studyconducted by Collins et al [3]on FVC, FEV1, FEV1/FVCand PEFR showed lower decrease in PFT parametersthis may be due to they have studied it on 7thpostoperative day. Very few authors have studied effectof laparotomy on PIFR.We found that post-operatively there wasstatistically significant decrease in all PFT values exceptthat of FEV1/FVC. Thus post-operatively there isrestrictive type of ventilatory dysfunction which isresponsible for various post-operative pulmonarycomplications. The various mechanisms responsible forthis post-operative pulmonary dysfunction are:Impaired ventilation in post-operative period dueto diaphragmatic dysfunction which can be proved by:a) Decreased diaphragmatic excursions [4]b)Paradoxical motion of the diaphragm [5]c) Loss of thediaphragm’s normal inspiratory - expiratory phasicactivity [6]d) Decrease in trans-diaphragmatic pressureby almost 70% [7]Adaptation of shallow breathing pattern withoutperiodic deep breathing in post-operative period resultsin decreased surfactant secretion by type II alveolarepithelial cells. This decrease in surfactant secretioncauses post-operative atelectasis, thus decreasing PFTvalues.[8]It has been proved that there is dysfunction ofintercostal muscles in post-operative period. Intercostalmuscles play an important role in forceful respiration.So their dysfunction results in decrease in PFTvalues.[8]The situation is further aggravated by certain33. pradeep nahar--170-175.pmd 2/7/2013, 8:08 PM173
  • 180. 174 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1post-operative factors such as prolonged recumbency,supine position and tight dressing over abdomen.[9]Intergroup statistical analysis showed that malepatients are more severely affected than female patients.Various reasons that can be put forward for thisdifference are1) Type of breathing[10], Normally during quietrespiration males show abdomino-thoracic type ofbreathing, while females have thoraco-abdominaltype of breathing. Thus abdominal component ispredominant in males and this abdominalcomponent is mainly affected during laparotomy.2) Progesteron, the female sex hormone, has its owninfluence on chemoreceptor cells in medulla.Progesterone increases sensitivity of respiratorycenter to CO2. So whenever there are postoperativeventilation abnormalities in females, it causesstimulationofrespiratorycenterduetoprogesteroneand this may improve postoperative pulmonaryfunction in them.[11]Patients undergoing upper abdominal surgery aremore affected than that of lower abdominal surgeriesThis can be explained by the fact that thediaphragmatic weakness is the main cause of post-operative pulmonary dysfunction and thisdiaphragmatic dysfunction mainly depends uponproximityof operative site todiaphragm.Theproximityof operative site is inversely related to diaphragmaticfunction. This finding has been supported by thedecrease in maximum inspiratory pressure, trans-diaphragmaticpressureandexpiratorymusclepressureobserved after upper abdominal surgery in severalstudies. [ 12 13,14,15]This decrease is sustained for 48 hoursafter surgery and may persist for a week. [16,17]Furthermore, upper abdominal surgeries causepredominantly rib cage breathing in post-operativeperiod, as shown by an increase in the ratio ofoesophageal to gastric pressure swings (ÄPoes/ÄPga)and by decrease in the abdominal to rib cage excursions.This indicates that the intercostal inspiratory musclesare more active after upper abdominal surgery. [12,14]Thisis because the diaphragm is the muscle that is mainlyaffected during upper abdominal surgery. Themechanism that underlies the reduction indiaphragmatic strength and the shift to predominantlyrib cage breathing is not fully understood, butanaesthesia and pain are definitely responsible for thisdysfunction, some studies in animals and humans alsoshowed that an inhibitory reflex generated during thesurgical procedure is the major mechanism.Manipulation of the splanchnic organs duringlaparotomy causes reflex inhibition of the phrenic nerveoutput decreasing diaphragmatic function. [15]Thus upper abdominal operations are associatedwith substantially worse diaphragmatic functionpostoperatively than are lower abdominal operations,and the risk of postoperative pulmonary complicationsis accordingly higher by a factor of 1.5. [18]CONCLUSIONWe found after laparotomy in postoperative period,therearerestrictivetypeofventilatorychanges.Allthesepostoperative PFT decrease are more in male patients,in patients undergoing upper abdominal surgeries andin obese patients.All these changes are favorable for producingpostoperative pulmonary complications. These changesare mainly due to altered pattern of ventilation inpostoperative period.Since these postoperative pulmonary changes canbe easily diagnosed by spirometer, all patientsundergoing laparotomy should undergo preoperativeand postoperative spirometry. Also prophylacticpreoperative physiotherapy and postoperativeinterventions such as deep breathing exercises,incentive spirometry and chest physiotherapy shouldbe advised to all patients undergoing laparotomy. Thesesimple and inexpensive procedures can make asignificant difference in patients outcome afterlaparotomy.This will definitely reduce mortality and morbidityafter laparotomy and will give very good results tosurgeon who had used good surgical technique andalert mind for betterment of his patients.REFERENCES1. Miller MR, Hankinson J, Brusasco V, Burgos F,Casaburi R, Coates A et al. Standardization ofspirometry. Eur Respir J 2005;26:319-382. Beecher HK. Effect of laparotomy on lung volume:Demonstration of a new type of pulmonarycollapse. J Clin Invest 1933;651:12.3. Collins CD, Darket MD, knowelden J. Chestcomplications after upper abdominal surgery:Their anticipation and prevention. Brit Med J 1968;1: 401-06.33. pradeep nahar--170-175.pmd 2/7/2013, 8:08 PM174
  • 181. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 1754. Rehder K, Sessler AD, Marsh HM. Generalanesthesia and the lung. Am Rev Respir Dis 1975;112:541-63.5. Marsh HM, Rehder K, Sessler AD, Fowler WS.Effects of mechanical ventilation, muscle paralysisand posture on ventilation-perfusionrelationships in anesthetized man.Anesthesiology 1973; 38(1): 59-67.6. Russel WJ. Position of patient and respiratoryfunction in immediate postoperative period.BMJ1981;283:1079-807. Simonneau G, Vivien V, Saltine R. Diaphragmaticdysfunctioninducedbyupperabdominalsurgery:roleofpostoperativepain.AmRevRespirDis1983;128:8998. Rehder K. Anesthesia and the respiratory system.Can Anesth Soc J 1979; 26(6):451-62.9. Brook lord. Abdominal operations.1969.5thed.New York. p 484-9110. Guyton and Hall. Textbook of Medical Physiology.11thed. Elsevier Pvt. Ld.;2006: p 471-80.11. Keele C, Neil E, Joels N. Samsung WrightsAppliedPhysiology. 13thed. Oxford University Press;2000p 58412. Ford GT, Whitelaw WA, Rosenal TW, Cruse PJ,Guenter CA. Diaphragm function after upperabdominal surgery in humans. Am Rev Resp Dis1983; 127: 431-36.13. Celli BR, Rodriguez KS, Snider GL. A controlledtrial of intermittent positive pressure breathing,incentive spirometry, and deep breathing exercisesin preventing pulmonary complications afterabdominal surgery. Am Rev Resp Dis 1984; 130:12-15.14. Ford GT, Rosenal TW, Clergue F. Respiratoryphysiology in upper abdominal surgery. ClinChest Med 1993;14:237–52.15. Watters JM, Clancey SM, Moulton SB. Impairedrecovery of strength in older patients after majorabdominal surgery. Ann Surg 1993; 218:380–90.16. Putensen-Himmer G, Putensen C, Lammer H.Comparison of postoperative respiratory functionafter laparoscopy or open laparotomy forcholecystectomy.Anesthesiology 1992; 77:675–80.17. Siafakas NM, Stoubou A, Stathopoulou M. Effectof aminophylline on respiratory muscle strengthafter upper abdominal surgery: a double blindstudy. Thorax 1993; 48:693–7.18. Mitchell C, Garrahy P, Peake P. Postoperativerespiratory morbidity: identification and riskfactors. Aust N Z J Surg 1982; 52:203–9.33. pradeep nahar--170-175.pmd 2/7/2013, 8:08 PM175
  • 182. 176 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Evaluation of Standardized Backpack weight and itsEffect on Shoulder & Neck PosturePardeep PahwaLect. in Physical Therapy, Composite Regional Centre for Persons with Disabilities (Ministry of Social Justice &Empowerment , Govt of India) Sundernagar (HP)ABSTRACTThe Backpack is one of several forms of manual load carriage that provides versality and is often usedby hikers, backpackers, and soldiers as well as school student. Students have emerged as anotherpopulation of backpackers who carry their school supplies in book bags which are backpacks. As thestudents progress through the school grades the amount of homework and backpack loads of schoolage children increases. We all want our children to do well in school.16 To initiate an educationalprogram regarding school backpack safety in our area, it is essential to know the weight of backpackstudents are currently carrying.Keywords: Backpackpack, Craniohorizontal angle, Craniovertebral angle, Sagittal Shoulder posture, AnteriorHead Alignment.INTRODUCTIONThe Backpack is one of several forms of manual loadcarriage that provides versality and is often used byhikers, backpackers, and soldiers as well as schoolstudent. The Backpack is an appropriate way to loadthe spine closely and symmetrically, whilstmaintaining the stability. However, musculoskeletalproblems associated with backpack use have becomean increasing concern with school children.1Students have emerged as another population ofbackpackers who carry their school supplies in bookbags which are backpacks. Carriage of backpack appliesa substantial load to spine to school children.2As the students progress through the school gradesthe amount of homework and backpack loads of schoolage children increases. As a result the students carryall their materials in book bags. This has lead to physicalcomplaints in the form of muscle soreness (67.1%), backpain (50.8%), numbness (24.5%) and shoulder pain(14.7%). The most commonly reported medical problemis plexus or peripheral nerve injury. Physicalexamination can often reveal weakness, numbness andpossible muscle atrophy.3The Backpack loadingproduce changes in standing posture when comparedwith unloaded standing posture which has been relatedto spinal pain.4Although it is unclear whether backpacks can causepermanent damage, the healthcare costs associatedwith strain and pain could be enormous.5School bagsare felt to be heavy by 79% of children, to cause fatigueby 65.7%10.We all want our children to do well in school.7Toinitiate an educational program regarding schoolbackpack safety in our area, it is essential to know the‘weight’ of backpack students are currently carrying.This information could be incorporated into schoolcurriculum or distributed as a handout for children totake home to their parents. Many researches have beendone on amount of load carried by student and theireffect on shoulder and neck alignment is between 10%and 17% of students’ body weight.1Chansirinukor et al6suggested that a backpack loadof 15% body weight is too heavy for adolescents tomaintain a prolonged standing posture.Furjuouh el al5reported that backpack carried bymajority of school students, in the sample are no longerheavier than 10% of body weight which is associatedwith complaints of pain in back, shoulder, neck or otherareas of body. Pascoe et al6reported that mean weightof school bags was 17% of students mean body weight.The previous study done by Chansirinukor et al1showed that carrying a load of less than 15% of bodyweight should be recommended, but none of study hasshown the particular amount of backpack weight, fromwhere the change in craniohorizontal andcarniovertebral angle starts which leads to change incervical and shoulder posture.34. Pradeep pehwa--176-184.pmd 2/7/2013, 8:08 PM176
  • 183. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 177Aims and Objectives• To determine the particular amount of backpackweight carried by students that does not changethe students cervical and shoulder posture.• To implement and recommend maximum weight ofbackpack that should be carried by students.Statement of Question• How much percentage of backpack weight shouldbe carried by students that does not change studentposture?METHODOLOGYSampleA total of 10 school boys aged between 13 and 17yearsoldrecruitedassubjects.Theywererecruitedfromthe G.N.D public school, Dehradun. This study wasconducted at gymnasium of Dolphin Institute,Dehradun.Inclusion Criteria1. Subjects with in age group of 13-17years.2. Height of subjects 90-160 cms .3. Weight of subjects 30-60 kg.Exclusion Criteria1. Subjects with postural abnormality , LLD, cervicaland shoulder pain2. Balance disorder3. Congenital abnormality such as spina bifida,cervical rib, deformity of spine.4. Subjects with forward head posture, history ofrecent fracture.Instrumentation1. Metter Digital Electronic Scale2. Digital Video Camera3. Height Statuometer4. Adhesive Markers5. Book Bags6. Educational Material7. Motion Analysis SoftwareStudy DesignThis study was an observational study design.PROCEDUREAll the subjects were tested in DIBNS gymnasiumTo capture postural information on body segments,clothing was rearranged so that shoulder and upperhalf body exposed. With the subjects standing, adhesivemarkers (Bindis) were placed on anatomical pointscomprising :-1. The External canthus of right eye.2. Right tragus of the ear.3. Inferior margins of both ears.4. A midpoint between greater tuberosity of humerusand posterior aspect of acromion process of rightshoulder; and5. Spinous process of C7.A small reflective ball was placed over the spinousprocess of C7The lateral malleoli were placed betweenparallel lines, which are perpendicular to frontal Plane,2 cm apart. The photographs were obtained using adigital kodak camera that was attached to tripod. Thetripod was secured in correct position on floor by usingmasking tape for the sagittal view photography, thesubject were placed 2.8 m from the camera and 1.8 mfrom the camera for frontal view photography. Thenthe subject were photographed from both lateral viewand from anterior aspect at same time with1. Unloaded2. Carrying a backpack weighing 8% to 20% of bodyweight by adding 1% weight of body weight & soon.In order to evaluate posture of cervical and shoulderregion, motion analysis software (protrainer 6.1 sportsmotion) was employed to calculate the angles from eachanatomical landmark from the photographs. The anglesin the lateral and frontal view thus calculated andreadings taken for the data analysis.The four angles of measurement areCraniohorizontal Angle1The angle formed at intersection of a horizontalline through tragus of ear and a line joining the tragusofearandexternalcanthusofeye.Itisbelievedtoprovidean estimation of head on neck angle or position of uppercervical spine34. Pradeep pehwa--176-184.pmd 2/7/2013, 8:08 PM177
  • 184. 178 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Craniovertebral Angle1It is angle formed at the intersection of a horizontalline through the spinous process of C7and a line to thetragus of ear. This is believed to provide an estimationof neck on upper trunk position.Sagittal Shoulder Posture1The angle formed by intersection of horizontal linethrough C7and a line between the mid point of greatertuberosityofhumerusandposterioraspectofacromion.ThisangleprovidesameasurementofforwardshoulderpositionAnterior Head Alignment1Alinedrawnbetweentheinferiortipofleftandrightears, and the angle of this line to horizontal. Thismeasurement described how level the head was whenviewed from the frontal.DATA ANALYSISThe significance of postural changes from wherethe change starts in data were estimated by using pairedt-test on each postural angle within which plannedcontrast were made of unloaded condition with loadedbackpack weight from pair 1 to pair 13 including 8%upto 20% of body weight. The statistical significant levelof this study was set at 0.025.RESULTSThe mean and standard deviation for physicalcharacteristics of all the 10 subjects were taken i.e. age(14.1 + 1.19) yrs, weight (44.3 + 7.84) kg and height(145.4 + 8.60) cms. The mean and standard deviation ofboth unloaded and loaded CHA, CVA, SSP and AHAfrom pair 1 to pair 13 were analysed by using paired ‘t’test.Table: 1 Showing comparison of mean and standard deviation for each unloaded and loaded condition ofCraniohorizontal angle at different percentages of body weight (8%-20%)Variable Mean±SD t-value p-value Variable Mean±SD t-value p-valuePair 1 Pair 8ULCHA 16.4±2.5 2.53 .032 ULCHA 16.4±2.5 8.29 .000LCHA819.0±3.9 LCHA1524.2±1.98Pair 2 Pair 9ULCHA 16.4±2.5 6.10 .000 ULCHA 16.4±2.5 8.33 .000LCHA921.2±2.2 LCHA1625.8±3.0Pair 3 Pair 10ULCHA 16.4±2.5 3.86 .004 ULCHA 16.4±2.5 15.73 .000LCHA1021.3±4.3 LCHA1727.4±2.3Pair 4 Pair 11ULCHA 16.4±2.5 4.02 .003 ULCHA 16.4±2.5 16.14 .000LCHA1122.9±4.8 LCHA1827.7±1.8Pair 5 Pair 12ULCHA 16.4±2.5 4.81 .001 ULCHA 16.4±2.5 12.75 .000LCHA1224.1±4.9 LCHA1928.0±2.1Pair 6 Pair 13ULCHA 16.4±2.5 6.74 .000 ULCHA 16.4±2.5 11.69 .000LCHA1325.3±3.7 LCHA2028.1±2.9Pair 7ULCHA 16.4±2.5 7.20 .000LCHA1425.0±3.034. Pradeep pehwa--176-184.pmd 2/7/2013, 8:08 PM178
  • 185. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 179Graph: 1 Showing comparison of backpack load at different percentage of body weight with unloaded condition forCraniohorizontal Angle.0510152025308 9 10 11 12 13 14 15 16 17 18 19 20Percentage of body weightDegreeTable: 2 Showing comparison of mean and standard deviation for each unloaded and loaded condition ofCraniovertebral angle at different percentages of body weight (8%-20%)Variable Mean±SD t-value p-value Variable Mean±SD t-value p-valuePair 1 Pair 8ULCVA 48.7±3.9 .937 .373 ULCVA 48.7±3.9 3.80 .004LCVA847.9±4.4 LCVA1542.9±6.8Pair 2 Pair 9ULCVA 48.7±3.9 .929 .377 ULCVA 48.7±3.9 4.65 .001LCVA947.2±6.4 LCVA1642.8±6.2Pair 3 Pair 10ULCVA 48.7±3.9 1.27 .235 ULCVA 48.7±3.9 3.75 .006LCVA1046.7±6.6 LCVA1742.0±6.6Pair 4 Pair 11ULCVA 48.7±3.9 2.74 .023 ULCVA 48.7±3.9 4.89 .001LCVA1145.4±5.8 LCVA1841.8±6.4Pair 5 Pair 12ULCVA 48.7±3.9 3.32 .009 ULCVA 48.7±3.9 4.311 .002LCVA1243.4±6.9 LCVA1942.3±6.9Pair 6 Pair 13ULCVA 48.7±3.9 2.90 .017 ULCVA 48.7±3.9 4.451 .002LCVA1343.3±7.14 LCVA2041.1±7.6Pair 7ULCVA 48.7±3.9 3.47 .007LCVA1443.0±6.73734. Pradeep pehwa--176-184.pmd 2/7/2013, 8:08 PM179
  • 186. 180 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Graph: 2 Showing comparison of backpack load at different percentage of body weight withunloaded condition for Craniovertebral Angle3537394143454749518 9 10 11 12 13 14 15 16 17 18 19 20Percentage of body weightDegreeTable: 3 Showing comparison of mean and standard deviation for each unloaded and loaded condition of Sagittalshoulder posture at different percentages of body weight (8%-20%)Variable Mean±SD t-value p-value Variable Mean±SD t-value p-valuePair 1 Pair 8ULSSP 59.1 ± 6.2 1.66 0.131 ULSSP 59.1 ± 6.2 .478 0.644LSSP856.9 ± 6.1 LSSP1558.6 ± 6.3Pair 2 Pair 9ULSSP 59.1 ± 6.2 .246 0.811 ULSSP 59.1 ± 6.2 .599 0.564LSSP956.9 ± 5.08 LSSP1659.7 ± 7.04Pair 3 Pair 10ULSSP 59.1 ±6.2 .969 0.358 ULSSP 59.1 ± 6.2 .073 0.944LSSP1057.8 ± 5.5 LSSP1759.2 ± 6.3Pair 4 Pair 11ULSSP 59.1 ± 6.2 .793 0.448 ULSSP 59.1 ± 6.2 .209 0.839LSSP1159.8 ± 5.9 LSSP1858.8 ± 6.3Pair 5 Pair 12ULSSP 59.1± 6.2 .194 0.850 ULSSP 59.1 ± 6.2 .635 0.541LSSP1259.3 ± 7.1 LSSP1960.0 ± 7.2Pair 6 Pair 13ULSSP 59.1 ± 6.2 .588 0.571 ULSSP 59.1 ± 6.2 .082 0.936LSSP1358.2 ±7.1 LSSP2059.0 ± 6.6Pair 7ULSSP 59.1± 6.2 .085 0.934LSSP1459.2 ± 6.434. Pradeep pehwa--176-184.pmd 2/7/2013, 8:08 PM180
  • 187. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 181Graph: 3 Showing comparison of backpack load at different percentage of body weight with unloadedcondition for Sagittal shoulder posture.01020304050608 9 10 11 12 13 14 15 16 17 18 19 20Percentage of body weightDegreeTable: 4 Showing comparison of mean and standard deviation for each unloaded and loaded condition of Anteriorhead alignment at different percentages of body weight (8%-20%)Variable Mean±SD t-value p-value Variable Mean±SD t-value p-valuePair 1 Pair 8ULAHA 1.0± .66 1.0 0.34 ULAHA 1.0± .66 4.9 0.001LAHA81.2 ±.42 LAHA152.3± .82Pair 2 Pair 9ULAHA 1.0± .66 1.9 0.081 ULAHA 1.0± .66 4.8 0.001LAHA91.3 ± .48 LAHA162.2 ± .63Pair 3 Pair 10ULAHA 1.0± .66 1.8 0.104 ULAHA 1.0± .66 4.7 0.001LAHA101.4 ± .51 LAHA172.6 ± 1.07Pair 4 Pair 11ULAHA 1.0± .66 1.8 0.096 ULAHA 1.0± .66 8.5 0.000LAHA111.5 ± .70 LAHA182.3 ± .67Pair 5 Pair 12ULAHA 1.0± .66 2.2 0.051 ULAHA 1.0± .66 9.7 0.000LAHA121.6 ± .57 LAHA192.6 ± .51Pair 6 Pair 13ULAHA 1.0± .66 3.2 0.011 ULAHA 1.0± .66 7.2 0.000LAHA131.8 ± .78 LAHA202.8 ± .42Pair 7ULAHA 1.0± .66 3.3 0.008LAHA142.0 ± .9434. Pradeep pehwa--176-184.pmd 2/7/2013, 8:08 PM181
  • 188. 182 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Graph: 4 Showing comparison of backpack load at different percentage of body weight with Unloaded condition forAnterior Head Alignment0. 9 10 11 12 13 14 15 16 17 18 19 20Percentage of body weightDegreeDISCUSSIONFor all three angles i.e craniohorizantal angle,carniovertebral angle and anterior head alignment, thechange starts at 9%,11% and 13% respectively, whichis less than 15% of body weight. According toChansirinukor et al (2001), who recommended that 15%ofbodyweightrepresentanoverloadtothisageofyoungchildren support the present study.According to National Back Pain Association (1997)and Voll & Klimt11(1997) who recommended that schoolchildren should carry no more than 10% of their bodyweight, supporting this study. But change in anteriorhead alignment in present study starts at 13% of bodyweight which is against the study done by Voll andKlimt.For sagittal shoulder position, the result of presentstudy shows insignificant difference from 8% to 20% ofbody weight and so does not show any change insagittal posture at any percentage of body weight.There is lot of controversy about the accurateanatomical landmarks of this angle according todifferent authors. Based on Rainey and Twomey’s study(1994)1,12, a more rounded shoulder is represented by asmaller sagittal shoulder angle; provided the positionof C7remains fixed. But study done by Chansirinukoret al.,1shows that sagittal plane shoulder postureincreases under load, when a marker was placed inbetween greater tuberosity of humerus and posterioraspect of acromion.Braun and Amundson8in their study pointedbicipital tendon groove as acromion angle for assessingshoulder position in sagittal plane.There might be reason that different positionadopted for measurement might have contributed tocontrasting outcome. So further studies using a 3-dimensional approach is required to identify therelationship between body landmark and their correctplacement for sagittal shoulder posture.FUTURERESEARCHFuture research is needed to investigate the effect ofbackpack carriage on Unilateral side in dynamicconditions on cervical and shoulder posture changes.Girls students were not included in the study,because of exposure. As the spine is maturing, theremay be gender based difference which can affect theresults of the study.34. Pradeep pehwa--176-184.pmd 2/7/2013, 8:08 PM182
  • 189. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 183Relevance to Clinical PracticeThe carriage of heavy school bag coupled with longcarriage duration and lack of access of lockers in Indianschoolsmayrepresentandailyphysicalstressfor schoolstudents and could lead to musculoskeltal symptoms.Therefore, if preventive measures can be introducedwith regard to safe load carriage in school students. Itwill not only help to protect students while they arestill developing but it will also ensure that theprinciples they learn now are carried through toworkplace as adults.RECOMMENDATIONS1. Wear padded, wide shoulder straps both sides.2. Backpack should not too heavy than 10% of studentbody weight.3. Advice the students to keep the load close to thebody.Limitations of Study1. If the number of subjects had been more, resultswould have been better enhanced.2. The study was limited to only one school andparticular age group. So, results may not begeneralized to the source population.CONCLUSIONPrevious studies suggest that postural response inhigh school students are sensitive to load carriageequivalentto15%ofbodyweight.Theamountofweightthat does not change the student’s head and neckposture, that can be recommended lies between 9-10%of body weight. So, up to 10% of body weight, there issafeguard limit for adolescents.According to these results, teachers, children andfamilies should be equally involved in safe carrying ofbackpack load. As a part of physiotherapy intervention,students were often advised about their habitualposture in relation to carrying backpack load.REFERENCES1. Wunpen Chansirinukor, Dianne Wilson, KarenGrimmer and Brenton Dansie., Effects ofBackpacks on students: Measurement of cervicaland shoulder posture. Australian Journal ofphysiotherapy, 47, 110-116. 2001.2. Yong Tai wang, D.D. Pascoe, W. Weimar. ,EvaluationofBookBackpackloadduringwalkingErgonomics , 44 (9), 858 – 869, 20013. David D. Pascoe, Donna E. Pascoe,Yong Tai Wang,Dong-Ming-Shim and Chang K. Kim., Influenceof carrying book bags on gait cycle and posture ofyouths. Ergonomics, 40, (6 ),631-641, 1997.4. Karen Grimmer, brenton dansie, S. Milanese, U.Pirunson and Patricia trott., Adolescent standingpostural response to backpack loads: arandomized controlled experimental study.BMCMusculoskeltal Disorders, 3, 1-10, 20025. Forjuoh SN, Lane BL, Schuchmann J., Percentageof Body weight carried by students in their schoolbackpacks.Am. J Phys. Med. Rehabil , 82, 261– 266,2003.6. Youlian Hong, Chi-kin Cheung., Gait and postureresponses to backpack load during level walkingin children. Gait and posture, 17,28-33, 2003.7. Richard- Pistolese., Backpacks- Your child’s spineat risk.International chiropractic pediatric association-ICPA, 3,1-2, 20008. Barbara lafferty brawn, Louis R. Amundson.,Quantitative assessment of head and shoulderposture. Arch. Phys. Med. Rehabil, 70, 322-329,1998.34. Pradeep pehwa--176-184.pmd 2/7/2013, 8:08 PM183
  • 190. 184 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 19. Daniel H.K. Chow, Monica L.Y Kwok, AlexanderC.K.,A.V.Yang,AndrewD. Holmes,Jack YCheng,Y.D. YAO. M.S Wong., The Effect of backpack loadon the gait of normal adoloscent girls. Ergonomics,48 (6) , 642 – 656, 2005.10. Stefano Negrini, Roberta carabalona., Back packson ! School Children’sPerception of Load, Associations with Backpainand factors determining the load. Spine, 27,187-195, 200211. J.K.Whittfield,S.J.Legg,DIHedderley.,Theweightand use of school bags in Newzealand SecondarySchools. Ergononics , 44 (9) , 819- 824, 200112. Raine S, Twomey Lt .,Posture of Head Shouldersand thoracic spine in comfortable erect standing.Australlian J. Physiotherapy , 40 (1) , 25-32, 1994.34. Pradeep pehwa--176-184.pmd 2/7/2013, 8:08 PM184
  • 191. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 185Effect of Abductor Muscle Strengthening in OsteoarthritisPatients: A Randomized Control TrialNishant H NarConsultant Physiotherapist Wockhardt Hospital, RajkotABSTRACTBackground: Osteoarthritis is a chronic, localized joint disease affecting approximately one-third ofadults, with the disease prevalence increasing with advancing age. OA affects many joints includingthe large, weight bearing joints of the hips and knees and also the spine, hands, feet and shoulders. Theknee is the most common weight bearing joint affected by OA, with the disease predominantly affectingthe medial compartment of the tibio-femoral joint. Patients with knee OA frequently report symptoms ofknee pain and stiffness as well as difficulty with activities of daily living such as walking, stair-climbing and house keeping.Objectives: To compare the effectiveness of hip abductor muscle strengthening exercises andconventional physiotherapy treatment with conventional physiotherapy treatment alone in peoplewith unilateral medial compartment knee osteoarthritis.Materials and Methodology: Study included 30 (Thirty) subjects with unilateral medial compartmentknee OA, aged 45 years or above. The subjects were randomly divided into 2 groups: Group -A andGroup -B. The subjects were treated for a period of 6 weeks, 6 days a week, once daily. Pain wasassessed by VAS score and physical function was assessed by WOMAC Index of Osteoarthritis.Results: The results were analyzed by Wilcoxon Signed Rank Test. Group A showed significantimprovement in pain (T=120, p<0.05) and physical function (T=120, p<0.05). In Group B, resultsshowed significant improvement in pain (T=91, p<0.05) and physical function (T=120, p<0.05).Comparison of GroupAand Group B was done with Wilcoxon Sum Rank Test (Mann Whitney U Test),Group A showed significant improvement in pain (z = -2.82, p<0.0052) and physical function (z = -3.56, p<0.0004).Conclusion: Hip abductor muscle strengthening exercises showed over all improvement in pain andphysical function and is a useful adjunct exercise therapy in treating patients with unilateral medialcompartment knee osteoarthritis.Keywords: Shortwave Diathermy (SWD), Visual Analoge Scale (VAS), WOMACINTRODUCTIONThe term arthritis literally means inflammation of ajoint, but is generally used to describe any condition inwhich there is damage to the cartilage. The cartilagecoats the joint surfaces to absorb stress, and allowsmooth joint movement. The proportion of cartilagedamageandsynovialinflammation(theliningandfluidin the joint capsule) varies with the type and stage ofarthritis. Usually the early pain is due to inflammation.Later in the disease, pain is from the irritation of theworn joint structures and inability of the joint to moveproperly.Osteoarthritis (OA) is a chronic, localized jointdiseaseaffectingapproximatelyone-thirdofadults,withthe disease prevalence increasing with advancingage[1]. Concomitant with this high prevalence is a largeeconomic cost, with direct and indirect costs estimatedto be $23.9 billion in Australia in 2007[2]. Indeed, giventhe changing demographics of the adult population[3],expectations are for the prevalence of disease and itsburden on the health care system to increase in comingdecades[4].The knee is the most common weight bearing jointaffected by OA, with the disease predominantlyaffecting the medial compartment of the tibio-femoraljoint[5,6]. Patients with knee OA frequently reportsymptoms of knee pain and stiffness as well as difficultywith activities of daily living such as walking, stair-climbing and house-keeping[7].35. nishant--185-190.pmd 2/7/2013, 8:08 PM185
  • 192. 186 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Todate,mostkneeOAresearchexaminingtreatmentfor knee OA has focused on surgical or pharmacologicalstrategies. Although effective, these types ofinterventions have many potential side effects and areexpensive[8]. Thus, recent knee OA clinical guidelinesreinforce the importance of non-pharmacologicalstrategies in the management of the condition[9,10].However, there is an absence of high quality evidenceto support the use of such therapies[9].There are several reasons for the development of OAincluding age, being overweight, heredity factors, andjoint damage from a previous injury or during earlydevelopment of a joint. Increased loading across thejoint has been implicated in the progression of knee OAseverity[11]. In knee OA, the medial tibiofemoralcompartment is the most common site of disease. Thesusceptibility of the medial compartment to OAdevelopmentmayrelatetogreaterloaddistribution(i.e.,60–80%) to the medial than the lateral compartment,even in healthy knees, during gait. Excessive medialcompartment loading is widely believed to contributeto medial OA progression. Because direct measurementof knee load is invasive, external knee adductionmoment during gait, a correlate of medial load, has beenused in knee OA studies[12]. The role of gait analysis inthe quantification of dynamic joint load has receivedmuch attention in the literature in light of the difficultyin performing in vivo measurement of joint loadingduringmovement[13, 14, 15].Fromtheresearch,theexternalknee adduction moment, an indirect measure of load inthe medial compartment of the tibio-femoral joint[16],hasemerged as an important and widely acceptedbiomechanical marker of knee load.Cross-sectional studies demonstrate that patientswith knee OA have a higher peak knee adductionmomentduringwalkingwhencomparedtohealthyage-matched controls[17, 18]. It is also likely that the higherprevalenceofmedialcomparedwithlateraltibiofemoraljointOAistheresultofdifferencesintherelativeloadingwithin the tibiofemoral joint. The external kneeadduction moment determines load distribution acrossthe medial and lateral tibial plateaus[12, 19, 20], with forceacross the medial compartment almost 2.5 times that ofthe lateral[16]. It has also been reported that for patientswith knee OA, the magnitude of the adduction momentis predictive of clinical outcomes such as severity ofknee pain and radiographic disease[21, 22].AvarietyofexerciseprogramsforkneeOAhavebeendescribed in the literature. These have included generalaerobic exercise programs such as walking or cyclingas well as more specific programs involvingstrengthening of particular muscle groups and/orflexibility exercises.The primary aim of this study is to determinewhether strengthening of the hip abductor muscles inpeople with medial compartment knee OA can reduceknee pain and improve physical function. It ishypothesized that a 6-week programme ofstrengthening the hip abductor muscles will improvepain and physical function in people with medialcompartment knee OA.AIMS AND OBJECTIVE1) To determine the effectiveness of hip abductormuscle strengthening in people with medialcompartment knee osteoarthritis.2) Tocomparetheeffectivenessofhipabductormusclestrengthening and conventional treatment withconventional treatment in people with medialcompartment knee osteoarthritis.STUDY DESIGN AND MATERIALSStudy DesignAn Experimental study was conducted to study theeffects of hip abductor muscle strengthening exercisesin patients with osteoarthritic knee joints.Study SettingAll patients were referred from Orthopaedic Out-patient Department, Civil Hospital, Ahmedabad to B1ward, Physiotherapy Department, Civil Hospital,Ahmedabad where they all were treated during studyperiod.Sample SelectionThe sample size consisted of 30 (thirty) patients, whowere diagnosed with unilateral medial compartmenttibiofemoral OA, as per the Inclusion Criteria and theExclusion Criteria.Study DurationThe total duration of the study was 6 months. Thesubjects were treated for a period of 6 weeks, 6 days aweek, one session daily.Sample SizeThe sample size of 30 (thirty) patients was dividedin to two groups.35. nishant--185-190.pmd 2/7/2013, 8:08 PM186
  • 193. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 187Group A: 15 patients.Group B: 15 patients.Age Group45 years or older.Gender: Both sexesMale: 14Female: 16SELECTION CRITERIAInclusion Criteria1. Age greater than or equal to 45 years.2. Unilateral medial compartment tibiofemoral OAwithout involvement of any other compartment ofknee joint.3. Duration of symptoms: Chronic according to IASPclassification.4. AtleastsomedifficultyindailyfunctionduetokneeOA.5. Both genders are included.6. Kellgren-Lawrence radiographic grade I, II and III.7. Patients who are able to comprehend commands.8. Willingness to participate in the study.Exclusion Criteria1. History of trauma within one year to affected kneejoint.2. Associated with any other pathological conditionsuch as neoplasm, osteomyelitis, vascular problemetc.3. Low back pain radiating to knee joint.4. Knee surgery or intra articular corticosteroidinjection within 6 months to affected knee joint.MATERIALS USED IN THE STUDYConsent form, universal goniometer, vas scale,weight cuffs, WOMAC Index of Osteoarthritis,Examination Table, Thera-bands, Short-waveDiathermyMachine,KodakC875ZoomDigitalCamera,Paper, Pencil, Scale, Pins.Description of the ToolsVisual Analog Scale (VAS)WOMAC Index of OsteoarthritisMETHODOLOGYEthical clearance was obtained from the EthicalClearance Committee of wockhardt hospitals,rajkotprior to the study. Those who fulfilled the inclusioncriteriaweretakenupforthestudy.Thewholeprocedureof the study was explained to all the subjects. A writteninformed consent of all the subjects was taken prior tothe study. All the subjects were assessed as per theassessment form.30 (thirty) subjects were taken for the study withdiagnosis of unilateral medial compartment knee OA;14 male and 16 female. They were randomly divided into two groups for the study. Each subject of the studywas treated for a period of 6 weeks, 6 days a week, onesession daily.An assessment was done prior to startingof treatment and weekly assessment was taken for thesesubjects.EXERCISE PROTOCOLAll the subjects were informed in detail about thetype and nature of the study. The subjects were dividedin to two groups; Group A and Group B, 15 patients ineach group. All the subjects were randomly selectedand assigned in to each group.Group AThe subjects in Group A were given hip abductormuscle strengthening exercises and conventionalphysiotherapy treatment.Group BThe subjects in Group B were given conventionalphysiotherapy treatment.Conventional Physioterapy Treatment for BothGroup -a & Group -b: - (Ref)A. Short wave DiathermyB. Stretching Exercises1) Standing Calf Stretch2) Supine Hamstring Stretch3) Prone Quadriceps Stretch35. nishant--185-190.pmd 2/7/2013, 8:08 PM187
  • 194. 188 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1C. Range of Motion Exercises1) In long sitting position, knee mid-flexion to endrange extension2) In long sitting position, knee mid-flexion to endrange flexion3) Stationary bicycleD. Strengthening Exercise1) Static quadriceps sets in knee extension2) In high sitting position knee mid-flexion to endrange extension with weight cuff3) In prone position knee end range extension to mid-flexion with weight cuffHip Abductor Muscle Strengthening Exercises forGroup -aSubjects in Group A were given a series of threeexercisesdesignedtostrengththehipabductormuscles,6 days a week for 6 weeks.Type of exercise1) Abduction in side lying2) Abduction in standingUnilateral hip abduction performed in standing atmoderate resistanceWith the use of resistance band.3) Standing wall isometric hip abduction:Performed in unipedal stance with the opposite limbin 90 degrees of hip and knee flexion.The whole study was extended for a period of 6months. The duration of treatment programme for eachsubject was 6 weeks. All the thirty (30) subjectscompleted the whole treatment programme of 6 weekswith out any discomfort.RESULTSTable 1 show the gender distribution of the 30subjects who participated in the study. In the Group Awhere the subjects underwent hip abductor musclestrengthening exercises and conventionalphysiotherapy treatment had 8 males and 7 femalesand in the Group B where the subjects underwentconventional physiotherapy treatment alone had 6males and 9 females. There was no significantpredominance of sex.Table 1 Gender Distribution of the Subjects:Gender Group A Group BMale count% 853.33% 640%Female count% 746.66% 960%Total 15 15Table 2 displays the statistics of age distribution ofthe 30 subjects. Among the 30 subjects, the mean age of15 subjects in Group A was 51.33 with a standarddeviation (SD) of 5.2326, and the mean age of 15 subjectsin Group B was 52 with a standard deviation of 5.0142.No significant age difference was seen across the twogroups.Table 2 Age Distribution of the Subjects:Group N Mean SDGroup A 15 51.33 5.2326Group B 15 52 5.0142Wilcoxon Signed Rank Test (1,2) was applied inGroup A and in Group B for with-in group analysisand it is as follows:InGroupA,resultsshowedsignificantimprovementon VAS score (T = 120 > 95, p < 0.05).InGroupA,resultsshowedsignificantimprovementon WOMAC score (T = 120 > 95, p < 0.05).In Group B, results showed significant improvementon VAS score (T = 91 > 74, p < 0.05).In Group B, results showed significant improvementon WOMAC score (T = 120 > 95, p < 0.05).Wilcoxon Sum Rank Test (Mann Whitney ‘U’ Test)(1,2) was applied for between-group comparison ofGroup A and Group B, and it is as follows:On comparing Group A and Group B for post-treatment VAS score, results showed significantdifference in improvement (z = -2.82, p = 0.0052).On comparing Group A and Group B for post-treatment WOMAC score, results showed significantdifference in improvement (z = -3.56, p = 0.0004).For Group AScore PreMean + SD PostMean+SD T p<VAS 7 + 1.690 2 + 1.463 120 0.05WOMAC 66.66 + 6.986 27.66 + 4.237 120 0.05ForGroupB:Score PreMean + SD PostMean+SD T p<VAS 6.93 + 1.387 4.066 + 1.907 91 0.05WOMAC 67.13 + 6.577 37.46 + 6.356 120 0.0535. nishant--185-190.pmd 2/7/2013, 8:08 PM188
  • 195. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 189OncomparingGroupAandGroupB:Score z Value pValueVAS -2.82 0.0052WOMAC -3.56 0.0004The ‘z’ values (corresponding to ‘p’) are highlysignificant which suggest that hip abductor musclestrengtheningexercisesareeffectiveinreductionofpainand improvement of physical function along withconventional physiotherapy treatment.Hence, Null Hypothesis of no significant effect ofhip abductor muscle strengthening exercises can berejected and Alternative Hypothesis of , there is anadditive effect of hip abductor muscle strengtheningexercises on reduction of pain and improvement ofphysical function can be accepted.REFERENCES1. Felson DT, Naimark A, Anderson J, Kazis L,Castelli W, Meenan RF: The prevalence of kneeosteoarthritis in the elderly. The FraminghamOsteoarthritis Study. Arthritis and Rheumatism1987, 30:914-918.2. Australia A: Painful Realities: The economicimpact of arthritis in Australia in 2007. 2007.3. Hamerman D: Clinical implications ofosteoarthritis and aging. Annals of the RheumaticDiseases 1995, 54:82-85.4. Badley E, Wang P: Arthritis and the agingpopulation: projections of arthritis prevalence inCanada 1991 to 2031. Journal of Rheumatology1998, 25(1):138-144.5. Ledingham J, Regan M, Jones A, Doherty M:Radiographic patterns and associations ofosteoarthritis of the knee in patients referred tohospital. Ann Rheum Dis 1993, 52(7):520-526.6. Iorio R, Healy WL: Unicompartmental arthritis ofthe knee. J Bone Joint Surg Am 2003, 85-A (7):1351-1364.7. Guccione AA, Felson DT, Anderson JJ, AnthonyJM, Zhang Y, Wilson PWF, Kelly-Hayes M, WolfPA, Kreger BE, Kannel WB: The effects of specificmedical conditions on the functional limitationsof elders in the Framingham study. AmericanJournal of Public Health 1994, 84:351-358.8. Dieppe PA, Ebrahim S, Martin RM, Juni P: Lessonsfrom the withdrawal of rofecoxib. Bmj 2004,329(7471):867-868.9. Jordan K, Arden N, Doherty M, Bannwarth B,Bijlsma J, Dieppe P, Gunther K, Hauselmann H,Herrero-BeaumontG,KaklamanisP, etal.:EULARrecommendations 2003: an evidence basedapproach to the management of kneeosteoarthritis: report of a task force of the StandingCommittee for International clinical StudiesIncluding Therapeutic Trials (ESCISIT).Annals ofthe Rheumatic Diseases 2003, 62:1145-1155.10. OA ASo: Recommendations for the medicalmanagement of osteoarthritis of the hip and knee.2000 update. Arthritis and Rheumatism 2000,43(9):1905-1915.11. Miyazaki T, Wada M, Kawahara H, Sato M, BabaH, Shimada S: Dynamic load at baseline canpredict radiographic disease progression inmedial compartment knee osteoarthritis. AnnRheum Dis 2002, 61:617-622.12. Hurwitz D, Sumner D, Andraicchi T, Sugar D:Dynamic knee loads during gait predict proximaltibial bone distribution. Journal of Biomechanics1998, 31:423-430.13. Andriacchi T, Lang P, Alexander E, Hurwitz D:Methods for evaluating the progression ofosteoarthritis. J Rehabil Res Dev 2000, 37(2):163-170.14. Andriacchi T, Mundermann A: The role ofambulatory mechanics in the initiation andprogression of knee osteoarthritis. CurrentOpinion in Rheumatology 2006, 18:514-518.15. Sharma L, Kapoor D, Issa S: Epidemiology ofosteoarthritis: an update. Current Opinion inRheumatology 2006, 18:147-156.16. Schipplein OD, Andriacchi TP: Interactionbetween active and passive knee stabilizers duringlevel walking. Journal of Orthopaedic Research1991, 9:113-119.17. Bailunas A, Hurwitz D, Ryals A, Karrar A, Case J,Block J, Andriacchi T: Increased knee joint loadsduring walking are present in subjects with kneeosteoarthritis. Osteoarthritis & Cartilage 2002,10:573-579.18. Hurwitz D, Ryals A, Case J, Block J. Andriacchi T:The knee adduction moment during gait insubjects with knee osteoarthritis is more closelycorrelated with static alignment than radiographicdisease severity, toe out angle and pain. J OrthopRes 2002, 20:101-108.35. nishant--185-190.pmd 2/7/2013, 8:08 PM189
  • 196. 190 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 119. Jackson B, TeichtahlA, Morris M, WlukaA, DavisS, FM C: The effect of the knee adduction momenton tibial cartilage volume and bone size in healthywomen. Rheumatology 2004, 43:311-314.20. Wada M, Maezawa Y, Baba H, Shimada S, SasakiS, Nose Y: Relationships among bone mineraldensities, static alignment and dynamic load inpatients with medial compartment kneeosteoarthritis. Rheumatology 2001, 40:499-505.21. Shrader M, Draganich L, Pottenger L, PiotrowskiG: Effects of knee pain relief in osteoarthritis ongait and stair-stepping. Clinical Orthopaedics andRelated Research 2004, 421:188-193.22. Sharma L, Hurwitz DE, Thonar E, Sum JA, LenzME, Dunlop DD, Schnitzer TJ, Kirwanmellis G,Andriacchi TP: Knee Adduction Moment, SerumHyaluronan Level, and Disease Severity in MedialTibiofemoral Osteoarthritis. Arthritis &Rheumatism 1998, 41(7):1233-1240.35. nishant--185-190.pmd 2/7/2013, 8:08 PM190
  • 197. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 191Effects of Scapular Stabilization Exercises and Taping inImproving Shoulder Pain & Disability Index in Patientswith Subacromial Impingement Syndrome due toScapular DyskinesisBhavesh Patel1, Praful Bamrotia2, Vishal Kharod3, Jagruti Trambadia41Physiotherapist, Mahavir Physiotherapy Clinic, Mumbai, 2Tutor, Parul Institute of Physiotherapy, Vadodara, 3JuniorLecturer, Shri K K Sheth Physiotherapy College, Rajkot, Gujarat, 4Physiotherapist, Shri Sai Physiotherapy andRehabilitation Center, VadodaraABSTRACTBackground & purpose: Shoulder disorders are among the most common of all peripheral jointcomplaints1,2, with Subacromial Impingement Syndrome considered to be one of the most commonforms of shoulder pathology3, accounting for 44% to 60% of all complaints of shoulder pain duringarm elevation or overhead activities4. Researches for Subacromial Impingement Syndrome due toScapular Dyskinesis show that scapular stabilization exercises provide good results39. On the otherhand one of the study shows that effect of changing posture by taping will reduce the symptoms ofSubacromial Impingement Syndrome41. So the study is to compare the effectiveness of ScapularStabilization Exercises and Taping in improving shoulder pain & disability index in patients withSubacromial Impingement Syndrome due to Scapular Dyskinesis.Objective: To check the effect of Scapular Stabilization Exercises and Taping in improving shoulderpain&disabilityindexinpatientswithSubacromialImpingementSyndromeduetoScapulardyskinesis.Method: Atotal of 60 patients were taken for the study. All subjects were diagnosed with SubacromialImpingement Syndrome due to Scapular Dyskinesis. The purpose of the study was explained to all thesubjects and informed consent was taken from each subject. All subjects were randomly assigned toeither Scapular Stabilization Exercises group (Group A) and Taping group (Group B). The base linedata of SPADI was obtained to check for the pain functional outcome. SPADI was later taken at the endof the treatment after 6 weeks on follow up.Study design: Experimental designSampling technique: Purposive sampling techniqueOutcome measure: Spadi Score MeasurementResult: Results show that Scapular Stabilization Exercises showed a significant improvement ShoulderPain and Disability Index (SPADI sub scores and total scores), when compared to Taping in individualswith Subacromial Impingement Syndrome.Conclusion: Scapular Stabilization Exercises showed a significant improvement Shoulder Pain andDisability Index (SPADI sub scores and total scores), when compared to Taping in individuals withSubacromial Impingement Syndrome.Keywords: Subacromial Impingement Syndrome, Adhesive Tapes, Shoulder Pain and Disability Index.INTRODUCTIONShoulder disorders are among the most common ofall peripheral joint complaints1, 2, with SubacromialImpingementSyndromeconsideredtobeoneofthemostcommon forms of shoulder pathology3, accounting for44% to 60% of all complaints of shoulder pain duringarm elevation or overhead activities4.The disorder was first recognized by Jarjavay in1867, and the term Impingement Syndrome waspopularized by Neer in the 1970’s5.Subacromial Impingement Syndrome refers toencroachment of the coraco-acromial arch on theunderlying mechanism of the rotator cuff5. TheImpingement Syndrome can be diagnosed by certain36. Praful Bamrotia--191--195.pmd 2/7/2013, 8:08 PM191
  • 198. 192 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1impingement tests, that is, Neer test, Kennedy –Hawkin’s test and the Cross – Over Impingement(Horizontal adduction) test6.Shoulder impingement disorders are currentlyclassified as primary or secondary7.Primary shoulder impingement occurs when therotator cuff tendons, long head of the biceps tendon,glenohumeral joint capsule, and/or subacromial bursabecome impinged between the humeral head andanterior acromion8. Secondary shoulder impingementisdefinedasarelativedecreaseinthesubacromialspacedue to glenohumeral joint instability or abnormalscapulothoracic kinematics8.Some evidence exists that; Scapular dysfunction isassociated with Shoulder Impingement9.Scapular Dyskinesis is the alteration in the normalstatic or dynamic position or motion of the scapuladuring coupled scapula-humeral movements. Othernames given to this catch-all phrase include: “FloatingScapula” and “Lateral Scapular Slide”10.The scapular muscles facilitate upper extremitymovement via the scapular motions of protraction,retraction, upward (lateral) rotation, and downward(medial) rotation. The main muscles providing scapularstabilization are the rhomboids, trapezius, and serratusanterior17. Researches for Subacromial ImpingementSyndrome due to Scapular Dyskinesis show thatscapular stabilization exercises provide good results39.One of the study shows that effect of changing postureby taping will reduce the symptoms of SubacromialImpingement Syndrome12. Taping is particularly usefulin addressing movement faults at the scapula-thoracic,gleno-humeral and acromio-clavicular joints13. Thebasic rationale for taping is to provide protection andsupport for a joint while permitting optimal functionalmovement.Itisassumedthatexternalsupportincreasesjointstabilitybyreinforcingtheligamentsandrestrictingmotions14.OBJECTIVES1. To study the effectiveness of Scapular StabilizationExercises in improving Shoulder pain anddisability index in patients with SubacromialImpingement Syndrome due to ScapularDyskinesis.2. To study the effectiveness of Taping in improvingShoulder pain & disability index in patients withSubacromial Impingement Syndrome due toScapular Dyskinesis.3. To compare the effectiveness of ScapularStabilization Exercises and Taping in improvingShoulder pain & disability index in patients withSubacromial Impingement Syndrome due toScapular Dyskinesis.HYPOTHESISNull hypothesis (H0) There is no significantdifference between the effectiveness of ScapularStabilization Exercises and Taping in improvingShoulder pain and disability index in patients withSubacromial Impingement Syndrome due to ScapularDyskinesis.Alternative hypothesis (H1) There is a significantdifference between the effectiveness of ScapularStabilization Exercises and Taping in improvingShoulder pain and disability index in patients withSubacromial Impingement Syndrome due to ScapularDyskinesis.Study Design – Experimental designSampling Technique – Purposive samplingtechniqueSamples – 60 patients were taken for the study thatwere diagonesed as having subarcromail impingementsyndrome and were randomly devided into two groupsof 30 eachAge Group – 35 to 60 years.Inclusion Criteria• Pain produced or increased during flexion and /or abduction of the symptomatic shoulder.• And at least 4 of the following :• Positive Neer Impingement Sign.• Positive Hawkins Sign.• Pain produced during Supraspinatous Empty-Cantest.• Painful Arc of movement between 60 and 120degrees.• Pain with palpation on greater tuberosity of thehumerusExclusion Criteria• Patient suffering with any shoulder fracture.• Patient suffering with Frozen Shoulder or AdhesiveCapsulitis.36. Praful Bamrotia--191--195.pmd 2/7/2013, 8:08 PM192
  • 199. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 193• Patient suffering with any neurological condition.• Pregnancy.• Known allergies to taping.• Presence of a Positive Sulcus SignMETHOLOGYA total of 60 patients were taken. The purpose of thestudy was explained to all the subjects and informedconsent was taken from each subject. All subjects wererandomly assigned to either Scapular StabilizationExercises group (Group A) and Taping group(Group B).PROCEDURESThe patients were informed about the wholeprocedure, the treatment merits and demerits and areturn consent were obtained from them for voluntaryparticipation in the study. They were randomly dividedinto Group A and Group B of 30 subjects each. The baseline data of SPADI was obtained to check for the painfunctional outcome. SPADI was later taken at the endof the treatment after 6 weeks on follow up.Techniques of applicationGroup A – Scapular Stabilization Exercises along.The Scapular Stabilization Exercises are given forthe muscles that include Upper Trapezius, MiddleTrapezius, Lower Trapezius, Rhomboids, SerratusAnterior.Duration of Exercises : the scapular stabilizationexercises are given for six weeks.Group B – TapingTaping is given for the muscles that include UpperTrapezius, Middle Trapezius, Rhomboids, SerratusAnteriorDuration of Taping : Taping is given for two timesa week for six weeks.Ultrasound was given to both the groups once daily5 times a week for six weeks. Pulsed mode was given ata frequency of 1Mhz for 10 minutes.Tools used for the study1. Ultrasound Therapy Unit2. Adhesive Tapes3. Shoulder Pain And Disability Index.Assessment of Pain and Disability Evaluation.SPADI SCORE MEASUREMENTPain and disability is evaluated by using SPADI. Itconsists of 2 self report sub scales of pain and disability.TheitemsofbothscalesareVAS(VisualAnalogueScale)and the 5 items pain subscales asks people about theirpain during ADLs (Activities of Daily Livings) and eachitem is anchored by the descriptions “no pain” (leftanchor) and “ worst pain imaginable” (right anchor).The 8 disability items ask people about their difficultyin performing ADL. Higher scores on the sub scaleindicate greater pain and greater disability. To obtainthe total score of SPADI both the pain and disabilitysubscales are averaged.Study Duration: 6 weeks.Procedures of Scapular Stabilization ExercisesFor Upper TrapeziusIt is done by Prone Row Exercise, where the patientlies prone over the edge of the bed with the affectedlimb out of the bed, and performs rowing movement.For Lower TrapeziusIt is done by, patient lying prone at the edge of thebed, with the affected limb out of the bed and thenperforms overhead arm raise in line with lowertrapeziusFor Middle Trapezius and RhomboidsIt is done by, patient lying prone at the edge of thebed, with the affected limb out of the bed and thenperforms horizontal abduction neutrally.One of the functional exercise for Serratus Anterior: The patient performs stepping alternating punchexercise, with a resisted Thera tube.Procedure of Taping target musclesTaping for Upper TrapeziusFrom anterior aspect of upper trapezius just abovethe clavicle over the muscle belly to approximately thelevel of rib seven in a vertical line. Once partiallyattached, a firm downward pull is applied and the tailof the tape attached.Taping for Middle Trapezius and RhomboidsFromtheanterioraspectoftheshoulder,2cmmedial36. Praful Bamrotia--191--195.pmd 2/7/2013, 8:08 PM193
  • 200. 194 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1to the joint line, around deltoid muscle just belowacromial level to T6 area without crossing midline. Tapepull is into retraction.Taping for Serratus AnteriorFrom 2 cm medial to the scapula border, followingthe line of the ribs down to the mid-axillary line. Fourone-third overlapping strips are applied with the originand insertion pulled together and bunching the skin.RESULTSTable1: Average improvement in pain, disability andtotal SPADI score in group ASPADI Average Z-value p-value ResultimprovementPain 54 4.813 0.000 p<0.05 significantDisability 60 4.813 0.000 p<0.05 significantTotal 56.93 4.800 0.000 p<0.05 significantTable2:- Average improvement in pain, disability andtotal SPADI score in group BSPADI Average Z-value p-value ResultimprovementPain 40 4.832 0.000 P<0.05 significantDisability 53.75 4.808 0.000 P<0.05 significantTotal 48.46 4.807 0.000 P<0.05 significantTable 3:- Comparison of Pain, Disability and TotalSPADI before and after the treatment within Group-Aand Group-B using Mann-Whitney U test:-SPADI Average Averag U-value p-value Resultimprovement(A) improvement(B)Pain 54 40 263.50 0.005 P<0.05significantDisability 60 53.75 254.00 0.003 P<0.05significantTotal 56.93 48.46 239.00 0.002 P<0.05significantDISCUSSIONSubacromial impingement syndrome is caused bynarrowing of the subacromial space with secondaryimpingement of the bursal surface of the rotator cuff onthe undersurface of the acromion16. Some evidenceexists that, Scapular dysfunction is associated withShoulder Impingement9.Clinical authorities have suggested that poor upperbody posture and muscle imbalance may cause orperpetuate Subacromial impingement syndrome. Theaim of many conservative rehabilitation programs is tocorrect posture and muscle imbalance using musclestrengthening, muscle stretching, and joint mobilizationtechniques. The evidence to support the efficacy of theseclinical practices is limited12.Therapeutic exercises have previously beendetermined to have long-term benefits for patients withshoulder impingement syndrome8. The therapeuticexercise stretches the anterior and posterior shouldergirdle, relaxes the muscle, helps in motor learning tonormalize dysfunctional patterns of motion, andstrengthening the rotator cuff and scapular muscles,whichleadstoimprovementsinpain,levelsofdisabilityand functional loss, strength, shoulder range of motion,pain with subacromial compression4.A potential mechanism by which proprioceptiveshoulder taping may be effective is via augmentedcutaneous input. Tape is applied in such a way thatthere is little or no tension while the body part is held ormoved in the desired position or plane. It will thereforedevelop more tension when movement occurs outsideof these parameters. This tension will be sensedconsciously thus giving a stimulus to the patient tocorrect the movement pattern. Over time and withenough repetition and feedback, these patterns canbecome learned components of the motor engrams forgiven movements. It also causes increase in length anddecrease in tension thereby producing greater forcedevelopmentintheinnerrangethroughoptimisedactin-myosin overlap during the cross-bridge cycle13. One ofthe study demonstrated that taping was effective indecreasing Upper Trapezius and increasing LowerTrapezius activity in individuals with shoulderimpingement during overhead reaching tasks, thusimproving scapular dyskinesis15.Here, both the groups had received Ultrasoundtherapy as a modality in the treatment, as it is effectivein healing process, helps in decreasing inflammationand swelling.In present study, the results shows that ScapularStabilization Exercises is more effective than Taping inpatients with Subacromial Impingement Syndrome dueto Scapula Dyskinesis.LIMITATIONS1. In present study only SPADI is taken in outcomemeasures.2. In this study there is no control group is present.3. It’s a short duration study as study duration is 6weeks.CONCLUSIONScapular Stabilization Exercises and Taping36. Praful Bamrotia--191--195.pmd 2/7/2013, 8:08 PM194
  • 201. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 195produced significant improvement in Shoulder Painand Disability (SPADI Sub scores and Total scores)values in patients with Subacromial ImpingementSyndrome due to Scapula Dyskinesis, when appliedindividually. However Scapular Stabilization Exercisesshowed a significant improvement Shoulder Pain andDisability Index (SPADI sub scores and total scores),when compared to Taping in individuals withSubacromial Impingement Syndrome.REFERENCES1. Chard MD, Hazleman BL, King RH, Reiss BB.Shoulder disorders in the elderly : a communitysurvey. Arthritis Rheum. 34:766-769.1991.2. Herberts P, Kadefors R, Andersson G, Petersen I.Shoulder pain in industry : an epidemiologicalstudy on welders. Acta Orthop Scand. 52:299-306.1981.3. Ashim Bakshi. A combination approach usingManual Therapy and Supervised Exercises.Management of Subacromial ImpingementSyndrome. Journal of Exploring Hand Therapy.7(2):1-5.2007.4. Lori A Michener, Matthew K. Walsworth, EvinBurnet. Effectiveness of Rehabilitation for patientswith Subacromial Impingement Syndrome : Asystemic review. Journal of Hand Therapy. 17:152-164.2004.5. David Morrison,Anthony.D.Frogameni and PaulWoodworth. Non-Operative Treatment OfSubacromial Impingement Syndrome. Journal ofBone Joint Surgery Am. 79:732-737.1997.6. Palmer LM and Epler ME : Fundamentals ofMusculoskeletal Assessment techniques 2nded.Lippincott, Williams and Wilkins. 106-124.1998.7. Fu FH, Harner CD, Klein AH. ShoulderImpingement : a critical review. Clin Orthop.269:162-173.1991.8. Neer CS. Anterior acromioplasty for the chronicimpingement syndrome in the shoulder: Apreliminary report. J Bone Joint Surg Am. 54:41–50.1972.9. Philip W McClure, Jason Bialker, Nancy Neff,Gerald Williams, Andrew Karduna. ShoulderFunction and 3-dimensional kinematics in peoplewithShoulderImpingementSyndromebeforeandaftera6-weekExerciseProgram.PhysicalTherapy.84(9):832-848.2004.10. W. Ben Kibler, John McMullen. ScapularDyskinesis And its Relation to Shoulder Pain.Journal Of American Academy Of OrthopaedicSurgery. 11:142-151.2003.11. Farhad O Moola. Orthopaedic SurgeryDepartment. Scapular Stabilizing Muscles :RehabilitationProtocol.NewWestOrthopedicandSports Medicine Center. University Of BritishColumbia.12. Jeremy S. Lewis, Christine Wright, Ann Green.Subacromial Impingement Syndrome : The effectof changing posture on shoulder range ofmovement. Journal Of Orthopaedic and SportsPhysical Therapy. 35:72-87.200513. Dylan Morrissey. Proprioceptive shoulder taping.Journal of Bodywork and Movement Therapies.4(3),189-194.2000.14. A.M.Cools, E.E. Witvrouw, L.A. Danneels,D.C.Cambier. Does Taping influenceelectromyographic muscle activity in the Scapularrotatorsin healthy shoulders?. Manual Therapy.7(3)154-162.2002.15. Selkowitz DM, Chaney C, Stuckey SJ, et al. Theeffects of scapular taping on the surface ofelectromyographic signal amplitude of shouldergirdle muscles during upper extremity elevationin individuals with suspected shoulderimpingement syndrome. J Orthop Sports PhysTHer. 37:694-702.2007.16. BenjaminBlair,AndrewS.Rokito,FrancesCuomo,Kenneth Jarolem and Joseph D. Zuckerman.Efficacy of Injections of Corticosteroids forSubacromial Impingement. J Bone Joint Surg Am.78:1685-9.1996.17. Jason Brumitt, Erika Meira. Scapula StabilizationRehab Exercise Prescription. Strength andConditioning Journal. 28(3):62-65.2006.36. Praful Bamrotia--191--195.pmd 2/7/2013, 8:08 PM195
  • 202. 196 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Effects of Osteopathic Manipulative Treatment in Patientswith Chronic Obstructive Pulmonary DiseasePraniti P. Bhilpawar1, Rachna Arora21M. P. Th. from T.N. Medical College and B.Y.L. Nair Hospital, Mumbai, 2Asst. Professor in T.N. Medical College andB.Y.L. Nair Hospital, MumbaiABSTRACTBackground: The study was carried out to assess the effects of osteopathic manipulative treatment inpatients with chronic obstructive pulmonary disease.Subjects: 30 patients with chronic obstructive pulmonary disease were selected for the study.Method: Patients were selected from the respiratory OPD at a tertiary care centre using conveniencesampling technique. The patients were recruited after signing the ethics approved consent forms.Outcome measures: chest expansion, peak expiratory flow rate and respiratory rate were assessed anddocumented prior to and following the intervention. The subjects were given seven osteopathicmanipulative techniques. The entire duration for osteopathic manipulative treatment session wasapproximately 20 minutes for each subject.Results: Significant improvements were found in chest expansion at axillary and xiphisternal level,peak expiratory flow rate and significant decrease in respiratory rate after single session of osteopathicmanipulative treatment.Conclusion: Osteopathic manipulative treatment increases chest expansion at both axillary andxiphisternal level and peak expiratory flow rate and leads to reduction in respiratory rate in patientswith COPD.Keywords: Chronic Obstructive Pulmonary Disease (COPD), Osteopathic Manipulative Treatment, PEFRINTRODUCTIONChronic obstructive pulmonary disease (COPD)refers to a group of disorders characterized by chronicairflow obstruction/limitation. It includes two distinctpatho-physiological processes—chronic bronchitis andemphysema1, 2, 3, 4. It is associated with an abnormalinflammatory response of the lungs to noxious particlesor gases, especially tobacco smoke and air pollution -both indoor and outdoor.The term COPD was accepted in the British ThoracicSociety(BTS)guidelinesonmanagementofthisdisease5.Chronic obstructive pulmonary disease (COPD) iscurrently the fourth leading cause of death worldwide.The male to female ratio varied from 1.32:1 to 2.6:1 withmedian ratio of 1.6:11.The disadvantages of bio mechanical alterations ofhyperinflation are compounded by the increaseddemandforventilationinCOPD.Moreworkisrequiredof a less effective system. The energy cost of ventilation,or the work of breathing, in COPD is markedlyincreased.Conventional management of COPD includessmoking cessation, pharmacological therapy, long-termoxygen therapy, and pulmonary rehabilitation. COPDhave been shown to decrease compliance of the chestwall, force-generating capacity of the diaphragm,residual volume (RV) increases, and forced vitalcapacity (FVC). Therefore, the therapeutic interventioncommonly done for chest wall and related structuresare respiratorymuscle stretching exercises. They havebeen reported toimprove chest wall mobility, improvevital capacity, and decrease dyspnea6. However, COPDis an important disease whose incidence is risingworldwide and that there is a need to develop newtreatments to prevent theprogression of the disease7.The osteopathic medical profession has developeda variety of techniques for the specific purpose ofimproving chest expansion, quality of life andpulmonary function. These techniques are well37. praniti--196-201.pmd 2/7/2013, 8:08 PM196
  • 203. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 197described and target various aspects of themusculoskeletal, neuronal and lymphatic componentsof the pulmonary system. The efficacy of osteopathicmanipulative treatment (OMT) is thought to beenhanced by using techniques in combination, whereone technique works synergistically with another toachieve an overall therapeutic effect8.Masarsky CS, Weber M, Virginia ChiropracticAssociation Research Committee, Vienna 22180,studied Chiropractic management of chronicobstructive pulmonary disease. They noted that apatient with a history of chronic obstructive pulmonarydisease going back more than 20 years was treated witha combination of chiropractic manipulation,nutritional advice, therapeutic exercises, and inter-segmental traction. Improvements were noted in forcedvital capacity, forced expiratory volume in one second,coughing, fatigue, and ease of breathing9.The study was thus designed in order to determineif one session of OMT treatment could produceimmediate changes on chest expansion, respiratory rateand PEFR in patients with COPD.MATERIAL AND METHODStudy design: An Experimental hospital based studyPlace of study: Physiotherapy OPD of TopiwalaNational Medical College & Nair Hospital Mumbai.Type of Sampling: convenience non-random samplingOperational definitions were provided.Inclusion criteriaPatients with Chronic Obstructive PulmonaryDisease with FEV1/FVC < 70%.Exclusion criteria• Unstable medical condition.• Acute bronchitis.• Pneumonia.• Acute Exacerbation within 1 month of datacollection.• Chest wall deformity.Measurement tool• Measuring tape.• Peak flow meter.• Watch with seconds hand.Outcome measures• Chest expansion at axillary, xiphisternal level(using measuring tape).• Peak expiratory flow rate (using peak flow meter).• Respiratory rate (for 1 minute)Thirty patients with COPD were selected andincluded in the study after signing ethics approvedconsent forms. The patients were evaluated prior totreatment and data was documented. The subjects weregiven seven osteopathic manipulative techniques. Theduration of entire osteopathic manipulative treatmentsession was approximately 20 minutes for each subject.The outcome measures were documented posttreatment. The patient was instructed to inform thetherapist immediately any discomfort during treatmentsession.Allthesubjectsinthestudywereabletotoleratethe manipulative techniques with no sign of anydiscomfort.Techniques of Osteopathic manipulation1. Soft tissue kneading (paraspinal muscles in lowercervical and thoracic region bilaterally)2. Rib raising3. “Redoming” the abdominal diaphragm (indirectmyofascial release)4. Suboccipital decompression5. Thoracic inlet myofascial release6. Pectoral traction7. Thoracic lymphatic pump with activationDATA ANALYSISData analysis was performed by using Paired t-testand Wilcoxon Sign rank test.Table No 1: Distribution of study group as per sexshows the distribution of sex in the study group. Studygroup consists of 7% female and 93% male.Sex Count PercentFemale 2 7%Male 28 93%Total 30 100%37. praniti--196-201.pmd 2/7/2013, 8:08 PM197
  • 204. 198 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1Table No 2: Comparison of Chest expansion (axillary) ‘before’ and ‘after’ treatment: shows that there is statisticallysignificant improvement in chest expansion (axillary level) after single session of osteopathic manipulativetreatment, p value=1.17E-05 (<0.05)Chest Expansion (Axillary) N Mean SD Median IQR Wilcoxon Signed p valueRank TestPre treatment 30 1.13 0.46 1 0.6 -4.383 1.17E05Post treatment 30 1.43 0.50 1.4 0.65 Difference is significantTable No 3: Comparison of Chest expansion (Xiphisternal) ‘before’ and ‘after’ treatment: shows that there isstatistically significant improvement in chest expansion (xiphisternal level) after single session of osteopathicmanipulative treatment, p value= 3.06E-05 (<0.05)Chest Expansion N Mean SD Median IQR Wilcoxon Signed p value(Xiphisternal) Rank TestPre treatment 30 1.19 0.45 1.2 0.6 -4.169 3.06E-05Post treatment 30 1.48 0.51 1.6 0.8 Difference is significantTable No 4: Comparison of PEFR l/min ‘before’and ‘after’treatment: shows there is statistically significant improvementin peak expiratory flow rate after single session of osteopathic manipulative treatment, p value= 2.84E-04 (<0.05)PEFR l/min N Mean SD Median IQR Wilcoxon Signed p valueRank TestPre treatment 30 159.74 54.65 150 64 -3.629 2.84E-04Post treatment 30 171.47 60.45 160 82.5 Difference is significantTable No 5: Comparison of RR/min ‘before’ and ‘after’ treatment: shows that there is statistically significant decreasein respiratory rate after single session of osteopathic manipulative treatment, p value= 4.50E-03 (<0.05)Respiratory Rate (per min) N Mean SD Median IQR Paired T test p valuePre treatment 30 25.37 7.50 24 9 3.08 4.50E-03Post treatment 30 23.23 5.56 23 8 Difference is significantDISCUSSIONThe results of the present study indicate that thereis statistically significant increase in chest expansionat axillary and xiphisternal level. Also an increase isseen in peak expiratory flow rate and decrease inrespiratory rate after osteopathic manipulativetreatment, thereby supporting the experimentalhypothesis. In this study, the mean age of the patientsranged from 37-81 years of age. The distribution ofpatients, according to sex is 93% male and 7% female.The ventilation depends on the rib motion,diaphragm function, muscles of respiration andmechanical properties of the airways10.In COPD thereis hyperinflation of lungs and therefore chest wall isfixed in inspiration (barrel shaped chest) 11.This resultsin shortening of soft tissue of upper chest. COPDpatients generally have a kyphotic posture withrounded shoulders (pectoral tightness) and elevatedshoulder girdle (trapezius tightness) to effectively useaccessory muscle of respiration. When the muscles arein a shortened position, the fascia overlying the musclealso gets shortened. Due to the barrel shaped chest, theribs are horizontally oriented. This further reduces theexcursion of ribs during inspiration. There by reducingchest expansion.According to handbook of osteopathic technique byLaurie Hartman, kneading of paraspinal muscles relaxthem by reducing fluid congestion and tonic irritability.Theunderlyingmechanismisthoughttobeduetoreflexbalancing or from fluid interchange and lymphaticdrainage within the tissues12. Luce Helen and RobinsonMark stated that soft tissue kneading decreases musclespasm, stretches and improves elasticity of soft tissues,improves circulation, improves venous and lymphaticdrainage and promotes relaxation13.Principles and practices of therapeutic massage bySinha states that kneading produces a local increase inthe flow of blood due to pumping action, liberation ofH substance and elicitation of axon reflex. This alsodecreases the stagnation of fluid and oedema as wellas improves the nutrition of the area. It stretches thetight fascia and helps in restoration of mobility of skinand subcutaneous fascia. The intermittent pressure mayalso stimulate tension dependent mechanoreceptor, i.e.Golgi tendon organ, etc. and decreases the excitabilityof motoneuronal pool in neurologically healthy37. praniti--196-201.pmd 2/7/2013, 8:08 PM198
  • 205. Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 199individuals. This helps in decreasing the tension ofmuscles.14Pectoral traction technique, a Myofascial releasetechnique, also helps in increasing chest expansion bylengthening the tight structures12.The combination oftraction and respiratory motion releases the upperanterior thoracic muscle tension15.In COPD there is increase in sympathetic nervoussystem activity leads to release of catecholamines intothe blood stream and there is narrowing of airwayswhich leads to reduction in peak expiratory flow rate.7Paraspinal muscle kneading and rib raising probablystimulate Chapman’s reflexes. Suboccipitaldecompression probably improves parasympatheticfunction by releasesing restricted tissues around vagusnerves.13, 16This may lead to normalization ofsympathetic tone and which in turn may increase PEFRand reduce RR.The American Academy of Osteopathy states thatthe rib raising technique improves movement of ribsand thoracic cage by mechanical stimulation ofsympathetic chain ganglia and related structures. Thisresults in improved sympathetic tone in lung. This issupported by the study done by Aaron T. Hendersonwhich shows that sympathetic nervous system activitymay decrease immediately after rib raising17.Effectivelymphaticdrainageofthelungsisnormallyachieved by contraction of the diaphragm and thoraciccagemovementduringrespiration.However,inpatientswith COPD, both of these mechanisms may becompromised, leading to impaired lymphatic drainage.There are several OMT techniques which address theproblem of lymphatics such as rib raising, diaphragmrelease, and lymphatic pumps18.Numerous techniques are given in osteopathic textsfor controlling circulation and drainage. Chapman’sreflexes are one example that has already beenmentioned. Kuchera also gives ideas for detailedtreatment of lymphatic system dysfunction. The threebasic goals are:a. To promote the free flow of lymph through itslymphatic vessels and fascial pathways.b. To improve function of the abdominal diaphragm,the extrinsic pump for the lymphatic system.c. To reduce sympathetic outflow19.Treatment techniques include manipulation of thethoracic inlet, stretching the abdominal diaphragm,fascial releases and thoracic lymphatic pump. Kucheraand Kuchera have this to say regarding lymphaticdrainage and the lungs.Myofascial release techniques such as diaphragmrelease and thoracic inlet release also contributes toincrease in chest expansion and improves motion ofdiaphragm. It releases connective tissue tension withinstructures of thorax. It helps in removing restriction tolymphatic flow. It releases tissue restriction, improveslymphatic drainage and improves mechanics ofrespiration.11, 14According to handbook of osteopathic technique byLaurie Hartman, myofascial release techniquesattempts to ‘normalize’ these areas by allowingimproved circulation and ‘re-setting’ of the neuralcontrol of tendons and muscles. Its main action is onconnective tissues, fascia and muscle attachments10.The reduction in RR could be attributed tonormalization of sympathetic tone through Chapman’sreflexes. The increase in chest expansion probablysuggests that the patients tidal breathing has increasedand therefore reflected as reduced RR.Donald R. Noll studied the Efficacy of OsteopathicManipulation in Chronic Obstructive PulmonaryDisease. He stated that OMT sessions are designed toimprove chest wall compliance and diaphragmaticfunction which produce an immediate positive changein pulmonary function parameters and chest wallmobility20.As this study supported our experimentalhypothesis OMT can be used as an adjunct treatmentin COPD along with pulmonary rehabilitation.Conclusion: Osteopathic manipulative treatmentincreases chest expansion at both axillary andxiphisternal level in patients with COPD. There isincrease in peak expiratory flow rate followingosteopathic manipulative treatment in patients withCOPD. Osteopathic manipulative treatment leads toreduction in respiratory rate in patients with COPD.Limitations of the study• Small sample size• Patients are not divided according to GOLDclassification• Occupational background and socioeconomicstatus were not considered37. praniti--196-201.pmd 2/7/2013, 8:08 PM199
  • 206. 200 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1SUMMARYIn order to investigate the effects of osteopathicmanipulative treatment in patients with chronicobstructive pulmonary disease, 30 patients wereenrolled in this study. The patients were given singlesession of Osteopathic manipulation techniques suchas soft tissue kneading, rib raising, “Redoming” theabdominal diaphragm, suboccipital decompression,thoracic inlet myofascial release, pectoral traction andthoracic lymphatic pump with activation. The outcomemeasures of chest expansion at axillary andxiphisternal levels, peak expiratory flow rate andrespiratory rate were measured pre and post treatment.The mean pre treatment and post treatment score ofchest expansion at axillary level were analysed usingthe Wilcoxon signed ranks test and the improvement inchest expansion was found to be significant, pvalue=1.17E-05 (< 0.05).The mean pre treatment and post treatment score ofchest expansion at xiphisternal level were analysedusing the Wilcoxon signed ranks test and theimprovement in chest expansion was found to besignificant, p value= 3.06E-05 (< 0.05).The mean pre treatment and post treatment score ofpeak expiratory flow rate were analysed using theWilcoxon signed ranks test and increase in PEFR wasfound to be significant, p value= 2.84E-04 (< 0.05).The mean pre treatment and post treatment score ofrespiratory rate were analysed using paired t-test andreduction in RR was found to be significant, p value=4.50E-03 (< 0.05).Therefore these results support the hypothesis ofthe study that Osteopathic manipulative treatmentshows improvement in Chest Expansion, PeakExpiratoryFlowRateandreductioninRespiratoryRate.Conflict of Interest StatementI, Dr. Praniti P. Bhilpawar (PT) the primaryinvestigator hereby declare that there are no conflicts ofinterest and the present study is an original work.REFERENCES1. Murthy KJR, Sastry JG. Economic burden ofchronic obstructive pulmonary disease. NCMHBackground Papers· Burden of Disease in India;2005.2.