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

Occupational Therapy
www.ijpot.com
Contents
Volume 07 Number 01
January - March 2013
1.
3 Weeks Continuous Passive Motion Vs Joint Mobilization and their Combination in ..................................................... 01
Knee Stiffnes - A Comperative Study
Anil kumar, Santosh Metgud
2.
Comparison of Blood Pressure and Heart Rate between Young Males and Females ......................................................... 06
During Dominant and Non-Dominant Single-Leg Stance
Ankita Samuel, Manish Rajput, Chhavi Gupta, Sumit Kalra
3.
Effectiveness of Transcutaneous Electrical Nerve Stimulator (TENS) in Reducing ........................................................ 11

Neuropathic Pain in Patients with Diabetic Neuropathy
Apeksha O. Yadav, G. J. Ramteke
4.
Evaluation of effects of Nebulization and Breathing Control in Asthmatic Patients .......................................................... 14

Kesharia, Amita Mehta
5.
Effect of Neuromuscular Electrical Stimulation Combined with Cryotherapy on ............................................................. 21

Spasticity and Hand Function in Patients with Spastic Cerebral Palsy
Chandan Kumar, Vinti
6.
Phonophoresis in Continuous Mode Ultrasound has Significant effect in the Reliving .................................................... 26
Pain in Upper Trapezius Tender Point
Chhavi Gupta, Manish Rajput, Ankita Samuel, Sumit Kalra
7.
Prediction of Relationship of Visual Attention Deficits to Balance and Functional ............................................................ 31

Outcome in Persons with Subacute Stroke
Chintan Shah, Hasmukh Patel, Komal Soni, Dhaval Desai, Harshit Soni
8.
The effects of Therapeutic Application of Heat or Cold Followed by .................................................................................. 37

Static Stretch on Hamstring Flexibility Post Burn Contracture
Emad T. Ahmed, Safa S. Abdelkarim
9.
Pulsed Electromagnetic Therapy Improves Functional Recovery in Children with Erb's Palsy ...................................... 42
Reda Sarhan, Enas Elsayed, Eman Samir Fayez
10. Effectiveness of PNF Stretching and Self Stretching in Patients with Adhesive .................................................................. 47
Capsulitis - A Comparative Study
Harshit Mehta, Paras Joshi, Hardik Trambadia
11. Effect of Modified Hold-Relax and Active Warm-Up on Hamstring Flexibility ................................................................. 52
Swapnil U Ramteke, Hashim Ahmed, Virenderpal Singh, Piyush Singh
12. A Comparative Study of effectiveness between Superficial Heat and Deep Heat along with .......................................... 58
Static Stretching to Improve the Plantar Flexors Flexibility in Females Wearing High Heel Foot Wears
Hasmukh Patel, Dhaval Desai, Harshit Soni, Komal Soni, Chintan Shah
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II
13. Influence of different Types of Hand Splints on Flexor Spasticity in Stroke Patients ......................................................... 65
Eman Samir Fayez, Hayam Mahmoud Sayed
14. Interferential Current Therapy versus Narrow Band Ultraviolet B Radiation in the Treatment ...................................... 70
of Post Herpetic Neuralgia
Intsar Salim. Waked
15. Effect of the Duration of Play on Pain Threshold and Pain Tolerance in Soccer Players ................................................... 76
Shahid Raza, C.S. Ram, Jamal Ali Moiz
16. Neuromuscular Electrical Stimulation Versus Intermittent Pneumatic Compression on .................................................. 81
Hand Edema in Stroke Patients
Eman S.M.Fayez, Hala Ezz Eldeen
17. A Combination Approach using Manual Therapy and Exercise in the Treatment .............................................................. 87
of Shoulder Impingement Syndrome
Annamma Mathew, Abedi Afsaneh
18. Musculoskeletal Pain among Computer Users .......................................................................................................................... 90
Shweta Keswani, Lavina Loungni, Tiana Alexander, Hebah Hassan, Shatha Al Sharbatti, Rizwana B Shaikh, Elsheba Mathew
19. A Report of Body weight Supported Overground Training in Acute Traumatic Central Cord Syndrome .................... 96
Asir John Samuel, John Solomon, Senthilkumaran, Nicole D'souza
20. Effects of Ischemic Compression on the Trigger Points in the Upper Trapezius Muscle ................................................... 99
Bhavesh H. Jagad, Karishma B. Jagad
21. Prevalence of Upper Limb Dysfunction in Subjects with Chronic non Specific ................................................................ 105
Neck Pain in Bangalore City, Karnataka
Kinchuk DB, Soumya G, Payal D
22. Randomized Controlled trial of Group Versus Individual Physiotherapy Sessions for .................................................. 110
Genuine Stress Incontinence in Women
Komal Soni, Harshit Soni, Dhaval Desai, Chintan Shah, Hasmukh Patel
23. A Study of Electromyographic Changes in Muscle Post Exercise Induced Muscle Soreness ........................................ 116
Manish Rajput, Ankita Samuel, Chhavi Gupta, Sumit Kalra
24. Effect of Pelvic Floor Muscle Strengthening Exercises in Chronic Low Back Pain ........................................................... 121
Manisha Rathi
25. Comparing Hold Relax - Proprioceptive Neuromuscular Facilitation and Static Stretching .......................................... 126
Techniques in Management of Hamstring Tightness
Ali Ghanbari, Maryam Ebrahimian, Marzieh Mohamadi, Alireza Najjar-Hasanpour
26. Reliability and Feasibility of Community Balance and Mobility Scale (CB&MS) in Elderly Population ..................... 131
NagaRaju, Arun Maiya, Manikandan
27. Core Stability Training with Conventional Balance Training Improves Dynamic Balance in ......................................... 136
Progressive Degenerative Cerebellar Ataxia
Khan Neha Tabbassum, Nayeem-U-Zia, Harpreet Singh Sachdev, Suman K
28. Restoration of Normal Length of Upper Trapezius and Levator Scapulae in .................................................................... 141
Subjects with Adhesive Capsulitis
Pandit Niranjan Hemant, Mhatre Bhavana Suhas, Mehta Amita Anil
29. Comparison of Vmo/Vl Ratio in Patello-Femoral Pain Syndrome (Pfps) Patients: A Surface Emg Study .................. 148
Nishant H Nar
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III
30. A Study to Check Added effects of Electrical Stimulation with Task Oriented Training in ............................................ 154
Hand Rehabilitation among Stroke Patients
Paras Joshi
31. Relationship of Cognition, Mobility and Functional Performance to Fall .......................................................................... 160
Incidence in Recovering Stroke Patients
Paras Joshi, Hardik Trambadi
32. Reliability of Modified Modified Ashworth Scale in Spastic Cerebral Palsy ..................................................................... 165
Divya Gupta, Pooja Sharma
33. Evaluation of Pulmonary Function Tests in Patients Undergoing Laparotomy ................................................................ 170
Nahar P S, Shah S H, Vaidya S M, Kowale A N
34. Evaluation of Standardized Backpack weight and its Effect on Shoulder & Neck Posture ............................................. 176
Pardeep Pahwa
35. Effect of Abductor Muscle Strengthening in Osteoarthritis Patients: A Randomized Control Trial .............................. 185
Nishant H Nar
36. Effects of Scapular Stabilization Exercises and Taping in Improving Shoulder Pain & ................................................. 191
Disability Index in Patients with Subacromial Impingement Syndrome Due to Scapular Dyskinesis
Bhavesh Patel, Praful Bamrotia, Vishal Kharod, Jagruti Trambadia
37. Effects of Osteopathic Manipulative Treatment in Patients with ......................................................................................... 196
Chronic Obstructive Pulmonary Disease
Praniti P. Bhilpawar, Rachna Arora
38. Comparison of Stretch Glides on External Rotation Range of Motion in ........................................................................... 202
Patients with Primary Adhesive Capsulitis
Paras Joshi, Bhavesh Jagad
39. A Study of Electromyographic Activity of Masseter Muscle After Gum Chewing in Young Adults ............................ 208
Preeti Baghel, Nidhi Kalra, Sumit Kalra
40. A Study to Evaluate the effect of Fatigue on Knee Joint Proprioception ............................................................................. 213
and Balance in Healthy Individuals
Purvi K. Changela, K. Selvamani, Ramaprabhu
41. Effect of Core Stabilization and Balance-Training Program on Dynamic Balance ............................................................ 218
Rabindra Basnet, Nalina Gupta
42. A Retrospective Analysis of Disability-Related Data on Disabled ....................................................................................... 223
Children and their Families in Turkey
Rasmi Muammer
43. Effect of Postural Brace for Correcting Forward Shoulder Posture and Kyphosis in ....................................................... 228
Patients with Chronic Obstructive Pulmonary Disease: A Pilot Study
Ravi Savadatti, Gajanan. S. Gaude, Prashant Mukkannava
44. Effect of Neck Extensor Muscles Fatigue on Postural Control Using Balance Master ..................................................... 234
Reshma S.Gurav, Rajashree V.Naik
45. Aerobic Capacity in Regular Physical Exercise Group and Indian Classical Dancers: .................................................... 238
A Comparative Study
Rupali B. Gaikwad, Vijay Kumar R. waghmare, D.N. Shenvi
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IV
46. Comparative Study to Determine the Hand Grip Strength in Type-II Diabetes ................................................................ 243
Versus Non-Diabetic Individuals - A Cross Sectional Study
Jayaraj C. Sindhur, Parmar Sanjay
47. Study of Correlation between Hypermobility and Body Mass Index in Children aged 6-12 Years ............................... 247
Parmar Sanjay, Praveen. S. Bagalkoti, Rajlaxmi Kubasadgoudar
48. Comparison of Reaction Time in Older Versus Middle-aged ................................................................................................ 250
Type II Diabetic Patients - An observational Study
Shruti Bhat, Sanjiv Kumar
49. Effect of Rehearsal Digit-Span Working Memory Intervention on Sensory Processing ................................................... 254
Disorder in children with Autism: A Pilot Study
Smily Jesu Priya V, Jayachandran V, Noratiqah S, Vikram M, Mohamad Ghazali M, Ganapathy Sankar U
50. Evaluation of Inter-Rater Reliability to Measure Hand and Arm Function in ................................................................... 259
Reaching Performance Scale for Stroke Patients
SureshKumar T., Leo Rathinaraj A.S., Jeganathan A., Vignesh waran Vellaichamy
51. Effect of Incentive Spirometry on Cardiac Autonomic Functions in Normal Healthy Subjects ..................................... 264
Trupti Ajudia, Pravin Aaron, Subin Solomen
52. Concurrent Validity of Clinical Chronic Obstructive Pulmonary Disease (COPD) ......................................................... 270
Questionnaire (CCQ) in South Indian Population
C.M. Herbert, V.K. Nambiar, M. Rao, S. Ravindra
53. To Study the effect of Mental Practice on one Leg Standing Balance in Elderly Population ........................................... 274
Vidya V Acharya, Saraswati Iyer
54. Effect of Midprone Decubitus on Pulmonary Function Test Values in ................................................................................ 280
Young Adults with Undesirable Body Mass Indices (BMI)
Junaid Ahmed Fazili, Ajith S, A.M.Mirajkar, Mohamed Faisal C K, Ivor Peter D'Sa
55. Comparison of Quality of Life in off-pump Versus on-pump Coronary ............................................................................ 285
Artery bypass Graft (CABG) Patients before and after Phase II Cardiac Rehabilitation
Nikhil Vishwanath, Ajith S, Ivor Peter D'Sa, M.Gopalakrishnan, Mohamed Faisal C K
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3 Weeks Continuous Passive Motion Vs Joint

Mobilization and their Combination in Knee
Stiffnes - A Comperative Study
Anil kumar1, Santosh Metgud2
Post Graduate, Asst Prof, KLE University Institute of Physiotherapy
ABSTRACT
Study design: Randomized clinical trial.
Objectives : To determine the effect of continuous passive motion in treatment of knee joint stiffness. To
determine the effect of joint mobilization in the treatment of knee joint stiffness. To determine the
combined effectiveness of continuous passive motion and joint mobilization in the treatment of knee
joint stiffness.
Methods : The present randomized clinical trial was conducted among 45 participants which included
both male and female symptomatic individuals between the age of 18 to 50 years with knee joint
stiffness. Pre-interventional and post-interventional outcome measurements were taken in the form of
Range Of Motion, KOSADLS.
Results : In the present study, intra - group analysis showed that improved range of motion and
functional outcome was statistically significant in all the three groups (p=0.0001) whereas considering
the reliability and validity of Knee Outcome Survey Of Activity Daily Living Scale, the between group
analysis revealed that Group C was significant as compared to Group A and Group B in knee range of
motion and in functional outcome Group B was significant compared to Group A and C .
Conclusion : In conclusion, the present randomized clinical trial provided evidence to support the
physical therapy regimen in the form of continuous passive motion with joint mobilization in improving
range of motion, improving functional performance in subjects with post operative knee joint stiffness.
Keywords: Knee Joint Stiffness; Joint Mobilization; Continuous Passive Motion; Exercise
INTRODUCTION
The knee is a complex, compound, condyloid variety
of a synovial joint. It actually comprises three functional
compartments: the femuro-patellar articulation consists
of the patella, and the patellar groove on the
front of the femur through which it slides; and the
medial and lateral femuro-tibial articulations linking
the femur, or thigh bone, with the tibia, the main bone of
the lower leg.1 Knee injuries from trauma or overuse
can cause pain, swelling and sometimes disability, short
or long-term depending on how bad the injury is.
Injuries can occur to the bones, the ligaments, the
cartilage or the tendons.2
Incidence of fractures was 100 per 10,000 population
for males and 81 per 10,000 population for females.
1. Anil Kumar 2nd april-1-5.pmd
Below the age of 55 years of all fractures showed a

higher incidence amongst males but amongst the over
55, there was consistent fall in male:female incidence
ratio with some sites showing a striking female
preponderance.3
Continuous passive motion (CPM) refers to passive
motion performed by a mechanical device that moves a
joint slowly and continuously through a controlled
range of motion. CPM is effective in lessening the
negative effects of joint immobilization and also
improves the recovery rate and ROM after a variety of
surgical procedures. It also prevents development of
adhesions and contractures and thus prevents joint
Stiffness. It also provides a stimulating effect on the
healing of tendons and ligaments and enhances healing
of incisions over the moving joint. 4 CPM is used
2/7/2013, 8:08 PM
2 Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1
following various types of reconstructive joint surgery

such as knee replacement and ACL reconstruction.5
Joint mobilization stimulates biological activity by
moving synovial fluid, which brings nutrients to the
avascular articular cartilage of the joint surfaces and
intra-articular fibrocartilage of the menisci6. Atrophy
of the articular cartilage begins soon after
immobilization is imposed on joints7,8,9.
Maitland techniques involve the application of
passive and oscillatory movements to spinal, vertebral
and peripheral joints to treat pain and stiffness of a
mechanical nature. The techniques aim to restore
motions of spin, glide and roll between joint surfaces
and are graded according to their amplitude10.
day 01 and on day 21 in the study groups. Once all

measurements obtained subjects was randomly
allocated into 3 Groups viz. group A, Group B, and
Group C. Final scores on the scale and range of motion
was measured after 3 weeks of treatment and was then
subjected to statistical analysis
Participants of all the 3 Groups i.e.
Group A - Hot moist pack with Continuous passive
motion and exercise for affected knee joint stiffness.
Group B - Hot moist pack with Joint Mobilization
and Exercise for affected knee joint stiffness.
Group C Hot Moist pack, Continuous Passive
Motion, Joint Mobilization and Exercise for affected knee
joint stiffness.
METHOD
Study design is randomized clinical trial. Data was
collected from KLES Dr. Prabhakar Kore Hospital ,
Belgaum. Study period of one year (Feb 2011 to Jan 2012).
Sample size Forty five (45) participants
Inclusion Criteria
Both male and female participants with knee joint

stiffness of duration more than 2 months.
Post fracture stiffness of knee joint
Ligament injuries of grade 1 and 2
Age group between 18-50 years.
The patient was asked to rest supine on the

treatment table with affected leg on CPM machine. The
speed was kept constant, so that a full cycle lasts for 45
to 60 seconds. The treatment was given for 40 minutes
daily in split sessions i.e 20 minutes in the morning
and 20 minutes in the afternoon, supervised by
physiotherapist. The range was adjusted individually
and increased gradually by 10 degrees daily within
participants limits of pain. CPM was given for 3weeks
during which various parameters was monitored.
Anterior-posterior glide
Exclusion Criteria
Total Knee Replacement.
Osteoarthritis of knee joint.
Knee joint effusion.
Bone tumours around knee joint
Osteoporotic patients
Knee joint malignancy
Any local or systemic infection.

PROCEDURE
Once the patient was included in the study, the

demographic data was collected range of motion (ROM)
was measured and scores on the scale was noted on
Moist heat therapy was given as conventional

treatment for a period of 15 minutes, 2 sessions/day for
3 weeks prior to the CPM and Joint mobilization.
The physiotherapist performed an anterior

tibiofemoral glide on participants operative limb, the
physiotherapist grasps the dorsal aspect of the
participants proximal lower leg with one hand and
holds it firmly against his body while placing his other
hand over the dorsal lateral aspect of the tibia just distal
to the knee joint. He passively moves the knee joint to
the maximum available knee-extension ROM. He then
glides the participants tibia in an anterior direction
parallel to the surface of the femoral condoyle to the
point where the resistance provided by the knee limited
further movements. The mobilization was given for 10
repetitions for 5 times. Total duration lasted for 20 mins.
Posterior- Anterior glide
The physiotherapist performed an posterior
tibiofemoral glide on participants operative limb, the
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Indian Journal of Physiotherapy & Occupational Therapy. January-March 2013, Vol. 7, No. 1 3
physiotherapist grasps the dorsal aspect of the

participants proximal lower leg with one hand and
holds it firmly against his body while placing his other
hand over the dorsal lateral aspect of the tibia just distal
to the knee joint. He passively moves the knee joint to
the maximum available knee-flexion ROM. He then
glides the participants tibia in an posterior direction
parallel to the surface of the femoral condoyle to the
point where the resistance provided by the knee limited
further movements. The mobilization was given for 10
repetitions for 5 times. Total duration lasted for 20 mins.
Exercise like open kinetic chain exercise and closed
kinetic exercise was given to the patients. Open kinetic
chain exercise is typically non weight bearing exercises
such as knee extension performed when sitting on a leg
extension machine. Closed chain exercise includes a
squat or step-up.the exercises were done twice a day
and it comprise of 3 sets of 15 repetitions with equal
hold and contract time.
OUTCOMES
Range of motion was measured with a Universal
Goniometer and Physical function outcome measured
by Knee outcome survey activities of daily living scale,
a well validated, self-report, self-complete questionnaire
was used.
Statistical Analysis
Statistical analysis for the present study was done
manually as well as using the statistics software SPSS
13 version so as to verify the results obtained. For this
purpose the data was entered into an excel spread
sheet, tabulated and subjected to statistical analysis.
Various statistical measures such as mean, standard
deviation (SD) and test of significance such as paired
sample test for within group analysis and between
group analysis was done with Multiple Scheffe Test,
ANOVA was used for age and demographic
distribution.
RESULTS
Table 1. Age distribution & Anthropometric variables
Groups
Mean Age
(Years)
Mean Height Mean Weight

(mts)
(Kgs)
Mean BMI
(Kg/mt 2)
Group A
36.8010.23
1.67 0.05
67.8 10.15
24.2 3.86
Group B
34.86 7.94
1.650.052
65.8 8.82
23.92 2.31
Group C
32.80 7.84
1.670.08
65.6 9.06
23.37 2.01
F-Value
0.785
0.512
0.253
0.513
P-Value
0.463
0.603
0.778
0.603
Table 2. Intra group mean difference

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

Groups
KOSADLS
MD
ROM
P
Flexion
Extension
MD
MD
0.035
-10.06
0.213
-10.06
0.213
A-B
-9.38
A-C
-2.90
0.709
19.20
0.006
-19.20
0.006
B-C
6.48
0.190
-9.13
0.227
-9.13
0.227
DISCUSSION
Results of the study were focused on the
improvement of knee range of motion and percentage
of activity of daily living based on knee outcome survey
of activity of daily living scale Score. It was notified
that there was recovery of all the above parameters in

all the three groups.
Both the three groups had equal number of
participants and showed no statistical significance
with respect to their gender distribution, which could
2/7/2013, 8:08 PM
have altered the results of the study and were well

matched.
The average age in the present study was 34.82,
ranging from 18-50 years. When compared between the
three groups showed equal distribution and has no
statistically significant difference in age between the
group. A study conducted by Peter J. Millett(2004) has
taken the age group of 18-57 years with average of total
participants was 35.6, which coincides with the present
data.11 .
Macrae and wright in 1969 showed a substantial
difference in stiffness between male and female knee
joint. Males are much stiffer than females even when
age, size of thigh, and size of knee is taken into account.
It is interesting to note that while this work shows that
females are less stiff than males. The finding of this
study correlates with the above reference since
maximum number of patients was males, showing more
stiffness than females.12 Hutchinson M studied on
gender difference in active knee joint stiffness concluded
that females have reduced active stiffness compared to
age matched males. The present study correlates with
the above study in gender differences and has no effects
on altering the results between the groups.13
When the intra group mean values of active knee
range of motion of flexion was analysed, it showed
statistically significant improvement in knee flexion
range of motion in both the groups pre to post
intervention, with the p values of 0.000 in both the
groups, but when comparison was done inter-group,
group C showed more improvement in knee range of
motion as compared to group A and B. In the present
study increase in range of motion, with the application
of continuous passive motion in one group and joint
mobilization in another group is consistent with the
findings of previous studies. This is the first study till
date has compared the combined effect of continuous
passive motion and joint mobilization. Present results
showed that continuous passive motion with joint
mobilization is better than giving individually.
In the present study the application of moist heat
for 15 mins in all three groups prior to CPM and joint
mobilization showed increase in range of motion.
Knight et al. Investigated the effect of 15 min hot pack
application paired with static stretching on plantar
flexor extensibility over four weeks and noted increases
in range of motion. These findings suggest that hot pack
application may be a beneficial modality when
increased range of motion is desired.14
The results of the present study group receiving
CPM, has shown that alone CPM is not a beneficial
method to mobilize post-operative knee stiffness. As
suggested by Bearpre et. al., (2001), a prospective,
investigator-blinded RCT compared three rehabilitation

regimens in patients who had undergone primary TKA
for osteoarthritis. The results suggest that adjunct CPM
and adjunct SB may not provide additional therapeutic
benefit in an active mobilization regimen following TKA
for osteoarthritis. Hence the present study consistent
with the above study as the result concluded the same.
The study done by Beaupre et. al., hypothesized that
continuous passive motion may not provide therapeutic
effect in active mobilization of post-operative knee
stiffness.15
In the present study, group receiving CPM only,
showed an average increase in ROM for post operative
knee stiffness of 49.733, which was less compared to
the other 2 groups ie., group B-59.80 and group C-68.93.
The present study correlates with the study done by
Engstrom et al. (1995) reported on a prospective
randomized study of 34 patients with unilateral
anterior cruciate ligament ruptures. Engstrom et al
concluded that after six weeks followup, there was no
difference in ROM between the two groups, and joint
swelling was more pronounced in the early active
motion group. The data suggests that CPM did not
improve ROM.16
Randall et al, showed that in patients with
supracondylar fracture, mobilization and exercise led
to a greater increase in joint movement than exercise
alone. The present study is in consistent with the above
study as the results concluded the same. Hence the effect
of joint mobilization has an effect in increasing range
of motion17.
Michael A. Hunt, Stephen R. found the effect of
anterior tibiofemoral glides on knee extension during
gait in patients with decreased range of motion after
anterior cruciate ligament reconstruction. The authors
concluded that a single session of anterior tibiofemoral
glides increases maximal knee extension during the
stance phase of gait in patients with knee extension
deficits. In the present study 21 sessions of mobilization
increased maximal knee extension range of motion and
could not comment on the immediate effect of joint
mobilization18.
In the present study closed kinetic chain exercises
were performed by the participants for 10 repetitions
per session with each contraction held for 10 seconds,
which is consistent with the findings of Cristina Maria
and Nunes Cabral.19
Study done by Mei Hwa Jan MS et al to investigate
the effect of weight bearing exercises on function, pain
and knee strength in patients with knee stiffness. The
results showed that weight bearing exercises were
effective in decreasing pain and disability and
increasing knee strength.20
2/7/2013, 8:08 PM
The findings of the present study show that

improving ROM by joint mobilization is effective which
was due to stimulation of biological activity by moving
synovial fluid, which brings nutrients to the avascular
articular cartilage of the joint surfaces and intraarticular fibrocartilage of the menisci21.
CONCLUSION
In conclusion, the present randomized clinical trial
provided evidence to support the physical therapy
regimen in the form of continuous passive motion with
joint mobilization in improving range of motion,
improving functional performance in subjects with post
operative knee joint stiffness
9.
10.
11.
12.
13.
14.
LIMITATIONS
Intermediate readings of the outcome measures was

not noted.
There was no control group in the present study

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2/7/2013, 8:08 PM
Comparison of Blood Pressure and Heart Rate between

Young Males and Females During Dominant and
Non-Dominant Single-Leg Stance
Ankita Samuel1, Manish Rajput1, Chhavi Gupta1, Sumit Kalra2

Student-Bachelors of Physiotherapy, 2Assistant Professor, Banarsidas Chandiwala Institute of Physiotherapy
ABSTRACT
Background: It has been observed that Blood Pressure and Heart Rate of an individual changes with
posture. This study is performed to study the change in Blood Pressure and Heart Rate while standing
on dominant and on non-dominant single -leg stance in males and females.
Objective: The objective of this study is to compare the significant changes in Blood Pressure and Heart
Rate in young college going males and females while standing on there dominant and non-dominant
lower limb (single-leg stance).
Subjects: 200 subjects (100-males, 100-females) of the age group of 18 to 25yrs
Study Design: Co-relational
Data Analysis: P-Value was calculated for the systolic and diastolic blood pressure separately and as
well as of Heart Rate in resting, single-leg stance on dominant leg and single-leg stance on nondominant leg in both Males and Females.
Conclusion: From The study it can be concluded that while training any individual on single -leg
stance on dominant and non-dominant a therapist should take care of the blood pressure and Heart
Rate specially while working on hypertensive's, amputees, individuals with cardio-vascular,
neurological, psychological and neuro muscular disorders.
Keywords: Heart Rate, Blood Pressure
INTRODUCTION
Human Heart rate can vary as the bodys need to
absorb oxygen and excrete carbon dioxide changes,
such as during exercise or sleep.
The one-leg stance is a valid measure to assess
postural steadiness in a static position by temporal
measurement. The examination of balance with oneleg stance test is a functional and logical approach,
since transient balancing on a single limb is essential
for normal gait and critical activities of daily living such
as turning, stair climbing and dressing and it is also
essential for sports person who need good
proprioception to be good in their field of sports.
In addition to identifying single-leg balance testing
as a reliable indicator of functional instabilities.
Freeman and colleagues provided sound support for
the use of single-leg proprioceptive training to decrease
the effects of functional instabilities. Since that time,
2. Ankita 5th april --6-10.pmd
clinicians have continued to use single-leg stance

manipulations for both the evaluation and
rehabilitation of proprioceptive deficits related to
orthopedic injury.
During rehabilitation, this method is used both for
a baseline measurement of balance and to progress
patients as they recover.
Short-term cardiovascular responses to postural
change involve complex interactions between the
autonomic nervous system, which regulates blood
pressure, and cerebral auto regulation, which
maintains cerebral perfusion. A physiologically based
change is used to describe effects of gravity on venous
blood pooling during postural change. Two types of
control mechanisms are included:
1) Autonomic regulation mediated by sympathetic
and parasympathetic responses, which affect heart
2/7/2013, 8:08 PM
rate, cardiac contractility, resistance, and

compliance, and
2) Auto regulation mediated by responses to local
changes in myogenic tone, metabolic demand, and
CO2 concentration, which affect cerebrovascular
resistance.
The change on Heart Rate are due to muscular
activity changes when posture changes, abdominal
wall tension increases while standing on single leg,
the aortic pressure increases according to Mareys law
and also due to carotid sinus reflex.
The Blood Pressure and Heart Rate vary in
respiratory, neurological, psychological and in cardiovascular disorders. BMI also plays a major role when it
comes to one leg standing, the individuals with BMI
more than of 25cm2/kg has a higher Blood Pressure
and Heart Rate while standing on single leg.
Static contraction of muscles on a large scale, e.g.
with the knees bent as described, soon causes a
remarkably large rise of systolic and diastolic bloodpressures, comparable to what may be induced by
strenuous muscular exercise, but differing in certain
respects in the mechanism of its production.
As it always seen that men have more muscle power

as compared to women, indirect evidence indicates19,20
that women will experience less compressive force and
intramuscular pressure in the muscle21,22,23, allowing
greater perfusion and oxygen supply compared with
the men during the sustained contraction during the
change in posture.
It also seen that women have lower risks of
cardiovascular events than men. They are also
characterized by different spectral indexes of HRV24,
and by higher HRV entropy25.
The need of this study is to have a better
understanding that how does Blood Pressure and Heart
Rate changes in young individuals who are under going
physiotherapy to increase their proprioception, balance
and co-ordination, a hypertensive individual ,an
individual using prosthesis or an amputee (any limb),
an individual under going any cardio-vascular,
neurological, psychological or neuro-muscular disorder
when they stand on there single lower limb (dominant
or non-dominant) and does the gender of the individual
plays in any significant role in it.
METHODOLOGY
Assumption of the upright posture requires prompt

physiological adaptation to gravity .There is an
instantaneous descent of ~500 ml of blood from the
thorax to the lower abdomen, buttocks, and legs. In
addition, there is a 10-25% shift of plasma volume out
of the vasculature and into the interstitial tissue.
This
shift decreases venous return to the heart, resulting in a
transient decline in both arterial pressure and cardiac
filling. This has the effect of reducing the pressure on
the bar receptors, triggering a compensatory
sympathetic activation that results in an increase in
heart rate and systemic vasoconstriction (countering
the initial decline in blood pressure). Hence,
assumption of upright posture results in a 10-20 beat
per minute increase in heart rate, a negligible change in
systolic blood pressure, and a ~5 mmHg increase in
diastolic blood pressure. Assumption of the upright
posture requires prompt physiological adaptation to
gravity.
RESEARCH DESIGN- Co-relational
The response of blood pressure to change in body

position is well suited as a measure of cardiovascular
reactivity for epidemiological studies. Several
experimental studies have suggested a differential
response of blood pressure to standing due to ethnicity1
and gender2, 3.
4. Any pain in upper limb, lower limb or spine
SAMPLE SIZE- 200 (male-100, female-100)

SOURCE OF SUBJECTS - Students from various
colleges in Delhi.
SAMPLE DESIGN- Random sampling
INCLUSION CRITERIA27, 28:
1. Males and Females in the age group of 18 to 25years
2. BMI between 18 to 25 kg/m2
EXCLUSION CRITERIA
1. BMI less than 18 and more than 25 kg/m2
2. A diagnosed case of any cardio-vascular,
respiratory, psychological or neurological disorder.
3. Any bony/Muscular deformity present of upper
limb, lower limb or spine
5. Use of any limb prosthesis

6. Any limb amputation
7. Subjects are not involved in any physical or
muscular activity in last one hour before testing.
2/7/2013, 8:08 PM
INSTRUMENTATION
FEMALES
1. The Omron M6 (HEM-7001-E) digital blood

pressure and heart rate monitor.
Table 1. Resting and Dominant

S. No.
P-Value
2. A stop watch
Systolic
0.014
3. Football
Diastolic
0.890
Heart Rate
0.291
4. measuring tape
Table 2. Resting and Non-Dominant
5. weighing tape
S. No.
INDEPENDENT VARIABLES
1. Age
P-Value
Systolic
0.000
Diastolic
0.480
Heart Rate
0.056
2. Height
Table 3. Dominant and Non-Dominant
3. Weight
S. No.
DEPENDENT VARIABLES
1. Blood pressure (both systolic and diastolic)
P-Value
Systolic
0.197
Diastolic
0.072
Heart Rate
0.436
2. Heart rate
MALES
PROCEDURE
Total of 265 subjects were taken out of which 200
subjects fulfilling the inclusion criteria and after
checking that they had not gone for any vigorous
physical or muscular activity in last one hour were taken
into consideration. The procedure was explained to the
subjects and a written consent was taken after
explaining the benefits and clearing the doubts of the
subject regarding study. To check the lower limb
dominance subjects were asked to kick a football and
the leg from which he/she kicked was considered as
his/her dominant leg. After this subjects BP and HR
was taken while sitting on chair. They were given a rest
period of 5 minutes then, they were made to stand on
their dominant leg for a minute. After which their BP
and HR was recorded in seated position, and they were
made to rest for 5 minutes again. Post rest period the
subjects were asked to stand on their non-dominant leg
for a minute this time again their BP and HR were taken
in seated position.
S. No.
P-Value
Systolic
0.426
Diastolic
0.473
Heart Rate
0.737

S. No.
P-Value
Systolic
0.282
Diastolic
0.169
Heart Rate
0.070

S. No.
P-Value
Systolic
0.198
Diastolic
0.073
Heart Rate
0.430
MALES AND FEMALES

S. No.
RESULT
P-value of the collected data was calculated using
SPSS software version 16
P-Value
Systolic
0.032
Diastolic
0.725
Heart Rate
0.339

S. No.
P-Value
Systolic
0.001
Diastolic
0.27
Heart Rate
0.09
2/7/2013, 8:08 PM
S. No.
P-Value
Systolic
0.695
Diastolic
0.493
Heart Rate
0.171
Table 10. Dominant (male & female)

S. No.
P-Value
Systolic
0.000
Diastolic
0.000
Heart Rate
0.05
Table 11. Non-Dominant (male & female)

S. No.
P-Value
Systolic
0.069
Diastolic
0.00
Heart Rate
0.00
respective of the postural change, i.e. standing on

dominant and non-dominant leg there was a significant
increase in HR and decrease in BP. Although muscle
activity increases body oxygen consumption and energy
expenditure, the temporal increase in HR and decrease
in BP associated with changing position suggests that
it is likely to have resulted from the metabolic or
hormonal consequences of increased muscle activity.
We speculate that this increase was largely induced by
the skeletal muscle reflex15-17. Although anticipation of
exercise may also cause a rapid increase in heart rate18.
The changes in BP and HR were significantly seen
with respect to gender also. Both the systolic and
diastolic BP in males increases while standing on there
single-leg and that too on there non-domianat leg
whereas there was increase in HR in case of females on
their non-dominant leg.
REFERENCES
DISCUSSION
Variation of heart rate is associated with postural
change26. In accord with previous reports, this study
showed that HR was highest in standing on NonDominant leg compared to sitting or lying positions4-11.
Thus, the hypothesised that the increase in HR with
standing follows a decease in venous return due to
venous pooling in the lower limbs due to
gravitational effects12. The increase in peripheral venous
volume is accompanied by an increase in both venous
and arterial pressure in the lower extremities. The shift
in blood volume from the central to the peripheral system
induces a decrease in venous return and central venous
pressure. The smaller the venous return, the smaller
the end-diastolic and subsequent stroke volume. A
reduction in venous return will lead to a reduced
cardiac output, which in turn will lead to a reduction
in baroreceptor stimulation in the aorta and carotid
arteries13. This reduction in baroreceptor firing results
in decreased parasympathetic and increased
sympathetic activity14, 11. These two actions directly affect
the cardiovascular centre in the medulla oblongata
which increases the HR, the arteriolar and venous
tones, and the cardiac contractility to compensate for
the decrease in stroke volume and provide a cardiac
output which can meet body demands. Upon returning
the posture from sitting to lying, the increase in venous
return increases the stroke volume through the Frank
Starling mechanism, thus a lower heart rate is sufficient
to maintain the cardiac output demanded by the body.
In present study we can conclude that not only
the HR but BP also changes significantly while on
standing on dominant single-leg and on non-dominant
single-leg in Males and Females. Haemodynamics can
be disturbed even by slight movements 15. In accord with
previous findings4-11, our results showed that with
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Jacob, G., Ertl, A.C., Shannon, J.R., Furlan, R.,
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Pump, B., Christensen, N.J., Videbaek, R., Warberg,
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Mechanisms of hypotensive effects of a posture
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Saborowski, F., Krahe-Fritsch, G., Krakau, M.,
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2/7/2013, 8:08 PM
Effectiveness of Transcutaneous Electrical Nerve

Stimulator (TENS) in Reducing Neuropathic Pain in
Patients with Diabetic Neuropathy
Apeksha O. Yadav1, G. J. Ramteke2
Assistant Professor, Director & Principal, Department of Physiotherapy, Ravi Nair
Physiotherapy College, DMIMS (DU) Sawangi (M) Wardha
ABSTRACT
Objective: To evaluate the effectiveness of TENS in reducing neuropathic pain in patients with Diabetic
Neuropathy.
Design: Prospective Experimental Study.
Participants and Outcome Measure: 20 Patients with a diagnosis of Diabetic Neuropathy were included
in the study and they were explained regarding the treatment & its duration. Outcome measures were
recorded before & after the treatment session using numerical pain rating scale.
Result: After collecting data statistical analysis was done using Student's paired t test to determine the
effect of TENS and it showed a significant difference in reduction in pain post treatment.
Conclusion: It can be concluded that High frequency TENS can be given to Diabetic Neuropathy
patients for three weeks to achieve pain reduction.
Keywords: Diabetes, Neuropathic Pain, Transcutaneous Electrical Nerve Stimulator.
INTRODUCTION
Diabetes mellitus is caused by an insufficient
insulin-mediated response to blood glucose. People
with the disorder are classified as being insulin
dependent (ie, having type I diabetes) or non-insulin
dependent (ie, having type II diabetes) depending on
whether they require exogenous insulin for survival. A
frequent sequella of both types of diabetes is the
development of peripheral neuropathy in either motor
or sensory nerves, or both.1 Crawford2 estimated that 13
million people in the United States have diabetes, and
30% to 40% of these people are believed to have at least
sensory neuropathy.3
A consequence of any neuropathy affecting motor
and sensory peripheral nerves is reduction or loss of
strength and sensation. Another potential consequence
of peripheral neuropathy in people with diabetes is
severe, unremitting pain.1, 4 People with painful diabetic
neuropathy describe their pain as constant, burning,
or searing. Allodynia, to light touch, the experience of
light touch as painful, frequently develops, and even
contact with bedclothes can be painful. Deep pain,
described as being located in the centre or marrow of
the bone, can also occur. When pain is severe, people
3. apeksha 25th may--11-13.pmd
11
with diabetic neuropathy may have difficulty sleeping

and can experience depression and weight loss.1
Diabetic peripheral neuropathy (DPN) endoneurial
hypoxemia is the most common complication of
diabetes, estimated to affect 50% to 90% of patients,
depending on the criteria used for diagnosis5-10. Its
prevalence increases with the patients age, duration
of diabetes, and poor glycemic control.11-14
DPN is often referred to as the forgotten complication
because, despite how commonly it occurs, it is the
chronic diabetes complication that is least often
addressed by health care providers.15 Results of the 2005
American Diabetes Association (ADA) National Survey
found that only one in four patients surveyed who
experience symptoms of DPN have been diagnosed with
the condition. 16 This is partly because many
practitioners have had very little success with its
treatment as well as a lack of awareness of available
treatment strategies. A wide range of treatments are
available for neuropathic pain, however, many patients
remain inadequately treated. This prescribing pattern
suggests that no one treatment addresses all factors.
Foot complications are the greatest burden of all serious
chronic complications among patients with diabetes.
2/7/2013, 8:08 PM
As many as 40% to 60% of lower-extremity amputations

(LEAs) are related to DPN, and more than 50,000 LEAs
are performed each year in this country. 17,18
Approximately 15% of patients with diabetes will
develop a foot ulcer and one in six will need to have an
amputation. Additionally, half of those patients who
develop an ulcer will have one on the opposite foot
within 3 years 19-21. Short of ulceration and amputation,
DPN limits mobility, impairs sleep, and seriously affects
overall QoL. It is a progressive disease that may actually
begin before any alteration in sensation is detected.
Dinesh Kumar, MD, Inderjeet S. Julka, MD, Michael

S. Alvaro, DPM & Howard J. Marshall, DPM, did three
independent studies utilizing TENS & amitriptyline to
relieve DPN pain was reviewed. There were 14 patients
in this group. Two of them did not tolerate amitriptyline.
Symptomatic improvement occurred in 12 (85%)
patients; 11 received the combination of amitriptyline
and electrotherapy and 1 received electrotherapy only.
Three patients improved by 3 pain grades, 8 by 2 grades,
and 1 by 1 grade. Five (36%) of them experienced
complete symptomatic relief.
For reduction of the symptoms of diabetic peripheral

neuropathy some modalities have been used are;
Material and Methodology: This is a Prospective

experimental study carried out in Physiotherapy OPD
in Tertiary Care Hospital. Material used were TENS
apparatus. 20 subjects were selected with a diagnosis
of Diabetic Neuropathy. Both Males and Females were
included. Patients recently underwent surgery for lower
limb fracture with an implant and patients with
pacemakers were excluded from the study. Study was
explained to them & written consent was taken from
them to undergo treatment for three weeks. Observations
were recorded using numerical pain rating scale pre
treatment i.e. 1week before the commencement of
program and post treatment i.e. third week after the
completion of treatment program. Patient was assessed
before starting the treatment. Patient was made to lie in
prone position and then the TENS electrodes were
applied on the lumbar region with the use of aqua sonic
gel. Frequency used was 80 Hertz. Duration of treatment
was 20 mins daily for three weeks.
- TENS
- Micro vascular therapy
- Monochromatic near infrared treatment.
By using high frequency TENS, reduction in the
symptoms of diabetic peripheral neuropathy can be
achieved.
David & Somers in a case study stated that by using
high frequency TENS for 20 minutes daily for 3 weeks
over lumbar region relieves pain of neuropathy of a 73
years old lady the outcome were measured by the
regular assessment and by using VAS as it is reliable
and valid tool for the quantification of perceived pain,
the intensity of perceived pain was reduced from 7.4 to
4.6 cm on the VAS and reduction of pain was gradual
in given 3 weeks22.
STATISTICAL ANALYSIS
Table 1: Comparison of Numerical Pain Rating Scale before and after treatment
A: Descriptive Statistics
Mean
Std.
Deviation
Std.
Error Mean
Before Treatment
6.46
20
0.88
0.19
After Treatment
4.11
20
0.56
0.12
B: Students paired t test

Paired Differences
Before t/t-After t/t
Mean
Std.
Deviation
2.35
0.88
Std. Error 95% Confidence Interval

Mean
of the Difference
0.19
20 patients diagnosed of diabetic neuropathy

between the age group of 60 to 80, were given treatment
with high frequency TENS for 3 weeks, showed a mean
12
Lower
Upper
1.93
2.76
11.81
df
p-value
19
0.000 S,
p<0.05
rating of pain before the treatment was 6.46cms on NPRS

and mean reduction of the symptoms after 3 weeks was
4.11cms on the same scale showing improvement.
2/7/2013, 8:08 PM
CONCLUSION
It can be concluded that, treatment with high
frequency TENS for 3 weeks given to patients with a
diagnosis of diabetic neuropathy shows significant
reduction of neuropathic pain.
13.
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Daousi C, MacFarlane IA, Woodward A, et al.
Chronic painful peripheral neuropathy in an
urban community: a controlled comparison of
people with and without diabetes. Diabet Med.
2004; 21: 976982.
10. Davies M, Brophy S, Williams R, Taylor A. The
prevalence, severity, and impact of painful diabetic
peripheral neuropathy in type 2 diabetes. Diabetes
Care. 2006; 29: 15181522.
11. Boulton AJM. Management of diabetic peripheral
neuropathy. Clin Diabetes. 2005; 23: 915.
12. Tamer A, Yildiz S, Yildiz N, et al. The prevalence
of neuropathy and relationship with risk factors
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in diabetic patients: a single-center experience.

MedPrinc Pract. 2006; 15: 190194.
Valensi P, Giroux C, Seeboth-Ghalavini B, Attali
JR. Diabetic peripheral neuropathy: effects of age,
duration of diabetes, glycemic control, and
vascular factors. J Diabetes Complications. 1997;
11: 2734.
Booya F, Bandarian F, Larijani B, et al. Potential
risk factors for diabetic neuropathy: a case control
study. BMC Neurol. 2005; 5:24.
Marks JB. The forgotten complication. Clin Diab.
2005; 23: 34.
American Diabetes Association survey finds most
people with diabetes dont know about highly
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serious
complication.
w w w. d i a b e t e s . o r g / f o r - m e d i a /
2005pressreleases/ diabeticneuropathy.jsp.
Accessed Sept. 21, 2009.
Borssen B, Bergenheim, Lithner F. The
epidemiology of foot lesions in diabetic patients
aged 15-50 years. Diabetic Med. 1990; 7: 438444.
Reiber GE, Boyko EJ, Smith DG. Lower extremity
foot ulcers and amputation. In Diabetes in America.
2nd ed. 1995. Washington, DC. Department of
Health and Human Services.
Gordois A, Scuffham P, Shearer A, et al. The health
care costs of diabetic peripheral neuropathy in the
U.S. Diabetes Care. 2003; 26: 17901795.
Reiber GE, Vilekyte L, Bokyo EJ, et al. Causal
pathways for incident lower-extremity ulcers in
patients with diabetes from two settings. Diabetes
Care. 1999; 22: 157162.
Pecoraro RE, Reiber GE, Burgess EM. Pathways to
diabetic limb amputation. Basis for prevention.
Diabetes Care.1990; 13: 513521.
Somers DL, Somers MF. Treatment of neuropathic
pain in a patient with diabetic neuropathy using
transcutaneous electrical nerve stimulation
applied to the skin of the lumbar region. Phys Ther.
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Dinesh Kumar, MD, Inderjeet S. Julka, MD, Michael
S. Alvaro, DPM & Howard J. Marshall, DPM.
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relief Diabetes Care. Diabetes Care.1998; 21: 13221325.
2/7/2013, 8:08 PM
Evaluation of effects of Nebulization and Breathing

Control in Asthmatic Patients
Kesharia1, Amita Mehta2
M.P.Th., Cardiovascular and Respiratory Sciences, 2Professor & Head, P.T. School and Centre, Seth G.S.M.C. and
K.E.M. Hospital, Parel, Mumbai.
ABSTRACT
Background: Asthma is a disease characterized by airflow limitation that is either fully or partially
reversible. There is a growing realization that in asthma the airflow limitation leads to further mechanical
consequences that result in dyspnea which is also a very important domain along-with airflow limitation
to build up strategies to effectively cope up with asthma. To treat asthma effectively means to achieve a
better level of control of asthma. Various strategies have been adopted by the patients themselves to
keep their asthma level in control and avoid frequent exacerbations. Asthma has many dimensions to
it rather than only airway obstruction. Asthma is affected by anxiety, cold, emotional quotient & also by
the level to which other nonpharmacological means to control asthma adopted by the patient like
yoga, meditation and various breathing strategies. It was seen that pharmacological measures though
were very essential to treat asthma, but along-with its long term use; factors like adverse effects of
medications, patient's non-compliance, cost effectiveness of treatment, patients sense of satisfaction of
their disease control came into focus. Hence, various non-pharmacological measures were researched
in the past trials, of which breathing control was one of the measures used.
Purpose: The purpose of our study was to evaluate the effects of nebulization and breathing control
(N+B combination) as against only breathing control(B) on airway obstruction [by measuring peak
expiratory flow rate(PEFR), forced expiratory volume in 1st second(FEV1) and dyspnea [by measuring
respiratory rate (RR) and rate of perceived exertion (RPE)] in asthmatic patients.
Method: In total, 60 patients were selected according to the inclusion and exclusion criteria. Written
informed consent was taken from the patients and asthmatic patients were randomly allocated to two
groups either N+B or only B. Parameters PEFR, FEV1, RR and RPE on Borg's modified 10 point category
ratio scale were obtained before and after the treatment session. Data was analyzed using SPSS 15. For
statistical significance, p value of <0.05 was considered.
Results: There was a statistically significant improvement in PEFR, FEV1, RR and RPE in both the
groups. However, there was no statistically significant difference in PEFR and FEV1 i.e. airway
obstruction between the two groups. But, there was a statistically significant difference in RR and RPE
i.e. dyspnea between the two groups, with breathing control showing greater improvement in dyspnea.
Conclusion: Thus, asthmatic patients not only could reverse their airway obstruction (PEFR, FEV1)
with Breathing control but also improved in terms of dyspnea (RR, RPE) as compared for Nebulization
and Breathing control group. Nebulization and Breathing control group though it showed statistical
significant improvement in airway obstruction(PEFR,FEV1) than only Breathing control; but the overall
energy expenditure and thermogenic effect of nebulization with salbutamol did not help reverse
dyspnea(RR and RPE)to the effect the breathing control could to.
Keywords: Asthmatics, Nebulization, Breathing control, Airway obstruction, Dyspnea.
INTRODUCTION
Asthma is a problem world wide, with an estimated
300 million affected individuals. 1 The WHO has
estimated that 15 million disability adjusted life years
(DALYS) are lost annually due to asthma. Absence from
school and days lost from work are substantial social
& economic consequences of asthma in studies from
India.1
4. bhakti 22ND oct--14--20.pmd
14
In Asthma, the predominant feature clinically is

episodic shortness of breath, physiologically episodic
airway obstruction characterized by expiratory airflow
limitation & pathologically airway inflammation,
which persists even during the asymptomatic periods.
Airway narrowing is the final common pathway
leading to symptoms and physiological changes in
asthma.
2/7/2013, 8:08 PM
Severity determines both the severity of the

underlying disease and its responsiveness to treatment,
but it may change over months or years. Therefore,
periodic assessment of asthma control is more relevant
and useful. Asthma is a growing problem with a huge
economic burden. The annual cost of asthma to the
NHS, constitutes about 83% i.e. Majority of it is due to
medications. Accordingly, the development and
evaluation of interventions to prevent asthma, to reduce
its severity or improve its prognosis are the priority
researches.2
Pharmacotherapy is the mainstay of asthma
management, but the outcomes remain suboptimal for
complex reasons including under treatment and noncompliance. 3 Also, many patients have concerns about
regular medications and many use nonpharmacological and complementary therapies
including breathing modification techniques. 3 There
has recently been renewed interest in the breathing
techniques used in asthma. 3
A 2000 systematic review of breathing techniques
concluded that too few studies had been carried out to
warrant firm judgments, but that collectively the data
implied that physiotherapeutic breathing techniques
may have some potential benefit4. A 2004 Cochrane
review of breathing exercises for asthma concluded that,
due to the diversity of breathing exercises and outcomes
used, it was impossible to draw conclusions from the
available evidence5.
A 2007 RCT demonstrated that breathing retraining
and relaxation significantly reduced respiratory
symptoms and improved health-related quality of life
in a cohort of patients with asthma.6 A 2008 RCT adds
further strong support to this work, also finding
significant reduction in asthma symptoms.7
Thus, various Physical therapy interventions aimed
at overcoming dyspnea by overcoming early airway
closure were chosen: Nebulization with selective B-2
sympathomimetic bronchodilator i.e. Salbutamol &
Breathing control- wherein during inspiration normal
tidal volume breaths are taken; with more effective use
of diaphragm as it itself is an active inspiratory muscle
during inspiration and during expiration, use of Pursed
lip Breathing is emphasized.
Thus, it was important to understand the effect of
physiotherapeutic techniques on dyspnea as a result
of airway obstruction in asthmatic patients & to
appropriately emphasize breathing control techniques
15
in addition to pharmacological treatment & hence the

above study was undertaken.
Methodology Study design- Experimental study- A
Randomized controlled trial. Study settingPhysiotherapy department, Seth G.S.M.C and K.E.M.H,
Mumbai. Sample size- 60 patients with asthma who
satisfied the inclusion criteria were selected. Inclusion
criteria- Clinically diagnosed asthmatics in the age
group of 18-35 8 years, either sex included, who were
referred for physiotherapy treatment. Exclusion criteriaAsthmatics with acute exacerbation in previous week1.
Asthmatics with status asthmaticus 9 . Use of
bronchodilator puff, oral medications within last 6
hours and patients on intravenous medications 9.
Patients having cardiac impairments, cardiac failure,
hypertensives, those receiving Digitalis, in Cor
Pulmonale9. Patients with other respiratory conditions,
neurological, musculoskeletal and orthopedic
limitations. Duration of study-2010-11
PROCEDURE
The study was approved by the ethics committee for
research on human subjects (ECRHS) of the institute &
written informed consent was taken from patients.
Patients were assigned randomly in two groups by
computer generated random number chart and given a
30 minutes session:
Group I: Nebulization for 10 minutes and breathing
control for 20 minutes.(N+B)
Group II: Breathing control for 30 minutes. (B)
Starting position for both the groups-Patient sitting
supported with back support and hip knee flexed and
both hands placed just below the xiphisternum.
GROUP I: Asthmatic patients were given nebulization
and all the factors affecting deposition of drug particles
in the airways was taken into consideration.9 Asthmatic
patients were nebulized using salbutamol (Asthalin)
with saline in the ratio of 1:1 i.e. 2 ml of Asthalin in 2 ml
of saline; with Pulmomist nebulizer in relaxed sitting
position with head and neck adequately supported.
Patients were asked to inhale the aerosol generated with
a slight pause after inspiration9. Nebulization was given
for 1 st 10 minutes and same patients were given
breathing control for next 20 minutes (during which
time the peak effect of nebulization was also reached).
Patients were given Breathing control immediately by
using8
2/7/2013, 8:08 PM
a) Proper relaxed sitting position-sit with hip knee

flexion and lower back supported creating a
posterior pelvic tilt position which facilitates use of
diaphragm more effectively.
b) During inspiration-controlled diaphragmatic
breathing (only tidal volume breaths i.e.-normal
inspiration was emphasized).
c) Relaxation of upper chest and shoulders by giving
verbal commands and proprioceptive feedback
where necessary.
d) During expiration-pursed lips breathing (PLB) was
given.
Group II: Patients in this group were given 30 minutes
session of breathing control only 10. The procedure for
the breathing control technique is same as above.
Parameters like PEFR and FEV1 (using Mini-Wright
Digital Peak flow meter), RPE on Borgs 10 point scale,
Parameters
N+B
No. of Cases (N)

Age(years)*
RR using watch were taken before and after the

procedure time for both the groups. Both the PEFR and
FEV1 were taken in the standing position and the best
of the three efforts was taken.1 BTS Guidelines 11 were
followed: PEF was recorded as the best of the three
forced expiratory blows from total lung capacity with a
maximum pause of 2 seconds before blowing, with
patient in standing position. Further blows were done
if the larger of the 2 PEFR was not within 40 L/min.
RESULTS
Statistical analysis was done using software SPSS
version 15.The normal distribution of data was found
out with Kolmogorov-Smirnov Test. The collected data
was analyzed statistically with Paired t Test, Unpaired
t Test, Mann Whitney U Test and Chi Square Test as
appropriate. Characteristics of 60 asthmatic patients
(Mean [95% C.I.]), Median (Range) is:
B
P Value
Significance
30
30
30.33[27.33, 33.33]
31.37[29.21, 33.53]
0.498
Ns
Male:Female**
10:20
9:21
0.781
Ns
Severity (I:Mp:Mop:Sp)**
7:9:9:5
9:9:7:5
0.919
Ns
256.50[213.08,299.92]
278.00[235.14,320.86]
0.474
Ns
1.31[1.06, 1.56]
1.60[1.34, 1.86]
0.112
Ns
32.267[30.185, 34.349]
32.667[30.572,34.581]
0.774
Ns
2:0:5:12:9:2
2:0:5:10:10:3
0.75
Ns
Pefr*( Liters/ Minute)

Fev1*(Liters)
Rr *(Breaths/ Minute)
Rpe** (on Borgss 10 Point
Scale At The Mark
of 0:0.5:1:2:3:4)
I:-Intermittent, MP:-Mild persistent, MoP:-Moderate

persistent, SP:-Severe persistent, NS-Non-Significant.
Thus, the data for each of the parameter in N+B and B
group is statistically not significant & hence were
comparable. Following is the graphical representation

of comparison within & between groups for all the
parameters taken in the study.
1) Evaluation of peak expiratory flow Rate (PEFR) in N+B and B group
16
2/7/2013, 8:08 PM
2) Evaluation of forced expiratory volume in 1st second (FEV1) in N+B and B group
3) Evaluation of Respiratory Rate (RR) in N+B and B group
17
2/7/2013, 8:08 PM
4) Evaluation of perceived exertion (RPE) in N+B & B group
DISCUSSION
To reduce the airway obstruction; two physiotherapy
modalities mainly nebulization with bronchodilator and
breathing control were used. Thus, the overall
comparison between the two groups stated that: For
Airway Obstruction in two groupsThe difference in PEFR between both the groups i.e.;
in nebulization and breathing control (N+B) and
breathing control (B) was not statistically significant
(p=0.10). Similarly, the difference between the % change
PEFR in (N+B) and (B) was not statistically significant
(p=0.381). The difference in FEV1 between both the
groups i.e.; in nebulization and breathing control (N+B)
and breathing control (B) was not statistically
significant (p=0.906). Similarly, the difference between
the % change FEV1 with (N+B) and (B) was not
statistically significant (p=0.21). For Breathing control
in two groupsThe difference in RR between both the groups i.e.; in
nebulization and breathing control (N+B) and
18
breathing control (B) was statistically significant

(p<0.001); indicating that breathing control (B) group
improved better post intervention. The difference in RPE
between both the groups i.e.; in nebulization and
breathing control (N+B) and breathing control (B) was
statistically significant (p=0.028); indicating that
breathing control (B) group improved better post
intervention. Hence, both the maneuvers help effectively
in improving airflow obstruction (PEFR, FEV1) and
dyspnea (RR, RPE). Breathing control is more effective
in relieving dyspnea.
In a study done by Kendrick, et al it was
found that the Modified Borgs Score(MBS) is a valid
and reliable assessment tool for dyspnea and correlated
well with other clinical parameters and could be useful
when assessing and monitoring outcomes in patients
with acute bronchospasm. In asthmatics, the mean MBS
rating decreased from 5.1 at baseline to 2.4 after
treatment. The mean PEFR increased from 286 at
baseline to 414 after treatment. In the asthma group,
there was a significant negative correlation between
2/7/2013, 8:08 PM
change score in MBS & change scores in the PEFR from

pre-scores to post-scores (r = -.31, P < .05). As the PEFR
score increased, the MBS score decreased; thus the better
the patients peak flow scores, the lower the patients
dyspnea ratings12. Thus, the above may be one of the
reasons the improvements in our study of decrease in
airway obstruction and improvement in dyspnea go
hand in hand.
Ambroso et al, found that inhaled salbutamol
significantly increases the resting metabolic rate of the
patient due to thermogenic effects of salbutamol
nebulization which may not effectively help to decrease
the perceived exertion and thus respiratory rate13.The
above may be one of the reasons why nebulization
component may have added the energy expenditure
and hence dyspnea in terms of RR and RPE. This also
emphasizes that PLB in our study does not increase the
energy cost of breathing as the dyspnea in terms of RR
and RPE improve. By learning and understanding
Breathing control, patients control their own breath,
thus anxiety is also reduced; which is also one of the
factors why they perceive less dyspnea.
However, Lewis et al in a systematic review
evaluated the short term effects on outcomes related to
the mechanism of intervention and physiological
outcomes. A beneficial effect was found for abdominal
movement, diaphragm excursion, respiratory rate, tidal
volume, arterial oxygen saturation. However, breathing
control had a detrimental effect on the work of breathing
and dyspnea. The study proposed that when used as a
sole intervention, there was a beneficial effect on
outcomes related to the mechanism of intervention and
physiological outcomes. Only in people with severe
respiratory disease, breathing control resulted in a
detrimental effect on dyspnea and work of breathing.
There was no clear evidence on gas exchange and
energy cost of breathing14.
Thus, the physiotherapeutic techniques used in
various above studies helps control the symptoms of
asthma and hence their manifestation. Also, most of
the studies have evaluated the long term i.e. At least 1
month and 6 month results of lung function and overall
asthma control; but immediate effects of breathing
control were not studied. Thus, the improvements in
lung function measures of PEFR and FEV1based on
breathing control techniques suggest that there is
immediate improvement in lung function measures.
Asthma is a chronic disease; the goal of treatment
should be to decrease its overall manifestation and
achieve a better level of control and hence improve the
19
overall Quality of life. Though, nebulization by B-2

agonists showed immediate improvement in asthma
symptoms and lung function in terms of PEFR and
FEV1. However, regular inhalation of B-2 agonists was
associated with deterioration of asthma control and
such trends in treatment may be an important causal
factor in the worldwide increase in the morbidity from
asthma. Whereas, when intervention with breathing
control was performed not only was there immediate
improvement in measures of PEFR and FEV1 and
overall symptoms; but also studies support the view of
regular use of breathing control techniques helps to
achieve both the goals of treatment i.e. Decrease in
overall manifestation of asthma and improve Quality
of life. In view of all the above, breathing control is an
important technique to intervene dyspnea along-with
proper pharmacological treatment.
CONCLUSION
All 30 patients in (N+B) and all 30 patients in (B)
group responded and improved with intervention.
Asthmatic patients showed statistically significant
improvement in airway obstruction and dyspnea with
nebulization and breathing control and with only
breathing control also. There was no statistically
significant difference between the groups in terms of
airway obstruction as measured by PEFR and FEV1
.There was a statistically significant difference between
the groups in terms of dyspnea as measured by RR and
RPE. Breathing control is more effective to reduce
dyspnea.
Acknowledgement - None
Conflict of interest- None
Source of support - Professor and Head of
Physiotherapy Department.
REFERENCES
1.
2)
3)
Global Initiative for asthma: global Strategy for

Asthma Management and Prevention: GINA 2008
Update. Bethesda, MD: National, Heart, Lung and
Blood Institute, National Institutes of Health.
Definition and Overview, Diagnosis and
classification, pg. 1-23. Available from URL: http:/
/www.ginasthma.org
Cristopher A Kellett, Jacqueline A Mullan.
Breathing Control Techniques in the Management
of Asthma.Volume 88, Issue 12, Pages 751-758
(December 2002).
M Thomas, R K McKinley, S Mellor, G Watkin, E
Holloway, J Scullion, D E Shaw, A Wardlaw, D
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4)
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9)
Price, I Pavord. Breathing exercises for asthma: a

randomised controlled trial .Thorax 2009; 64:
55-61.
E. Ernst. Breathing techniques - adjunctive
treatment modalities for asthma? A systematic
review Eur Respir J 2000; 15: 969-972.
Hollway E, Ram FS. Breathing exercises for
asthma. Cochrane Database Syst Rev 2004;
1):CD001277.
Elizabeth A Holloway, Robert J West. Integrated
breathing and relaxation training (the Papworth
method) for adults in asthma with primary care: a
RCT. Thorax 2007; 62: 1039-1042.
Cowie RL, Conley DP, Underwood MF. A RCT of
the Buteyko technique as an adjunct to
conventional management of asthma. Respir Med
2008:726-732.
Donna Frownfelter, Elizazbeth Dean. Cardio
pulmonary Pathophysiology. In Marjory Frazer,
Donna Morrisey editors. Principles and practice
of Cardio pulmonary physical therapy; 3rd edition,
Mosby Inc; 2006. P. 77,391,420-421.
R.B. Cole. Bronchodilator Drugs. In: editors.
Respiratory Diseases. 2 nd edition. Churchill
Livingstone Inc.; 1981:pg. no.190.
20
10) C A Slader, H K Reddel, L M Spencer, E G

Belousova, C L Armour, S Z Bosnic-Anticevich, F
C K Thien, C R Jenkins. Double blind randomised
controlled trial of two different breathing
techniques in the management of asthma
Thorax 2006;61: 651-656.
11) Diagnosis of Asthma. Evidence 2.5.2.Peak
Expiratory Flow Monitoring. Edinghburgh: SIGN
2009.Available from url:http://www.sign.ac.uk/
12) Usefulness of the modified 0-10 Borg scale in
assessing the degree of dyspnea in patients with
COPD and asthma Authors: San Diego, California.
Karla R. Kendrick, Sunita C. Baxi, Robert M. Smith,
Emergency Department and Urgent Care Clinic,
Veterans Administration San Diego HealthCare
System, San Diego, Calif.
13) P Amoroso, S R Wilson, J Moxham, J Ponte. Acute
effects of inhaled salbutamol on the metabolic rate
of normal subjects .Thorax 1993;48: 882-885.
14) Lewis LK, Williams MT, Olds T. Short-term effects
on outcomes related to the mechanism of
intervention and physiological outcomes but
insufficient evidence of clinical benefits for
breathing control: a systematic review. Aust J
Physiother. 2007;53(4):219-227.
2/7/2013, 8:08 PM
Effect of Neuromuscular Electrical Stimulation Combined

with Cryotherapy on Spasticity and Hand Function in
Patients with Spastic Cerebral Palsy
Chandan Kumar1, Vinti2
Assistant Professor, M.p.t (Neurology-student)), M. M. Institute Of Physiotherapy And Rehabilitation, Mullana, Ambala
ABSTRACT
Purpose: To determine the effectiveness of Neuromuscular electrical stimulation combined with
Cryotherapy on spasticity and hand function in patients with spastic Cerebral Palsy. Children with CP
often demonstrate poor hand function due to spasticity in wrist and finger flexors.
Methodology: This was an experimental study of 30 spastic CP patients aged 5-15 yr with mild to
moderate spasticity. All the subjects were divided into two groups (A & B) with equal subject number in
each group. Group A were treated with passive stretching, cryotherapy followed by Neuromuscular
Electrical Stimulation (NMES) and Group B treated with passive stretching and cryotherapy, 3 times a
week on alternate days for 6 weeks. Spasticity and hand function were assessed pretreatment and post
treatment using the Modified Ashworth Scale (MAS) and Manual Ability Classification System (MACS).
We tried to find out the additional effect of NMES on spastic CP patients.
Results: Showed that both the group improved significantly but group A improved much better than
group B.
Conclusions: This study suggests that NMES combined with cryotherapy is more effective as compared
to cryotherapy alone in reducing spasticity and improving hand function in spastic CP patients.
Keywords: Spasticity, Cerebral Palsy, Neuromuscular Electrical Stimulation, Cryotherapy.
INTRODUCTION
Cerebral palsy is a well-recognized
neurodevelopmental condition beginning in childhood
& persisting throughout the lifespan. Cerebral palsy is
a group of permanent disorders of the development of
movement and posture, causing activity limitation, that
are attributed to non-progressive disturbances that
occurred in the developing fetal or infant brain. The
motor disorders of cerebral palsy are often accompanied
by disturbances of sensation, perception, cognition,
communication, and behavior; by epilepsy, and by
secondary musculoskeletal problems.1 Cerebral palsy
is the commonest physical disability in childhood,
occurring in 2.0 to 2.5 per 1000 live births.2 The causes
are congenital, genetic, inflammatory, infections, anoxic,
traumatic & metabolic. The injury to the developing
brain may be prenatal, natal or postnatal.3 Causes of
CP were prenatal in 50% of the cases, perinatal in 33%,
postnatal in 10%, and mixed in 7%.4 75% of children
with CP have spastic cerebral palsy.3 Spasticity is
classically defined as a tonal abnormality of skeletal
muscle characterized by a velocity-dependent
5. chandan kumar 17TH april-21-25.pmd
21
resistance to passive stretch.5 Studies done to find out

development of spasticity with age shown that the
degree of muscle tone increased upto 4 year of age. After
4 year of age the muscle tone decreased each year upto
12 year of age.6
Physiotherapy Treatment For Spasticity
Various treatment approaches & modalities to
manage spasticity associated with spastic cerebral palsy
include the use of oral neuropharmacological agents
or injectable materials such as botulinum-A toxin7,
surgical treatment through tendon transfer8 or selective
rhizotomy 9. The other treatment approaches are
application of cryotherapy10, progressive resistive
exercises to improve muscle strength, repetitive passive
range of motion exercises to improve & maintain joint
mobility. Passive, static, gentle stretches are performed
on individual joints to decrease & prevent joint
contractures. Neurodevelopmental treatment (NDT),
sensory integration, electrical stimulation, constrained
induced therapy & orthosis are also used in
management of cerebral palsy.11, 12
2/7/2013, 8:08 PM
CRYOTHERAPY
INCLUSION CRITERIA
Cold application has been used for some time to

reduce spasticity clinically. Decrease in resistance to
passive stretch lasts from a few minutes up to 24 hours.
Cold anesthesia of peripheral sensory end-organs
changes the balance of facilitatory-inhibitory influences
playing on the anterior horn cell in favor of inhibition.
Unmasking of spasticity permits strengthening of
voluntary mechanisms normally snowed under by
undesired reflexes.10
1. Patient diagnosed with spastic cerebral palsy

(quadriplegic and hemiplegic).
Neuromuscular Electrical Stimulation

Neuromuscular electrical stimulation has gained
support since its inception as a treatment for cerebral
palsy in the 1970s. With neuromuscular electrical
stimulation, electrical stimulation of sufficient intensity
generally to produce visible muscle contraction is
applied at the muscle motor point. Electrical stimulation
is thought to improve strength, reduce spasticity of the
antagonist muscle, reduce co-contraction, and create
soft-tissue changes permitting increased range of
motion. 13 There are few studies that report the
effectiveness of NMES and cryotherapy on reduction of
spasticity & improvement of hand function in patients
with spastic cerebral palsy and found that both the
modalities used are effective and none of the two
modalities is superior to other.14 Therefore, aim of this
study is to determine the effectiveness of
Neuromuscular electrical stimulation combined with
Cryotherapy on spasticity and hand function in
patients with spastic Cerebral Palsy.
In present study, hand function is measured using
the Manual Ability Classification System (MACS)
instead of Zancolli system 14 because a review of
classification systems of upper limb function &
deformity in cerebral palsy supports the use of MACS
to classify upper limb function and Zancolli system is
recommended to classify thumb, hand &wrist
deformity.15
METHODOLOGY
30 subjects were selected by means of convenience
sampling based on inclusion and exclusion criteria.
All the parents received a written explanation of the
trial before entry into the study and then gave signed
consent to participate their children in the study. The
patients were randomly allocated into 2 groups.
22
2. Patient having wrist flexor spasticity upto Grade 3

according to Modified Ashworth Scale.
3. Age 5-15 yr, both male & female.
4. Patient who can comprehend and comply with
instructions.
5. Normal skin sensation of upper limb.
EXCLUSION CRITERIA
1. Dermatological problems
2. Seizures
3. Patients on muscle relaxing medications
4. Patient having contracture or deformity of upper
limb
5. Patient undergone any surgery for upper limb
PROCEDURE
Thirty patients of CP who fulfill the inclusion criteria
were included in this study. Total numbers of patients
were equally divided into two groups (A & B). Each
group contained 15 patients. All participants were
evaluated by modified ashworth scale for wrist flexor
spasticity and manual ability classification system for
hand function.
Modified Ashworth Scale measure spasticity and is
applied manually to determine the resistance of muscle
to passive stretching. This scale has been shown too
valid and reliable.16 Manual Ability Classification
system describes how children with cerebral palsy (CP)
use their hands to handle objects in daily activities.
MACS describe five levels. The levels are based on the
childrens self-initiated ability to handle objects and
their need for assistance or adaptation to perform
manual activities in everyday life. The objects referred
to are those that are relevant and age-appropriate for
the children, used when they perform tasks such as
eating, dressing, playing, drawing or writing.17 MACS
has shown to be valid and reliable.18 All patients were
assessed by modified ashworth scale and manual
ability classification system before and after giving
intervention.
2/7/2013, 8:08 PM
The technique for application of passive stretching

was based on passive range of motion (PROM)
therapeutic exercises described by Kisner and Colby.19
The PROM consists of moving the elbow, wrist, fingers
and thumb passively and holding it in position for 60
seconds. This procedure was repeated 5 times giving
duration of 5 minutes bout. The procedure of passive
stretching was given prior to every treatment session in
all the subjects, both in group A & B.
Treatment procedure for group A subjects
The subject was placed in sitting position. The entire
forearm from elbow to the fingers was carefully and
decently exposed. The area was cleaned with cotton
wool and with methylated spirit. The upper limb of the
subject was positioned on a pillow on the plinth with
the shoulder in mild abduction. The forearm was also
positioned in mid flexion and supination with the
fingers and thumb in anatomical position .The ice
lollipop was applied to the flexor compartment of the
forearm and gently massaged using stroking technique
from the proximal to the distal end of the forearm. This
was applied continuously for 20 minutes. The sequence
of treatment was 3 times a week on alternate days for 6
uninterrupted weeks.
After cryotherapy, subjects received electrical
stimulation to the dorsum of the forearm. The electrical
stimulation was consist of a dual channel devise with
current outcome between 0 and 100 MA , pulse width
of 200 microseconds and the pulse set between 30 and
40 Hz to produce tolerable muscle contraction. The
electrical stimulation was applied for duration of
30minutes, 3 times in a week on alternate days for a
period of 6 uninterrupted weeks.
Treatment procedure for group B subjects
Following the application of passive stretching, the
subjects received Cryotherapy as describe for the
subjects in group A.
RESULTS
Patients in both the groups were assessed at baseline
level for spasticity with modified ashworth scale &
hand function with manual ability classification scale
prior to the commencement of the treatment sessions.
Post-test measurements were taken after 6 weeks after
completion of treatment sessions. There were no drop
outs in the study. A total of 16 female and 14 male
subjects participated in the study.
Demographic characteristics of both the group are
shown in table 1.
Table: 1 Demographic characteristic of the subjects
VARIABLES
GROUP A
Sex F:M
GROUP B
7:8
9:6
7.53 1.35
7.66 1.63
8 (53%)
7 (46%)
Right Hemiplegic (%)
5 (33.3%)
5 (33.3%)
Left Hemiplegic (%)
2 (13.3%)
3 (20%)
15
15
Mean Age
Spastic CP (Type)
Quadriplegic (%)
Dominating hand (number)

Right hand
Above table showing that subjects in both the groups

are matched for baseline level
Table: 2 Baseline score of MAS and MACS of
both the group
MAS
Mean S.D
P value (<0.05)
MACS
2.460.611
2.330.587
4.600.632
0.59
B
4.530.639
0.77
Above table showing mean value of baseline scores

of MAS & MACS of both groups. After analysis, the p
value is >0.05 which is statistically non-significant.
Table: 3 Pre and Post value of MAS and MACS of
group A
Data and Statistical Analyses

GROUP A
Comparison was performed between the groups first

at baseline level. Then again, comparisons were done
after treatment at 6 week as well as from baseline to 6
week and results were noted. Wilcoxon signed rank
test and Mann Whitney U test was used to analyze the
pre and post treatment values of MAS scores and MACS
scores within the groups and between the groups
respectively. The level of significance was set at p<0.05.
Data were analyzed using SPSS 17.0.
23
Variables
Mean S.D
p value (<0.05)
Pre value
Post value
MAS
2.4660.611
1.3330.408
0.0003
MACS
4.600.632
2.530.833
0.0003
Above Table showing mean value of pre MAS and

post MAS & pre MACS and post MACS of group A.
After analysis, p value is <0.05 which is statistically
significant.
2/7/2013, 8:08 PM
Table: 4 Pre & post value of MAS and
MACS of group B
GROUP A
Variables
Mean S.D
p value (<0.05)
Pre value
Post value
MAS
2.3330.587
1.6660.308
0.0008
MACS
4.530.639
3.460.828
0.0005
Above Table showing mean value of pre MAS and

post MAS & pre MACS and post MACS of group B.
After analysis, p value is <0.05 which is statistically
significant.
Table: 5 Post intervention MAS and MACS value of
group A & B
MAS
A
Mean S.D
1.330.408
P value (<0.05)
MACS
B
1.660.308
2.530.833
0.02
B
3.460.828
0.01
Above Table showing mean value of post

intervention scores of MAS & MACS of both groups.
The result obtained from the study data showed that
there was significant difference within group A and B
in reducing spasticity and improving hand function.
Group A showed more significant difference in outcome
measures in comparison to group B.
DISCUSSION
In this experimental design study, result showed
the combined effect of neuromuscular electrical
stimulation and cryotherapy on spasticity and hand
function in patients with spastic cerebral palsy. The
results support the hypothesis that NMES along with
cryotherapy produce good results as compared to
cryotherapy alone. Cold facilitates alpha-motor neuron
activity and decreases gamma motor neuron firing
through stimulation of cutaneous afferents. There is
also a decrease in the afferent-spindle discharge by
direct cooling of the muscle. When nerves are cooled,
synaptic transmission are impeded or blocked by
altering the transmembrane ionic flow. The possible
explanation of the mechanism of relief of spasticity can
be that cold anesthesia of peripheral sensory endorgans changes the balance of the sum of facilitatoryinhibitory influences playing on the anterior horn cell
in favor of inhibition. Unmasking of spasticity permits
strengthening of voluntary mechanisms normally
snowed under by undesired reflexes.10
24
The results of this study are supported by previous

studies which tell that the neuromuscular electrical
stimulation is helpful in increasing muscle strength by
increasing cross sectional area of the muscle & by
increasing recruitment of Type 2 muscle fibers.12 With
NMES, unused muscles can be stimulated when needed
and the sensory input from NMES can give added
sensory awareness of what is happening in the hand
to allow motor learning to occur and to permit motor
control.20 Neuromuscular electrical stimulation, when
applied to the peripheral muscles has a direct effect on
the cerebral cortex.21 In group A as we have given
cryotherapy first and after that NMES, combined effect
of both the modalities leads to significant improvement
in experimental group.
Result of this study showed that improvement is
more significant in subjects of group A treated with
cryotherapy followed by neuromuscular electrical
stimulation when compared with subjects of group B
treated with cryotherapy alone (table 5). This showed
that additional improvement in group A is because of
neuromuscular electrical stimulation. First cryotherapy
has reduced spasticity in wrist flexors and then NMES
applied to wrist extensors has further reduced spasticity
in wrist flexors via reciprocal inhibition and increased
strength in wrist extensors. Few studies have been done
on neuromuscular electrical stimulation and
cryotherapy in isolation which shows their effectiveness
but the result obtained from this study is novel that
proves the combined efficacy of neuromuscular
electrical stimulation and cryotherapy on spasticity.
Neuromuscular electrical stimulation is a non-invasive
therapy and offers a better clinical outcome.
CLINICAL IMPLICATION
The results of the present study enlighten the use of
combination therapy approach (NMES+Cryotherapy)
as an more effective approach than the either
intervention alone in the clinical settings for the
management of spasticity and hand function in patients
with spastic cerebral palsy.
Limitations of the study
Subjective measures used for measuring spasticity
and hand function challenges the results obtained. No
follow up was taken to see the long term effects.
Dominating hand was only treated in quadriplegics to
avoid collecting paired data.
2/7/2013, 8:08 PM
Future Research Suggestion

Future research can be done using objective
measures for measuring spasticity and hand function.
There should be long term follow up of the patient to
determine the sustained effects of combination therapy
(NMES+Cryotherapy).
11.
12.
13.
CONCLUSION
This study describes the management of spastic
cerebral palsy patients with hand function
impairments, who responded favorably to an
intervention program focused NMES and cryotherapy.
14.
REFERENCES
15.
1.
R peter, P. Nigel, G murray, G martin. The Definition

and classification of cerebral palsy. Developmental
Medicine & Child Neurology. 2007; 49(109):814.
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Reddihough Dinah S, Collins Kevin J. the
epidemiology and causes of cerebral palsy.
Australian Journal of Physiotherapy. 2003; 49:
7-12.
3.
S. chitra, M nandani. Cerebral palsy-definition,
classification, etiology and early diagnosis. Indian
journal of pediatric. 2005: 865-868.
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Holm Vanja A. the Causes of Cerebral Palsy. JAMA.
1982; 247:1473-1477.
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R Susan, G Joan T. Non operative management of
spasticity in children. Child nervous system. 2007;
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6.
H Gunnar, W philippe. Development of spasticity
with age in a total population of children with
cerebral palsy. BMC Musculoskeletal Disorder.
2008; 9:150-159.
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Patel Dilip R, S olufemi. Pharmacological
intervention for reducing spasticity in cerebral
palsy. Indian journal of pediatrics. 2005; 72:
896-872.
8.
Das Shakti P, Mohanthy Ram N, Das Sanjay K.
Management of upper limb in cerebral palsy-role
of surgery. IJPMR. 2002 April; 13:15-18.
9.
F Jean P, J abdulrehman. Selective dorsal rhizotomy
in the treatment of spasticity related to cerebral
palsy. Child nervous system. 2007 July 21; 23:
991-1002.
10.
Mead Sedwick, Knott Margaret. Topical
Cryotherapy: Use for Relief of Pain and Spasticity.
California Medicine. 1966; 105(3):179-181
25
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Sharan Deepak. Recent advances in management

of cerebral palsy. Indian journal of pediatric. 2005;
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Patel Dilip R. Therapeutic intervention in cerebral
palsy. Indian journal pediatrics. 2005; 72:979-983.
Kemper Derek G, Yasukawa Audyer M. Effects of
neuromuscular electrical stimulation treatment of
cerebral palsy on potential impairment
mechanism. Pediatric physical therapy. 2006;
18:31-38.
Akinbo S R A, Tella B A, Otunla A. Comparison of
the effect of neuromuscular electrical stimulation
and cryotherapy on spasticity and hand function
in patient with spastic cerebral palsy. Nigerian
medical practitioner. 2007; 51:128-132.
K McConnell, L Johnston, C Kerr. Upper limb
function and deformity in cerebral palsy: a review
of classification systems. Dev Med Child Neurol.
2011; 53(9): 799-805.
Bohannon Richard W, Smith Melissa B. Interrater
Reliability of a Modified Ashworth Scale of Muscle
Spasticity. Physical Therapy 1987 Feb; 67(2):
206-207.
Kuijper M. A, Ketelaar M. Manual ability
classification system for children with cerebral
palsy in a school setting and its relationship to
home self-care activities. American Journal of
Occupational therap. 2010; 64:614-620.
Eliasson Ann-Christin, Krumlinde-Sundholm
Lena, Rosblad Birgit, Beckung Eva, Arner
Marianne, Ohrvall Ann-Marie, Rosenbaum Peter.
The Manual Ability Classification System (MACS)
for children with cerebral palsy: scale development
and evidence of validity and reliability.
Developmental Medicine & Child Neurology 2006;
48(7):549-554. DOI: 10.1017/S0012162206001162
Kisner C, Colby L. A. Therapeutic Exercise:
Foundation and Techniques. 4thed. New Delhi:
Jaypee Brothers, Medical Publishers (P) Ltd; 2003.
Scheker L R, Ramirez S. Neuromuscular electrical
stimulation and dynamic bracing as a treatment
for upper extremity spasticity in children with
cerebral palsy. Journal of hand surgery. 1999;
24:226 -232.
Han BS, Jang SH, Chang Y, Byun WM, Lim SK,
Kang DS. Functional magnetic resonance image
finding of cortical activation by neuromuscular
electrical stimulation on wrist extensor muscles.
Am J Phys Med Rehabil. 2003 Jan; 82(1):17-20.
2/7/2013, 8:08 PM
Phonophoresis in Continuous Mode Ultrasound has

Significant effect in the Reliving Pain in Upper Trapezius
Tender Point
Chhavi Gupta1, Manish Rajput1, Ankita Samuel1, Sumit Kalra2
Student-bachelors of Physiotherapy, 2Asst Professor, Banarsidas Chandiwala Institute of Physiotherapy
ABSTRACT
Purpose: The aim of this study was to find the significance of continous mode on the immediate effect
on pain threshold and range of motion which follows a single treatment of tender points in the upper
trapezius muscle among using diclofenac sodium as coupling medium.
Methods: 30 subjects presenting with upper trapezius muscles spasm, aged 20-30 years old, participated
in this Study. Subjects underwent a screening process to establish the presence of tender points in
upper trapezius muscle. Subjects were divided randomly into 2 groups.
Group A = continuous mode of ultrasound (0.8 w/cm2 for 5 minutes)
Group B = pulsed mode of ultrasound (0.8 w/cm2 for 5 minutes)
Visual Analogue Scale and Range of Motion is assessed pre treatment and immediately post treatment.
Result the p value of VAS (post treatment) and ROM (post treatment) in continous mode was 0.000
Conclusion: continous mode of ultrasound is better for immediate pain relive as compared to pulsed
mode when diclofenac sodium is used as the coupling medium.
Keywords: Tender Point, Phonophoresis, Ultrasound, Diclofenac Gel.
INTRODUCTION
Neck pain is common and can limit individuals
ability to participate in normal daily activities. Neck
pain frequently becomes chronic1.
Tender point is defined as the places on muscles
that when touched with enough pressure, elicits a
feeling of sensitivity in the location of point. Pain does
not refer anywhere else in the body; pain is confined to
tender point itself. They are usually no bigger than 1
cm 2.
The presence of tender points in patients is closely
associated with their current anxiety, and patients with
a history of psychological trauma associated with
anxiety (for example, childhood trauma or sexual abuse)
have an increased number of tender points.4
US is a modality which involves the generation of
high frequency sound waves, and their transmission
through the skin to the structures desired to be affected.
US generators used clinically are limited by government
6. chhavi gupta 5th april --26-30.pmd
26
regulation to approximately 1,000,000 Hertz (1

megahertz).5
Phonophoresis was first used to treat polyarthritis
of the hand by delivery of hydrocortisone ointment into
inflamed areas in 1954. Since then it has been reported
to be used in the treatment of various dermatological
and musculoskeletal disorders.7
The mechanism by which ultrasound enhances the
transdermal penetration of substances is not entirely
clear. One could think of the vasodilation observed on
macroscopic examination, but this would certainly not
be enough on its own, since it does not imply any
change of the waterproof keratin layer of the skin, which
should necessarily be altered.8
Sodium Diclofenac was chosen for the experiment
for being a well-known and widely used nonsteroidal
anti-inflammatory drug whose analgesic effects
manifest quickly after administration.8 Evidence from
clinical and pharmacological studies imply that
Diclofenac exerts its actions by inhibiting cycloxygenase
2/7/2013, 8:08 PM
(COX) enzyme. Inhibition of COX reduces the

production of inflammatory mediators such as
prostaglandins, interleukin-6 and substance P. It is also
suggested that Diclofenac can alter G-protein mediated
signal transduction pathways and exerts an enhanced
effect on hyperalgic muscle by directly interacting with
nociceceptors.11
Reliability of the visual analogue scale for
measurement of pain
A VAS is measurement instrument that tries to
measure a characteristic or attitude that is believed to
range across a continuum of values and cant easily be
directly measured.9
Operationally a VAS is usually a horizontal line,
100mm in length, anchored by word descriptors at each
end. The patient marks the line the point they feel which
represents their perception of their current state. The
VAS score is determined by measuring inn millimetres
from left hand end of the line to the point that the patient
marks.9
Reliability of the VAS for acute pain measurement
as assessed by the ICC appears to be high. Ninety
percent of the pain ratings were reproducible within 9
mm. These data suggest that the VAS is sufficiently
reliable to be used to assess acute pain.10
Reliability of Goniometer
The full-circle goniometer, or universal goniometer
(UG), is a versatile device for recording measurements
of peripheral joint ROM in healthy subjects and in
patients. Based on a clinical study of 60 patients with
orthopaedic disorders in a physical therapy outpatient
department, conclusion was drawn that AROM
measurements on the cervical spine made by the same
physical therapist have good to high reliability,
regardless of whether the therapist used the CROM
device or the UG. Repeated measurements with the UG
had poor to fair between tester reliability.15
The purpose of this study is to compare the
effectiveness of pulsed and continuous ultrasound
with topical Diclofenac gel as the coupling medium in
the immediate pain relive of tender point.
METHODOLOGY
Number and Source
30 subjects were taken from young population.
27
Inclusion Criteria
1. Male or Female with age of 20-30 years.
2. Subjects with upper trapezius muscle spasm.
Exclusion Criteria
1. Subjects with trigger point of trapezius muscle.
2. Subjects with musculoskeletal disorder that would
limit performance in these subjects.
3. Skin disorders which would irritate by either
increase in warmth of the part or by the lubricants
which might be used, e.g. eczema.
4. In presence of malignant tumours.
5. In case of any previous fracture or surgery at neck.
6. All contraindications of ultrasonic therapy.
Method of selecting & assigning subjects to groups
40 subjects having an upper trapezius muscle spasm
were considered for this study. They were then screened
to remove the subjects who did not fulfil the criteria for
the study. After screening, the subjects they were
randomly divided into two groups.
Instruments and Tool used
1. Ultrasound machine Meditek Ultrasonic digital ,
Meditek cooperation
2. Diclofenac sodium gel
3. Ultrasound gel
Research Design
It is an experimental design.
Variables
Independent variables- Ultrasonic Therapy
Dependent variables- Visual Analogue Scale
PROCEDURE
Subjects fulfilling the inclusion criteria were taken
subject regarding study. After pain level assessment by
help of visual analogue scale (VAS) and Range of
Motion using the universal goniometer they were
randomly divided into two groups namely, A and B.
2/7/2013, 8:08 PM
Group A were given pulsed ultrasound with diclofenac

sodium as coupling medium and Group B were given
continuous ultrasound with diclofenac sodium as
coupling medium. The ultrasound was given for 5
minutes at 0.8 w/cm2 16. After the treatment pain level
and Range of Motion is taken again.
RESULT
A paired sample t test reveal a statistically reliable
difference between the mean number of VAS pre and
post in continous mode (M= 6.7333, s =1.03280) and
(M= 3.9333, s =1.48645) that the t(14)=12.582, P()= .000
at two tail test.
A paired sample t test reveal a statistically reliable
difference between the mean number of ROM pre and
ROM post in continous mode (M=27.0000, s=5.29150)
and (M= 37.0667, s = 4.19977) that the t(14) = -11.093,
P()= .000 at two tail test.
A paired samples t test reveal a statistically reliable
difference between the mean number of VAS pre and
VAS post in pulsed mode (M=-6.8000, s = 1.32017) and
(M 4.4000, s=1.50238) that the, t(14) =8.806, P() = .000.at
two tail test.
A paired samples t test reveal a statistically reliable
difference between the mean number of ROM pre and
ROM post in pulsed mode (M=-23.7333, s=10.73357)
and (M=33.7333, s=9.51290) that the, t(14) = -10.569,
P() = .000.at two tail test.
An independent-samples t-test was conducted to
compare VAS post treatment in pulsed mode and
continous mode. There was a significant difference in
the scores for pulsed (M=4.4, SD=1.5) and continous
(M=3.93, SD=1.48) conditions; t(28)=0.855, p = 0.400.
the result suggest that VAS decreases more in continous
mode than in pulsed mode.
An independent-samples t-test was conducted to
compare ROM post treatment in pulsed mode and
continous mode. There was a significant difference in
the scores for pulsed (M=33.73, SD=9.51) and continous
(M=37.06, SD=4.19) conditions; t(28)=-1.24, p=0.225.
The result suggest that ROM increases more in
continous mode.
28
2/7/2013, 8:08 PM
Hence it can be said that continuous mode has more

of a thermal effect rather than non-thermal.
Mild heating has the effect of reducing pain and
muscle spasm and promoting healing process. Kramer
(1987), investigating the increase in conduction velocity
in motor and sensory nerves following therapeutic
ultrasound, concluded that this was likely to be related
to the heating effect of ultrasound.12
Diclofenac sodium is a very commonly used nonsteroidal anti-inflammatory drug (NSAIDs). It is an
analgesic-anti-pyretic-anti-inflammatory drug, similar
in efficacy to naproxen. It inhibits PG synthesis and is
somewhat COX-2 selective.13
The mechanism by which ultrasound enhances the
transdermal penetration of substances is not entirely
clear. One could think of the vasodilation observed on
macroscopic examination, but this would certainly not
be enough on its own, since it does not imply any
change of the waterproof keratin layer of the skin, which
should necessarily be altered.18
DISCUSSION
According to the unpaired t test done between post
values of VAS in case of pulsed mode and continous
mode the p value is <0.005. The post value of ROM in
pulsed mode and continous mode the p value is <0.005.
In this study, the clinical efficacy of diclofenac gel
as a coupling agent using continuous mode of was
compared with pulsed mode.
According to the study, by using continuous mode
of ultrasound there is more pain relive rather than by
using pulsed mode.
Continuous mode has been recommended for
muscular cellular disorders such as muscle spasm, joint
stiffness or pain whereas pulsed mode is preferred for
soft tissue repair.12
This could be because in pulsed mode the time
average intensity is reduced which reduces the amount
of energy available to heat the tissues while ensuring
that the energy available in each pulse is high enough
for mechanical or non-thermal effects rather than the
thermal effects to predominate.12
29
No volunteers presented any complication of any

kind nor did they report any discomfort with the
treatment at any time, all of them resuming normal life
immediately after the end of treatment Apart from slight
redness and a temperature increase on touch, no sign
of local irritation was detected by macroscopic
inspection of the irradiated areas.8
CONCLUSION
The study concludes that continous mode of
ultrasound is better for immediate pain relive as
compared to pulsed mode when diclofenac sodium is
used as the coupling medium for immediate pain relive
in tender point in muscles all over the body.
REFERENCES
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2.
3.
Ali Gur; Physical Therapy Modalities in

Management of Fibromyalgia; Current
Pharmaceutical Design, 2006 12, 29-35
Haraldsson B, Gross A, Myers CD, Ezzo J, Morien
A, Goldsmith CH, Peloso PMJ, Brnfort G, Cervical
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Reviews 2006, Issue 3. Art. No.: CD004871. DOI:
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Sheila Kitchen, Electrotherapy Evidence-based
Practice, Eleventh Edition, pg 221-228
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Sangita Chakrabarty, Md, Msph, Roger Zoorob,

Md, Mph; Fibromyalgia; American Family
Physician; Volume 76, Number 2 July 15, 2007
Sunday Akinbo, Oluwatoyosi Owoeye, Sunday
Adesegun; Comparison of the Therapeutic
Efficacy of Diclofenac Sodium and Methyl
Salicylate Phonophoresis in the Management of
Knee Osteoarthritis; Turk J Rheumatol
2011;26(2):111-119
Peter Croft, Jonathan Burt, Joanna Schollum, Elaine
Thomas, Gary Macfarlane, Alan Silman; More
pain, more tender points: is fibromyalgia just one
end of a continuous spectrum?; Annals of the
Rheumatic Diseases 1996; 55: 482-485
Giovana c. Rosim, Cludio Henrique Barbieri,
Fernando Mauro Lanas, and Nilton Mazzer;
Diclofenac Phonophoresis In Human Volunteers;
Ultrasound in Med. & Biol., Vol. 31 No. 3 pp. 337343, 2005
Russell Rothenberg, MD; Fibromayalgia,
pathophysiology and treatment; Fibromyalgia
frontiers, 2010, vol. 18, No. 1
Prerna Paul et. al.; Effect of Lumbar Stabilization
Exercise in Treatment of Young Individuals With
Non Specific Low Back Pain; The Physiotherapy
Post; July-September 2011. Vol 3, No. 3
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10. Afyonkarahisar, Turkey; Effectiveness of

Ultrasound Therapy in Cervical Myofascial Pain
Syndrome: A Double Blind, Placebo-Controlled
Study; Turk J Rheumatol 2010; 25: 110-5
11. Robert D Gerwin; A review of myofascial pain and
fibromyalgia factors that promote their
persistence; ACUPUNCTURE IN MEDICINE
2005; 23(3):121-134.
12. John low BA(Hons.), FCSP, DipTP, SRP, Ann Reed
BA, MCSP, DipTP, SRP; Electrptherapt Explained
Principles and Practice, 3rd edition, pg 172-196
13. KD Tripathi; Essentials of Medical Pharmacology;
6th edition; page 184-194
14. Bijur PE, Silver W, Gallagher EJ.; Reliability of the
visual analog scale for measurement of acute pain;
Acad Emerg Med. 2001 Dec;8(12):1153-7
15. James W Youdas, James R Carey and Tom R
Garrett; Reliability of Measurements of Cervical
Spine Range of Motion-comparison of Three
Methods; PHYS THER. 1991; 71:98-104
16. Kamal Dua, V.K.Sharma, UVS Sara, D.K.Agrawal,
M.V.Ramana; Penetration Enhancers for TDDS: A
Tale of the Under Skin Travelers; Adv. in Nat. Appl.
Sci., 3(1): 95-101, 2009
2/7/2013, 8:08 PM
Prediction of Relationship of Visual Attention Deficits to

Balance and Functional Outcome in Persons with
Subacute Stroke
Chintan Shah1, Hasmukh Patel2, Komal Soni1, Dhaval Desai1, Harshit Soni1
Lecturer, Spb Physiotherapy College, Surat, 2Clinical Therapist, U. N. Mehta Institute of
Cardiology and Research Centre, Ahmedabad
ABSTRACT
Background: Stroke is a focal neurological disorder lasting for more than twenty-four hours, giving rise
to functional disabilities in speech, vision, balance and ADL. As stroke has been found to impair
vision, balance and ADL, this study is done to predict the relationship of visual attention deficits to
balance and functional outcomes in persons with subacute stroke. Awareness of such relationship
may be of useful assistance to the physiotherapists in planning treatment interventions in persons
with subacute stroke.
Objective: To predict and estimate strength of the relationship of visual attention deficit to balance and
functional outcomes in persons with subacute stroke.
Materials and Methods: 50 subjects with subacute stroke were selected for the study. All the patients
were assessed on the basis of Star Cancellation Test (SCT), Berg Balance Scale (BBS) and Barthel Index
(BI) for visual attention, balance and functional outcomes respectively both at the time of discharge
from the hospital and also after 6 months post-stroke. At the end of the study, visual attention scores
were correlated (using Pearson product correlation "r" value) with the balance scores and functional
outcome scores obtained at the time of discharge from the hospital and 6 months post-stroke.
Result: MeanSD of scores for Star Cancellation test, Berg Balance scale and Barthel index measured at
the time of discharge from hospital and 6 months post stroke was 48.092.04, 49.861.91, 40.002.00,
42.601.90, 70.0010.00, 75.109.92 respectively. Moreover, there was strong positive and highly
significant correlation of SCT scores with BBS scores and BI scores both at the time of discharge and 6
months post stroke.
Interpretation & Conclusion: Visual attention deficit is an important factor to predict the balance and
functional outcomes in persons with subacute stroke.
Keywords: Stroke, Visual Attention Deficit, Balance, Functional Outcome.
INTRODUCTION
Stroke is an acute onset of neurological dysfunction
due to an abnormality in cerebral circulation with
resultant sign and symptoms that correspond to
involvement of focal areas of brain.1 Cognitive deficits
are common after stroke2,3 and have been linked to poor
recovery of ADL (Activities of Daily Living) abilities
and rehabilitation outcome.4,5 For many people, these
impairments are the major obstacles preventing their
return to independence and quality of life.6
Corresponding author:
Chintan Shah
B-701, Aagam Vihar Apt, Opp Lakhoz Club, Umra,
Surat-07, Gujarat, India
E-mail: chintoo601@gmail.com
7. chintanshah 23rd april-31-36.pmd
31
Attention is one of the aspects of cognitive

functioning that has been reported as the basis for other
components of cognition.7 Visual attention is a type of
selective attention that lays a very important role in
balance because balance is maintained mainly by
feedback through eyes, ears and vestibular apparatus.
In this visual contribution is inevitable and if there is
visual inattention, then there will be difficulty in
feedback mechanism and this will directly affect the
balance and eventually ADLs. Visual impairments
commonly encountered by patient with hemiplegia
include poor eyesight, diplopia, homonymous
hemianopia, damage to visual cortex and retinal
damage. 8 In its purest form, unilateral spatial
inattention is defined as a condition in which an
individual with normal sensory and motor system fails
2/7/2013, 8:08 PM
to orient toward, respond to, or report stimuli on the

side contralateral to the cerebral lesion.9 Attention is
also a key component in learning new motor skills,
particularly in the early stages of learning.10 This clearly
portraits that attentional component plays a very
important role in motor learning and also depicts
importance of attention in rehabilitation of stroke
patients especially in Motor Relearning Programme
which is the latest approach in physiotherapy
rehabilitation.
2. To find out the relationship between visual

attention deficits and functional performance at the
time of discharge and after 6 months post-stroke.
In stroke, physical impairments include motor,

sensory, balance, urinary impairment, speech disorder,
perceptual problems, etc. Balance has been defined as
the ability to maintain upright posture.11,12 In stroke,
ones ability to balance may be impaired because of
deficits of strength, range of movements, proprioception,
vision, vestibular function and endurance.13 Studies
have showed that balance and perceptual disturbance
are found as risk factors for falls in stroke patients.14
Study Setting: Laxmi Memorial College of

Physiotherapy and A.J. Hospital and Research Centre,
Mangalore
ADL are the activities necessary for daily self care,

personal maintenance and independent community
living such as feeding, bathing, dressing, hygiene, and
physical mobility.15 Studies have reported decline in
cognition, mobility and functional daily activity after
stroke.16 Also the presence of visual field deficit is being
reported as a significant prognostic sign, predicting
both a higher death rate following stroke and poor
performance in ADLs, even following rehabilitation.17,18
Further, attention deficits being common among
hospitalized people with stroke, a study describing
association between distractibility, auditory selective
attention, balance and function impairments shown
that those who scored well on the auditory selective
test had better balance scores at the final assessment
than those with auditory selective attention deficits or
distractibility.19
However there are no clear cut studies that show
that whether visual attention deficits correlate with
balance, and eventually functional outcomes in
subacute stroke patients. Keeping in view the above
point, this study is set out to predict the relationship of
visual attention deficits to balance and functional
outcome in patients with subacute stroke.
The aims and objectives of the study were
METHODOLOGY
Study design: An Observational Correlation study
Sample size: 50 individuals
Sampling method: Purposive sampling technique
Study duration: 6 months (from the time of discharge of

patient from the hospital upto 6 months post-stroke).
Inclusion criteria
1. Above 50 years of age.
2. Both sexes.
3. All type of stroke and first time stroke.
4. Attention deficits should be present in the patient.
5. Deemed to be fit by the physician and medically
stable.
6. Subjects should undergo continuous conventional
physiotherapy.
Exclusion criteria
1. Major musculoskeletal problems (amputation or
recent joint replacement surgery).
2. Any other neurological disorders in addition to
stroke.
3. Severe perceptual disorders.
4. Severe cognitive deficit (Mini Mental State
Examination score < 23/30).
Materials used: Test paper of size 8.5 inch x 11 inch
with 52 large stars, 13 letters and 10 short words
interspersed with 56 small stars for the testing of visual
attention. Other materials included were pencil, stop
watch/wrist watch, ruler, two standard chairs (one
with and one without arm-rest), foot-stool or step.
(Fig: 1)
1. To find out the relationship between visual

attention deficits and balance at the time of
discharge and after 6 months post-stroke.
32
2/7/2013, 8:08 PM
Fig: 1 Tools Used
Outcome Measures
Star Cancellation Test (SCT) to assess visual attention,
Fig. 3 stepping activity for Barthel Index
Berg Balance (BB) scale to assess balance and

Barthel Index (BI) to assess functional performance
(ADL).
PROCEDURE
After signing the written informed consent (to
participate in the study and to allow reproduction of
their photographs) subjects were made to participate
in study and baseline measurements of demographic
factors and outcome measures were recorded. Every
patients were given proper instructions (but no training)
prior to assessing the outcome measures viz. Star
Cancellation Test (Fig: 2), Barthel Index (Fig: 3) and Berg
Balance Scale (Fig: 4)
Fig. 4 Therapist Testing Berg Balance Scale
All outcome measures were taken at the time of

discharge from hospital and later 6 months after stroke.
Following the recording of the above parameters,
the obtained scores were tabulated and compared
among both the study groups.
Ethical Consideration: Procedures followed were in
accordance with the ethical standards of Helsinki
Declaration of 1975, as revised in 2000.20
Fig. 2 Star Cancellation Test
33
2/7/2013, 8:08 PM
RESULTS
Of the 50 participants who participated in the study,

none were lost to follow up assessment at the end of the
study.
Graph 1: Age & Gender distribution of the subjects
At the end of the study, visual attention scores were

correlated with the balance scores and functional
outcome scores both at the time of discharge from the
hospital and also after 6 months post-stroke. Pearson
product correlation r value was used to find the
relationship among the variables. P value< 0.01 was
taken up for statistical significance. Data analysis
software SPSS 13.0 version has been used for the data
analysis of present study.
Table 1: Descriptive statistics for Outcome measures

Star Cancellation test
Berg Balance Scale
Barthel Index
Time of
Discharge
After
6 months
Time of
Discharge
After
6 months
Time of
Discharge
After
6 months
Min
45
51
37
43
55
85
Max
47
53
40
46
60
90
Mean
48.06
49.86
40.00
42.60
70
75.10
Std. Deviation
2.045
1.917
2.000
1.906
10.000
9.923
Table 2: Correlation of SCT scores with the BBS scores & BI scores at the time of discharge from the hospital
Star Cancelation test

(Time of Discharge)
r value
Level of
Significance/
Interpretation
Berg Balance Scale

(Time of Discharge)
.978
.000
HS
Barthel Index
(Time of Discharge)
.978
.000
HS
As shown in table 2, there is strong positive and highly significant (p<0.01) correlation between SCT scores (at
the time of discharge) and BBS scores (at the time of discharge) and also between SCT scores (at the time of
discharge) and BI scores (at the time of discharge).
Table 3: Correlation of SCT scores with the BBS scores & BI scores after 6 months post stroke

(After 6 months)
r value
Level of
Significance
Berg Balance Scale

(After 6 months)
.951
.000
HS
Barthel Index
(After 6 months)
.966
.000
HS
As shown in table 3, there is strong positive and

highly significant (p<0.01) correlation between SCT
scores (6 months post stroke) and BBS scores (6 months
34
post stroke) and also between SCT scores (6 months

post stroke) and BI scores (6 months post stroke).
2/7/2013, 8:08 PM
Table 4: Correlation of SCT scores at the time of discharge with the
BBS scores & BI scores after 6 months post stroke

(Time of Discharge)
Berg Balance Scale

(After 6 months)
Barthel Index
(After 6 months)
As shown in table 4, there is strong positive and

highly significant (p<0.01) correlation between SCT
scores (at the time of discharge) and BBS scores (6
months post stroke) and also between SCT scores (at
the time of discharge) and BI scores (6 months post
stroke).
DISCUSSION
Stroke is a focal neurological disorder lasting for
more than 24 hours, giving rise to functional disabilities
in speech, vision, balance and ADL. Hence, in our study
we have tried to predict the relationship between visual
attention deficits, balance and functional outcomes in
persons with subacute stroke. Results from our study
indicates that attention deficits were present among the
persons with subacute stroke, Sinclair R (1995) also
reported similar findings using some of the same
subtests among subacute stroke patients.19 Moreover,
the visual attention deficits have a significant influence
on the balance both at the time of discharge from the
hospital and also after 6 months post-stroke. Sebstina
and Vyas (2001)21 also concluded that cognitive and
perceptual deficits following stroke influences sitting
and standing balance among patients. Visual attention
has directly proportional relation with balance.
However, findings of Stapleton and colleagues (2001)
suggested a weak or no relationship between attention
deficits and balance control, but their sample size being
too small (n=13) the results can be doubted for being
statistically significancant.22
There was significant correlation between the SCT
scores at the time of discharge from the hospital with
the BBS score and BI score after 6 months post-stroke.
Thus, the present study not only finds the relationship
between visual attention, balance and functional
outcome but it also predicts the balance and functional
outcome after 6 months with the visual attention score
at discharge. However, present study showed that
visual attention deficits affect the balance and
functional outcome significantly but visual attention
deficit is not the only factor that can affect the balance
35
r value
Level of
Significance
.944
.000
HS
.970
.000
HS
and functional outcome. The assessment of such

attention deficits post-stroke may be a useful tool in
predicting functional recovery and response to
rehabilitation. Awareness of possible deficits of
attention may be of assistance to physiotherapists in
planning interventions with patients recovering from
stroke.
The study was done on a small sample size.
The study only included visual attention among

the various types of attention.
Only old aged i.e. above 50 years patients with

subacute stroke were assessed to find the prediction,
young age stroke patients were not at all assessed.
Scope of further studies
In future studies, all types of attention (sustained

attention, divided attention, etc.) other than visual
attention can be taken as predictor of balance and
functional outcomes.
Same study can be done in subacute stroke patients

without ongoing physiotherapy.
BBS does not include gait items so some other scale

can be used to assess the dynamic balance of
subjects with stroke.
CONCLUSION
Visual attention deficits are an important factor

responsible for predicting balance and functional
outcomes in persons with subacute stroke. There is
significant one to one relationship between visual
attention deficit to balance and functional recovery in
persons with subacute stroke.
ACKNOWLEDGMENTS
We are thankful to all our subjects who participated
with full cooperation and showed voluntary interest
2/7/2013, 8:08 PM
REFERENCES
Susan B. OSullivan, Thomas J. Schmitz, Physical
Rehabilitation: Assessment & treatment, 4 th
Edition: Jaypee Brothers, 2001:519-581
2.
Hom J, Reitan RM. Generalized cognitive function
after stroke. J Clin Exp Neuropsychol. 1990
Oct;12(5):644-654.
3.
Pedersen PM, Jrgensen HS, Nakayama H,
Raaschou HO, Olsen TS..Orientation in the acute
and chronic stroke patient: impact on ADL and
social activities. The Copenhagen Stroke Study.
Arch Phys Med Rehabil. 1996 Apr;77(4):336-339.
4.
Wade DT, Skilbeck C, Hewer RL. Selected cognitive
losses after stroke. Frequency, recovery and
prognostic importance. Int Disabil Stud. 1989 JanMar;11(1):34-39.
5.
Benson C, Lusardi P.Neurologic antecedents to
patient falls. J Neurosci Nurs. 1995 Dec;27(6):
331-337.
6.
Polly Laidler, Stroke Rehabilitation-structure and
stratergy, 1st Edition, 1994: 99-114
7.
Whyte J .Attention and arousal: basic science
aspects. Arch Phys Med Rehabil. 1992
Oct;73(10):940-949.
8.
Susan B. OSullivan, Thomas J. Schmitz, Physical
Edition: Jaypee Brothers, 2001: 961-99
9.
Dascy Umphred, Neurological rehabilitation, 4th
Edition:821-851
10. Schmist R, Motor Control and Learning: A
behavioral emphasis (2nd Edition)Champaing, IL:
Human Kinetic Publisher
11. Nashner LM (1989) Sensory, neuromuscular and
biomechanical contributions to human balance.
In: Proceedings of the American Physical Therapy
Association Forum. Nashville. TN. pp. 5-12.
12. Roberta Newton. Review of tests of standing
balance abilities. Brain Injury 1989; 3(4):335-43
1.
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13. Nashler L: Evaluation of postural stability,

movement and control. In Hasson(ed): Clinical
exercise physiology, Philadelphia, CV Mosby, 1994
14. Lars Nyberg, Yngve Gustafson. Patient Falls in
Stroke Rehabilitation: A Challenge to
Rehabilitation Strategies. Stroke, 1995;26:838-42
15. Susan B. OSullivan, Thomas J. Schmitz, Physical
Edition: Jaypee Brothers, 2001:328-329
16. Medline plus, a service of the us national library
of medicine and the national institute of health,
15th may, 2008
17. Pak R and Dombrovy ML: Stroke. In Good, DC
and
Couch
JR(eds):
Handbook
of
Neurorehabilitation. Marcel Dekker, Newyork,
1994:461
18. Armin F. Haerer. Visual Field Defects and the
Prognosis of Stroke Patients, Stroke 1973; 4:
163-168
19. Sinclair R, A study examining sitting balance and
the presence of attention deficit post-stroke, Msc
Thesis, University of Southampton, UK, 1995.
20. WMA Declaration of Helsinki - Ethical Principles
for Medical Research Involving Human Subjects.
[59th WMA General Assembly Seoul, Korea, Oct
2008]. Available from: http://www.wma.net/en/
30publications/10policies/b3/
21. Sebstina A. Borges, Ona A. Vyas. Study addressing
the impact of cognitive and perceptual deficits on
sitting and standing balance following CVA.
Journal of occupational therapy;33(1):
april- july 2001.
22. Stapleton, T., Ashburn, A. and Stack, E. (2001) A
pilot study of attention deficits, balance control
and falls in the subacute stage following stroke.
Clinical Rehabilitation;15(4):437- 444.
2/7/2013, 8:08 PM
The effects of Therapeutic Application of Heat

or Cold Followed by Static Stretch on Hamstring
Flexibility Post Burn Contracture
Emad T. Ahmed1, Safa S. Abdelkarim2
Assistant Professor of Physical Therapy , Physical Therapy Department for Surgery, Faculty of Physical Therapy, Cairo University, Egypt,
2
Physical Therapist, Naser Hospital, Cairo , Egypt
ABSTRACT
Objective : The purpose of this study was to determine the best warming up modality prior to static
stretching exercises to increase flexibility in post burn contracture of the hamstring muscle, as measured
by knee extension range of motion.
Materials and methods: Thirty male patients ranging in age from 18 to 27 years and who had decreased
hamstring muscle flexibility as a result of partial thickness burn were classified into 3 equal groups 10
of each, Group (1): received 1 minutes of stretching exercise in addition to ultrasound , Group (2):
received 1 minutes of stretching exercise in addition to cold application. And Group (3): received 1
minutes of sating stretching only. All groups received stretching exercises 5 days per week for 8 weeks.
Measurements of knee extension range of motion were conducted before treatment, post 2 weeks of
treatment, and after 4 weeks of treatment.
Results: The one way analysis of variance was used to compare knee extension range of motion which
revealed that both treatment group (ultrasound and cold application) had significant (P< 0.05) gains in
knee extension ROM after 2 and 4 weeks post stretching exercises.
Conclusion: The results of this study suggest that either deep hot or cold application in addition to
stretching exercise is more effective than static stretching alone to improve a hamstring muscle.
Keywords: : Burn, Contracture, Range of motion, Ultrasound, Cold application, Flexibility.
INTRODUCTION
Contractures are defined as an inability to perform
full range of motion of a joint.1 They result from a
combination of possible factors- limb positioning,
duration of immobilization and muscle, soft tissue, and
bony pathology. Individuals with burn injuries are at
risk for developing contractures. Patients with burns
often are immobilized, both globally, as a result of
critical illness in the severely burned, and focally, as a
result of the burn itself because of pain, splinting, and
positioning. Burns, by definition, damage the skin and
also may involve damage to the underlying soft tissue,
muscle, and bone. All of these factors contribute to
contracture formation in burn injury.
Contractures place patients at risk for additional
Emad T.Ahmed
Designations: Faculty of Physical Therapy,
Cairo University, Cairo, Egypt
Address: Taif, KSA, Box: 2425
8. Emad cairo-37-41.pmd
37
medical problems and functional deficits. Contractures

interfere with skin and graft healing. Functionally,
contractures of the lower extremities interfere with
transfers, seating, and ambulation. Contractures of the
upper extremities may affect activities of daily living,
such as grooming, dressing, eating, and bathing, as well
as fine motor tasks.2,3
Ill treatment or inadequate splinting and
rehabilitation after burn injuries inevitably result in
debilitating post burn contractures that impair various
functional abilities of the involved limb. Among these,
hamstring post burn contracture remain a frequent
problem due to difficulties of knee extension against
the contractile evolution of the scar 4.
Historically, clinicians have prescribed different
static stretching techniques as a means of increasing
flexibility 5. Research has shown static stretch to be
effective in increasing the length of connective tissue6.
Warren et al explored the effects of stretching on rat tail
tendon6.They found that low-load, long duration
2/7/2013, 8:08 PM
stretching of rat tail tendon was more effective in

increasing rat tail tendon length than high load, short
duration stretching6. Therapists often use deep heating
modalities to increase tissue extensibility to allow for
increased efficacy of stretching techniques. Wessling et
a1 found that static stretch combined with ultrasound
increased the extensibility of triceps surae muscle
(measured by changes in dorsiflexion) more than static
stretch alone 7. Laboratory studies also indicate that
passive warming of the musculotendinous unit
increases its extensibility 8.9. Noonan et al and Strickler
et al interpreted their research as evidence that passive
warming may decrease the possibility of strain injury
secondary to extensibility changes 8.9.
The basis for using cold in combination with
stretching, like heat, is pain reduction and decreased
muscle guarding. Cold may relieve pain by acting as a
counterirritant10
The purpose of our study was to determine if the
application of a superficial heating or cooling modality,
followed by a 1-minute static stretch to the hamstring
muscle, increases the efficacy of the hamstring stretch
alone.
Subjects material and method
Subjects
Patients treated from burn injuries at El-Hussein
teaching hospital were randomly selected for
participation in this study. This study eligibility
required that patients be more than 18 years of age; 3 to
8 months after the occurrence of the burn injury; had
unilateral scars across popliteal fossa of the knee and
the percentage of burn did not exceed 20%, and had no
history of other lower extremity pathology.
Inclusion assessment to participate in the study,
subjects must have exhibited unilateral tight hamstring
muscles. Operationally defined as having greater than
30 degrees loss of knee extension . In addition, subjects
who were not involved in any exercise activity at the
start of the study had to agree to avoid lower extremity
exercises and activities other than those prescribed by
the research protocol. During the 8 weeks of training 20
male subjects, with age range from 18 to 32 years, met
the established criteria and completed the study.
Group assignment
To ensure equal distribution of hamstring muscle
contracture, the patients were stratified into three
groups based on their degree of hamstring muscle
38
contracture. Patients assigned to group 1 (n=10 patients,

age=23.80 years, and range=60.2) served as treatment
group 1 and received deep heat in addition to static
stretch for 1 minute. Patients assigned to group 2 (n=10
patients, age=24.30 years, and range=60.2) served as
treatment group 2 and received cold in addition to static
stretch for 1 minute. Patients assigned to group 3 (n=10
patients, age=24.30 years, and range=60.2) served as
control group 3 and received stretch only for 1 minute.
INSTRUMENTATION
Measurement tools
A double-arm (30.5 cm) clear plastic goniometer was
used to measure knee extension ROM. Prior to data
collection; we performed a pilot study to establish intratester reliability of measurements of knee extension
ROM. A test-retest design was used on 10 subjects of
similar hamstring contracture, with measurements
taken week a part. Reliability was determined using an
intraclass correlation coefficient. An ICC of 0.96 was
considered appropriate for continuing the study.
Treatment tools
A sonopulse 434 ultrasound unit was used to
administer the deep heat as warming up prior to
stretching, on the other hand, Enraf nonius chilling unit
C5 was used to deliver cold at temperature average from
-12C to - 6C prior to stretch.
Experimental procedure
Measurement protocol
Measurement of knee extension ROM was made
with the subject lying supine with the opposite lower
extremity extended and the lower extremity being
measured positioned at 90 degrees of hip flexion. The
greater trochanter and lateral epicondyle of the femur
and the lateral malleolus were palpated and served as
landmarks during measurement. We attempted to
maintain hip flexion at 90 degrees while the tibia was
moved into the terminal position of knee extension,
which was defined as the point at which the subject
reported feeling of discomfort. Zero degree was
considered to be 90 degrees of knee flexion. The
goniometric value was recorded. The measurement of
knee extension ROM was considered to be an indirect
measure of hamstring muscle flexibility, with hamstring
muscle tightness being the purported cause of a lack of
knee extension ROM. All subjects were measured on
the same day and at the same time, before they had
stretching for that day. Measurements were taken before
2/7/2013, 8:08 PM
treatment, post 2 weeks of treatment and post 4 weeks

of treatment.
Treatment protocol
Ultrasound treatments were performed using an
sonopulse 434 ultrasound unit at a frequency of 1 MHz
with an intensity of 1.5 W/cm2. A water based gel,
maintained at room temperature, was used as a
conducting medium. A template was placed over the
musculotendinous junction of the hamstring muscle
group to ensure that the treatment area remained at
four times the effective radiating area of the transducer
head. The principle investigator performed all
treatments using the same ultrasound unit which had
been recently calibrated. Each US treatment lasted seven
minutes. If subjects complained of intense heat or any
abnormal sensations, treatment was discontinued.
The cold treatment consisted of a -12C gel pack
wrapped in one layer of a wet terry cloth towel applied
to the posterior thigh for 20 minutes. The stretch only
group received no modality. All subjects were in a prone
position for the duration of their treatments. At the end
of 20 minutes, the hot or cold treatments were removed.
All subjects then performed the static stretch to the
hamstrings by the following method. In a long sitting
position, each subject rested the heel of the untreated

lower extremity along the medial surface of the treated
thigh. The subject then reached forward to grasp the
ankle of the treated lower extremity. Each subject then
performed one continuous stretch to pain tolerance,
without bouncing, for 1 minute.
DATA ANALYSIS
The equivalence of treatment groups regarding the
amount of knee flexion contractures prior to the study
was checked by conducting one way analysis of
variance on knee range of motion. Inferential analysis
of the data obtained in this study was done via 2 X 3
analysis of variance experimental design for treatmentsby-treatments by subjects. For all statistical tests and
all follow-up tests, the 0.05 level of probability was used.
RESULTS
The descriptive characteristics of the subjects in both
treatment groups and control group are shown in table
(1) There was no statistical difference between the two
treatment groups and control group regarding the age,
depth of burn, percentage of burn and the duration post
burn.
Table (1): Descriptive characteristics of patients in the three groups .

Comparison
G1
Mean SD
G2
Mean +SD
G3
Mean +SD
P value
Significance
Age in years s
22.8802.064
22.7602.589
23.420 2.669
P>0.05
NS
Depth of burn in millimeters
2.5190.3644
2.4880.3672
2.620 0.5714
P>0.05
NS
Duration post burn in months
4.1250.8345
4.750 1.035
4.3750.9161
P>0.05
NS
% of burn
16.3880.5463
16.3750.9223
16.5501.589
P>0.05
NS
Table (2): Comparison between two treatment groups and control group mean results measured before the
application of any treatment modality.
Comparison
Pre treatment measurement

G1
G2
G1
G3
G2
G3
Mean
60.780
61.620
60.780
62.520
61.620
62.520
SD
2.619
1.844
2.619
1.085
1.844
Sig.
P-value
1.085
NS
NS
NS
P>0.05
P>0.05
P>0.05
S= Significant, HS= Highly significant , NS= not significant
In the first treatment group (ultrasound and

stretching), the mean values for knee extension were
60.7 degrees (SD = 2.619), for the pre-test
measurement, 61.620 degrees (SD = 1.844), for the
second treatment group i.e: cold application and
39
stretching, and 62.520 degrees (SD = 1.085) for

control group i.e: stretching only. One way analysis
of variance demonstrated no statistically significant
difference between the two treatment groups and
control group knee extension range of motion (P>0.05)
table(2).
2/7/2013, 8:08 PM
Table (3): Comparison between two treatment groups and control group mean results measured after 2 weeks of
the application of any treatment modality.
Comparison
Post (1) treatment measurement

G1
G2
G1
G3
G2
G3
Mean
73.450
70.190
73.450
67.380
70.190
67.380
SD
2.061
1.996
2.061
1.248
1.996
Sig.
P-value
1.248
HS
P<0.01
P<0.001
P<0.05

73.450 degrees (SD = 2.061), for the post(1) treatment
stretching, and 67.380 degrees (SD = 1.248) for control
group i.e: stretching only. One way analysis of variance

demonstrated a statistically significant difference
between the two treatment groups and control group
regarding knee extension range of motion (P<0.01)
table(3).
Table (4): Comparison between two treatment groups and control group mean results measured after 2 weeks of
the application of any treatment modality.
Comparison
Post (2) treatment measurement

G1
G2
G1
G3
G2
G3
Mean
93.290
87.960
93.290
84.830
87.960
84.830
SD
2.418
1.435
2.418
1.760
1.435
Sig.
P-value
1.760
HS
P<0.001
P<0.001
P<0.05

93.290 degrees (SD = 2.418), for the post(2) treatment
stretching, and 84.830 degrees (SD = 1.760) for control
group i.e: stretching only. One way analysis of variance
demonstrated a statistically significant difference
between the two treatment groups and control group
regarding knee extension range of motion (P<0.01)
table(4).
DISCUSSION
Our study was designed to obtain a more thorough
understanding of stretching protocols for increasing
ROM and how the use of therapeutic physical agents
can affect these protocols in the clinical setting.
According to the data, in a treatment lasting 4 weeks or
less, cold packs, or ultrasound prior to stretching or
stretching alone achieved similar results in increasing
knee extension ROM.
The results of the current study support the findings
of other studies that static stretching is effective in
increasing hamstring length11,12.
40
The results indicated that either deep heating or

cold application followed by static stretching for one
minute was more effective in increasing knee extension
ROM than static stretching alone for one minute after 3
to 8 months post burn contracture. These results goes
hand in hand with those of Wessling et al13, who
claimed that a significant increase in ankle dorsiflexion
with the use of ultrasound combined with static stretch
compared to static stretch alone.
Ultrasound and other deep heating modalities are
believed to cause collagen to become more extensible,
thus increasing the efficacy of a stretch13,14.Fischer and
Solomon suggest that heating of the skin reduces
gamma motor neuron excitability 15 . This would
decrease the sensitivity of muscle spindles, which may
decrease muscle guarding. On the other hand,
Brodowicz et al16 observed that ice application during
stretching increased hamstring flexibility, whereas heat
and static stretching was not effective.
Cold may reduce muscle guarding by reducing the
activity of the muscle spindles. Knuttsson and Mattsson
suggest that superficial cooling can cause reduction in
gamma motor neuron activity through the stimulation
of skin receptors17. On the other hand , Newton found
2/7/2013, 8:08 PM
the use of vapocoolants, in a spray and stretch

technique, did not increase passive hip flexion in
healthy adults18.
4.
CONCLUSION
5.
All experimental groups in this study produced

increases in the extensibility of the hamstring muscle,
resulting in increases in PROM when compared with
the control group. The group receiving ultrasound prior
to stretching obtained the greatest increases in knee
extension PROM over a 4-week period. This study will
allow clinicians more options in effectively increasing
the extensibility of the hamstring muscles. In addition,
the results of this study will permit the clinician the
choice of a cost-effective treatment alternative in an era
of more stringent reimbursement.
ACKNOWLEDGEMENT
We are indebted to Cairo University, Cairo, Egypt,
Faculty of Physical Therapy, Department of Physical
therapy for Surgery, for their permission to
commencement the study in the El-Hussein Teaching
Hospital / physiotherapy departments and to the
participants.
6.
7.
8.
9.
10.
11.
Conflict of interest
We certify that there is no conflict of interest with
any financial organization regarding the material
discussed in the manuscript.
12.
Source of funding
13.
This research received no specific grant from any

funding agency in the public, commercial, or not / for
profit sectors.
14.
Ethical clearance
We certify that this study involving human subjects
is in accordance with Helsinky declaration of 1975 as
revised in 2000 and that it has been approved by the
relevant ethical committee.
REFERENCES
1.
2.
3.
Mosbys Dictionary. 6th ed. St. Louis: Mosby, Inc.;

2002.
Palmieri TL, Petuskey K, Bagley A, et al. Alterations
in functional movement after axillary burn scar
contracture: a motion analysis study. J Burn Care
Rehabil 2003;24:1048.
Kowalske KJ, Voege JR, Cromes GF Jr., et al. The
relationship between upper extremity
contractures and functional outcome after burn
injury (abstr). Proc Am Burn Assoc 1996;28:55.
41
15.
16.
17.
18.
Nisanci M., Ergin E.R., Selcuk I. & Mustafa S.:

Treatment modalities for post burn axillary
contractures and the versatility of the scapular
flap. Burns, 28: 177-180, 2002.
Stanish WD, Hubley-Kozey CL: Neurophysiology
of stretching. In: D Ambrosia R, Drez D (eds),
Prevention and Treatment of Running Injuries,
Thorofare, NJ: Slack, 1989.
Warren CG, Lehmann JF, Koblanski JN: Elongation
of rat tail tendon: Effect of load and temperature.
Arch Phys Med Rehabil. 52:465-472, 1971.
Wessling D, DeVane D, Hylton C: Effects of static
stretch versus static stretch and ultrasound
combined on triceps surae muscle extensibility in
healthy women. Phys Ther 67:674-679, 1987.
Noonan TI, Best TM, Seaber AV, Garrett WE:
Thermal effects on skeletal muscle tensile behavior.
Am J Sports Med 2 1 :5 17-522, 1993.
Strickler T, Malone T, Garrett WE: The effects of
passive warming on muscle injury. Am J Sports
Med 18:141-145, 1990.
Fruhstorfer H, Hermanns M, Latzke L: The effects
of thermal stimulation on clinical and
experimental itch. Pain 24:259-269, 1986
Gajdosik RL: Effects of static stretching on the
maximal length and resistance to passive stretch
of short hamstring muscles. J Orthop Sports Phys
Ther 14:250-255, 1991.
Henricson AS, Fredriksson K, Persson I ,Pereira
R, Rostedt Y, Westlin N: The effect of heat and
stretching on the range of hip motion. J Orthop
Sports Phys Ther 13:110-115, 1984.
Wessling D, DeVane D, Hylton C: Effects of static
stretch versus static stretch and ultrasound
healthy women. Phys Ther 67:674-679, 1987.
Lehmann JF, Masock AJ, Warren CG, Koblanski J:
Effect of therapeutic temperatures on tendon
extensibility. Arch Phys Med Rehabil51:481-485,
1970.
Fischer E, Solomon S: Physiological responses to
heat and cold. In: Licht S(ed), Therapeutic Heat
and Cold (2nd Ed), pp 126-1 69. Baltimore, MD:
Waverly Press, 1965.
Brodowicz, g.r., r. Welsh, and j. Wallis. Comparison
stretching with ice, stretching with heat, or
stretching alone on hamstring flexibility. J. Athletic
Train. 31(4):324327. 1996.
Knuttsson E, Mattsson I: Effects of local cooling
on monosynaptic reflexes in man. Scand J Rehabil
Med 1 :126-132,1969
Newton RA: Effects of vapocoolants on passive
hip flexion in healthy subjects. Phys Ther 65:
1034 - 1036, 1985.
2/7/2013, 8:08 PM
Pulsed Electromagnetic Therapy Improves Functional

Recovery in Children with Erb's Palsy
Reda Sarhan1, Enas Elsayed2, Eman Samir Fayez2
Physical Therapy Department, Al-Hussien University Hospital, Al-Azhar University, 2Department of Physical Therapy for Neuromuscular
Disorders & Surgery, Faculty of Physical Therapy, Cairo University, Egypt
ABSTRACT
Purpose: The purpose of the study was to evaluate the influence of pulsed electromagnetic field therapy
(PEMFT) on functional recovery in Erb' palsy.
Design: Randomized controlled trial.
Subjects: Thirty patients were included (16 males and 14 females) with age ranged from six to twelve
months (mean=7.31.1).
Methods: Children were divided randomly into two equal groups, control and experimental. Both
groups received a physiotherapy training program; in addition, the study group received PEMFT for 30
min. Treatment regimen was once a day, three times/ week for three months. Measurements of the
affected upper extremity (length, girth and width, muscle strength and range of motion) were carried
out before and after treatment.
Results: There was significant improvement in most of the measured test parameters in the study group
compared to those of the control group.
Conclusion: Pulsed electromagnetic therapy, in conjunction with conventional therapy program, was
effective in improving functional recovery in children with Erb's palsy.
Keywords: Pulsed electromagnetic therapy, Brachial plexus injuries, Erb's palsy.
INTRODUCTION
Obstetric brachial plexus lesions (OBPLs) are
typically caused by traction to the brachial plexus
during labor. The incidence of OBPL is about 2 per 1000
births. Most commonly, the C5 and C6 spinal nerves
are affected. The prognosis is generally considered to
be good, but the percentage of children who have
residual deficits may be as high as 20% to 30%1. The
incidence ranges from 0.38 to 3 per 1000 live births in
industrialized countries. The difference in incidence
may depend on the type of obstetric care and the average
birth weight of infants in different geographic regions
.Improvements in obstetric technique have lowered the
prevalence of obstetrical brachial plexus palsy to the
range of 0.19-2.5 per 1000 2. The incidence of permanent
impairment is 3-25% and the rate of recovery in the first
few weeks is a good indicator of final outcome.
Complete recovery is unlikely if no improvement is
noted in the first two weeks of life 3.The neonatal injury
is clinically classified according to the nerve roots
involved. Injuries affecting the upper plexus(C5,C7
9. Eman-42-46.pmd
42
roots) or so-called Erbs injuries are dominant,

compared to injuries in which the C8eT1 nerve roots
are also affected 4.
Children with BPL are at risk for developing
complications such as progressive contractures, bony
deformities, scoliosis and posterior shoulder
dislocation5. Most infantile injuries to the brachial
plexus predominantly involve the upper trunk (C5,6);
the classic Erbs palsy which results from excessive
lateral traction on the head away from the shoulder.
The infant with upper plexus palsy (C5, 6, 7) keeps the
arm adducted and internally rotated with the elbow
extended, forearm pronated, wrist flexed and the hand
in a fist. In the first hours of life, the hand also may
appear flaccid but strength soon returns 5. Papazian
and associates 6 reported that unfavorable functional
outcome is related more often to aberrant reinnervation
than to lack of reinnervation. Aberrant reinnervation is
especially common in brachial plexus lesions secondary
to the close proximity of the nerves involved.
2/7/2013, 8:08 PM
The application of pulsed electro-magnetic field

therapy (PEMFT) for treating specific medical problems
such as arthritis, chronic pain syndromes, wound
healing, insomnia, headache and others has steadily
increased during the last decade7. Results from basic
science research demonstrated certain biological effects
of PEMFT that provide a rationale for investigating more
potential clinical benefits. Human and animal
organisms consist of a large number of cells which
function electrically .These cells have rest potential that
is necessary for normal cellular metabolism. Diseased
or damaged cells have an altered rest potential. If the
ions move into an area of pulsating magnetic fields,
they will be influenced by the rhythm of the pulsation.
The rest potential of the cell is proportional to the ion
exchange occurring at the cell membrane. The ion
exchange is also responsible for the oxygen utilization
of the cell 8. Pulsating magnetic fields can dramatically
influence the ion exchange at the cellular level and
thereby greatly improve the oxygen utilization of
diseased or damaged tissues. The deterioration of the
oxygen utilization is known to be a problem in several
medical branches, especially delayed healing. There are
no contraindications to magnetic therapy except in
cases of hemorrhage or where electrical implants are in
use. Previous studies indicated that PEMF of proper
frequency, intensity and duration provides beneficial
effects in a wide variety of cellular processes and
mechanisms9. In the field of nervous tissue injuries,
previous studies found positive effects of PEMF therapy.
Byers et al 10 reported that PEMF stimulation enhanced
early regeneration of the transected facial nerve in rats.
AIM OF THE STUDY
The purpose of the study was to evaluate the
effectiveness of PEMF in improving functional recovery
of the affected upper extremity in patients with Erbs
palsy.
MATERIAL AND METHOD
Thirty patients were included (sixteen boys and
fourteen girls) suffering from Erbs palsy. Regarding
the side of injury, there were 19 patients (57%) with
right side and 11patients (33%) with left side. They were
selected from different pediatrics out-patient clinics. The
children were divided into two equal groups (control
and study groups). Inclusion Criteria: All patients were
between six to twelve months in age, asymmetry Erbs
palsy was the sole reason for referral to the physical
therapy out-patient clinic, onset of the injury was from
9. Eman-42-46.pmd
43
birth, all participants were having free passive ROM in

all joints of the affected upper extremity, active
movement score grades ranged from two to four.
Exclusion Criteria: History of malignancy,
inflammatory diseases or any surgical intervention of
the affected upper extremity. Informed consent was
obtained for all patients separately and signed by the
parents of the patients.
EVALUATION
All children participated in one measurement
session before and after the suggested period of
treatment in warm environment with the affected arm
undressed. The affected arm length, forearm and hand
length (cm), arm and forearm girth (cm) were measured
and recorded by means of tape measure. Range of
motion of shoulder abduction and external rotation,
elbow flexion and wrist extension was also evaluated
by using goniometer. The paediatric physiotherapist
facilitated maximal shoulder abduction and external
rotation, elbow flexion, forearm supination and wrist
extension of the affected upper extremity through play,
and quantified them on the active movement scale and
joint movement grading scale.
TREATMENT
The control group was assigned for conventional
physical therapy exercise program consisting of
positioning, facilitatory stimuli, functional
strengthening exercises, passive range of motion
exercises, stretching exercises, scapular mobilization,
manipulative exercises and splinting. The study group
was assigned for PEMF followed by the previously
mentioned physical therapy program. During PEMF
application, the patient was placed in the supine
position and the affected arm was comfortably placed
inside a closed pediatrics circuit coil, using PEMF device
(EL0064 MAGNETO II). The device generated a pure
magnetic field output signal that employed direct
current with unidirectional biological frequencies 20
Hz and intensity 0.3 mT (0.03 mT=30 Gauss). Induction
of treatment took place for 30 minutes. Treatment for
both groups continued for three months, three sessions
per week, each session lasted about one hour.
Data was presented as mean and standard deviation.
Paired t-test was used to analyze the data within each
group and unpaired t- test was used to analyze the
data between study and groups. The p-value was <0.05.
2/7/2013, 8:08 PM
RESULTS
girth in the study group after treatment compared to

that before treatment (p=0.0001, 0.01, 0.01, 0.0001
respectively). Moreover, a significant difference was
shown between the study and control groups after
treatment (table 1).
Upper extremity length and girth

The findings revealed significant increase in mean
values of arm and forearm length, and arm and forearm
Table (1): Comparison between study and control groups regarding upper extremity length and girth mean values
before and after treatment.
Test Parameters(cm)
Pre(MeanSD)
Post(MeanSD)
Control group
Study group
Control group
Study group
16.275.27
15.334.53
-0.4
0.6
16.904.1
21.603.60
2.96
0.001 *
13.43333.28
12.933.19
-0.42
0.7
13.73333.06
17.034.15
2.48
0.02 *
Arm girth
16.302.10
15.552.1
-0.69
0.5
16.703.51
20.706.03
2.22
0.03 *
Forearm girth
14.032.33
13.652.30
-0.47
0.6
14.332.60
19.033.70
4.04
0.0001 *
Arm length
Forearm length
in the study group after treatment compared to that

before treatment (p= 0.001, 0.0001, 0.02, 0.0001 and
0.002 respectively). Additionally, a significant
difference was shown between the study and control
groups after treatment (table 2).
Upper extremity muscle strength

The results showed significant increase in mean
values of strength of deltoid, external rotators, biceps
brachii, supinator, and wrist flexors of the affected arm
Table (2): Comparison between study and control groups regarding upper extremity muscle strength mean values
before and after treatment.
Muscle Strength
Pre(MeanSD)
Post(MeanSD)
Control
Study
Control
Study
Deltoid
3.000.84
3.130.92
-0.33
0.77
3.250.70
4.80.77
-4.05
0.0001 *
External Rotators
2.600.74
2.66670.72
-0.3
0.77
2.870.83
4.66670.70
-3.7
0.0001 *
Biceps Brachii
3.000.93
3.130.91
-0.44
0.66
3.330.72
4.130.1
-2.24
0.04 *
Supinator
2.530.83
2.670.72
-0.45
0.7
2.870.74
4.400.91
-3.83
0.0001 *
Wrist Extensors
3.670.49
3.670.49
-1.5
0.1
3.870.64
4.60.5
-2.94
0.007 *
the study group after treatment compared to those

before treatment (table 3).
Upper extremity active ROM

There was significant improvement in the mean
values of active ROM of the affected upper extremity in
Table (3): Comparison between mean values of active range of motion before and after treatment in the
study and control groups
ROM
(degrees)
Shoulder
abduction
Shoulder external
rotation
Elbow
flexion
Forearm
supination
Wrist
extension
Post
Pre
Post
Pre
Post
Pre
Post
Pre
Post
Pre
0.68 0.34
1.27 0.88
0.680.34
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 0.19
9.54
8.80
-8.80
-9.28
-2.62
0.06
0.16
0.7
0.3
0.002
DISCUSSION
Obstetric brachial plexus palsy (OBPP) is a
complication of childbirth, which is characterized by
one or more nerve conduction blocks within the brachial
plexus . These blocks range in severity and location
within the plexus and primarily affect the childs ability
9. Eman-42-46.pmd
44
to move and effectively use their affected upper

extremity 5.
Thirty children with OBPP participated in the study.
All were able to perform elbow and shoulder
movements with gravity eliminated. Most of those
children presented to the out-patient clinics with slightly
2/7/2013, 8:08 PM
different degrees of injury and respond differently to

therapeutic interventions. Experience in treating
children teaches that children who present at six
months of age with no signs of recovery generally are
subjected to development of sequelae, including mild
scapular winging, inability to fully supinate the
forearm, limitation in shoulder abduction and forward
flexion. In the current study, there was no need for
electrophysiological monitoring or guide as muscle
strength can be considered as an indicator for prognosis
and recovery. This is supported by Yilmaz and
coworkers 11 who compared magnetic resonance
imaging (MRI), electrophysiologic studies, and muscle
strength scoring in infants with BPP to determine
which indicator provided the most accurate prognosis
of the outcome at one year. They found that scoring of
muscle strength (eg, elbow flexion; wrist, finger, and
thumb extension) was the most reliable measure, with
94.8% confidence at 3 months.
There have been few reports about the effect of PEMF
therapy on muscle strength and functional activities in
children with brachial plexus injuries (Erbs palsy). The
results of the present study showed clearly the beneficial
effects of PEMFT on improving muscle strength, range
of motion and functional activities of the affected upper
limb. These findings coincide with that of Zborowski et
al12 who evaluated the effects of a low frequency
electromagnetic field on fast axonal transport changes
in speeds and densities of retrograde fast organelle
transport in the rat sciatic nerve. Preparations were
measured in vitro upon exposure to 15 and 50 Hz pulsed
magnetic fields with peak intensities of 4.4 and 8.8 mT.
They reported that strong effects were observed in
myelinated axons. Such effects may eventually be used
as part of a neuroprosthesis to noninvasively modify
or couple to various parts of the nervous system. These
findings also, are supported by Sharrard et al14who
concluded that pulsed electromagnetic fields have
encouraged healing of fractured bones and benefited
re-anastomosis of peripheral nerves after transection.
Many mechanisms could explain the improvement
in children with Erbs palsy as biological stimulation
by PEMF exposures can modify cellular functions in
bone and nervous tissue, and evidence is accumulating
that the regeneration capacity of the tissue may be
affected6. For example, selective changes in levels of
calcium , cyclic adenosine monophosphate, the
synthesis of collagen and proteoglycans, DNA, and
RNAhave been demonstrated in osseous, nervous, and
mesenchymal tissue 12,13,15,16,17,18.
9. Eman-42-46.pmd
45
CONCLUSION
The results of the present study showed that the
main advantages of PEMFT are the enhancement and
acceleration of the recovery of injured nerve tissue. Also,
it indicates that PEMFT is a low-cost, non-invasive, non
thermal method of physical therapy modalities and
should be recognized as standard additional treatment
for improving the functional recovery in patients with
Erbs palsy.
ACKNOWLEDGMENT
The invaluable assistance of the paediatric physical
therapists in the out patients clinics to the study are
much appreciated
REFERENCES
1.
Martin TA and obestetric brachial plexus

injuries.Neurosurg clin N Am.2009; 20, 1:14.
2.
3-Pollack RN, et al. Obstetrical brachial palsy:
pathogenesis, risk factors, and prevention. Clin
Obstet Gynecol 2000;43:236-46.
3.
Gilbert WM, Nesbitt TS, Danielsen B. Associated
factors in 1611 cases of brachial plexus injury.
Obstet Gynecol. 1999; 93(4):536-40.
4.
Else Spaargaren et al , Aspects of activities and
participation of 7-8 year- old children with an
obstetric brachial plexus injury ,European journal
of pediatric neurology.2011; 1 5, 345-352.
5.
Alphonso DT . Causes of Neonatal Brachial
Plexus Palsy. Bull NYU Hosp Jt Dis. 2011;69:
11-16
6.
Papazian O, Alfonso I, Yaylali I, Velez I, Jayakar P.
Neurophysiological evaluation of children with
traumatic radiculopathy, plexopathy, and
peripheral neuropathy. Semin Pediatr Neurol.
2000; 7(1):26-35.
7.
Marko S. Expanding Use of Pulsed
Electromagnetic Field Therapies. Electromagn Biol
Med. 2007; 26: 257-274
8.
M. Cifra et al. Electromagnetic cellular interactions.
Progress in Biophysics and Molecular Biology ,
2011;105 : 223-246
9.
R. Lightwood. The remedial electromagnetic field.
J. Biomed. Eng. 1989, 1 I:429-436.
10. Byers J, Clark K, Thompson G. Effect of pulsed
electromagnetic stimulation on facial nerve
regeneration. Arch Otolaryngol Head Neck Surg.
1998;124(4):383-9.
11. Yilmaz K, Caliskan M, Oge E, Aydinli N, Tunaci
M, Ozmen M. Clinical assessment, MRI, and
EMG in congenital brachial plexus palsy. Pediatr
Neurol. 1999; 21(4):705-10.
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12. Zborowski M , Atkinson M , Lewandowski JJ ,

Jacobs G , Mitchell D , Breuer A, Nos Y. In vitro
low frequency electromagnetic field effect on fast
axonal transport. ASAIO Trans. 1988 JulSep;34(3):669-7.
13. Bassett CA, Chokshi HR, Hernandez E, Pawluk
RJ, Strop M. The effect of pulsing electromagnetic
fields on cellular calcium and calcification of nonunions. Brighton GT, Black J, Pollack SR. eds.
Electrical Properties of Bone and Cartilage:
Experimental Effects and Clinical Applications
New York, NY Grune & Stratton Inc1979;427.
14. Sharrard WJ, Sutcliffe ML, Robson MJ,
MacEachern AG. The treatment of fibrous nonunion fractures by pulsing electromagnetic
stimulation. J Bone Joint Surg Br. 1982;64:
189-193.
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15. +Fitton-Jackson S, Bassett CA. The response of

skeletal tissues to pulsed magnetic fields.
Richards RJ, Rajan KT.eds. Tissue Culture in
Medical Research (International Symposium on
Tissue Culture in Medical Research) .New York,
NY Pergamon Press Inc1980; 21.
16. Eugene M.Goodman et al. Effects of
Electromagnetic Fields on molecules and cells,
International review of cytology.1995; I58:279-338.
17. Fitton-Jackson S, Farndale R. The influence of
pulsed magnetic fields on skeletal tissue grown
in organ culture. Trans Orthop Res Soc.
1981;6300+
18. Shteyer
A,
Norton
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Rodan
GA. Electromagnetically induced DNA
synthesis in calvaria cells. J Dent Res.
1980;59A:362.
2/7/2013, 8:08 PM
Effectiveness of PNF Stretching and Self Stretching in

Patients with Adhesive Capsulitis - A Comparative Study
Harshit Mehta1, Paras Joshi2, Hardik Trambadia3
Physiotherapist, Samarpan Orthopedic Hospital, Jamnagar, 2Lecturer, K K Sheth College of Physiotherapy,
3
Lecturer, Parul Institute of Physiotherapy, Vadodara
ABSTRACT
Background: Adhesive capsulitis of shoulder is characterized by insidious and progressive pain and
loss of active and passive mobility of glenohumeral joint. In many physical therapy programs for
subjects with adhesive capsulitis of shoulder mobilization techniques are an important part of the
intervention. The purpose of this study is to compare the efficacy of PNF stretching techniques and Self
stretching techniques in subjects with adhesive capsulitis.
Objective: To compare the effectiveness of PNF stretching and self stretching in improving ROM,
shoulder pain & disability index in patients with adhesive capsulitis.
Method: 30 subjects diagnosed by an orthopedic surgeon as having adhesive capsulitis of shoulder
joint and who showed a typical restriction of external rotation and abduction were selected. Subjects
were randomly taken, divided into two groups each of 15 subjects. Group A: (n=15):- Treated with PNF
stretching. Group B: (n=15):- Treated with self stretching. Analysis was based on ROM and Shoulder
Pain and Disability Index (SPADI) sub scores and total scores.
Outcome measures: The following outcome measures were measured at baseline, 2nd week and 4th
week follow up.
1. Active ROM of shoulder External rotation and Abduction.
2. Shoulder pain and disability index (SPADI).
Results: The ROM and SPADI percentage across baseline, 2nd week and 4th week follow up showed a
significant improvement statistically in their mean scores within Group A and Group B. Statistically
significant greater changes in score were found in PNF Stretching (Group A) for ROM and SPADI as
compared to Self Stretching (Group B).
Conclusion: The results indicate that PNF Stretching (Group A) and Self Stretching (Group B) are
significantly effective in improving ROM and SPADI (sub scores and total scores).
However PNF Stretching (Group A) appears to be more effective in improving glenohumeral joint
mobility and reducing disability as compared to Self Stretching (Group B).
Keywords: Adhesive Capsulitis, PNF Stretching, self stretching, SPADI.
INTRODUCTION
ADHESIVE CAPSULITIS is a common but poorly
understood syndrome of painful shoulder stiffness.1 It
is most common cause of pain & disability in shoulder
in general population.2 Frozen shoulder syndrome was
first describe by Duply in 1872. He used the term periarthritis scapula-humerale. In 1934 Codman used the
term FROZEN SHOULDER first time to describe the
condition.1 In 1945, Nevieser termed condition as
ADHESIVE CAPSULITIS based on surgically
10. hardik 16th april--47-51.pmd
47
explored cases of frozen shoulder finding absence of

the glenohumeral synovial fluid as well as thickening
& contraction of capsule which had become adherent
to humeral head.3 The prevalence of frozen shoulder is
2% to 3% of general population it starts between age of
40- 70 years. It is more commonly seen in females than
males.2
Currently adhesive capsulitis & frozen shoulder are
the preferred terms and can be used interchangeably.4
Adhesive capsulitis has typically been classified into 2
2/7/2013, 8:08 PM
forms, primary & secondary. In the primary form, no

known precipitating factors can be identified, so it is
also known as idiopathic type. The secondary form is
associated with other illness or events such as some
trauma or surgery.4
3. To compare the effectiveness of PNF stretching and

self stretching in improving ROM, shoulder pain &
disability index in patients with adhesive
capsulitis.
HYPOTHESIS
The classic frozen shoulder has 3 stages

Stage 1: Painful stage or Freezing phase (Lasts for 2 to 9
months) 2, 6
Stage 2: Stiffness or Frozen phase (Lasts for 4 to 12
months) 2, 6
Stage 3: Thawing phase (Lasts for 6 to 9 months) 2, 6
Stage 1:- The freezing or painful stage, in which
the patient has diffuse lateral shoulder pain begins
gradually and insidiously. Pain is the main initial
complaint. The pain is worse at night & exacerbated by
lying on the affected side, is often associated with
significant disability.2
Stage 2:- The stiff or frozen stage, in which
stiffness with decreased range of motion predominates.
Pain, though still present with extreme movement,
subsides and loss of movement becomes the patients
chief complaint. Ability to care for oneself and to work
might be significantly affected, especially if the patients
dominant arm is involved.2
Stage 3:- The thawing stage during which,
exacerbations of pain still occur, often because of
excessive activity. Gradually pain subsides and
movement becomes almost normal.
Five methods developed to improve flexibility have
emerged: ballistic stretching, static stretching,
proprioceptive neuromuscular facilitation stretching
techniques (PNF), dynamic range of motion using active
contraction and eccentric training.14
Null Hypothesis (H0)

There is no significant difference between the
effectiveness of PNF stretching and self stretching in
improving ROM, shoulder pain and disability index in
patients with adhesive capsulitis.
Alternate Hypothesis (H1)
There is a significant difference between the
effectiveness of PNF stretching and self stretching in
improving ROM, shoulder pain and disability index in
patients with adhesive capsulitis.
METHODOLOGY
Study design: Experimental study.
Inclusion criteria
Symptomatic subjects between the age group of 4060 (both male and female).
Subjects having stiff and painful shoulder for more

than 1 month.
Minimum 50 % of restriction in abduction and

external rotation of shoulder joint.
Unilateral involvement and stage 2 adhesive

capsulitis.
Exclusion criteria
History of recent shoulder trauma in and around

shoulder joint.
Rotator cuff injuries or previous surgery
OBJECTIVES OF THE STUDY
1. To study the effectiveness of PNF stretching in

improving ROM, shoulder pain and disability
index in patients with adhesive capsulitis.
Intrinsic glenohumeral pathology such as

glenohumeral arthritis.
Diabetic patients.
2. To study the effectiveness of self stretching in

improving ROM, shoulder pain & disability index
in patients with adhesive capsulitis.
48
Tools used for the study:
Universal Goniometer
Shoulder pain and disability index
2/7/2013, 8:08 PM
Method of data collection

The patients were evaluated using shoulder
evaluation form. The patients were informed about the
whole procedure, the treatment merits and demerits and
a written consent were obtained from them for voluntary
participation in the study. They were randomly divided
in two Group A and Group B of 15 subjects each. The
base line data of ROM of all the movements of shoulder
was obtained using universal goniometer. The pain and
disability data were obtained using SPADI to check for
the functional outcome. The ROM and SPADI were
taken at the baseline, after 2 weeks of the treatment and
after 4 weeks on follow up.
Study Duration: 4 weeks.
Same procedure is done to improve shoulder

abduction. In this patient is in sitting position and
therapist stands at the back of the patient on the affected
side.
Duration : It is given once in a day for 5 days in a
week for 4 weeks.
Group B: Self stretching.
Starting position: Patient is in standing position.
Subjects is asked to place the upper extremity on a
firm surface at 90 of forward elevation and greater than
90 of horizontal abduction while turning the trunk in
the opposite direction to improve the external rotation.
Subjects is asked to pull the elbow overhead with
the opposite arm to improve the abduction
Techniques of application
Group A: PNF stretching.
Starting position: Patient is in sitting position and
therapist in sitting at the side of the patient.
(PNF stretching) Therapist will passively move the
shoulder joint in external rotation until the stretch begin
to feel uncomfortable to the subject. Then subjects
will be asked to perform a maximal isometric contraction
for 6 seconds followed by 10 seconds of relaxation.
During the 10 seconds of relaxation a tester slowly
externally rotates the subjects shoulder joint, if the
subjects still consider the stretch to be uncomfortable; it
is kept as previous position.
The subjects then perform 2 more 6 seconds maximal
contraction (total 3 contractions) with 10 second
relaxation period in between.
Duration : The stretching is given 3 times for 30

seconds and 10 second relaxation between 2 stretch 5
days in a week for 4 weeks.
Both the groups were given short-wave diathermy

before stretching procedure at the therapeutic
frequency of 27.12 MHz for 10 to 15 min.13
Post hoc analysis (Bonferroni test) is used to

compare the baseline, 15th day and 30th day scores
of ROM and SPADI within Group A and Group B.
Two way ANOVA test is used to compare the mean

difference across the time periods (Baseline, 15th day
and 30th day) between Group A and Group B.
P value < 0.05 is taken up for statistical significance.
RESULTS
Table 1:-Multiple comparisons of ACTIVE EXTERNAL ROTATION scores across different periods within Group A
and within Group B using post hoc analysis- Bonferroni test.
AER in Group A
Period
Periods
Mean
Std. Error
p-value
Level of significance
Baseline
2nd wk
-21.667
2.065
.000
HS at p < 0.01
HS at p < 0.01
th
AER inGroup B
4 wk
-31.733
1.850
.000
2nd week
4th wk
-10.067
.658
.000
HS at p < 0.01
Baseline
2nd wk
-14.400
2.908
.001
HS at p < 0.01
4th wk
-21.800
2.694
.000
HS at p < 0.01
4th wk
-7.400
.466
.000
HS at p < 0.01
nd
49
week
2/7/2013, 8:08 PM
Table 2:- Multiple comparisons of ACTIVE ABDUCTION scores across different periods within Group A and
within Group B using post hoc analysis- Bonferroni test.
Period
AAB inGroup A
Baseline
2nd week
AAB inGroup B
Baseline
2nd week
Periods
nd
Mean
Std. Error
p-value
wk
-38.200
3.151
.000
HS at p < 0.01
4th wk
-48.533
2.862
.000
HS at p < 0.01
4th wk
-10.333
.779
.000
HS at P < 0.01
nd
wk
-23.000
2.556
.000
HS at p < 0.01
4th wk
-31.600
2.124
.000
HS at p < 0.01
4th wk
-8.600
1.125
.000
HS at p < 0.01
Table 3:- Multiple comparisons of Total SPADI scores across different periods within Group A and within Group B
using post hoc analysis- Bonferroni test.
Period
Total SPADI in Group A
Baseline
Total SPADI in Group B
Periods
nd
Mean
wk
46.800
2.387
.000
HS at p < 0.01
4th wk
50.067
2.566
.000
HS at p < 0.01
4th wk
3.267
.330
.000
HS at P < 0.01
Baseline
2nd wk
37.867
1.612
.000
HS at p < 0.01
4th wk
40.000
1.721
.000
HS at p < 0.01
4th wk
2.133
.291
.000
HS at p < 0.01
week
From the above Table 1, 2 & 3 multiple comparison

of active external rotation, active abduction and total
SPADI scores shows that difference is statistically
significant from baseline to 2nd week and 2nd week to 4th
week, but the difference from baseline to 2nd week and
2nd week to 4th week is significantly higher in group A
than group B
DISCUSSION
Primary adhesive capsulitis affects 2% to 3% of the
general population and is the main cause of shoulder
pain and dysfunction in individuals aged 40 to 70
years. The etiology and pathology of this syndrome
remains enigmatic. The physical therapy is commonly
prescribed for this condition. For predominant adhesive
capsulitis and associated soft tissue tightness,
mobilizations techniques, PNF stretching techniques
have been most commonly address in clinical treatment
approaches and research studies.
The result of present study examined the efficacy of
PNF stretching to self stretching in subjects with
adhesive capsulitis both within groups and between
groups. 30 subjects are taken who were diagnosed as
adhesive capsulitis of shoulder by orthopedic and were
normally assigned to either PNF stretching (Group A)
or Self stretching (Group B).
PNF stretching utilizing a shortening contraction
of the opposing muscle to the place the target muscle
on stretch, followed by a static contraction of the target
muscle, The inclusion of a shortening contraction of
50
p-value
2nd week
nd
Std. Error
the opposing muscle appears to have the greatest impact

on enhancing ROM.17 Some researchers have found
that the alteration of stretch perception plays a
important role in success of contract relax PNF
stretching and contract relax stretch are recommended
to get greatest ROM gain.7
PNF stretching and soft tissue mobilization is the
application of specific and progressive forces with the
intent of promoting changes in the myofascia, allowing
for elongation of shortened structures. PNF stretching
combined with soft tissue mobilization and both are
used to effect changes in myofascial length. Contract
relax PNF procedures have been shown to be effective
in increasing ROM. The immediate effects of PNF
stretching and soft tissue mobilization interventions
were demonstrated in a another study using healthy
subjects, where improvements were made in hip ROM.8
One study done on overhand athletes for the effects
of proprioceptive neuromuscular facilitation shows that
Contract relax and hold relax PNF stretching
techniques are effective in increasing ROM in overhand
athletes.9
Stretching import physiological changes such as
remodeling of elastin and collagen molecules, these
changes may be associated with alterations on the
muscle tendon units and fascia, caused by increase on
tissue elasticity. In other words, the range of motion
would be influenced by the increase on the length of
the tissue.10
2/7/2013, 8:08 PM
In one study researchers have concluded that PNF

stretching produce more tension in muscle and also
provide greatest potential for muscle lengthening than
static stretching. In another study researchers have
concluded that PNF stretching shows greater ROM
gains than static stretching.11
In one study researchers concluded that 30 seconds
static stretch was more effective then dynamic ROM
training for improving ROM. Given the fact that 30
seconds static stretch increase ROM more than 2 times
that of dynamic ROM training.12
4.
5.
6.
7.
Limitations
1. In present study only 2 ROM (External Rotation
and Abduction) are taken in outcome measures.
2. In this study there is no control group is present.
8.
3. Its a short duration study as study duration is 4

weeks.
4. In the present study the sample size is 30 that are
small.
CONCLUSION
1.
2.
3.
PNF Stretching and Self stretching produced

significant improvement in ROM and shoulder
Pain and Disability (SPADI Sub scores and Total
scores) values in patients with adhesive capsulitis
when applied individually. However PNF
Stretching showed a significant improvement in
ROM and shoulder Pain and Disability Index
(SPADI sub scores and total scores), when compared
to Self Stretching in individuals with adhesive
capsulitis.
REFERENCES
Giggs SM, Ahm A and Green A. Idiopathic
Adhesive Capsulitis. A Prospective Functional
Out Come, Study of non operative Treatment. J
Bone Joint Surg, Vol. 82, Oct-2000, 1398-1407.
H.A. Anton. Frozen Shoulder. Can Fam Physician
1993;39:1773-1777.
R.A Donatelli, Physical Therapy of the Shoulder,
3rd edition, CHARCHILL LIVINGSTONE. Pp
257- 278.
51
9.
10.
11.
12.
13.
14.
Rick Sandor. Adhesive Capsulitis; Optimal

Treatment Of Frozen Shoulder. THE
PHYSICIAN AND SPORTSMEDICINE, Vol.28,
No.9, SEP-200.
Henricus M Vermeulen, Wim R Obermann, Bart J
Burger, Gea J Kok, Piet M Rozing, CorneliaHMvan
den Ende. End- Range Mobilization techniques
in Adhesive Capsulitis of the Shoulder joint: A
Multiple- Subject Case Report.
S.B.Brotzman, K.E.Wilk, Clinical Orthopaedic
Rehabilitation, 2nd edition, Shoulder Injuries, page
125-250.
Mitchell UH, Myrer JW, Hopkins JT, Hunter I,
Feland JB, Hilton SC acute stretch perception
alteration contributes to the success of the PNF
contract-relax stretch. J Sports Rehab. May 2007;
16(2):85-92.
Godges JJ, Matson-Bell M ,Thorpe D; Shah D, The
immediate effect of soft tissue mobilization with
PNF on gleno humeral external rotation &
overhead reach; J Orthop Sports Phys Ther, Dec
2003; 33 (12) : 713-718.
Decico PV, Fisher MM, The effects of PNF stretching
on shoulder ROM in overhead athletes. J Sports
Med Phy Fitness, Jun 2005; 45(2):183-187.
Lus Viveiros, Marcos Doederlein Polito, Roberto
Simo and Paulo Farinatti Immediate and late
responses of flexibility in the shoulder extension
in relation to the number of series and stretching
duration. Rev Bras Med Esporte. Nov/Dec 2004;
Vol 10, N 6:464-467.
Funk DC, Swank AM, Mikla BM, Fagan TA, Farr
BK. Impact of prior exercise on hamstring
flexibility: a comparison of proprioceptive
neuromuscular facilitation and static stretching. J
Strength Cond Res. 2003 Aug; 17(3):489-92.
Bandy WD, Irion JM, Briggler M. The effect of time
and frequency of static stretching on flexibility of
the hamstring muscles. Phys Thera. 1998 Mar;
78(3):321-2.
Leung MS, Cheing GL. Effects of deep and
superficial heating in the management of frozen
shoulder. J. Rehabil Med. 2008 Feb; 40(2):145-50.
Murphy DR.A critical looks at static stretching;
are we doing our patient harm? Chriopract sport
med, 1991; 5:67-70.
2/7/2013, 8:08 PM
Effect of Modified Hold-Relax and Active Warm-Up

on Hamstring Flexibility
Swapnil U Ramteke1, Hashim Ahmed2,Virenderpal Singh3, Piyush Singh4
Research Student, Jamia Hamdard, New Delhi, 2Head department of Physiotherapy, Shreya Hospital, Shalimar Garden Extension,
Ghaziabad, U.P, 3Head of Department of Physiotherapy, Mata Gujri Charitable Hospital, New Delhi , 3Assistant Profesor, Indian Spinal
Injury Center of Rehabilitation, New Delhi
ABSTRACT
Objective: The study aimed to find out how long the flexibility lasted after a one time modified hold
relax stretching & active warm up and its comparison with modified hold relax technique alone.
Design: Pre-test, Post-test comparative study with repeated measures.
Setting: Mata Gujri Fitness center, Kailash colony, New Delhi.
Method: 30 male subjects were randomly assigned to two groups; Group A- Modified Hold Relax: On
the 15 subjects a one time modified hold-relax stretching was performed.
Group B: 15 male subjects completed an active warm up on treadmill followed by modified hold relax
stretching. The pre stretch measurement was taken by Active Knee Extension (AKE) test. After both the
interventions the post stretch measurements were taken at following intervals, 0, 6, 12, 18, 24 min,
respectively.
Results: A significant improvement in ROM was observed when post stretch measurements were
compared to pre test in both groups respectively. However, the flexibility lasted for longer duration that
is 12 min in group B when compared to group A that is 6 min.
Conclusion: Both the methods are equally effective to improve the range of motion. But the improved
ranges can be maintained for larger duration when active warm up was implemented prior to Modified
hold relax stretching.
Keywords: P.N.F, Active Warm up, AKE, Flexibility,
INTRODUCTION
Flexibility is an essential component for normal
biomechanical functioning in sports. The length of the
muscle tissue is thought to play an important role in
efficacy and effectiveness of human movement. 1
Theoretically, a more flexible muscle-tendon unit should
be more compliant to external loads, less stiff, and less
likely to be injured.2 In sports even small change in
performance can have a drastic effect on the outcome of
an event.
Besides hamstrings strains in the athletic
population, hamstrings tightness as shown in some
studies have shown that reduced hamstring flexibility
is considered to be one of the leading cause/risk factor
for patellar tendinopathy and patellofemoral pain etc..3
In the ACSMs guidelines,a clinical evidence for
11. hashim 4th may--52-57.pmd
52
relationship between hamstring inflexibility with

avulsion fractures of ischial tuberosity ,muscle strain,
low back ache and increased sway back or round back
posture has been mentioned. 4 Proprioceptive
neuromuscular Facilitation (PNF) exercises are
designed to promote the neuromuscular response of
the proprioceptors.There exists a limited data regarding
the lasting effects of increased ROM post stretching.
The duration of increased flexibility in the previous
research conducted by De pino et al, after one time
static stretching was found to be of 3 minutes, further
Spernoga et al carried out similar study in which, after
one time modified hold relax lasting effects remained
for 6 minutes, but this is a very short span of time, till
date limited studies have carried out to improve the
lasting effects. 5, 6. Hamstring flexibility has been
measured by active knee extension test, passive knee
2/7/2013, 8:08 PM
extension test, the sit and reach test and the assessment
of hip flexion. Range following the straight leg raise,
however reliability of these methods has not been
demonstrated. An active knee extension test is however
a reliable method for assessment of hamstrings.7 Warm
up consists of active or passive warming of body tissues
in preparation of physical activity. 8. There is a wide
spread belief that a warm up contributes to improved
athletic performance.9 Active warm up involves exercise
and is likely to induce greater metabolic and
cardiovascular changes than passive warm up.10 To our
knowledge no specifically warm up oriented studies
with regards to modified P.N.F hold relax technique
has been carried out to assess the lasting effects after a
specific warm up intensity.
Thus present study aimed to extract the information
that for how much duration the flexibility would be
retained after a warm up and modified hold relax
technique. In many clinical situations, patients may be
seen by practitioners once or twice a week, or even less
commonly in non-acute situations. It is therefore
important to examine whether modified hold relax
stretching produce either a greater or longer lasting effect
on range of motion. The objective of this study was to
investigate whether the application of a single session
of modified hold relax was more effective, and has
longer lasting effect, than a single session of modified
hold relax stretching with warm up on the extensibility
of the hamstring muscles measured by AKE over 6
different time interval (pre-treatment, immediately, 6,
12, 18 and 24 minutes) using goniometer.
METHOD
at 0 minutes (immediately) and at 6, 12, 18, and 24

minutes after the final stretch in the group A The group
B underwent the same post stretch measurement
protocol immediately after performing warm up on a
treadmill for 5 minutes followed by stretching. The
measurement of the angle of knee joint ROM was
recorded .The deficit (tightness) was calculated by
subtracting the available range from the full range.5
For each stretch, the investigator passively stretched
the hamstrings until the subject first reported a mild
stretch sensation and that position was held for 7
seconds. Next, the subjects were asked to perform
maximal isometric contractions of the hamstrings for
7 seconds by attempting to push their leg back
toward the table against the resistance of the
investigator.5 after the contraction, the subjects were
instructed to relax for 5 seconds. The investigator then
passively stretched the muscle until a mild stretch
sensation was reported. The stretch was held for
another 7 seconds. This sequence was repeated 5 times
on each subject in these experimental groups.5
Group B- Active Warm up and Modified hold Relax
Maximal heart rate was calculated by the formula,
M.H.R=220-age.
The difference between maximum heart rate and
resting heart rate is known as heart rate reserve(HRR).
Target heart rate = (HRR fraction) (HR max HR at rest)
+HR rest .The intensity fraction of HRR was selected at
60 %. As per the ACSMs position stand this percentage
represents lower intensity values enough to produce
the adequate training effects for cardio respiratory
fitness of warm up. 11.
The 30 subjects were randomly allotted to Two

groups viz group A- Modified hold relax ,& Group B
active warm up and modified hold relax.
STUDY DESIGN
Pre test post test design with comparison in the two
groups with repeated measures.
Instrumentation Goniometer, Treadmill (Sports Art
Fitness), Stop watch.
Procedure In prestretch measurements, subjects in
both the groups performed a total of 6 AKEs with a 60second rest period between repetitions. The sixth AKE
was recorded as the prestretch measurement. For Post
stretch Measurement : AKE measurement were taken
53
Fig.1: The Modified hold relax stretching technique.
2/7/2013, 8:08 PM
Subject characteristics
The subjects had following characteristics as mean
and standard deviations values:
Group A (Age = 23.00 1.73) (Height=166.40, 5.72)
(Weight= 62.80 6.75)(BMI= 22.672.16)
GroupB (Age = 22.601.29) (Height=161.86, 9.69)(
Weight= 61.60 6.21)(BMI= 23.313.49)
Table 1.Active Knee Extension Measurements in Group
A and Group B
Time intvl
Group A
Group B
Mean
s.d
Mean
s.d
Prestretch
39.26
3.76
38.66
4.23
31.13
3.75
28.73
3.86
33.20
3.87
31.20
3.74
12
36.06
3.36
34.20
4.34
18
36.93
3.80
35.60
4.11
24
38.13
3.48
37.46
4.65
Fig. 2: The subject performing active warm up on the treadmill

under the supervision.
DATA ANALYSIS
The alpha level of pd 0.05 was accepted as
significant for all analyses. Mean values and their
standard deviations were calculated for each variable.
The one way ANOVA (analysis of variance) was carried
for both the groups to compare the ROM within each
groups to pre stretch measurements. A t-test was
performed to compare ROM within both the groups.
The data was further analyzed by Dunnets post hoc
test.
Figure.3: Comparison between pre-test and post-test value of

range of motion between the groups.
Table.2: Between Group Comparison of Range of

Motion using t and p values
Time period
t-test for Equality

of Means
RESULTS
The ONE way analysis of variance revealed a
significant difference between pretest and post test ROM
measurements within groups respectively. However a
Dunnets post hoc analysis indicated that a significant
(p<0.05) increase in hamstring flexibility was
maintained in modified hold relax group for 6 min after
stretching protocol. Similarly increase in hamstring
flexibility was maintained in Active warm up &
Modified hold relax group for upto 12 min.
54
p-value
Pre Test
0.41
0.68
0 min
1.72
0.09
6 min
1.43
0.16
12 min
1.31
0.19
18 min
0.92
0.36
24 min
0.44
0.66
The subjects had following characteristics as mean

and standard deviations values:
2/7/2013, 8:08 PM
Group A (Age = 23.00 1.73) (Height=166.40, 5.72)

(Weight= 62.80 6.75)(BMI= 22.672.16)
GroupB (Age = 22.601.29) (Height=161.86, 9.69)(
Weight= 61.60 6.21)(BMI= 23.313.49)
Table.3: Dunnett Post hoc analysis for comparing
group B
Post
Treatment
Pre
treatment
Mean
Difference (I-J)
pvalue
0 min
Pre treatment
-9.93
0.000
6 min
Pre treatment
-7.46
0.000
12 min
Pre treatment
-4.46
0.019
18 min
Pre treatment
-3.06
0.172
24 min
Pre treatment
-1.20
0.896
DISCUSSION
Various studies have been conducted in the past to
assess the effects of various interventions on improving
hamstrings flexibility. However limited studies have
been performed which evaluated the lasting effects.5,6,12
These recently conducted studies on checking acute
effects of stretching revealed that the flexibility would
last for 3 min after static stretching & for upto 6 min
after one time modified hold relax stretching. These
lasting effecs were present for very less duration.
The relatively short time of increased hamstring
flexibility may be due to several factors The most
prominent are the viscoelastic, thixotropic, and neural
properties of the musculotendinous unit.
Neural properties
The proposed neural inhibition reduces reflex
activity, which then promotes greater relaxation and
decreases resistance to stretch, and hence greater range
of movement 13 moreover, other research has found PNF
techniques to promote greater relaxation.14
Viscoelastic properties
Previous researchers have attempted to explain
improvements in flexibility with viscoelastic properties,
overcoming the stretch reflex, or increasing the stretch
tolerance23. Musculotendinous units function in a
viscoelastic manner, and, therefore, have the properties
of creep and stress relaxation. Creep is characterized
by the lengthening of muscle tissue due to an applied
fixed load. Stress relaxation is characterized by the
decrease in force over time necessary to hold a tissue at
a particular length.
55
The musculotendinous unit deforms or lengthens

as it is being stretched and goes through elastic and
then plastic deformation before completely rupturing.
Our results suggest that a single session of hold-relax
stretching does not deform tissues enough to produce a
permanent change (i.e., a plastic deformation in the
musculotendinous unit). Therefore, the temporary
improvement in hamstring flexibility may be attributed
to changes in the elastic region caused by a single session
of hold-relax stretching.5
Thixotropic Properties
Thixotropy is the property of a tissue to become more
liquid after motion and return to a stiffer, gel like state
at rest. The thixotropic property of muscle is thought to
result from an increase in the number of stable bonds
between actin and myosin filaments when the muscle
is at rest. Hence, the stiffness of muscle increases.
Because we asked our subjects to lie still in between the
readings, the thixotropic properties of muscle may have
played a part in reducing the time that hamstring
flexibility was increased.
A linear relationship exists between the time a
muscle remains still and the stiffness of that muscle in
response to a stretch, and indeed, flexibility decreased
in both groups as time passed .However, with activity,
the muscle becomes more fluid-like because the stable
bonds are broken or are prevented from forming. Based
on thixotropic properties, we would expect the
temporary increase in flexibility to bemaintained
during periods of activity and to decrease during
periods of inactivity.
The present study revealed that there was no
statically significant difference in ROM gains in both
the groups. This shows that there is no extra
improvement/change in ROM when the modified hold
relax stretching was performed after the warm up. This
findings are similar to that of Cornelius et al in which
they concluded that effective increases in tissue length
were not affected by warm up when a modified hold
relax technique was used.27
In the present study, flexibility lasted for larger
duration i.e. 12 minutes in Group B (modified hold relax
and active warm up) which may be due to the various
factors. These findings are similar to that of various
studies conducted by Cornelius which stated that raised
tissue temperature, coupled with stretch, would result
2/7/2013, 8:08 PM
in effective tissue elongation and longer lasting

flexibility.27 However; these studies did not measured
lasting effects.
Influence of active warm up
An increase in intramuscular tissue temperature
has a beneficial effect on ability of collagen and the
myotendinous junction to deform. The effect of
temperature must also be considered in relation to the
innervations of the muscle tendon unit. There are
reports in the literature that sensitivity of GTO to
sustained stretch is increased with increase in
temperature and that the GTOs sensitivity to tension is
inversely correlated with the mechanical stiffness of
the musculotendinous structure in which it lies.
Possible effects of warm up due to elevated
temperatures are decreased resistance of muscles and
joints, Greater release of oxygen from haemoglobin and
myoglobin,Speeding of metabolic reactions, Increased,
nerve conduction rate, Increased thermoregulatory
strain.
These all factors would have played an important
role in improvement of the flexibility for group B by
reducing the resistance to stretch. 28
4.
5.
6.
7.
8.
9.
10.
11.
CONCLUSIONS
The result of our study leads to conclude that both
the techniques were equally effective for improving
ROM acutely.
12.
The important finding from this study was that if

subject specific active warm up was performed prior to
modified hold relax stretching ,the flexibility would last
for about double the duration ,than that of modified
hold relax technique.
13.
14.
REFERENCES
1.
2.
3.
Maximal Length and Resistance to Passive Stretch

of Short Hamstring Muscles Volume 14 Number 6
December 1991 JOSPT,250-55.
Magnusson SP, Simonsen EB, Aagaard P, Gleim
GW, McHugh MP, and Kjaer M. Viscoelastic
response to repeated static stretching in the human
hamstring muscle. Scand J Med Sci Sports 5: 342347, 1995
Hopper D, 2005, S Deacon, S Das, A Jain, D Riddell,
T Hall, K Briffa ,Dynamic soft tissue mobilization
increases hamstring flexibility in healthy male
subjects, Br J Sports Med 2005;39:594598.
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15.
16.
17.
ACSMs guidelines,1997.Exercise testing and

Prescription,Lippincott Wilkins & Williams , 1997
page13- 19.
Spernoga S.G , Timothy L. Uhl, Brent L. Arnold,
and Bruce M. Gansneder Duration of Maintained
Hamstring Flexibility After a One-Time, Modified
Hold-Relax Stretching Protocol ,J Athl Train. 2001
JanMar; 36(1): 4448.
DePino G.M,2000, Duration of Maintained
Hamstring Flexibility After Cessation of an Acute
Static Stretching Protocol Journal of Athletic
Training 2000;35(1):5659
Gajdosik R,1983,Hamstring Muscle Tightness
Reliability of an Active-Knee-Extension Test
Volume 63 / Number 7, July 1983,1085-1088
Knudson D ,2005, NSCA Guidelines, Warm up &
Flexibility , LWW,166-181.
Bishop, 2003 Warm Up II ,Performance Changes
Following Active Warm Up and How to Structure
the Warm Up, Sports Med 2003; 33 (7): 483-498
Bishop D, 2003 Warm Up I ,Potential Mechanisms
and the Effects of Passive Warm Up on Exercise
Performance, Sports Med 2003; 33 (6): 439-454.
ACSM Position Stand on The Recommended
Quantity and Quality of Exercise for Developing
and Maintaining Cardiorespiratory and Muscular
Fitness, and Flexibility in Adults. Med. Sci. Sports
Exerc., Vol. 30, No. 6, pp. 975991, 1998.
Draper D.O.2002;The Carry-Over Effects of
Diathermy and Stretching in Developing
Hamstring Flexibility ,Journal of Athletic Training
2002;37(1):374
Hutton R S 1993 Neuromuscular basis of
stretching exercises. In: Komi P V (ed). Strength
and power in sport, 1st edn, Vol 1. Blackwell
Scientic Publications, Oxford, pp 29-38;cross refPhysical Therapy in Sport (2001) 2, 186-193.
Etnyre B R, Abraham L D 1986b H-reflex changes
during static stretching and two variations of PNF
techniques J Athl Train. 2001 JanMar; 36(1):
4448.
Tanigawa MC. Comparison of the hold-relax
procedure and passive mobilization on increasing
muscle length. Phys Ther .1972; 52 (7): 725-35
Markos P.D.Ipsilateral & contra lateral effects of
PNF techniques on hip motion and
electromyographic activity. Phys Ther 1979; 59 (11):
1366-1373
Katz R, Penicaud A, Rossi A. Reciprocal Ia
inhibition between elbow flexors and extensors
in the human. J Physiol 1991; 437(1): 269-86
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18. Day BL, Marsden CD, Obeso JA, et al. Reciprocal

inhibition between the muscles of the human
forearm. J Physiol 1984; 349 (1): 519-34
19. Etnyre BR, Abraham LD. Gains in range of ankle
dorsiflexion using three popular stretching
techniques. Am J Phys Med pas1986; 65 (4):
189-96
20. Osternig LR, Roberston RN, Troxel RK, Muscle
activation during proprioceptive neuromuscular
facilitation (PNF) stretching techniques. Am J Phys
Med 1987; 66 (5): 298-307
21. Moore MA,1980, Hutton RS. Electromyographic
investigation of muscle stretching techniques.
Med Sci Sports Exerc 1980; 12(5): 322-9
22. Osternig LR,1990, Roberston RN, Troxel RK, et al
Differential responses to proprioceptive
neuromuscular facilitation (PNF) stretch
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106-1011
23. Garrett, WE. Muscle strain injuries: Clinical and
basic aspects. Med. Sci Sports Exerc. 22:436-443.
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24. Magnusson SP, Simonsen EB, Aagard P, et al.

Mechanical and physiological responses to
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contraction in human skeletal muscle. Arch Phys
Med Rehabil 1996; 77: 373-8
25. Magnusson SP. Passive properties of human
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Scand J Med Sci Sports 1998; 8: 65-77
26. Halbertsma JP, Goeken LN. Stretching exercises:
effect on passive extensibility and stiffness in short
hamstrings of healthy subjects. Arch Phys Med
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27. CorneliusW.L,1992 ,The Effects of a Warm -up on
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physiology, 5 th edition , Lippincott wilkins and
Williams, 574-575.
2/7/2013, 8:08 PM
A Comparative Study of effectiveness between Superficial

Heat and Deep Heat along with Static Stretching to
Improve the Plantar Flexors Flexibility in Females Wearing
High Heel Foot Wears
Hasmukh Patel1, Dhaval Desai2, Harshit Soni2, Komal Soni2, Chintan Shah2
1
Clinical Therapist, U. N. Mehta Institute of Cardiology & Research Centre, Ahmedabad.
2
Lecturer, SPB Physiotherapy College, Surat
ABSTRACT
Background: Lower extremity overuse injuries commonly occurs due to decreased flexibility of plantar
flexor muscles in females wearing high heeled foot wears. Plantar flexors shortening are treated by
various physiotherapeutic techniques. Superficial heat (moist heat) and Deep heat (ultra sound) along
with static stretching are treatment techniques used in physiotherapy.
Objective: To compare the effectiveness of superficial heat and Deep heat in combination with static
stretching in improving the plantar flexors flexibility in females wearing high heeled footwears.
Method: The study included a sample of 40 individuals those who were wearing high heel > 2 inch.
Out of that 20 individuals were in superficial heating group (group A) where moist heat was
administered for 15 minutes to Achilles tendon, and remaining 20 individuals were in deep heating
group (group B) where continuous ultrasound with frequency of 1 MHz at an intensity of 1.5 W/Cm2
was administered for 7 minutes to the Achilles tendon. Both the groups received 30 seconds of static
stretch with 4 repetitions performed 5 times per week. The duration of entire study was 3 weeks and
both the group received 1 session per day. Analysis was based on the Goniometer test score.
Result: Both the group A and group B showed improvement in ankle ROM postintervention when
compared with preintervention measurement and 't'calculated value for pre-postintervention measures
was statistically significant as it was above the 't' tabulated value. Moreover, MeanSD of pre-post
difference in right ankle dorsiflexion ROM for group A was 2.901.37 and for group B was 4.250.85
and MeanSD of pre-post difference in left ankle dorsiflexion ROM for group A was 3.601.04 and for
group B was 4.350.74. 't'calculated value for pre-post ROM difference was statistically significant as
it was above the 't' tabulated value of 1.96.
Interpretation & Conclusion: There was significant difference between the two groups. In conclusion
both the treatment programs are highly significant and effective in improving the ankle joint ROM, but
ultrasound with deep heating property was found to be more superior as compared to moist heat pack
with superficial heating property in improving plantar flexors flexibility in females wearing high heel
foot wears.
Keywords: Flexibility, Ultrasound Therapy, Moist heat, Static Stretching.
INTRODUCTION
Flexibility as defined by Gummerson1 is The
absolute range of movement in a joint or series of joints
that is attainable in a momentary effort with the help of
a partner or a piece of equipment.
The different types of flexibility according to Kurz

are:
1) Dynamic flexibility
2) Static-active flexibility
3) Static-passive flexibility
Hasmukh Patel
D-3 Kalyan Kunj, Radhaswami Road,
Ranip, Ahmedabad, Gujarat, India
E-mail: hasmukhphysio@gmail.com
12. Hasmukh patel 5th april--58-64.pmd
58
Tightness is a nonspecific term referring to mild

shortening of a healthy musculotendineous unit. In the
human body some muscle or a muscle group gets
tightness due to lack of proper exercise.2 The plantarflexor muscles play an important role in the gait cycle
2/7/2013, 8:08 PM
and in postural control. Lack of extensibility in this

muscle group may cause or be related to decreases in
ankle dorsiflexion, and it has also been hypothesized
to contribute to Achilles tendinitis, shin splints,3 plantar
fasciitis,4 and muscle strains.5
Use of high heeled footwear has become a common
trend nowadays. Biomechanical problems which seem
to be associated with long term use of such foot wears
results in shin pain, ankle sprain and altered gait
pattern.6 According to the American Orthopedic Foot
and Ankle Society, heel > 2 inches are consider as
high which creates three to six times more stress on
the front of the foot than a shoe with a modest one-inch
heel, and can lead to bunions, heel pain, toe deformities,
shortened Achilles tendons, and Back Pain. 7 AL
DALI Waleed et al. confirmed significant reduction in
calf flexibility and ankle dorsiflexion range of motion
(ROM) in 80 healthy college female students wearing
high heeled shoes.8
Many therapeutic maneuvers like different
stretching techniques namely static stretching, ballistic
stretching, PNF stretching and cyclic stretching are
useful to increase ROM by enhancing soft tissue
extensibility. Worrell TW demonstrated significant
increase in ankle dorsiflexion ROM in 11 female and 8
male subjects who received 20 seconds of calf stretching
repeated over 10 sessions followed by 10 close kinetic
chain gastronemius/soleus stretching sessions.9
Heating modalities used in clinical setup for
enhancing flexibility of muscle and promoting
relaxation are briefly divided into superficial and deep
heating modalities. Ultrasound, SWD and MWD fall in
the category of deep heating modalities. David Draper
evaluated tissue temperature rise during ultrasound
treatment in 20 males and concluded that application
of continuous ultrasound with 1MHz frequency and
1.5 W/cm2 intensity at the medial gastronemius muscle
for 10 minutes in humans raised the mean temperature
to 40.3 C, which was an increase of 4.9 C.10 Moist pack,
IRR, Wax, etc fall in the category of superficial heating
modalities. Funk D found that 20 minute moist heat
application produced significantly more hamstring
flexibility than 30 seconds of static stretching.11
Individual studies have been done on Superficial
heat combined with static stretching and Deep heat
combined with static stretching for improving flexibility
of plantar flexors muscles. But no study has been done
59
comparing the efficacy of these two treatment

techniques, which signifies the need of the present
study.
The aims and objectives of the study were;
1. To evaluate the effectiveness of superficial heat with
Static Stretching towards improving plantar flexors
flexibility in females wearing high heel footwears.
2. To evaluate the effectiveness of Deep heat with Static
Stretching towards improving plantar flexors
flexibility in females wearing high heel footwears.
3. To compare the effectiveness amongst the two
groups of females who were administered the above
mentioned therapies.
METHODOLOGY
Study design: Cohort Comparative Study
Sample size: 40 individuals
Sampling method: Randomized sampling
Study Setting: Shree Devi College of Physiotherapy,
Mangalore
Inclusion criteria
1. Female wearing high heel footwears >2 Inches.
2. Age: between 18 years to 30 years.
3. Individual who have ankle dorsi flexion active ROM
(AROM) less than 10 Degrees with knee extension
Exclusion criteria
1. Individuals with Impaired sensation.
2. Individuals with any orthopedic problem.
3. Individuals those who are having neuromuscular
disorder of hip, knee and ankle.
4. Lower extremity malignancy.
5. Individuals with ankle pathology. E.g. fractures.
Tools used
1) 360o Universal Goniometer.
2) Ultrasound, 1 MHz frequency, SL No. 2506,
Ultrasonic Gel
3) Moist pack
2/7/2013, 8:08 PM
1.5 W/Cm2 for 7 min by using Ultra sound machine in

transverse manner. (Fig. 4)
Static stretching to be administered to both the groups:
Calf stretch was performed for 20 seconds with the
knee in full extension, followed by a 10-second rest.
This sequence was repeated three more times, 5 days
per week for a period of 3 weeks. (Fig. 5)
Fig. 1. Tools Used
Outcome Measures
AROM Measurements for ankle dorsiflexion of both
legs with knee extension was taken by using a Universal
Goniometer. (Fig. 2)
The Measurement was taken Pre-treatment and
Post-treatment i.e. after 3 weeks of intervention.
PROCEDURE
Prior to procedure individual those who met the
inclusion criteria were assessed and evaluated
thoroughly by using the questionnaire. After signing
the consent form they were made to participate in study.
Fig. 2. Ankle ROM with knee extension
40 Individuals of 18-30 years were randomly

assigned into two groups.
Group A: Consisted of 20 Individual who were
administered moist heat for 15 min to Achilles tendon
for 3 weeks.
Group B: Consists of 20 Individual who were
administered continuous ultrasound with frequency
of 1 MHz at an intensity of 1.5 W/Cm2 for 7 min to the
Achilles tendon for 3 weeks.
Fig. 3. Superficial heat (Moist pack)
Both the groups received 30 seconds of static stretch

with 4 repetitions performed 5 times per week for 3
weeks.
Superficial heat administered to Group A persons
Superficial heat was administered by hot pack
which was placed on subjects Achilles tendon. Two
layers of terry cloth padding were placed between the
hot pack and the subject. (Fig. 3)
Deep heating for persons belonging to Group B
Ultrasonic gel, the coupling medium for treatment
was applied to Achilles tendon followed by continuous
ultrasound with frequency of 1 MHz at an intensity of
60
Fig. 4 Deep heat (Ultra sound)
2/7/2013, 8:08 PM
All participants received full treatments and there
were no drop outs.
Data analysis was done by using SPSS 13.0 version
software for present study. Unpaired t tests were used
to find out homogeneity of two groups for all the
parameters at baseline and to compare the outcome
measurement data between two groups. Paired t tests
were conducted to determine whether ankle dorsiflexion
ROM was significantly different before and after the
intervention. Each calculated t-value is compared with
t-table value to test two tailed hypothesis at 0.05 level of
significance.
Fig. 5. Static Stretching

among both the study groups for ROM change.
RESULTS
MeanSD of age for group A was 21.001.55 and
for group B was 21.101.68 and tcalculated value was
-0.195 at n1+n2-2 degree of freedom.

Table 1: shows descriptive statistics of age distribution among both groups.

Descriptive Statistics
N
Minimum
Maximum
Mean
Std. Deviation
Group A
20
19.00
24.00
21.0000
1.55597
Group B
20
19.00
25.00
21.1000
1.68273
tcalculated value for right and left ankle

dorsiflexion ROM preintervention among both the
groups was 0.718 and 1.637 respectively at n1+n2-2
degree of freedom. All the descriptive data for both the
groups was not significantly different, so both the

groups were homogenous for all possible confounding
factors and were valid for comparison.
Table 2: Pre and Post Intervention Comparison of both the Groups in terms of ankle dorsiflexion ROM
Variable
GROUP A
Pre
Right ankle
dorsiflexion ROM
Left ankle dorsiflexion ROM
Post
GROUP B
Change
Pre
Post
Change
7.310.59
11.200.90 2.901.37
7.180.56
11.690.64
4.250.85
7.370.49
11.270.70 3.601.04
7.080.59
11.560.51
4.350.74
Table 2 shows changes in terms of ankle dorsiflexion ROM of both sides pre and post intervention for both the
groups.
61
2/7/2013, 8:08 PM
Table 3: Paired t test for outcome measures of both the groups
tcalculated value in all these cases is statistically significant as it is above the t tabulated value; hence both
the treatments were effective in improving Ankle dorsiflexion ROM.
Table 4: Unpaired t test for outcome measures of both the groups
Both the groups showed improvement in ankle

dorsiflexion ROM postintervention. MeanSD of prepost difference in right ankle dorsiflexion ROM for group
A was 2.901.37 and for group B was 4.250.85 and
tcalculated value was -3.73 at n 1+n 2-2 degree of
freedom. MeanSD of pre-post difference in left ankle
dorsiflexion ROM for group A was 3.601.04 and for
group B was 4.350.74 and tcalculated value was 2.61 at n1+n2-2 degree of freedom. tcalculated value in
all these cases is statistically significant as it is above
the t tabulated value of 1.96.
DISCUSSION
Number of clinical methods and techniques are
available to improve flexibility, viz. therapeutic
application of heat in form of superficial and deep
heating modality, different stretching technique, pre
exercise warm up, etc. In stretching, static stretching is
the simplest, useful and most effective technique. This
62
study consisted of 40 individuals, who were divided

into 2 groups - Group A and Group B. Group A consisted
of 20 individuals with mean age of 21.00 1.55 and
group B consisted of 20 individuals with mean age of
21.10 1.68. Group A was treated with superficial heat
(moist heat pack) along with static stretching and group
B with deep heat (ultrasound) along with static
stretching for duration of 3 weeks. Ankle dorsiflexion
ROM with knee in extension was measured as an
outcome measure to evaluate the effect of superficial
and deep heating on calf flexibility and thereby on
dorsiflexion ROM. After retrieving the values, data was
statistically compared using paired and unpaired t
test for comparison within and between the groups
respectively.
The result demonstrated that the individuals treated
with both interventions showed improvement in means
of plantar flexors flexibility postintervention which was
evident from higher t calculated value. Moreover
2/7/2013, 8:08 PM
statistically when both groups were compared, Group

B showed more plantar flexor flexibility as it showed
much greater improvement in dorsiflexion ROM as
compared to that in Group A and also the t calculated
value was higher than t tabulated value (1.96). This
effect of ultrasound can be attributed to the sufficient
increase in tissue temperature brought by it and hence
thereby promoting greater relaxation of muscle as
compared to superficial heating modalities. These
findings are in line with those by David Draper (1993
and 1998).13,14 Moreover findings of Hendricson et al.
(1984),15 Wessling et al. (1987)16 and Rather Aijaz et al.
(2007)17 also support the fact that ultrasound when
combined with static stretching as compared to static
stretching alone is more effective in improving soft tissue
flexibility. Hence it is more suggestible to use a
combination of ultrasound and static stretching to
improve soft tissue extensibility.
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 with

large treatment groups can be done.
The study of same treatment approaches with the
inclusion of control group can be done.
A long term follow up study should be done to check
the recurrence rate and to know the long term effects
of interventions.
CONCLUSION
The individuals were treated with superficial heat

along with stretching and deep heat along with
stretching for 3 weeks and were found to be effective in
improving the ankle joint ROM in both the groups.
Statistically when both the groups were compared,
group B individuals showed more improvement as
compared to group A. In conclusion both the treatment
programs are highly significant and effective in
improving the ankle joint ROM, but ultrasound with
deep heating property is found to be more superior as
compared to moist heat pack with superficial heating
property in improving plantar flexors flexibility in
females wearing high heel foot wears.
63
ACKNOWLEDGMENTS
with full cooperation. We are also grateful to authors/
editors/ publishers of all those articles, journals and
books from where the literature for this article has been
reviewed and discussed.
REFERENCES
1.
Brad Appleton, Stretching and Flexibility. Version:

1.18, Last Modified 94/10/12.
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Kisner C, Colby LA. Therapeutic Exercise:
Foundation and Techniques. Philadelphia, Pa: FA
Davis Co, 1985:172.
3.
Reynolds NL, Warrell TW. Chronic Achilles
peritendinitis: etiology, pathophysiology and
treatment. J Ortho Sport Phys Ther.199; 13(4):
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4.
Middleton JA, Kolodin EL: plantar fasciitis-heel
pain in athletes. J Athl Train.1992; 27: 70-75.
5.
Millar AP: strains of posterior calf musculature
(tennis leg). Am J Sports Med.1992; 7: 172-174.
6.
Franklin ME, Chenier TC, Brauninger L, et al. Effect
of positive heel inclination on posture, J Ortho
Sports Phys Ther. 1995; Feb: 21(2):94-9.
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Wearing high heel- Effect on body. Personal health
zone, February 2009.
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AL DALI Waleed A, OLUSEYE Kamaldeen A
.Effect of high-heeled shoes and culturally
habitual posture on calf muscle flexibility, Arab
gulf journal of scientific research.
1999; vol.17 (3): 326-33
9.
Worrell TW, McCullough M, Pfeiffer a. Effect of
foot position on gastrocnemius/soleus stretching
in subjects with normal flexibility. J Ortho Sports
Phy Ther. 1994; 19: 352-356.
10. Draper DO, Sunderland S. Examination of the law
of grotthus-draper: Does ultrasound penetrate
subcutaneous fat in humans? J Athl Train 1993a;
28: 246-250.
11. Funk D, Swank A, Adams K, et al. Efficacy of moist
heat pack application over static stretching on
hamstring flexibility. J Strength Cond Res. 2001;
15: 123-126.
12. WMA Declaration of Helsinki - Ethical Principles
59th WMA General Assembly Seoul, Korea, Oct
2008. http://www.wma.net/en/30publications/
10policies/b3/
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13. Draper DO, Sunderland S, Kirkendall DT, Ricard

M. A comparison of temperature rise in human
calf muscles following applications of underwater
and topical gel ultrasound. J Orthop Sports Phys
Ther 1993;17: 247251.
14. David O. Draper, Chad Anderson et al. Immediate
and Residual changes in dorsiflexion range of
motion using an ultrasound heat and stretch
routine. Journal of Athletic Traning 1998;
33(2):141-144.
15. Hendricson A, Fredriksson K, Persson I, et al. The
effect of heat and stretching on the range of hip
64
motion. J Ortho Sports Phys Ther. 1984; 13:

110-115
16. Wessling KC, DeVane DA, Hylton CR. Effects of
static stretch versus static stretch and ultrasound
healthy women. Phys Ther 1987; 67: 674-679.
17. Rather Aijaz Y, Pooja Chaudhary. Ultrasound and
prolong long duration stretching increase triceps
surae muscle extensibility more than identical
stretching alone. Indian Journal of Physiotherapy
and Occupational Therapy, vol. 1, no. 3 (2007-07
2007-09).
2/7/2013, 8:08 PM
Influence of different Types of Hand Splints on Flexor

Spasticity in Stroke Patients
Eman Samir Fayez, Hayam Mahmoud Sayed
Assistant Professor in Department of Physical Therapy for Neuromuscular Disorders and its Surgery, Faculty of Physical Therapy,
Cairo University, Egypt
ABSTRACT
Objective: The aim of this study is to evaluate the efficacy of each static and dynamic splint on hand
flexor spasticity and to compare between their effectiveness on hemiplegic patients.
Design: Randomized controlled trial.
Subject: 29 hemiplegic (stroke) patients (45-65 Y/o) with mild to moderate spasticity of upper limb. The
onset of stroke was from 6 month to one year before starting the study.
Intervention: The patients were randomly assigned into two equal study groups of 15 (A and B). The
assessment were performed pre and post application of static splint for group A and dynamic splint for
group B. The duration of splint application was one hour for both groups. All participants were
receiving designed program of treatment of hemiplegia after application of splint.
Outcome measures: (1 The mean of active and passive range of motion for wrist extension using
goniometer, and 2) Grip strength by using digital hand dynamometer.
Keywords: Stroke ,Spasticity ,Static Splint And Dynamic Splint.
INTRODUCTION
Stroke, is defined as a cerebrovascular accident
(CVA), it is the rapidly developing loss of brain
functions due to disturbance in the blood supply to the
brain. As a result, the affected area of the brain is unable
to function, leading to inability to move one or more
limbs on one side of the body, inability to understand
or formulate speech, complications, and may lead to
death.1
Spasticity caused by an upper motoneuron
syndrome is usually defined as a velocity-dependent
increase in muscle resistance against passive
lengthening because of a supraspinal disinhibition of
both tonic and phasic stretch reflexes. This muscle over
activity may result in muscle imbalance and shortening,
leading to abnormal postures 4. Pain in the hemiplegic
upper limb is also widely reported to be a complication
of spasticity.2
Production of an effective powerful grip or even to
manipulate objects requires the wrist to be held in a
functional position of slight extension maintained by
activity of the wrist extensors4 .The inability to open the
hand when reaching for or releasing an object and
limited grip is a common functional problem after stroke.
13. Eman Fayej cairo--65-69.pmd
65
It may be due to weakness of the finger extensor muscles,

spasticity and stiffness of the finger and wrist flexor
muscles. Grip can be limited not only because of an
inability to activate finger flexors but also because of
weakness of the wrist extensors (extensor carpi radialis
longus, extensor carpi ulnaris).3
Splinting is commonly used by both physical and
occupational therapists to prevent joint deformities and
to reduce muscle hypertonia of hemiplegic upper limbs
after stroke.4 Orthoses and splints are commonly used
to improve and correct the position, range, quality of
movement, and function of a persons arm or hand 5.
It is proposed that inhibition results from the
application of splint can be due to altered sensory input
from cutaneous and muscle receptors during the period
of splint or cast application. Immobilization, applying
gentle continuous stretching of the spastic muscle at
submaximal passive range of motion (PROM), is seen
to reduce spasticity by altering the threshold response
to stretch of the muscle spindle and Golgi tendon organs
in the antagonist and agonist muscles. The effects of
neutral warmth and circumferential contact are also
thought to contribute to modification of spasticity seen
following casting.4
2/7/2013, 8:08 PM
The biomechanical effects of splinting relate to

changes in the length and extensibility of muscle and
connective tissue. Application of low-load prolonged
stretch to the contracted tissues at the end of their
available range allows histological changes to occur in
the tissues in response to the position imposed6. It was
suggested that the increase in passive ROM seen after
removal of casts in hemiplegic and cerebral palsy clients
results from the lengthening of connective tissue
elements along with addition of sarcomeres to the
muscle fiber5.
The types of splint designs commonly used are
dynamic splint and static splint. The dynamic splints
designed to maintain wrist joint alignment with
allowing movement at the wrist would improve
performance while maintaining activation of the
forearm muscles that control the wrist. In addition, the
dynamic splints would preserve and perhaps enhance
grip and manual dexterity skills7. Otherwise static
splints are designed to be rigid for controlled
immobilization of the involved joint for improved
function8.
In a study comparing muscle activation patterns
during perturbed balance when static and dynamic
ankle splints were worn, investigators reported that
static splints decreased muscle activation in ankle
musculature7. In contrast, dynamic splints allowed
activation of ankle muscles while improving balance
function. In addition, proximal muscles in the trunk
and thighs were more active with the static splints than
with the dynamic splints, suggesting increased muscle
activation proximal to the joint, which is fixed or
immobilized during static splint conditions 6.
Many studies concluded the effects of dynamic
splints on upper limb in hemiplegic patients that they
could reduce swelling, improve wrist posture, and
reduce wrist and finger flexor spasticity9. Other study
recommended that daily use of static splint in poststroke upper limb spasticity over an extended period is
associated with reduction of spasticity and pain, and
with an increase in wrist PROM8.
Also an overnight splint-wearing regimen with the
affected hand in the functional position does not
produce clinically beneficial effects in adults with
acquired brain impairment10. For optimal efficacy,
therapies aimed to improving function should address
both muscle shortening and muscle over activity;
measures to relax overactive muscles should be
combined with physical treatment to lengthen them9.
Therefore, the goal of the current study is to evaluate
and compare between the short term efficacy of
66
dynamic and static splints on hand flexor spasticity in

stroke patients.
MATERIALS AND METHOD
Subjects
Twenty nine stroke patients (17 women, 12 men)
were recruited from outpatient departments in King
Fahad Hospital of the University. Subjects were required
to meet the following inclusion criteria:(1) post stroke
hemiplegia with duration ranged from 6 months to
one year before the study; (2) upper-limb mild to
moderate spasticity (Modified Ashwarth Scale 1+ to 3
at the wrist), and (3) age between 45 and 65 years .
Exclusion criteria were : (1)cognitive impairment, (2)
major contracture affecting muscles of the spastic arm
at the time recruitment; (3) Joint pathology of the upper
limb (eg, previous fractures, articular blocks); (5)
Patients under antispastic drug . Informed consent was
obtained for all patients separately . Subjects were
arranged randomly into two groups; group I (G1) and
group II (G2). Group I consisted of 14 patients (9 males
and 5 females) and group II consisted of 15 patients (8
males and 7 females).
INSTRUMENTATION
Hand digital dynamometer was used to measure
the grip strength of affected hand. Goniometer was used
to measure active and passive range of motion of wrist
extension. Two types of splints were used in this study.
The static splint made from a low-temperature,
nontoxic, biodegradable material produced from a
strictly controlled cotton tissue, the splint held the hand
in the functional resting position (wrist positioned
between at 30 degree extension), thumb in abduction 2.
The dynamic splint was costumed made from
thermoplastic material and allowed 30 degrees of
movement at the wrist and the fingers were free 9.
INTERVENTION
All patients of both groups were evaluated at the
beginning and at end of one-hour period of splint
application. Patients of G1 were wearing static splint
for one hour while, patients of G2 were wearing
dynamic splint for one hour .Changes occurring with
static splint were then compared with changes
occurring with dynamic splint. Because the way in
which the splint is fitted to the arm may be important,
the fitting was performed by the same trained
investigator. All assessments were performed in a quiet
room while the patient was sitting with the shoulders
relaxed and arms resting comfortably on chairs arm
support.
2/7/2013, 8:08 PM
OUTCOME MEASURE
Three outcome measures were recorded, which were
active range of motion, passive range of motion and
grip strength .These measures were obtained before and
after application of static and dynamic splints in both
study groups.
Clinical and instrumental outcome goniometric
measurements of wrist extension from full flexion of
the patient were obtained in degrees to calculate the
active and passive range of motion. Each patient was
then cued to start grip strength using digital
dynamometer, elbow flexed 90 degree with hand and
forearm in mid position while rested on the table. For
statistical analysis, mean of 3 consecutive
measurements were taken to reduce possible
measurement errors, the number of repetitions given
were according to standardized methods established
during previous studies 2, 9.
For parametric data (AROM, PROM, grip strength)
differences of the changes occurring after wearing static
and dynamic splints for 1-hour period of time were
measured and compared using 2-tailed paired t tests.
Statistical analysis was performed using SPSS with level
of statistical significance at Pd0.05.
Comparison between pre and post-application of

static splint in group I, the results revealed that there
were statistical significant improvement in grip strength
and active ROM, while there was highly significant
improvement of passive ROM, after application of static
splint; data were shown in Table, 2.
Table 2: Comparison of G.S, AROM and PROM mean
values before and after static splint application for
group1.
Variables
Pre
Post
Mean SD
Mean SD
P value
Grip strength
3.96 0.61
4.9 0.83
0.003*
AROM
55.24 6.65
60.7 3.5
0.001*
PROM
101.665.6
115.636.36
0.0001**
AROM: Active Range Of Motion; PROM: Passive

Range of Motion; SD: standard deviation; *: significant;
**: highly significant.
Comparison between pre and post-application of
static splint in group I, the results revealed that there
were statistical significant improvement in grip strength
and active ROM, while there was highly significant
improvement of passive ROM, after application of static
splint; data were shown in Table, 3.
Table 3: Comparison of G.S, AROM and PROM mean
values before and after dynamic splint application for
group2.
RESULTS
This study was performed to evaluate the effect
of each static & dynamic splints on hand flexor
spasticity in stroke patients. There were not statistical
significant differences between both groups before
treatment, Demographic characteristics of both groups,
were shown in Table, 1.
Table 1: Demographic Data and Clinical Data of the
Study Population
Comparison
Age(year)
Group I
Group II
P value
Mean SD
Mean SD
63.5 8.1
60.83 6.5
0.693#
Height(cm)
170.35.13
173.98.4
0.432#
Weight(kg)
8313.4
85.510.6
0.649#
8.6
7.9
Male
Female
Duration of
Variables
Grip strength
Pre
Post
Mean SD
Mean SD
4.8 0.53
5.53 0.49
57.01 7.76
70.52 9.6
0. 01*
PROM
116.3312.5
135.5616.7
0.001**
AROM: Active Range Of Motion; PROM: Passive

Range of Motion; SD: standard deviation; *: significant;
**: highly significant.
Comparison between G1 and G2, regarding active
ROM, passive ROM and grip strength, the results
revealed that dynamic splint had significant
improvement in wrist AROM and PROM when
compared to results of static splint. However, patients
who wore dynamic splint had improvement in grip
strength when compared with those of static splint but
this improvement was not statistically significant, data
were shown in Table, 4 and figure, 1.
#: Not significant.
67
0.001*
AROM
stroke(months)
P value
2/7/2013, 8:08 PM
Table 4: Comparison between static and dynamic splint mean values of both groups pre and post splint
Variables
Pre (Mean SD)
P value
Post (Mean SD)
Group I
Group II
Grip strength
3.96 0.61
4.8 0.53
0.14
AROM
55.246.65
57.01 7.76
0.32
60.7 3.5
70.52 9.6
0.05*
PROM
101.665.6
116.3312.5
0.17
115.636.36
136.5616.7
0.001*
AROM; Active Range of Motion, PROM; Passive

Range of Motion; SD: standard deviation; *: significant..
DISCUSSION
This study was designed to investigate the short
term efficacy of dynamic and static splints on hand
flexor spasticity in stroke patient and compare between
them by changes in degrees of active and passive range
of motion and grip strength. The result showed that
patient with spastic hand in both groups had
demonstrated improvement after application of both
types of splints .However; the dynamic splint had
significant improvement in wrist AROM, PROM & grip
strength compared with static splint.
Because dynamic splints have moving parts that
allow the individual a range of voluntary controlled
movement, it has been proposed that their use may
prevent contractures while allowing opposing
antagonist muscle force to counter the force of the spastic
muscle16 .
Muscle activation patterns of the upper extremity
muscles of ten children with CP were compared during
reaching with and without a hand-positioning device.
Results suggested more normalized muscle activation
with the device application16 .In contrast, another study
using static splints that immobilize wrists reported
decreased muscle activation, which over time may lead
to disuse atrophy in the wrist muscles and overuse of
more proximal muscles.17 In contrast, dynamic wrist
splints that provide wrist support for more optimal
hand function allowed some movement, may not
produce this additional strain on proximal muscles19.
These finding agree with (Assunta,et al,2005)2 that
studied the effect of volar static splint in post stroke
spasticity of the upper limb .The author found that there
was an increase in wrist PROM after application of a
custom volar static splint for 2 to 3 hours a day in poststroke spasticity of the upper limb . The results of the
current study come in accordance with (Jean , et al
,2000)7 that studied the short term effects of dynamic
lycra splints on upper limb in hemiplegic patients , the
68
Group I
Group II
4.9 0.83
5.53 0.49
P value
0.13
study reported reduction in wrist and finger flexor

spasticity when lycra garments were worn over 3 hours.
Our results disagree with (Natasha, etal 2003)6 that
studied the effect of splinting the hand in the functional
position after brain impairment, the study indicated
that subjects with acquired brain impairment who were
participating in routine motor training and upper-limb
stretches did not showed detectable or important
changes in wrist flexor extensibility after wearing a
splint daily for 4 weeks.
Also , the current results counteract with (Turton
and Britton 2006)11 that found that application of an
intensive 4-week splinting program to prevent
contractures in the arm after stroke did not increase the
extensibility of the wrist and long finger flexor muscles
in adults after stroke, this trial evaluating stretch
positioning in the upper limb, reported a loss of 13 of
wrist extension range at 8 weeks.
RECOMMENDATION
Further investigation is necessary to determine
efficacy of the different splints over time and in different
functional activities to more clearly understand
splinting use for spastic hand in hemiplegic patient.
CONCLUSION
The study findings suggested that spastic hand in
hemiplegic patient may experience improvement in
PROM , AROM and hand grip strength as a result of
static and dynamic splint application , but better results
were found when dynamic splint were worn during
the same time of application .
REFERENCES
1.
2.
3.
Donnan GA, Fisher M, Macleod M, Davis SM.

Stroke. Lancet 2008; 371 (9624): 16121623.
Assunta Pizzi, Giovanna Carlucci, Catuscia
Falsini, etal. Application of a volar static splint in
poststroke spasticity of the upper limb. Arch Phys
Med Rehabil 2005; 86:1855-1859.
Ruth Turk, Jane H. Burridge, Ross Davis, etal.
2/7/2013, 8:08 PM
Therapeutic Effectiveness of Electric Stimulation

of the Upper-Limb Poststroke Using Implanted
Microstimulators. Arch Phys Med Rehabil 2008;
89:1913-1922.
4.
Katz R, Rymer WZ. Spastic hypertonia: mechanism
and measurement. Arch Phys Med Rehabil 1989;
70:144-155.
5.
Wilton JC: Splinting and casting in the presence
of neurological dysfunction. In: WIlton JC, Hand
splinting: principles of design and fabrication.
London: WB Saunders 1997; 168-197.
6.
Patricia A. Burtner, Janet L. Poole, Theresa Torres,
etal. Effect of wrist hand splints on grip, pinch,
manual dexterity, and muscle activation in
children with spastic hemiplegia: A Preliminary
Study. J HAND THER 2008; 21:3643.
7.
Collins K, Oswald P, Burger G, Nolden J.
Customized adjustable orthoses: Their use in
spasticity, Arch Phys Med Rehab 1985;66:397-8.
8.
Langlois S, Pederson L, MacKinnon J: The effects
of splintingon the spastic hemiplegic hand: report
of a feasibility study. Canadian J Occup Ther 1991;
58(1):17-25.
9.
Neeman R, Neeman M: Rehabilitation of a poststroke patient with upper extremity hemiparetic
movement dysfunction by orthokinetic orthoses, J
Hand Ther 1992; 3(5):147-155.
10. Natasha A. Lannin, Sally A, Horsley, etal.
Splinting the Hand in the Functional Position after
Brain Impairment: A Randomized, Controlled
Trial. Arch Phys Med Rehabil 2003; 84:297-302.
11. Jean-Michel Gracies, Jeno Emil Marosszeky, Roger
Renton, etal. Short-term effects of dynamic lycra
splints on upper limb in hemiplegic patients. Arch
Phys Med Rehabil 2000 ;( 81):1547-1555.
69
12. Lannin NA, Cusick A, McCluskey A, etal. Effects

of splinting on wrist contracture after stroke: a
randomized controlled trial. Stroke 2007; 38(1):
111-116.
13. Patricia A. Burtner, Jennifer Bradley Anderson,
Michelle Lee Marcum, etal. A comparison of static
and
dynamic
wrist
splints
using
electromyography in individuals with
rheumatoid arthritis. J HAND THER 2003 ;(
16):320325.
14. Stern EB, Yterberg SR, Krug HE, Mullin GT,
Mahowald ML. Immediate and short-term effects
of three commercial wrist extensor orthoses on grip
strength and function in patients with rheumatoid
arthritis. Arthritis Care Res 1996 ;(9):4250.
15. Turton AJ, Britton E. A pilot randomized controlled
trial of a daily muscle stretch regime to prevent
contractures in the arm after stroke. Clin Rehabil
2005 ;( 19):600612.
16. Feldman P.Upper extremity splinting and casting.
In: Glenn MB,Whyte J (eds). The Practical
Management of Spasticity in Children and Adults.
Malvern, PA: Lea & Febiger 1990; pp 59166.
17. Reid DT, Sochaniwskyj A. Influences of a hand
positioning device on upper extremity control of
children with cerebralpalsy. Int J Rehabil Res 1992;
(15):1529.
18. Bulthaup S, Cipriani DJ, Thomas JJ. An
electromyography study of wrist extension
orthoses and upper extremity function. Am J
Occup Ther 1999 ;(53):434440.
19. Jansen CWS, Olson SL, Hasson SM. The effect of
use of a wrist orthosis during functional activities
on surface electromyography of the wrist extensors
in normal subjects. J Hand Ther 1997 ;(10):
283289.
2/7/2013, 8:08 PM
Interferential Current Therapy versus Narrow Band

Ultraviolet B Radiation in the Treatment of Post Herpetic
Neuralgia
Intsar Salim.Waked
Lecturer of Physical Therapy, Department of Physical therapy for Surgery, Faculty of Physical Therapy, Cairo University, Egypt.
ABSTRACT
Objective: To compare the efficacy of interferential current therapy versus narrow band ultraviolet B
radiation in the treatment of post herpetic neuralgia.
Subjects: Forty nine patients suffering from distressing post herpetic neuralgia. assigned randomly
into 2 groups; interferential group and narrow band ultraviolet B group. Intensity of pain was recorded
before and after therapy using numerical rating scale.
Results: The results of this study showed no significant difference in pain intensity post treatment
between both groups in acute and subacute neuralgia as p value > 0.05 while there was significant
difference between both groups in established neuralgia as p value< 0.05.
Conclusion: The study concluded that interferential current and narrow band ultraviolet B were
effective in acute and subacute neuralgia, while only interferential is effective in established neuralgia.
Keywords: Interferential Current Therapy, Narrow Band Ultraviolet B Radiation, Numerical Rating Scale, Post
herpetic neuralgia.
INTRODUCTION
Herpes zoster ( HZ ) infection is caused by a
reactivation of the latent varicella zoster virus that
causes chicken pox. It appears predominantly in older
adults whose immunity for the virus has waned. Postherpetic neuralgia (PHN) is described as sharp, burning,
aching, or shooting constantly present in the dermatome
that corresponds with the herpes rash1.
Pain in HZ evolves in three phases: acute, subacute,
and chronic. The acute phase occurs with the onset of
the herpetic rash and lasts for less than 30 days, the
subacute phase lasts for 1-3 months after the onset of
the rash, and the chronic phase, or PHN, lasts for 3
months or longer after the onset of the rash2.
Post herpetic neuralgia (PHN) is a common,
debilitating complication of herpes zoster that has a
major impact on patients quality of life. It can cause
insomnia, fatigue, depression. Predictors of PHN are
greater age, acute pain and rash severity, prodromal
pain, the presence of virus in peripheral blood, as well
as adverse psychosocial factors3.
The treatment of PHN is medically challenging and
often frustrating in some situation as the exact
14. Instar cairo--70-75.pmd
70
mechanism of neuralgia is poorly understood and

multiple and complex pathophysiology is postulated
requiring poly pharmacy, which itself leads to many
side effects4.
Interferential current (IFC) is a common
electrotherapeutic modality used to treat pain. IFC
therapy is the application of alternating mediumfrequency current (4,000 Hz) amplitude modulated at
low frequency (0250 Hz). Despite IFCs widespread
use, information about it is limited. A review of the
literature reveals incomplete and controversial
documentation regarding the scientific support of IFC
in management of post herpetic pain5.
The inflammatory response plays a major role in
the pathogenesis of acute zoster pain and PHN.
Ultraviolet B radiation (UVB) may affect the course of
PHN through its suppressing effect on the inflammatory
response in the acute zoster attack, thus decreasing the
neuronal damage contributing to PHN 6.
The purpose of this study was to evaluate the
efficacy of interferential current therapy versus narrow
band ultraviolet B radiation in the treatment of post
herpetic neuralgia.
2/7/2013, 8:08 PM
PATIENTS AND METHOD

Subjects
Forty nine patients (24 male, 25 female) with
distressing post herpetic neuralgia were recruited from
department of dermatology and the study conducted
in outpatient department of physical therapy- ElMataria Teaching Hospital after approval of the
institutional ethical committee. The history & clinical
examination were done for all patients. Subjects who
fulfilled the following criteria were eligible for
enrollment in the study; (1) age ranged from 50 to 80
years, (2) elapsed time since the beginning of pain less
than 6 months. Patients were excluded if they had (1)
disseminated zoster, (2) malignancy, (3) diabetes, (4)
pregnancy (5) pacemakers (7) Patients were taking
immunosuppressive medication. The patients were
randomized into two groups of equal number. (1)
interferential group and (2) narrow band ultraviolet B (
nbUVB) group. Pain was assessed by numerical rating
scale before starting of the treatment and at the end of
the therapeutic period for all patients.
combined unit used to introduce interferential current

for group 1. This unit introduced a quadripolar IF as
well as bipolar mode. The unit was provided with two
output channels for interferential currents.
Treatment parameters
The parameters used were; frequency 250 Hz, a
pulse duration 120, 30 minutes. The treatment was
given for 3 sessions per week for 5 weeks. Intensity of
the impulse varied according to the patients tolerance9.
Electrodes placement
The dermatome that was affected by the shingles is

the treatment path for electrotherapy. Each channel
has one electrode that emits electricity and the other
electrode is the ground.
One electrode, from channel 1, was placed directly

beside the origin point where the dermatome exits
the spinal cord. The other electrode for channel 1
was placed about 2/3rds of the way down the
dermatome.
At the time of this study, Human Research Ethics

Committee had not been established in the faculty of
physical therapy, but the study was approved by the
departmental council of physical therapy for surgery
and all patients signed an informed consent at the first
visit to the physical therapy clinic .
On channel 2 one electrode was placed between

the two electrodes of the first channel approximately
1/3rd down, and the other electrode from channel
2 was placed at the distal end of the dermatome,.
This electrode placement now covers the entire
dermatome 5.
Outcome measures
Narrow Band Ultraviolet B Radiation Therapy (nUVB)
Measurement of pain intensity by Numeral Rating

Scale
Narrow band UVB apparatus (Waldmann - UV

100L) was used to introduce nbUVB (311-312nm) to
patients in group 2. The starting dose was 0.21 J/cm2
and gradually increasing the dose by 10 mJ/cm2 each
session to a maximum dose of 100 mJ/cm2. (as long as
there is no adverse effects reported such as persistent
erythema, burn, itching)10.
Numeral Rating Scale (NRS) is a common and

practical method for assessing pain severity. It is the
most widely used pain rating scale in clinical practice.
There is evidence, which supports the validity and
reliability of the NRS in younger. and older patients.
The reliability of the NRS is acceptable and it has a
high internal consistency, with a Cronbach range of
0.86 to 0.88 7.
The NRS is an 11-point pain scale, where patients
are requested to quantify the intensity of their pain on a
scale from zero to 10 (from 0 = no pain to 10 = worst
pain imaginable). The NRS scale can also be used
visually with both words and numbers along a vertical
or horizontal line. Patients are asked to express a
number that relates best to their pain intensity8.
Treatment procedures
Interferential current Therapy (IFC)
Description of apparatus
SONOSTIM ( Class 1-type BF, Norm: 601-1) was a
71
Patients were instructed to expose the involved body

part while the rest of the body was covered using
clothing. Patients were instructed to wear protective
goggles to avoid damage of the cornea. Treatment
sessions were repeated three times a week.
Data were coded and entered to a statistical package
of social science (SPSS, version 16). Mann-Whitney U
test was used to assess the difference in sex, type of
pain, type of neuralgia, affected dermatome as well as
the intensity of pain in acute, subacute and established
neuralgia between both groups, while wilcoxon test was
used to assess the intensity of pain within each group.
All p values less than 0.05 were considered to be
statistically significant.
2/7/2013, 8:08 PM
RESULTS
A total of 49 patients was screened for eligibility,
and 47 subjects fulfilled the inclusion criteria. Three
subjects of 47 reported poor adherence to the treatment,
(a participant with poor adherence to the program
defined as missing more than three consecutive sessions
or more than 20% of all sessions) and excluded from
the study, and their data were not used in the statistical
analysis. A total of 44 subjects completed the study and
were initially randomized into two groups of equal
number. IF group (n=22), and nbUVB group (n=22).
Table (1) presents the characteristics of the patients
completing the study. Both groups were comparable at
the baseline regarding to the demographic and clinical
characteristics.
Table 1: Demographic and clinical characteristics

Variables
IF group
nbUVB group
P values
60.907.19
59.908.39
0.673*
103.0562.00
98.5068.84
0.819*
Age (years) (mean SD)

Duration of pain (day)
(meanSD)
Type of neuralgia (%)
Acute
5(22.7%)
acute
7(31.8%)
Subacute
5(22.7%)
subacute
4(18.2%)
Established
12(54.5%)
established
11(50%)
Male
10(45.5%)
Male
11(50%)
Female
12(54.5%)
Female
11(50%)
Cervical
3(13.6%)
Cervical
5(22.7%)
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%)
Sex (Male - Female)

Affected dermatome
Type of pain ( %)
0.633*
0.765*
0.891*
Continuous burning
8(36.4%)
Continuous burning
7(31.8%)
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%)
Acute
8.00.8366
Acute
8.001.11
0.932*
Subacute
8.00.8366
Subacute
8.500.577
0.190*
Established
8.00.866
Established
8.000.894
0.558*
Intensity of pain
(medianSD)
* No significant differences
0.591*
SD; standard deviation
Measurements of pain intensity

In table (2); The results showed significant reduction
in pain intensity post treatment in IF group whatever
type of neuralgia ( acute, subacute, chronic) as p value
<0.05. In nbUVB group; the results showed significant

reduction of pain intensity post-treatment in acute and
subacute neuralgia as p value <0.05 however no
significant difference in established neuralgia as p
value > 0.05..
Table 2: pain intensity within both groups pre and post treatment.
Acute neuralgia
pre
IF Group
8.00.83
P value
pre
2.01.14
8.00.83
0.043**
NBUVB
8.01.11
P value
3.00.899
0.018**
* No significant difference
Subacute neuralgia
post
pre
3.00.84
8.00.87
0.041**
8.00.57
3.50.96
0.039**
* * Significant difference
72
Established neuralgia
post
2/7/2013, 8:08 PM
post
2.00.94
0.002**
8.00.89
7.51.00
0.55*
IF group
nbUVB group
Percentage of improvement in acute neuralgia
IF group
nbUVB group
Percentage of improvement in subacute neuralgia
IF group
nbUVB group
Percentage of improvement in established neuralgia
73
2/7/2013, 8:08 PM
In table (3); The results showed no significant

difference in pain intensity post treatment between both
groups in acute and subacute neuralgia as p value >
0.05 but significant difference between both groups post
treatment as regard to established neuralgia as p value<
0.05.
Table 3: Comparison of pain intensity between both
groups post treatment
IF Group
NBUVB
P value
Acute neuralgia
2.01.14
3.00.899
0.442*
Subacute neuralgia
3.00.84
3.00.96
0.439*
Established neuralgia
2.00.94
7.51.00
0.001**
* No significant difference
* * Significant difference
DISCUSSION
Postherpetic neuralgia is the major chronic
complication and is a difficult management problem.
The aim of this study was to compare the effects of
interferential current therapy versus narrow band
ultraviolet B radiation in the treatment of post herpetic
neuralgia. A prospective study of forty nine subjects
was carried out. Subjects were divided into two groups;
IF group that received interferential therapy and nbUVB
group that received narrow band UVB sessions.
Outcome measures were assessed using numerical
rating scale to assess pain intensity pre and post
treatment.
The results of the study showed that there was
significant reduction in pain intensity post treatment
in IF group in acute, subacute and chronic neuralgia as
p value <0.05. This support the efficacy of interferential
for minimizing pain and this may be attributed to
analgesic effects of interferential therapy.
The analgesic effect of interferential therapy can be
explained in part by Wednesky inhibition of Type C
nociceptive fibres, although other mechanisms are
certainly involved. Pain gate theory, proposed by
Malzack and Wall11 remains central to this explanation.
Another system that helps to reduce pain is the
descending pain suppression mechanism, which is
mediated by the endogenous opiates12.
Number of previous studies demonstrated the
effectiveness of inferential current therapy in order to
reduce neuropathic pain. Babu and Murali;13 and
Burchiel;14 analyzed analgesic effects of IFC in chronic
and acute neuropathic pain. Natarajan;15 also found
positive results of interferential currents in diabetic
neuropathy and post-herpetic neuralgia. Nabila; et al;9
74
concluded that Interferential therapy is an effective,

easy to use therapy with minimal side effects in patients
suffering from trigeminal neuralgia that not responding
to conventional treatment.
In a study compared IF with transcutanous electrical
nerve stimulation (TENS) Cheing and HuiChan;16confirmed the analgesic effects of IF and TENS
in their study and concluded that both TENS and IF
increased the heat pain threshold to a similar extent
during stimulation. However, the post-stimulation
effect of IF lasted longer than that of TENS.
As regard to the efficacy of nbUVB; the results of
study showed that there was significant reduction of
pain intensity in acute and subacute neuralgia however
non significant differences in chronic neuralgia. The
improvement in acute and subacute neuralgia may be
attributed to the anti-inflammatory effect of UVB. UVB
may affect the course of PHN through its suppressing
effect on the inflammatory response in the acute zoster
attack thus decreasing the neuronal damage
contributing to PHN17.
Langerhans cell (LCs) play an important role in PHN
as several molecules that sensitize cutaneous
nociceptors are released by LCs. And the langerhans
may be activated in acute PHN. UVB radiation
suppresses antigen presentation of LCs in different
ways. It stimulates keratinocytes and mast cells to
secrete immunosuppressive cytokines such as IL-10,
TNF-, IL-4, PG-E2, -MSH or CGRP, which inhibit the
antigen-presenting function of LCs. Furthermore, it
causes depletion of the LCs in the epidermis 18, which
may also explain the improvement induced by UVB in
PHN.
Also UVB modifies the T-cell response to persistent
VZV particles in nerve fibers, which might be involved
in the pathogenesis of PHN. UVB induces a shift from a
Th-1 immune response to a Th-2 response in different
ways19.
Two studies correlate with the results of this study.
Jalali et al;20 who reported 58.33 and 83.33% complete
pain relief at 1 month and 3 months follow up,
respectively. And concluded that UVB phototherapy in
the acute stage of zoster rash might reduce the incidence
and severity of PHN. Treatment after 3 months does not
seem to have a significant beneficial effect. Also ElNabarawy; 10 who used nbUVB for 17 patients with
post herpetic neuralgia and the results showed more
than 50% improvement was achieved in 6 (35.29%) and
8 (47.06%) patients, at the end of therapy and after 3
2/7/2013, 8:08 PM
months follow up, respectively. And concluded that

nbUVB may provide a potential tool in the management
of PHN.
To the best of our knowledge, there is no study
comparing the efficacy of interferential therapy versus
narrow band ultraviolet B radiation. The results of this
study showed no significant difference in pain intensity
post treatment between both groups in acute and
subacute neuralgia as p value > 0.05 but significant
difference in established neuralgia as p value< 0.05.
This confirm the efficacy of both interferential and
nbUVB for acute and subacute neuralgia, while only
interferntial is effective in established neuralgia. The
limitations of our study were no control group included
and no period of follow-up. Further studies including
control group and follow-up are needed to further
validate our findings.
6.
7.
8.
9.
10.
11.
There is no interest of conflict with any organization,
and this research is not funded
12.
ACKNOWLEDGEMENTS
We express our gratitude to all those who have
contributed in completing this research work, especially
all the subjects who willingly agreed to participate in
this study.
REFERENCES
1.
2.
3.
4.
5.
De Benedittis G, Besana F, Lorenzetti A A new

topical treatment for acute herpetic neuralgia and
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2/7/2013, 8:08 PM
Effect of the Duration of Play on Pain Threshold and Pain

Tolerance in Soccer Players
Shahid Raza1, C.S. Ram2, Jamal Ali Moiz3
Physiotherapist, Centre for Physiotherapy and Rehabilitation Sciences, Jamia Millia Islamia, 2Director, Department of Physiotherapy ITS
Paramedical college, Ghaziabad, 3Assistant Professor, Centre for Physiotherapy and Rehabilitation Sciences, Jamia Millia Islamia
ABSTRACT
Background: The athlete's capacity to tolerate pain is one of the most important features of sporting
success. Research suggest that a verity of pain suffers can benefit from exercise. Duration of play may
increase in pain threshold and pain tolerance in soccer players.
Objective: The purpose of this study was to evaluate the effect of pain threshold and pain tolerance on
participation in playing soccer.
Design: This was a same subject pre-test post-test trial.
Setting: The study was conducted at Siri Fort Sports Complex and Jawaharlal Nehru Stadium (Sports
Authority of India) New Delhi.
Participants: Thirty healthy male district level soccer player (aged 17-22 years) participated in the
study.
Measurements: A gross pressure device was used to induce pain, and to measure pain threshold and
pain tolerance. It consisted of a sphygmomanometer and rubber coated steel cleat. Cleat along with
shin guard was placed of the medial surface of the tibia approximately in the middle portion. Pain was
induced by inflating the sleeve at 10 mmHg every 10 seconds. The subjects were asked to inform when
they first sense pain. The pressure was noted as pain threshold reading. Pressure was further increased
till the subject cannot endure it readings were noted as pain tolerance and pressure was released. The
readings were taken before, between and after the game.
Results: Compared with three readings of pain threshold and pain tolerance a repeated measure of
ANOVA showed a significant difference. A bonferroni test was used for post hoc pair wise comparison
among all three conditions showed a significant difference among three possible pairs.
Limitations: Further work is needed to determine whether sex differences in pain coping mechanism
exist before, during after competition.
Conclusion: The present data suggest that changes in pain threshold and pain tolerance in soccer
player depend on the duration of play. The result of this study proves that the participation in game to
improve the pain threshold and pain tolerance in soccer players.
Keywords: Soccer, Pain Threshold, Pain Tolerance Introduction.
INTRODUCTION
The athletes capacity to tolerate pain is among the
most important features of sporting success.
Researchers contended that the pain tolerance is the
Jamal Ali Moiz
Assistant Professor,
Centre for Physiotherapy and Rehabilitation Sciences,
Jamia Millia Islamia (Central University),
New Delhi-110025,India, E-mail: jmoiz@jmi.ac.in
Phone: +91 (011) 26980544, Fax: +91 (011) 26980544
15. Jamal ali Moitz--76-80.pmd
76
most critical differentiator between successful and

unsuccessful athletes in endurance sports. The ability
to tolerate pain is often inherent in competitive sports
success. Performing physical skills at the optimal efforts,
particular when the movement involves contact with
other participants, virtually maintaining other effort
and skilled performance after experiencing pain during
the contest, and after rehabilitation.1
Dramatic anecdotes of dancers or athletes who
continue strenuous exercise in the face of severe injuries
and later report that they felt no pain have contributed
to the notion that exercise can increase pain tolerance.
2/7/2013, 8:08 PM
Such anecdotal evidence has been linked to theory to

data which indicate that exercise releases endorphins
and that endorphins reduce pain. This proposed
linkage has, intern, led to a belief that exercise-induced
analgesia is an established phenomenon.2
Ronalds Melzack,3 founder of pain gate theory had
described pain in his own words in the following ways
it is not a fixed response to a noxious stimulus ;its
perception is modified by past experiences, expectations
and even by culture. It has a protective function,
warning us that something biologically harmful is
happening. But anyone who has suffered prolonged
pain would regard it as Evil, punishing affection that
is harmful in its own right.
It has been reported by Raithel that most pain
management programmers prescribe some kind of
exercise regimen, some include aerobic exercise, others
include resistance exercise, and still others use a
combination of aerobic and resistance exercise.
Research has been conducted into whether aerobic
exercise, such as cycling and running , is associated
with an analgesic effect, and has indicated that aerobic
exercise at a sufficient intensity (>70% of maximum
aerobic capacity) has been associated with increases in
pain threshold.4
The Literature regarding whether or not exercise
induced analgesia is an established phenomenon in
humans is equivocal. Haier et al (1981)5 have reported
changes in pain threshold following exercise, while
others have not. a number of investigators have studied
changes in pain threshold using a dental pulp
stimulation. Pertovara et al. (1985)6 al investigated
changes in dental pain threshold during exercise at
different intensities and found that dental pain
threshold tends to increase with increasing workload.
The experiments are typical studies investigating
post-exercise analgesia. Their emphasis was not on
supporting the casual role of exercise in the analgesic
effect, but instead focused on whether the analgesic
effect is mediated by release of endorphins. However,
while these studies appear to support the analgesic
effect of exercise, a causal interpretation is limited by
the failure to include a no exercise control group.7
Willium P. Margan(1984)8 examined the effective
beneficence of vigorous physical activity and
concluded that distraction, release of monoamine as
well as endorphins during vigorous physical activities,
act synergistically to produce the analgesic effect.
Ashley Grossaman and John R. Sutton(1984) 9
77
investigated the relationship between the endorphin

relies and their role in exercise and found that the
endorphin concentration in the blood increases
considerably with exercise and play an important role
in regulation of ventilation especially at higher intensity
exercise , where they appear to inhibitory.
Another study by Conard Droste (1990) 10 on
experimental pain threshold and plasma beta
endorphine level dosages does not correlate
significantly with pain threshold, though short term,
exhaustive physical exercise can evoke transient pain
threshold. This exercise induced elevation in pain
threshold does not however, appear to be directly related
to plasma endorphine level.
Maria Gurevich (1994)11 and colleagues found that
submaximal exercise intensity produces analgesia
suggesting the possibility of using moderate exercise
in therapeutic intervention. Another study by Mark HA
and Kenith Russel (1994)1 confirmed that resistive
aerobic exercises can result in greater pain tolerance.
Though the growing body of research suggest that a
variety of pain sufferer can benefit from exercise, and a
greater reliance upon exercise as an effective , healthy
and less intrusive pain management alternatives, or
adjunctive, to pharmacological analgesics can be laid.
However relatively little research has been devoted to
examining the effectiveness of exercise on influencing
the persons threshold and tolerance of pain,
particularly acute.
PURPOSE
The purpose of this study was to evaluate the effect
of pain threshold and pain tolerance on participation
in playing soccer.
HYPOTHESIS
Duration of play will increase the pain threshold
and pain tolerance in soccer players.
METHOD
Subjects
A total number of 30 healthy male district level soccer
players were selected for the study from Siri Fort sports
complex and Jawaharlal Nehru stadium (sports
authority of India) New Delhi. Ethical approval was
obtained from the university ethical committee prior to
recruiting subjects. The mean age of the selected sample
2/7/2013, 8:08 PM
was 18.6 +1.4 ranging from 17to 22 years of age. An

informed consent was taken from all the participants
after describing in detail the procedure and purpose of
the study to all of them. The subjects were selected
according to the following inclusion and criteria.
Inclusion criteria
Age group between 16 to 25 years
Healthy district level soccer players
Only males
Exclusion criteria
Subjects taking pain killers or muscle relaxant drugs
Any recent or previous injury
Non co-operative persons
Those subjects whose pain tolerance exceeded more

than 300 mmHg(maximum rereading for the
sphygmomanometer) during pre-test
DESIGN OF THE STUDY
A same subject pre-test post test design was selected

for testing the hypothesis. A baseline reading was taken
prior to start of the game, a second reading of the
dependent variable were taken during the half time of
the game and final reading immediately after the game
was over. Only one subject was selected for
measurement of dependent variable during a single
game. These readings were then compared to find out
the effect of independent variables. The outcome
measure or dependent variables, selected for this study
were pain threshold and pain tolerance.
Instrument and tool
Sphygmomanometer
Rubber coated steel football cleat
Soccer shin guard
Digital stopwatch to record time

PROCEDURE
Before the warm-up a baseline measurement of pain

threshold and pain tolerance was taken from the
selected subject. The selected subject has been given
instructions regarding not to exercise, not to smoke, not
78
to consume alcohol or caffeine at least two hours before

the game. The subjects were made to lye supine on the
ground to make them comfortable and also to ensure
that they cannot see the sphygmomanometer readings
to avoid giving any visual feedback. A gross pressure
device was used to induce pain, and measure pain
threshold and pain tolerance. It consisted of a
sphygmomanometer and rubber coated steel cleat along
within the shin guard was placed on the medial surface
of the tibia approximately in the middle portion. The
sleeve of the sphinomanometer was fastened around
the shin guard and was inflated.
Pain was induced by inflating the sleeve at 10
mmHg every 10 seconds, which compressed the steel
cleat against the shin causing pain. The subjects were
asked to inform when the first sense the pain. the
pressure reading of the mercury column of the
sphygmomanometer was noted as pain threshold
reading. The pressure was increased further till the
subject cannot endure it. At this point again the
sphygmomanometer readings were noted as pain
tolerance and pressure was released.
Methods of instruction was standardized by giving
the subjects the following commands this apparatus
,using pressure for investigation of sensitivity to pain
you have to say start as soon as you are not able to
bear the pain . These readings were taken before game
again during half time and after the end of the game.
DATA ANALYSIS
Data analysis was done using SPSS software.
Demographic data of patient including age , sex were
descriptively summarised. A repeated measure of
ANOVA was performed to analysed the difference in
pain threshold and pain tolerance. An alpha level of
0.05 was used to determine statistical significance. All
possible pair wise post hoc analysis was conducted on
the significant dependant variable in order to compare
difference among duration of game.
RESULTS
A total thirty (n=30) district level soccer player with
mean+ SD age 18.6+14 years were selected for the
analysis. Before warm-up, prior to the game, during the
half time of the game and at the end of the game both
pain threshold and pain tolerance are summarised in
mean and standard deviation in table 1.
2/7/2013, 8:08 PM
Table 1. Results of pain threshold and pain tolerance at before game, between game and after game
BGM+SD
BTM+SD
AFM+SD
ANOVA
F
Bonferroni
P
BF Vs.BT
BFVs.AF
BTVs.AF
Pain threshold
151+20.6
158.5+21.8
164+25.84
17.05
0.000
0.002
0.000
0.033
Pain tolerance
188.2+27.9
200.2+28.6
209.5+30
19.69
0.000
0.001
0.000
0.019
Significant at p<0.05; BF= before game; BT= between game; AF= after game
To find out the difference among all the three

readings of pain threshold and pain tolerance a
repeated measure of ANOVA shows statistically
significant difference among all the three readings of
both pain threshold (F=17.05,p<0.0001)and pain
tolerance (F=19.69, p<0.0001). A bonferonnin post hoc
pair wise comparison shows significant difference
among three pairs before game vs. between game (pain
threshold p=0.02,pain tolerance =0.001) before game
vs. after game (pain threshold p<0.0001, pain tolerance
p<0.0001) and between game vs. After game (pain
threshold p=0.033, pain tolerance p=0.019) which is
presented in figure 1.
DISCUSSION
The results of this study suggest that competition
modulate pain threshold and pain tolerance responses
to noxious stimuli. Soccer player exhibits higher pain
threshold and pain tolerance during and after the game
compared to before the game.
We believe that the stress component of competition
contributes to the pain inhibition associated with
physical exertion. In soccer scoring chances are rare, a
defensive mistake in soccer, for example, may carry more
importance and cause a higher degree of anxiety and a
defensive mistake in a basketball game. If a defensive
mistake in a basketball game results in a basket for the
opposition, many opportunities to make up the deficit
are likely to occur. Soccer is a players game, during
a game, athletes are expected to make their own
decisions concerning what to do in every situation.
Athlete, who participated in soccer or basketball,
however experienced similar levels of analgesia prior
to game situations. The study provides evidence that
the competitive aspects of competition and its physical
stressors aroused the SIA mechanism. Much of the
existing research on anxiety in sports is too focused on
the characteristics of the athlete, while ignoring the
characteristics of the environment in which the
behaviour took place. Situational variables have been
shown to effect emotions elicited by the various
competitive environment.12
79
Winning experiences, social context, coaching style,

and the nature of sports all play a role in athlete pain
response to meaningful competition and should
therefore be considered in athletes who claim to feel no
pain following an injury. Exercise induced analgesia
is only produced in humans following high level of
exercise with a work load of at least 74% aerobic
capacity. Each testing session was not aerobically
challenging for the participants, and therefore was
unlike to lead to significant changes in pain threshold
and pain tolerance due to exercise.13
Athletes display a rise in pain threshold (analgesia)
in response to athletic completion as compared with
non competitive testing session. Hormonal levels in
soccer players, in game compared to before. Cortsol has
been identified as a reliable marker of stress. Both
analgesia and elevated cortisol levels measured before
games suggest that game situations can be considered
as reliable stressors. Many outside factors also
contribute to overall physiological status of a player
including conditioning activities, practice schedules,
academic demands, and physiological stressors, in
addition to completion. Such factors consistently affect
an athletes overall level of stress and confound
possible cortisol elevations in anticipation of practice.14
Research suggests that environmental stress is a
natural triggers of the inhibition of pain sensation. It
follows the athletes experienced both analgesia prior
to the game and elevated cortisol level due to the stress
of athletic competition. Stress is believed to activate the
endogenous opoid system which will cause the
observed analgesic response.15 Cortsol the stress
hormone is the dominant form of glucocorticiods in
humans. ACTH and -endorphine have roles in the
regulation of stress; Both ACTH and -endorphine have
roles in the regulation of stress; ACTH stimulates the
adrenal which releases cortisol and -endorphinebinds
to opoid receptors which produce analgesia. Thus, the
analgesic findings from the study could be due to the
stress elicited from comparative situations, which in
turn caused analgesia and subsequently higher pain
threshold and pain tolerance. The study supports the
2/7/2013, 8:08 PM
hypothesis that the duration of play increase pain

threshold and pain tolerance in soccer players. 14
Competition can be considered a stressor significant
enough to evoke analgesia in athletes. The study found
that the soccer players have higher pain threshold and
pain tolerance after the game compared to before and
between games.
CONCLUSION
The present data suggest that changes in pain
threshold and pain tolerance in soccer player depend
on the duration of play. The changes may be related to
stress mechanism that involves within the competition.
The result of this study proves that the participation in
game to improve the pain threshold and pain tolerance
in soccer players.
ACKNOWLEDGEMENTS
The authors wish to acknowledge the co-operation
of all the participants who participated in this study.
The authors extend their thanks to M.S. Basins, senior
Physiotherapist, Sports Authority of India, for his cooperation throughout this study process.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Conflict of Interest
The authors have no conflict of interest to declare.
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2/7/2013, 8:08 PM
Neuromuscular Electrical Stimulation Versus Intermittent

Pneumatic Compression on Hand Edema in Stroke
Patients
Eman S.M.Fayez1, Hala Ezz Eldeen2
Assistant Professor in Department of Physical Therapy for Neuromuscular Disorders and its Surgery, Faculty of
Physical Therapy, Cairo University, 2Professor in Department of Cardiopulmonary Rehabilitation and Geriatrics.
Faculty of Physical Therapy, Cairo University
1
ABSTRACT
Objective: the purpose of this study was to evaluate and compare between the effect of application of
neuromuscular electrical stimulation and intermittent pneumatic compression on reducing hand edema
in stroke patients.
Subjects: Thirty stroke patients of both sexes (18 females and 12 males).They assigned randomly into
2 study groups each one composed of 15 patients.
Method: Group I received intermittent pneumatic compression therapy and group II received
neuromuscular electrical stimulation three times per week for twelve weeks. The patients were assessed
for hand volume by using the volumetric measurement and by hand held dynamometer to measure
hand grip strength before and after the end of treatment period.
Results : The results of this study revealed that application of intermittent pneumatic compression
therapy had a significant effect on reducing hand edema in stroke patients than receiving neuromuscular
electrical stimulation .While hand function measured by hand grip strength was improved more
significantly with receiving neuromuscular electrical stimulation than the group who received
intermittent compression therapy.
Conclusion: Application of intermittent pneumatic compression therapy was more effective in reducing
hand edema than neuromuscular electrical stimulation while application of neuromuscular electrical
stimulation resulting in greater improvement in hand grip strength and hand function.
Keywords: Stroke, Hand Edema, Hand Function, Neuromuscular Electrical Stimulation and Intermittent
Pneumatic Compression Therapy
INTRODUCTION
In hemiplegic patients, swelling of the affected hand
is a recognized phenomenon. The mechanism of
swelling is uncertain, but it had many predisposing
factors as immobility, dependency, impaired venous
return and paralysis of the sympathetic control of
vasculature.1
Edema in paretic hand may be attributed to a
combination of dependency and insufficient muscle
pump resulted from hemiplegia that will hamper
venous return in the affected limb which in turn will
increase the capillary filtration resulting in edema
which can be the main mechanism of hand edema in
that cases.3-4
81
Pain and disfigurement resulted from edema which

in chronic cases may predispose to contractures. This
combined with the increased weight of the limb, which
may interfere with the rehabilitation of the limb and
affect hand function 5.
Hand edema following stroke is associated with pain
and stiffness, which can lead to a decrease in active
motion and disuse. The most widely accepted
explanation is due to increase venous congestion related
to prolonged dependency and loss of muscle pumping
function in the paretic limb6.
In stroke rehabilitation neuromuscular electrical
stimulation (NMES) can be used to modulate neural
activity to either regain voluntary muscle contraction
2/7/2013, 8:08 PM
or to prevent abnormal muscle reaction due to weakness

and spasticity7 .It was found that application of (NMES)
had a significant effect in reducing hand edema post
stroke because it produce an active muscle pump
resulted in removing excess fluid 8-9. Others studied the
application of intermittent pneumatic compression
(IPC) in treating hand edema following stroke but they
found that (IPC) had a limited role in reducing edema if
it used solely1. The aim of this study was to evaluate
and compare between effect of application of (NMES)
and (IPC) on reducing hand edema and improving
hand function in stroke patients.
MATERIAL AND METHOD
Subject selection
Thirty patients of both sexes (18 females and 12

males) who were diagnosed as stroke and referred
by a neurologist. All of the participants complained
from wrist and hand edema. The mean age was
547 years. They were selected from the out-patient
clinic of the faculty of physical therapy, Cairo
University. CT was performed for all patients to
confirm the diagnosis. All patients had grade 1 to 2
of spasticity according to the modified Ashworth
Scale10. Subjects were excluded if they had major
cognitive impairment, heart failure, myocardial
infarction, lymphedema, or trauma, . The patients
were assigned into 2 groups equal in number group
I which composed of 15 patients (10 females and 5
males ) and they received (IPC) .Group II composed
of 15 patients (8 females and 7 males ) and they
received (NMES).
Equipments
Volumeter which is used to objectively measure the
volume of body parts by using the fluid displacement
method1. Hand digital dynamometer was used to
measure the grip strength in affected hand to measure
the impact of treatment on hand function12. Vasotrain
447, Enraf-Nonius apparatus for application of (IPC).
The 2-channel Respond Select II electrical stimulator
(Texas, USA) was used for application of (NMES) .
Procedures
All patients received the same standard physical
therapy treatment designed for stroke patients, for 30
min on 3 days each week for 12 weeks, respectively.
Group I patients received (IPC) therapy as follows, a
stockinet layer was applied to the hemiplegic limb to
absorb moisture and a full arm-inflatable sleeve was
82
applied over this and attached to the compression

pump. The pressure levels were set as an intermittent
compression manner which composed of a pressure of
80-120 mmHg for 40 seconds as compression phase
and a pressure of 40 mmHg for 20 seconds as deflation
phase 1.Each patient in both study groups received
treatment once a day, 3 sessions weekly for 12 weeks.
The patients in (group II) were given (NMES). The
surface electrodes were applied on hand flexor muscle
group. This stimulation pattern will be administered to
this muscle group for approximately 20 minutes.
Electrodes will then be repositioned and applied to the
extensor muscle group for approximately 20 minutes.
The stimulation was at a frequency of 30 Hz, with a
pulse width of 300 s. The amplitude of the current was
adjusted to the maximal tolerance of the patient, in a
range up to 90 micro ampere , with a duty cycle of 5
second on and 5 second off. The total stimuli were 180
cycles during the treatment session. Patients were
focusing on the movement induced by (NMES) during
the treatment. Treatment lasted for 30 min., 3 days per
week for 12 weeks.
The outcome data were measured as follows the
volumeter was placed on a horizontal stable surface
and filled with tap water to the level of the spout. The
patient was asked to lower his hand into the volumeter.
This made the water to displace from the spout to be
collected into a graduated glass container. The collected
water in the graduated container which referred to
patients hand volume was measured. For measuring
hand grip strength each patient was instructed to start
grip strength measures by using digital dynamometer,
while elbow flexed 90 degree with hand and forearm in
mid position and rested on the table.
The measurements were repeated three times and
an average measure was taken for the hand volume
and hand grip strength.
Statistical analysis
The data were descriptively analyzed by
calculating: Mean Standard deviation. Student t. test
was used to compare the mean of pre and post study
measurements of hand volume and hand grip strength
in each group .The statistical significance difference
was determined with P value d0.05.Unpaired t.test
was used to compare these findings between study
groups. Pairson correlation was used to measure the
relationship between hand volume and hand grip
strength in each group.
2/7/2013, 8:08 PM
RESULTS
I Anthropometric characteristics of both groups:
Table (1) Anthropometric characteristics of the patients in the two groups represented in table (1)
Comparison
Group I
Mean
Group II
SD
P value
Mean
SD
Age
47.5
6.1
48.3
4.5
0.693
Height
170.3
5.13
173.9
8.4
0.432
Weight
83
13.4
85.5
10.6
0.649
Male
Female
10
23.7
4.1
25.6
2.8
0.635
BMI
II Comparison between the pre, and post hand, wrist volume and grip strength in group I.
Table (2) shows comparison between the pre, and post hand, wrist volume and grip strength in group I. There was a
significant decrease in hand and wrist volume. Also, there was a significant increase in hand grip strength in group
I who received (IPC)
Mean hand
volume (cm)
SD (cm)
Mean hand grip

strength (Newton)
SD
(Newton)
Pre
469.50
13.329
4.33
1.49
Post
421.40
19.687
6.65
P value
0.0001**
2.41
0.0475*
**highly significant * significant
III Comparison between the pre, and post hand , wrist volume and grip strength in group II.
Table (3) shows comparison between the pre, and post hand, wrist volume and grip strength in group II. There was
a significant decrease in hand and wrist volume. Also, there was a highly significant increase in hand grip strength
in group II who received (NMES)
Mean hand
volume (cm)
SD (cm)
Mean hand grip

strength (Newton)
SD
(Newton)
Pre
464.67
15.562
5.13
1.51
Post
447.00
14.938
7.35
P value
0.0032*
1.91
0.0001**
IV comparison between the pre, and post values of hand, wrist edema and hand grip strength in both study
groups
Table (4) reveals the pre, and post values of hand, wrist edema and hand grip strength in both study groups. There was
statistically significant decrease in hand volume in group I who received (ICP) when compared with group II who
received (NMES). While there was statistically significant improvement in hand grip strength in group II when compared
with group I.
Table (4) comparison between the pre, and post values of hand, wrist edema and
hand grip strength in both study groups
Mean hand
volume (cm)
P value
Mean hand grip

strength (Newton)
Group I
P value
Group I
Group II
Pre
469.50
464.67
0.4060
4.33
5.13
0.1185
Post
421.40
438.00
0.0356*
6.65
7.35
0.0008**
83
2/7/2013, 8:08 PM
Group II
V- Correlation between hand volume and hand grip strength in both study groups:
Table (5) There was a statistically significant correlation between hand volume and hand grip strength in group I.
While there was none statistically significant correlation between hand volume and hand grip strength in group II.
Group I
Hand
volume
Hand grip
strength
421.40
6.65
-0.6301
P value
0.0118
Group II
Hand
volume
Handgrip
strength
438.00
7.35
P value
-0.3979
0.1588
Figure (4) Correlation between hand volume and hand grip strength in both study groups
DISCUSSION
Edema of the hand is one of the complications that
can developed after stroke. The etiology of edema
formation might be due to dependency and loss of
muscle pump efficiency due to hemiplegia will hamper
the return of blood in the veins of the affected limb20.
Because there was great contradictions about the
effect of both IPC and NMES on reduction of edema in
stroke patients hand . So, this study was conducted to
help in determination the most effective modality with
more prolonged effects on the edema of the hand in
stroke patients. The study was performed on 30 stroke
patients (18 females and 12 males) complicated with
hand and wrist edema. Group I received therapy, while
group II received (NMES). Both groups underwent their
programs 3 times a week for 12 weeks. The collected
data included values of hand, wrist volumes and hand
grip strength which were measured before and after
the treatment program.
Looking for group I, showed reduction of mean value
of hand volume from the statistical analysis of data of
group I showed improvement of hand edema after three
months of treatment.
These results can be attributed to the evidence that
(IPC) increases venous velocity, reduces edema,
enhances fibrinolytic activity and reduces the damaging
effect of white cell activity13.
84
It can also be due to the increased venous and

lymphatic return as a result of external pressure on a
limb. This external compression not only moves the
lymph and fluids along, but also it may spread the
intercellular edema over a larger area, enabling more
lymph and venous capillaries to become involved in
removing the plasma proteins and water 21.
The mechanism of improving hand edema by the
use of intermittent pneumatic compression therapy can
also be explained as intermittent high pressure
compression allows limb salvage in patients with
hemostasis and limb-threatening ischemia who are not
candidates for revascularization.14.
The results of this study agree with (Armstrong and
Nguyen 2001 )19 who reported that pneumatic
compression is an effective tool for the reduction of
edema.
On the other hand there was contradiction with
(Roper et al,1999) 1 in his previous study for the
treatment of the edematous stroke hand with
intermittent pneumatic compression (IPC)using a
pressure of 50 mmHg, applied with 30 sec inflation
and 20 sec deflation duty cycle treatment comprised
daily for 1 month. This study showed no influence
neither on edema reduction nor upper limb function. It
seems that good results in our study were obtained
because we used higher pressure levels (a pressure of
80-120 mmHg for 40 seconds as compression phase I
2/7/2013, 8:08 PM
and a pressure of 40 mmHg for 20 seconds as

compression phase II, deflation) and longer treatment
periods (session period was 30 minutes, one session a
day, 3 days weekly for 12 weeks).
Concerning group II neuromuscular electrical
stimulation, their data showed reduction hand volume.
However the reduction in hand edema in group II may
be resulted from production of an active muscle pump
which cause removing excess fluid during application
of neuromuscular stimulation induced contraction of
the paralyzed muscles 7. Also, application of
neuromuscular stimulation resulted in increased
muscle bulk and strength. This will also lead to greater
capillary density and therefore improved local blood
supply and tissue condition17. Neuromuscular electrical
stimulation had also been reported to modulate edema
by reducing capillary permeability22.
The results of the present study were in accordance
with Gad e al 16 who reported that application of
neuromuscular electrical stimulation can improve
selected hand functions and impairment of chronic
stroke survivors.
This finding was also supported by previous study,
which reported reduction in hand volume due to
compression and squeezing of venous and lymphatic
vessels caused by skeletal muscles contraction that
results from the electrical stimulation. These repetitive
contractions may promote reabsorption of leakage fluid
and proteins with subsequent edema reduction11.
Our results demonstrated that there was a
significant increase in hand grip strength as an
indicator of hand function 12in both groups but this
improvement was significantly higher in group II than
in group I. These results may be attributed to improving
strength, voluntary movement, force production, and
functional skill abilities in the upper extremity resulted
from application of neuromuscular electrical
stimulation15.
Thus the present study revealed (IPC) was more
significantly effective than NMES in reducing hand
edema in stroke patients .Perhaps, this difference
resulted from increased venous and lymphatic flow due
to application of external compression was higher than
that caused by muscle pumping due to electrical
stimulation. Although NMES had an effect on reducing
capillary permeability this effect didnt cause edema
reduction as compression therapy.
85
RECOMMENDATION
It is recommended to use intermittent compression
therapy in conjunction with neuromuscular electrical
stimulation especially in patients who have been failed
in controlling their hand edema with standard therapy
modalities. Further studies needed to compare between
different types of current stimulation and the
summation effect of both therapy modalities.
REFERENCES
1.
Roper TA, et al. Intermittent compression for the

treatment of the edematous hand in hemiplegic
stroke: a randomized controlled trial, Age and
aging; 1999; 28:9-13.
2.
Boomkamp k., et al: post stroke hand swelling and
edema: prevalence and relationship with
impairment and disability. Clinical rehabililtation;
2005; 19:552-559.
3.
Wang JS, et al: Neuromuscular electric stimulation
enhances endothelial vascular control and
hemodynamic function in paretic upper
extremities of patients with stroke. Arch Phys Med
Rehabil; 2004; 85:1112-1116.
4.
Leibovitz A, et al. Edema of the paretic hand in
elderly poststroke nursing patients. Arch Gerontol
Geriatr. ; 2007; 44:37-42.
5.
Faghri PD, The effects of neuromuscular
stimulation-induced muscle contraction versus
elevation on hand edema in CVA patients. J Hand
Ther; 1997; 10:29-34.
6.
Chae J. A critical review of neuromuscular
electrical stimulation for treatment of motor
dysfunction in hemiplegia. Asst Technol; 2000; 12:
33-49.
7.
Maram J, et al. Neuromuscular stimulation after
stroke: from technology to clinical deployment.
Expert. Rev. Neurother, 2009; 4-9.
8.
Ashworth MS and Tardieu .Their Clinical
Relevance for Measuring Spasticity in Adult and
Pediatric Neurological Populations. Physical
Therapy Reviews; 2002; 1: 53-62.
9.
Griffin JW, et al .Reduction of post traumatic hand
edema: A comparison of high voltage pulsed
current, intermittent pneumatic compression and
placebo treatments. Phys Ther; 1996; 70; 5:279-285.
10. Alan S. et al. Arm functions after Stroke .An
evaluation of grip strength as a measure of recovery
and a prognostic indicator. J Neurol, Neurosurg,
and Psychiatry; 1989; 52:1267-1272.
11. Vowden K .The use of intermittent pneumatic
compression in venous ulceration. Br. J. Nurs. ;
2001; 10; 8: 491-509.
2/7/2013, 8:08 PM
12. Bemellen V, et al .Intermittent high-pressure

compression in homeostasis. Arch Surg; 2001;
136:1280-1285.
13. Ziling L and Tiebin Y.Long term effectiveness of
neuromuscular electrical stimulation for
promoting motor recovery of the upper extremity
after stroke. J Rehabil Med; 2011; 43:506510.
14. Gad A.et al. A home based self administered
stimulation program to improve selected hand
functions of chronic stroke. Neuro Rehabilitation;
2003; 18:215225.
15. Chae J, Yu D. A criical review of neuromuscular
electrical stimulation for treatment of motor
dysfunction in hemiplegia. Asst Techno; 2000; 12:
33-49.
16. Winsor T. et al .The effect of venous compression
86
17.
18.
19.
20.
on the circulation of the extremities. Arch Phys

Med Rehab; 1999; 34: 559-565.
Armstrong DG, Nguyen HC .Improvement in
healing with aggressive edema reduction after
debridement of foot infection in persons with
diabetes. Arch Surg.; 2001; 135:1405-1409.
Boomkamp KH et al, Post stroke hand swelling
and edema: prevalence and relationship with
impairment and disability .Clinical Rehabilitation;
2005; 19:552-559.
Wilkerson J External compression for control of
traumatic edema. Phys Sports Med.; 2001;
13(6):97-106.
Bettany JA,etal Influence of high voltage pulsed
direct current on edema formation following
impact injury. Phys Ther; 1990; 70(4):219-224.
2/7/2013, 8:08 PM
A Combination Approach using Manual Therapy and

Exercise in the Treatment of Shoulder Impingement
Syndrome
Annamma Mathew1, Abedi Afsaneh2
Assistant Lecturer, College of Allied Health Sciences, Gulf Medical University, Ajman, UAE
2
Physiotheapist, Gulf Medical College Hospital and Research Center, Ajman, UAE
ABSTRACT
The purpose of this case study was to compare the effectiveness of traditional physical therapy
interventions of using therapeutic modality and exercise versus a combined approach using
mobilization with movement and exercises in the treatment of shoulder impingement syndrome. A
total of 5 patients diagnosed with shoulder impingement syndrome were selected from the hospital.
Patients then participated in the programs, which were held twice a week for two months. Main
outcome measures included 24-hour pain (VAS), shoulder active range of motion (AROM), and shoulder
function (SPADI). Repeated-measures analysis indicated significant decreases in pain, improved
function, and increases in AROM. The MWM had a higher percentage of change from pre- to posttreatment on pain measures pain (VAS): 0.6 to 0.2 following 4 session treatment, higher percentage of
change on the SPADI and in AROM.
This study suggests that performing glenohumeral mobilizations with movement (MWM) in combination
with a supervised exercise program may result in a greater decrease in pain and improved function
although studies with larger samples and discriminate sampling methods are needed.
Keywords: Exercise, Glenohumeral Mobilization, Mobilization with Movement.
INTRODUCTION
Shoulder impingement syndrome, the most common
diagnosis of shoulder dysfunction1, is often de-scribed
as shoulder pain exacerbated by overhead activities.
Primary shoulder impingement occurs when the rotator
cuff tendons, long head of the biceps ten-don,
glenohumeral joint capsule, and/or subacromial bursa
become impinged be-tween the humeral head and
anterior ac-romion. Primary impingement may be due
to intrinsic factors: rotator cuff weak-ness2, chronic
inflammation of the rota-tor cuff tendons and/or
subacromial bursa, rotator cuff degenerative
tendi-nopathy, and posterior capsular tight-ness
leading to abnormal anterior/supe-rior translation of
Mrs. Annamma Mathew
College of Allied Health Sciences
Gulf Medical University
Ajman, UAE
Email: researchdivision2@gmail.com
17. JAYAKUMARI--87-89.pmd
87
the humeral head. It may also be due to extrinsic factors:

possession of a curved or hooked acro-mion, acromial
spurs, or postural dysfunction. Secondary shoulder
im-pingement is defined as a relative de-crease in the
subacromial space due to glenohumeral joint instability
or abnor-mal scapulothoracic kinematics. Commonly
seen in athletes engaging in overhead throwing
activities, second-ary impingement occurs when the
rota-tor cuff becomes impinged on the poste-riorsuperior edge of the glenoid rim when the arm is placed
in end-range ab-duction and external rotation. This
posi-tioning becomes pathologic during excessive
external rotation, anterior cap-sular instability, scapular
muscle imbal-ances, and/or upon repetitive over-load
of the rotator cuff musculature. Physical therapy has
been found to be effective in reducing pain and
disability in patients with shoulder impingement.
Effective interventions include therapeutic exercises
focusing on strengthening the rotator cuff and scapular
stabilizing musculature 3, stretching to decrease
capsular tightness, scapular taping techniques, and
patient education of proper posture.
2/7/2013, 8:08 PM
CASE PRESENTATION
The present study was conducted on five female
patients, aged 32-45 (mean 39.8 years) with chief
complaint of intermittent catching pain on shoulder,
complaint of night pain and unable to sleep on involved
side, who were diagnosed as having shoulder
impingement syndrome. The effect of treatment was
assessed based on the following dependent variables:
pain intensity measured with VAS scale; pain-active
ROM measured with a standard goniometer for flexion
and abduction; and a measurement of shoulder function
assessed with the Shoulder Pain and Disability Index
(SPADI)4-5. These traditional interventions included
TENS, posterior capsule stretching, postural correction
exercises, and an exercise program focusing on rotator
cuff strengthening and scapular stabilization. A manual
therapy approach to treating shoulder dysfunction is
the Mulligan concept of mobilization with movement
(MWM)6. The goal of per-forming MWM is immediate
and sus-tained improvement in joint pain and mobility.
Mulligans techniques6 entail having the physical
therapist apply an accessory mobilization to a
peripheral joint while the patient simultaneously
generates active movement. This procedure was
repeated for a total of 3 sets of 10 repetitions as long as
pain-free motion was sustained; if pain commenced
during any repetition of any set, the technique was
terminated. This technique involved the therapist
applying a sustained posterior accessory glide to the
glenohumeral joint while the subject simultaneously
actively flexed the shoulder to the pain-free endpoint
and applied a gentle overpressure force using the
contralateral arm. Total abolition of pain during the
technique was mandatory; if the patient started to
experience pain during active motion, the therapist
would investigate different force planes and/or grades
of force until pain-free motion was restored.
Table 1. Baseline demographics and pre-treatment
means
DVs
Mobilisation
with Movement
VAS
6/10
Flexion
90 0
Abduction
80 0
SPADI
48.6%
Age
39.8 years
VAS = visual analog scale;

SPADI = Shoulder Pain and Disability Index.
88
The study shows, significant decrease in pain (VAS):

0.6 to 0.2 following 4 session treatment spread over 3
weeks and increases in function (SPADI): 0.48 to 0.25.2
and Abduction ROM: 96 to 166 within 8 session
treatment following 5 weeks, compared to traditional
intervention, which was done without manual therapy
technique.
Table 2. Changes after treatment
DVs
Exercise
MWM
VAS
3/10
2/10
Flexion
150 0
170 0
Abduction
162 0
167 0
34.2%
15%
SPADI
MWM = mobilization with-movement group;

VAS = visual analog scale;
SPADI = Shoulder Pain and Disability Index.
The MWM (mobilization with movement) had a

higher percentage of change from pre- to post-treatment
on pain measures pain (VAS 6/10 to 2/10) following
four session treatment, and a higher percentage of
change on the SPADI and in AROM.
DISCUSSION
The purpose of this case study was to describe the
effect of exercise therapy combined with manual
therapy in treatment of patients with shoulder
impingement. It appears that the combined intervention
of manual therapy and exercises for five weeks provided
significant reductions in pain measures in subjects to
those received only modality and exercise alone. It is
important to note that the patients underwent
traditional physiotherapy for an extended period with
minimal improvement. Where as in patients who had
undergone physical therapy intervention of manual
therapy and exercise their end of treatment assessment
score reflected improvement in the symptoms such as
significant difference in the VAS, SPADI and AROM.
Thus the combined treatment of manual therapy and
exercises has proven to be effective in management of
shoulder impingement syndrome.
CONCLUSION
In summary, the physical therapy inter-ventions of
Manual therapy base on MWM in combination with
an exercise program resulted in decreasing pain and
improving function compared to traditional physical
therapy intervention.
2/7/2013, 8:08 PM
REFRENCES
1.
2.
3.
Millar AL, Jasheway PA, Eaton W, et al. A

retrospective, descriptive study of shoulder
outcomes in outpatient physical therapy. J Orthop
Sports Phys Ther 2006;36:403-14.
McClure PW, Michener LA, Karduna AR. Shoulder
function and 3-dimensional scap-ular kinematics
in people with and without shoulder
impingement syndrome. Phys Ther 2006;86:
1075-1090.
Belling SAK, Jorgensen U. Secondary impingement
in the shoulder. Scand J Med Sci Sports 2000;10:
266-278.
89
4.
5.
6.
Williams JW, Holleman DR, Simel DL. Mea-suring

shoulder function with the shoulder pain and
disability index. J Rheumatol 1995;22:727-32.
Ludewig PM, Borstad JD. Effects of a home exercise
program on shoulder pain and functional status
in construction workers. Occup Environ Med
2003;60:841-849.
Mulligan BR. Manual Therapy Nags, Snags,
Mwm, etc, 4th editon. Wellington, NZ: Plane View
Series Ltd, 1999.
2/7/2013, 8:08 PM
Musculoskeletal Pain among Computer Users

Shweta Keswani1, Lavina Loungni1, Tiana Alexander1, Hebah Hassan1, Shatha Al Sharbatti2,
Rizwana B Shaikh3, Elsheba Mathew4
1
MBBS students, College of Medicine, Gulf Medical University, Ajman, UAE
2
Professor and Head, 3Assistant Professor, 4Professor, Department of Community Medicine, College of Medicine,
Gulf Medical University, Ajman, UAE
ABSTRACT
Objective: The objective was to assess muscle pain as an effect of utilizing computers for more than five
hours and identify the variables associated with the occurrence of pain and the measures taken to
prevent.
Methods: It is a descriptive study conducted on 249 subjects in different private organizations in UAE.
All those who mentioned wrist, back or neck pain without any pre-existing musculoskeletal problems
among those who work on computer for more than 5 hours were included in the study. Questionnaires
were distributed to all those who satisfied the inclusion criteria in each of the offices identified.
Results: A significant association was noticed between age and wrist pain and no significant association
was observed between gender, onset of pain and wrist pain. Higher frequency of back pain was noticed
in older age group compared to younger. Neck pain was found to be higher among participants between
60-69 years of age. The incidence of pain in the wrist was more in men than in women and a similar
pattern was seen in hand and back pain too. Our study shows a positive relation between sleep hours
and musculoskeletal pain.
Conclusion: We concluded that wrist, neck and back pain is more prevalent in younger age groups and
it increases as the duration of computer use increases. Pain was a problem in majority of people
working on computer for more than 5 hours.
Keywords: Musculoskeletal pain, Computer users, Duration of computer use
INTRODUCTION
Musculoskeletal disorders affect all age groups and
frequently cause disability, impairments, and
handicaps. They consist of a variety of different diseases
that cause pain or discomfort in the bones, joints,
muscles, or surrounding structures, and can be acute
or chronic, focal, or diffuse. In one study among Detroit
residents who kept track of daily health symptoms in a
diary, musculoskeletal symptoms constituted the most
frequent category of health symptoms1.
Shatha Al Sharbatti
Professor and Head
Dept. of Community Medicine
Gulf Medical University
Ajman, United Arab Emirates
P O Box: 4184
Email: shatha_alsharbatti@yahoo.com
18. JAYAKUMAR--90--95.pmd
90
Musculoskeletal disorders (MSDs) are highly

prevalent; because of their association with aging, they
are likely to become more prevalent as the population
ages throughout the world. While many of these
disorders are not devastatingly disabling to affected
individuals, their prevalence is so great that more
mobility and other limitations are accountable to these
disorders than to any other type. While much of the
substantial cost of these disorders is due to the medical
care and medications and other treatments required by
patients, the preponderance of costs is due to work loss,
which is a frequent consequence of these disorders. Not
only do MSDs cause personal suffering and loss of
income, but they also cost businesses and affect national
economies. Any worker can be affected, yet MSDs can
be prevented by assessing work tasks, putting in place
preventive measures, and checking that these measures
stay effective.
Most work-related MSDs are cumulative disorders,
resulting from repeated exposure to high or low
2/7/2013, 8:08 PM
intensity loads over a long period of time. However,

MSDs can also be acute traumas, such as fractures, that
occur during an accident2.
These disorders mainly affect the back, neck,
shoulders and upper limbs, but can also affect the lower
limbs. Some MSDs, such as carpal tunnel syndrome in
the wrist, are specific because of their well-defined signs
and symptoms. Others are nonspecific because only
pain or discomfort exists without evidence of a clear
specific disorder3. Different groups of factors may
contribute to MSDs, including physical and
biomechanical factors, organizational and psychosocial
factors, individual and personal factors .These may act
uniquely or in combination.
An integrated management approach is necessary
to tackle MSDs. This approach should consider not just
the prevention of new disorders, but also the retention,
rehabilitation and reintegration of workers who already
suffer from MSDs4. Individuals with musculoskeletal
complaints should be evaluated with a thorough history,
a comprehensive physical examination, and, if
appropriate, laboratory testing. The initial encounter
should determine whether the musculoskeletal
complaint is (1) articular or nonarticular in origin, (2)
inflammatory or noninflammatory in nature, (3) acute
or chronic in duration, and (4) localized or widespread
(systemic) in distribution5. The present study was
conducted to assess the musculoskeletal problems
among computer users and rationalize the variables
that play a part in the occurrence of the pain and, to
assess the knowledge of face such problems and, to

evaluate the measures taken to tackle and prevent
musculoskeletal problems.
This descriptive study was conducted in the
following settings viz. Ajman chamber of commerce
building, Alco Shipping Services (Ajman), TNT branch
(Deira), Ocean View Real Estate (Dubai), Oman
Insurance (Ajman branch), AMB constructions, Gulf
Chain, GMU and GMCHRC. Total 249 employees in
the above settings participated in the study and the
data was collected from 2009 March to 2010 January.
We selected all those people who mentioned wrist, back
or neck pain without any pre-existing musculoskeletal
problems and those who work on computer for 5 hours
or more. All those who had previous musculoskeletal
problems, and who work less than 5 hours on the
computer were excluded. A questionnaire was used for
data collection including variables like Age, Sex,
Nationality, Smoking status, Alcohol status, Diabetes,
People with Wrist, Back and Neck pain.
The questionnaires were distributed to different
offices, selecting one office at a time to those who used
the computer for 5 hours or more and the completed
questionnaires were collected within two three days.
The whole process was repeated in all the above
mentioned offices. The data from the questionnaire was
then entered in an excel sheet and analyzed using PASW
18.0 version.
RESULTS
Table- 1. Distribution of wrist pain according to gender, age and duration of computer use
Variables
Group
Wrist pain
Yes
Gender
Duration of computer use
Percent
Number
Percent
82
61.2
73
63.5
Female
52
38.8
42
36.5
20-29
61
45.5
46
40.0
30-39
47
35.1
34
29.6
40-49
16
11.9
15
13.0
50-59
10
7.5
13
11.3
60-69
07
6.0
< 5 hrs
14
43.8
18
56.3
5-7 hrs
26
40.0
39
60.0
7-9 hrs
55
59.8
37
40.2
> 9 hrs
39
65.0
21
35.0
Male
Age group
91
No
Number
2/7/2013, 8:08 PM
Table 1 shows distribution of the study subjects by

wrist pain and gender. Higher
frequency of wrist pain was noticed among females
when compared with males. No
significant association was noticed between wrist
pain and gender (P>0.05). Distribution of the studied
sample by wrist pain and age shows a higher frequency
of wrist pain was noticed in younger age groups
compared with older ones. Statistically significant

association was found between age and wrist pain
(P<0.05). Distribution of the studied sample by wrist
pain and duration of computer use for the onset of pain
shows higher frequency of wrist pain was noticed
among worker after working for more than 5 hours. No
significant association was noticed between wrist pain
and duration for the onset of pain. (p>0.05)
Table 2. Distribution of Back pain according to gender, age, and duration of computer use
Variables
Group
Back pain
Yes
Gender
Age group
No
Number
Percent
Number
Percent
Male
113
61.1
42
65.6
Female
72
38.9
22
34.4
20-29
81
43.8
26
40.6
30-39
54
29.2
27
42.2
40-49
25
13.5
06
9.4
50-59
20
10.8
03
4.7
60-69
05
2.7
02
3.1
< 5 hrs
17
53.1
15
46.9
5-7 hrs
50
76.9
15
23.1
7-9 hrs
66
71.7
26
28.3
> 9 hrs
52
86.7
08
13.3
Higher frequency of back pain was noticed among

females compared with males. No
significant association was noticed between wrist
pain and gender (P>0.05). Higher frequency of back
pain was noticed in 50-60 years of age group. No
significant association was found between age and

back pain (P>0.05). Higher frequency of back pain was
noticed among worker after working for more than
5hours. Significant association was noticed between
wrist pain and duration for the onset of pain. (p<0.05)
(Table 2).
Table- 3. Distribution of neck pain according to gender, age and duration of computer use
Variables
Group
Neck pain
Yes
Gender
Male
Age group
92
No
Number
Percent
Number
Percent
114
61.6
41
64.1
Female
71
38.4
23
35.9
20-29
80
43.2
27
42.2
30-39
62
33.5
19
29.7
40-49
20
10.8
11
17.2
50-59
16
8.6
10.9
60-69
3.8
< 5 hrs
19
59.4
13
40.6
5-7 hrs
45
69.2
20
30.8
7-9 hrs
69
75.0
23
25.0
> 9 hrs
52
86.7
08
13.3
2/7/2013, 8:08 PM
Table 3 - Shows distribution of neck pain by gender.

Higher frequency of neck pain was noticed among the
studied females compared with males. No significant
association was noticed between wrist pain and gender.
(P>0.05)
Higher frequency of neck pain was noticed in 60-69
years age group. Statistically no significant association
was found between age and neck pain. Higher
frequency of neck pain was noticed in 60-69 years age
group. No significant association was found between
age and neck pain.
Higher frequency of neck pain was noticed among
worker after working for more than 5 hours. Significant
association was noticed between neck pain and
duration for computer use. (p<0.05). Lowest frequency
of headache was noticed in more than 60 years age
group. Significant association was found between age
and headache. Higher frequency of headache was
noticed among the studied females compared with
males.
Significant association was noticed between
headache and gender. (P<0.05). Highest frequency of
headache was seen in the age group 30-39 years.
Significant association was noticed between headache
per week and age group. (P<0.05). The higher frequency
of headache was noticed to be twice per week for males
and four times per week for females. Significant
association was found frequency of headache and
gender. Higher frequency of headache was observed
among participant who had neck pain. No significant
association was found between headache and neck
pain (P>0.05). Lower frequency of wrist pain was
noticed when ergonomic facilitates were available at
work place however no significant association was
found between availability of ergonomic facilities at
work place and wrist pain (P>0.05). No significant
association was found between availability of
ergonomic facilities at work place and back pain
(P>0.05). Lower frequency of neck pain was noticed
when these facilitates were available at work place.
Significant association was found between availability
of ergonomic facilities at work place and neck pain
(P>0.05). No Significant association was found between
availability of break in between work and wrist pain
(P>0.05). Lower frequency of back pain was noticed
when these breaks were available between work.
of break in between work and back pain. (P<0.05). No
93

of break in between work and neck pain (P>0.05).
Significant association was found between neck pain
and sleep hours. (P>0.05). Higher frequency of people
with wrist pain had complained of work affecting sleep.
Significant association was found between wrist pain
and work affecting sleep (P<0.05). Higher frequency of
people with back pain had complained of work
affecting sleep. Significant association was found
between back pain and work affecting sleep (P<0.05).
No Significant association was found between neck
pain and work affecting sleep (P>0.05). No Significant
association was found between change in posture
during work and wrist pain (P>0.05). Lower frequency
of back pain was noticed when change in posture
applied during work No Significant association was
found between change in posture during work and back
pain (P>0.05). No significant association was seen
between weight gain and breaks between work hours
(P>0.05). Higher frequency of diabetics had back pain,
but there is no significant association between the two
(P>0.05).
Higher frequency of diabetics had neck pain, but
there is no significant association between the two
(P>0.05). Highest frequency of moderate wrist pain was
observed with alcohol consumption. There is no
significant association between alcohol consumption
and severity of pain. Highest frequency of moderate
back pain was observed with alcohol consumption.
There is no significant association between alcohol
consumption and severity of pain. Highest frequency
of moderate neck pain was observed with alcohol
consumption. There is no significant association
between alcohol consumption and severity of pain.
Lower frequency of wrist pain was noticed when
change in posture applied during work.
Significant association was found between change
in posture during work and back pain.
(P<0.05). Significant association was found between
change in posture during work, neck pain and job
satisfaction (P>0.05). Lower frequency of neck pain
was noticed among job satisfied participants. No
significant association was found between neck pain
and job satisfaction (P>0.05). Higher job satisfaction
was noticed when facilities are available. Significant
association was found between facilities and job
satisfaction (P<0.05).
2/7/2013, 8:08 PM
Figure 1: Showing distribution of study sample

according to nationality
This chart shows the distributions of our study

sample to gender. Female population was seen to be
higher than the male population. (Fig-3)
according to duration on computer
This chart shows the distribution of our sample

according to nationality. The highest frequencies were
found to be Indians and the lowest were Iranians.
(Fig-1)
according to age group
This chart shows the distribution of our study

sample according to the duration on computer. A greater
frequency was found among the sample working for
more than 5 hours on the computer. (Fig-4)
Figure 5: Showing distribution of musculoskeletal
pain among the study sample
This chart shows the distribution of our study

sample according to age. The highest frequencies were
seen in the age groups 20-29 and 30-39 whereas the
lowest frequencies were in the higher age groups.
(Fig-2)
according to gender
94
Chart showing the distribution of musculoskeletal

pain among the studied sample. It was seen that back
and neck pain has a greater frequency while wrist pain
was lower. (Fig-5)
Figure 6. Distribution of the study sample with
frequency of exercise and musculoskeletal disorders
2/7/2013, 8:08 PM
41% of population who exercised twice a month

suffered from wrist pain whereas approximately 37%
of the population who exercised 4 times a month
suffered from back and neck pain.(Fig-6)
DISCUSSION
As the continuing use of machines and computers
increases in todays world there is a need for the general
masses to be educated about the increasing incidence
of musculoskeletal disorders. Many people have the
tendency to overlook all these hazards as trivial and do
not get it checked and hence end up with a series of
mechanically restricting injuries.
MSD ranks first in prevalence as the cause of
chronic health problems, long term disabilities and
consultations with a healthy professional and ranked
second for restricted activity all day and use of
prescription medications and drugs. Hence society has
come up with the intervention of ergonomics among
the working masses.
There were many factors that we had to take into
consideration for the completion of our study. These
were Age, Nationality, Sex, Duration of work, Sleep
hours, Pain intensity, Exercise, Diet, Smoking / Alcohol
etc. Average duration of computer use in our study was
5 hours. This was in accordance with Bureau of Labour
Statistics which said that average time of employees
working on computer is 35 hours per week6.
Through our study showed that there was a higher
incidence of pain among the males and females
although affected were not so severe. The incidence of
pain in wrist to be more in men (61%) than in women
(39%) and a similar pattern was shown in the hand
and back pain too. This was not in confirmation with
the other studies that we had gone through on MSDs. A
study done in Europe found a higher prevalence of
disorders in women (45%) than men (39%). This
difference could have occurred in the study as they used
a larger population for their study whereas our sample
size was comparatively smaller. Our study shows a
positive relation between sleep hours and
musculoskeletal pain similar results was seen in a study
by the psychosomatic research7.
95
CONCLUSION
From our study we concluded that wrist, neck and
back pain is more prevalent in younger age groups and
it increased as the duration of computer use increased.
The variables, age, duration of computer use, facilities
at work place, sleep hours, diabetes and job satisfaction
did play a part in occurrence of pain. The result showed
that the commonest complaints were back pain and
neck pain. Wrist pain was the least complained when
operating on a computer system. Pain was more severe
in people working for more than 5 hours. The result of
this study can help in preventing occupational injury
associated with the use of computer with emphasis on
good posture, work station ergonomics.
REFERENCES
1.
2.
3.
4.
5.
6.
7.
OSHA [Online]. European Agency for Safety and

Health at Work, 2010 [cited 2010 September 20].
Available from URL: http://osha.europa.eu.
Gerr F, Marcus M, Ensor CBS, et al. A prospective
study of computer users: Study design and
incidence of musculoskeletal symptoms and
disorders. Am J Ind Med 2002;41:221-35.
Pillinger J, Rutherford. Computer and neck pain.
Health News 2003;39:12-4.
European Agency for Safety and Health at Work
[Onine]. Research on work-related low back
disorders, 2000 [cited 2010 September 20].
Available from URL: http://osha.europa.eu/en/
publications/reports/204.
Uhlenberg P. International handbook of
population aging, 1st edition. New York, Springer,
2009;772.
US Deprtment og Labour [Onine]. Bureau of labour
statistics, 2007 [cited 2010 September 20].
Available
from
URL:
www.bls.gov/
news.releaseiatus.nrO.htm.
Akerstedta T, Knutssonb A, Westerholmc P, et al.
Sleep disturbances, work stress and work hours:
A cross-sectional study. J Psychosom Res
2002;53(3):741-8.
2/7/2013, 8:08 PM
A Report of Body weight Supported Overground Training

in Acute Traumatic Central Cord Syndrome
Asir John Samuel1, John Solomon2, Senthilkumaran3, Nicole D'souza4
Lecturer, Alva's College of Physiotherapy, Moodabidri, India, 2Associate Professor, Department of Physiotherapy,
Manipal College of Allied Health Sciences, Manipal University, Manipal, India, 3Associate Professor, Department of
Physiotherapy, Manipal College of Allied Health Sciences, Manipal University, Manipal, India, 4Neurophysiotherapist,
Parkinson's Disease & Movement Disorder Society, Mumbai, India
1
ABSTRACT
Study design: A case report of a patient with Traumatic Central Cord Syndrome (TCCS)
Objective: To analyse the benefits of BWSOT in early ambulation and gait performance.
Setting: Tertiary care, University teaching hospital.
Methods: A 25-year old man with TCCS at the C4 level, grade B on the American Spinal Injury
Association (ASIA) Impairment Scale (AIS) participated in BWSOT. Following the immobilization
phase, he underwent two BWSOT sessions per day (20 minutes each), six days a week, for three weeks.
AIS motor score, 10-m walk test, Walking Index for Spinal cord Injury-version II (WISCI-II), Spinal cord
Independence Measure-version III (SCIM-III) and Functional Independence Measure (FIM) were recorded
at the time of initiating of BWSOT and at the end of three weeks. He received regular physiotherapy and
occupational therapy during the entire hospital stay.
Results: Three weeks of BWSOT resulted in an increase in all the outcome measures. At the time of
initiating BWSOT, AIS motor score, 10-m walk test, WISCI-II, SCIM-III and FIM were 45/100, 3 min 14
sec, 3/20, 30/100 and 60/126 and by the end of three weeks, they were 68/100, 1 min 41 sec, 17/20,
50/100 and 72/126 respectively.
Conclusion: BWSOT may allow therapists to initiate gait training programs at an earlier stage among
those with stable TCCS with promising outcomes.
Keywords: Spinal Cord Injury, Central Cord Syndrome, Overground Training, Gait Training, Rehabilitation,
Locomotor Training.
INTRODUCTION
Traumatic Central Cord Syndrome (TCCS) is the
most common incomplete Spinal Cord Injury (SCI) with
the incidence varying from 15.7% to 25%.1 As the lower
limbs (LL) are less affected, early gait training can be
initiated. However, poor trunk control is a major obstacle
in achieving this goal. This can be overcome by
stabilizing the trunk using a body weight supported
approach.
To date, only a limited number of studies have
compared the benefits of task specific activities like body
D. A. Asir John Samuel
Lecturer,
Alva's college of Physiotherapy, Moodabidri - 574 227,
South Canara District, Karnataka, India.
Contact No. +91 9481939806
Email: asirjohnsamuel@gmail.com
19. Asir John--96--98.pmd
96
weight supported treadmill walking and BWSOT in

incomplete SCI. However, the use of BWSOT has not
been documented in incomplete TCCS.
CASE REPORT
A 25-year-old male presented with severe neck pain
and quadriplegia after sustaining a fall from a height
of 15m. He was managed conservatively and referred
to the Neuro Rehabilitation Unit within 24 hours of
injury. The patient was examined at the time of referral
by a qualified physiotherapist. His vitals were stable.
Neurological examination revealed normal higher
functions and cranial nerves. His tone was flaccid in
the upper limbs (UL) and increased in the LL at this
time. Sensory and muscle power evaluation revealed a
sensory and motor level of C4 with sacral sparing.
American Spinal Injury Association Impairment Scale
(AIS), motor score was 10/100 comprising 0/50 for UL
and 10/50 for LL. Using AIS he was graded as AIS B.
Deep tendon reflexes were absent in the UL and brisk
2/7/2013, 8:08 PM
in the LL. He had a flaccid bladder for which he was

catheterized.
His cervical spine x-ray showed no bony
abnormalities. Magnetic Resonance Imaging showed
an area of increased signal intensity on the T2-weighted
images of the sagittal sections of the cervical cord.
He was immobilized with a Philadelphia collar for
two weeks during which time he received conventional
physiotherapy. By the end of 4th week ASI motor score
improved to 45/100 with normal sensation below the
level of lesion bringing him to AIS grade C. As trunk
has not improved compared to lower limbs, we looked
for the method to make him walk which provide
supports to trunk. Hence we devised Body weight
supported overground training (BWSOT) system.
sessions per day (20 minutes each), six days a week, for
three weeks. Baseline and at the end of 3 weeks training
of AIS motor score, 10-m walk test, WISCI-II, SCIM and
FIM were recorded and showed improved in all the
outcome measures. By 8th week he was able to walk
with minimal pelvic support, Fig 2. At the time of
discharge he was graded on AIS as AIS D with normal
bladder function.
Fig 1 shows the BWSOT which consists of overhead

suspension system and harness to support a percentage
of the patients body weight as the patient walks on a
parallel bar and progressively decreasing the amount
of body weight supported as the gait pattern improves.
The body weight unloading is high in the beginning of
training and decreased gradually. The harness was
attached to an overhead suspension, usually a system
composed of ropes and pulleys (rope-and-pulley
system) connected to a counterweight. A counterweight
was used to dynamically unload part of the patients
body weight.
Fig. 2. Ambulation at the time of discharge.
DISCUSSION
Fig. 1. Gait training using BWSOT with pelvic support (a)
anterior view and (b) posterior view.
Informed consent was obtained from the patient

prior to initiating therapy. He performed two BWSOT
97
This case study highlights three important findings.

First, BWSOT found to accelerate the improvements
resulted in improved muscle power, gait speed, and
functional independence. Second, this set up uses a
2/7/2013, 8:08 PM
Table 1: Outcome of the patient following BWSOT
Weeks
ASIA MS
10-m WT
WISCI-II
SCIM-III
FIM
10/100
NA
0/20
10/100
50/126
45/100
3 min 14 sec
3/20
30/100
60/126
68/100
1 min 41 sec
17/20
50/100
72/126
Abbreviations: ASIA MS, America Spinal cord Injury Association Motor Score; WT, Walk Test; WISCI-II, Walking Index for Spinal
cord Injury-version II; SCIM-III, Spinal cord Independence Measure-version III; FIM, Functional Independence Measure.
simple and inexpensive device which can be used in

small set up. Third, it reduces the risk of secondary
complications. Improvements seen in muscle power,
gait and function could be due to the normal neurological
recovery process due to the decrease in cord edema.2
However; the addition of BWSOT initiated within three
weeks of injury could have augmented the observed
changes.
In developing countries, the uses of cost effective
methods, which produce significant results with regard
to patient outcomes are important. This simple and
inexpensive device appears to play a vital role in
improving the quality of rehabilitation and also in
facilitating early mobilization which would in turn
probably be cost-effective.
Cervical cord injuries have a higher risk of
secondary complications.3 Early mobilization and gait
training using the BWSOT may have a role in preventing
these complications. However, larger studies with long
term follow up will be required to test this hypothesis.
CONCLUSION
This case highlights the importance of BWSOT in
early rehabilitation of patients with stable TCCS in
98
initiation of gait training programs, as early as three

weeks post injury.
ACKNOWLEDGEMENT
The authors express special thanks Abraham
Samuel Babu, MPT, FCR, (PhD) for content review.
The authors declare no conflict of interest and have
no disclosures.
REFERENCES
1.
2.
3.
McKinley W, Santos K, Meade M, Brooke K:

Incidence and outcomes of spinal cord injury
clinical syndromes. J Spinal Cord Med 2007, 30:
215-224.
Uribe J, Green B, Vanni S, Moza K, Guest J, Levi A.
Acute traumatic central cord syndromeexperience using surgical decompression with
open-door expansile cervical laminoplasty. Surg
Neurol. 2005; 63:505510.
Sekhon HS, Fehlings M G. Epidemiology,
Demographics, and Pathophysiology of Acute
Spinal Cord Injury. Spine 2001; 26: S2-S12.
2/7/2013, 8:08 PM
Effects of Ischemic Compression on the Trigger Points in

the Upper Trapezius Muscle
Bhavesh H. Jagad, Karishma B. Jagad
Lecturer, Shri K. K. Sheth Physiotherapy College, Rajkot, Gujarat, India
ABSTRACT
Background and Purpose of The Study: A myofascial trigger point has been described as a hyperirritable
spot, usually within a taut band of skeletal muscles or in the muscles fascia. The myofascial trigger
point in the upper trapezius is most commonly found at the midpoint of the upper boarder of the
muscle.
The objective of the study is to determine the effectiveness of ischemic compression for the treatment of
myofascial trigger points in upper trapezius.
Method: 30 subjects were randomly assigned to either treatment group (group 1) or a control group
(group 2). Subjects in group 1 received ischemic compression on the primary trigger point followed by
stretching of the upper trapezius muscle. Subjects in group 2 received active neck exercise followed by
stretching. All the patients of group 1 and 2 received treatment for 7 days. Pressure Pain Threshold
(PPT) measured by pressure algometer was used to measure trigger point sensitivity and Visual
Analogue Scale(VAS) was scored as a measure of pain intensity on day 1 and day 8 in both the groups.
Results: In the treatment group (group 1) significant improvement was evident in the pressure pain
threshold values (t=7.02, p<0.05), however no such improvement was found in the control group
(group 2). Comparison between the two groups also showed significant difference in the pressure pain
threshold measurement.
Significant improvement was noted in the visual analogue scale score of group 1 (T=120, p<0.001) and
group 2 (T= 66, p<0.001) both; however greater improvement was noted in treatment group (group 1).
Conclusion: Ischemic compression technique is highly effective in reducing the trigger point sensitivity
and pain intensity in the trapezius muscle.
Keywords: Ischemic Compression, Upper Trapezius, Trigger Point.
INTRODUCTION
Neck pain is very commonly shown by most people
to be in the region of the back of the neck and between
the bases of the neck to the shoulder, primarily
indicating the region of the trapezius muscle1. About
two thirds of people will experience neck pain at some
time.2,3 Prevalence is highest in middle age with women
being affected more the men. The prevalence of neck
pain varies widely between studies, with mean point
prevalence of 13% (range 5.9 38.7%) and mean lifetime
prevalence of 50% (range 14.2 71.0%). In some
industries neck related disorders account for as many
days of absenteeism as low back pain4,5.
The myofascial trigger point in the trapezius is most
commonly found at the midpoint of the upper border of
the muscle. It has been described as a hyperirritable
20. Karishma--99-104.pmd
99
spot, usually within a taut band of skeletal muscles or

in the muscles fascia. The spot is painful on
compression and can give rise to characteristics referred
pain, tenderness and autonomic phenomena.6 There is
pain with passive or active stretching of the muscles
and limited range of motion.6,7
Several trigger point treatment methods have been
studied for effectiveness. These methods include
injection or dry needling 8,9 , spray and stretch 10 ,
transcutaneous electrical nerve stimulation
(TENS)31,41,42, and post isometric relaxation43. Injection
and spray and stretch are reported as the most common
forms of therapy for trigger points.6,11,12,13,14
Ischemic compression has been studied by several
authors to treat myofascial pain, fibromyalgia and
paraesthesias. It is a non invasive technique and does
2/7/2013, 8:08 PM
not produce muscle soreness. However due to

difference in study population and outcome measures
used to assess the effectiveness, there is lack of rigorous
evidence for use of ischemic compression in clinical
practice. The objective of the study is to determine the
effectiveness of ischemic compression for the treatment
of myofascial trigger points in upper trapezius.
MATERIALS & METHOD
Subjects
The study was conducted in Shri K. K. Sheth
Physiotherapy College, Rajkot, India. 30 volunteer
subjects who participated in the study were selected
from the patients attending OPD department of the
college.
EXCLUSION CRITERIA
-History of orthopedic surgery to neck or back
-Cardiovascular or neurological conditions
-Clotting disorders and
-Treatment of myofascial pain or trigger points at the
time of the study.
INCLUSION CRITERIA
Form, and Assessment Form.

METHOD
An experimental study was conducted to study the
effectiveness of ischemic compression on the trigger
points in trapezius muscle. Each subject was randomly
assigned to treatment group (group 1) and control group
(group 2).
The subject was required to complete the informed
consent form. Then the subject was asked to mark a
visual analogue scale with the average pain intensity
for their pain over past 24 hours. The subjects were
then acquainted with the sensation of pressure
algometer on an unaffected part of the body before
testing for pressure pain threshold of primary trigger
point. The pressure algometer was placed
perpendicular to the area to be tested, increasing the
pressure steadily at the rate of approximately 1 Kg/sec.
Examiner palpated the region of trapezius and marked
all the trigger points that matched the inclusion
criteria with a non permanent marker. Pressure pain
threshold was measured for each marked trigger point.
The trigger point with the lowest pressure pain
threshold was considered as primary trigger point and
was marked with Reynolds permanent marker.
Figure-2 Placement of Algometer for Measurement
of PPT
-A palpable tender spot in the neck or upper back

-Reproduction of the subjects pain upon palpation
-A jump sign characterized by patient vocalization or
withdrawl5, 7
INSTRUMENTATION
The pressure algometer was used in the study to
measure pressure pain threshold as an index of trigger
point sensitivity. It is a reliable technique, demonstrating
high interrater and intrarater reliability.15,16,17
Figure-1
A Visual Analogue Scale was used to measure

intensity of the subjects pain.
Other materials used include Reynolds Marker,
Kodak C875 Zoom Digital Camera, Paper, Pen, Consent
100
Group 1 - With the patient in comfortable sitting

position on an armless chair and both feet firmly
planted on the floor, gradual pressure was applied to
the primary trigger point using the right thumb with
the left thumb reinforcing it from the top. The patient
was asked to side bend the neck to the opposite side in
order to place mild stretch on the primary trigger point.
Pressure was gradually increased to produce localized
discoloration as well as symptoms in the target area.
The same pressure was held till the patient reported
2/7/2013, 8:08 PM
easing of local and referred pain followed by a release

of 10 seconds. The same sequence of ischemic
compression was repeated three times per session with
the pressure of ischemic compression increasing as the
patients tolerance increased.7,18 Ischemic compression
was followed by sustained stretch to the upper
trapezius. The stretch was maintained for 30 seconds
followed by rest of 10 seconds. The procedure was
repeated 5 times per session.
Group 2 - The patients were asked to perform active
neck flexion, neck lateral flexion, neck extension and
neck rotation while seated near the edge on an armless
chair with both the feet firmly planted on the floor. The
patients performed these exercises 10 times each.
Sustained stretch to the upper trapezius was given in
the same manner as described above.
Table 2. Mean age of subjects in group l and group 2
Mean age(Years)
Group 1
Group 2
28.73
29.53
There was no significant age difference seen across

two groups
Pretreatment and post treatment means and SD of
PPT value and VAS score of each group are shown in
chart 2 and chart 3 respectively. The scores reflect greater
improvement for group 1 than for group 2 on all the
variables.
Chart-1 Raw score Means for Pre-treatment and
Post-treatment PPT of group 1 and group 2
All the patients of group 1 and 2 received treatment

for 7 days. No treatment was given on the 8th day to
determine the short term effects of the intervention
without confounding effects from the treatment just
completed. On day 8, the therapist again obtained
measurements for each subject A Pressure Pain
Threshold measurement of primary trigger point and a
visual analogue scale score for the average pain
intensity for the past 24 hours were recorded.
Chart-2 Raw score Means for Pre-treatment and
Post-treatment VAS of group 1 and group 2
RESULTS
Wilcoxon signed rank test, wilcoxon sum rank test
and students T test were used to analyze the data. The
paired and unpaired t-tests were performed using SPSS
statistics 17.0
Table 1. Gender distribution of 30 subjects who
participated in the study.
Gender
Group 1
Group 2
Male count%
533%
533%
Female count%
1067%
1067%
15
15
Total
Table 3. Calculated and Observed t values for difference of PPT within

and between group 1 and group 2
CALCULATED
OBSERVED
Group 1 (t14)
6.910
2.15
P<0.001
Highly significant
Group 2 (t14)
1.871
2.15
P>0.05
Not significant
Between Groups 1&2 (t28-)
6.40
2.05
P<0.001
Highly significant
Table 4. T value calculated by Wilcoxon Signed Rank Test for group 1 and group 2
VA S
T value
Probability (P)
Group 1
120
<0.01
Group 2
66
<0.01
101
2/7/2013, 8:08 PM
Table-5 z value calculated by Wilcoxon Rank Sum
Test for between group comparison
Score
z value
Probability (P)
VA S
3.44
<0.0003
DISCUSSION
Point prevalence of neck pain is nearly 13%19,20 and
lifetime prevalence is 50%.21 In females, the fiber-type
distribution pattern of trapezius is similar to male but
the mean cross-sectional area of the fibers is
considerably smaller. The significantly smaller crosssectional fiber area, which indicates a lower functional
capacity, may be of importance in the development of
neck and shoulder dysfunction in females. 22
Researchers also found that shoulder abduction torque
and trapezius EMG amplitude were significantly
lower in the women with myalgia compared with
those without the muscle pain.23 Higher incidence of
neck pain in female population can be accounted for
the higher number of female subjects in the present
study.
Garvey et al found injection of a local anesthetic,
injection of a local anesthetic plus steroid,
acupuncture (dry needling), and acupressure with
vapocoolant spray to be effective in relieving pain.8
This conclusion is also supported by authors like
Rubin D (1981)12 Imich D et al (2002)24 and Hong C
(1994)9. Garvey et al reported that the acupressure plus
vapocoolant spray was the most effective at relieving
pain. This led them to propose that relief is likely due to
mechanical stimulation of the trigger point by the needle
or the acupressure, not the injection of a particular
substance. Hong C also suggested that, local
vasodilatation and removal of metabolites along with
mechanical disruption of abnormal functioning of
contractile elements or nerve endings is responsible
for trigger point inactivation by injection method.
However the treatment involves invasive procedure
and to the varying degree produces post injection
soreness and muscle necrosis.
When ischemic compression is used on the trigger
points, local chemistry changes due to blanching of the
nodules followed by hyperemia when the compression
is released. This flushes out the muscle inflammatory
exudates and pain metabolites, breaks down the
scar tissue, desensitizes the nerve endings and reduces
the muscle tone. Thus the ischemic compression has
essentially the same mechanism of action on the
trigger point as the injection therapy. However
ischemic compression is a non invasive technique that
102
does not produce post treatment soreness or

hemorrhage.
Stretching of the affected muscle is believed by
some -authors to be an integral part of trigger point
therapy. 6,10,13,14,25 Techniques like post isometric
relaxation, strain/ counter strain, reciprocal inhibition,
passive stretching of the affected muscle and spraystretch have been found to be effective in reducing the
pain intensity and trigger point sensitivity.7,18,26 Simons
(1981) hypothesized that stretching a muscle releases
the locked actin and myosin heads, allowing the ATP
to form. The ATP allows the sarcoplasmic reticulum to
return to normal and circulation to improve.27 However
the stretch works better when there are nerve impulses
from the skin being sent to the brain and inhibiting
the reflex pathway that produces trigger point activity
and pain messages. These conflicting skin impulses
are most viewed as a sustained stretch to a specific
point in the muscle and it gets right to the tight or
restricted area in a muscle. The conclusion would seem
to be that stretching alone is not enough but that as an
adjunct to ischemic compression it is helpful.
The present study demonstrates significant
improvement in pain intensity and pain threshold in
group 1 treated with ischemic compression and
trapezius stretching compared to group 2 treated with
active neck exercises and trapezius stretching. Research
in 1993 by Hong et al lends credibility to the statement
that ischemic compression is superior to other physical
medicine modalities for treating trigger points. Similar
result has been obtained by Jamie Dearing (2007)28
CONCLUSION
The results of this study indicate that ischemic
compression is highly effective in the short term
management of trigger point in the upper trapezius by
reducing the trigger point sensitivity and average pain
intensity.
Limitations And Future Suggestions
The study did not examine effectiveness relative to
any other outcome such as functional limitation or
disability.
The long term effects of the ischemic compression
on the trigger point sensitivity needs to be investigated
further.
The study includes a small sample size
The duration of pain relief associated with the
2/7/2013, 8:08 PM
control of contributing factors to the development of

trigger point needs to be investigated.
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Peter D Aker, Anita R Gross et al, Conservative
Management of Mechanical Neck Pain: Systematic
Overview and Meta-Analysis, BMJ 1996; 313:
1291-1296.
Travell JG et al, Myofascial Pain and Dysfunction:
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Siobahn Maguire, Myofacial Therapy And
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Garvey TA et al, A Prospective, Randomized,
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Hong C, Lidocaine Injection Versus Dry
Needling To Myofascial Trigger Point: The
Imvortance Of The Local Twitch Response, Am J
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Pain, 1986, 27:203-210.
Grosshandler SL et al, Chronic Neck and Shoulder
Pain: Focusing On Myofascial Origins, Postgrad
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Rubin D, Myofacial Trigger Point Syndromes: An
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Fricton JR, Management of myofascial pain
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Algometer As A Measure Of Myofascial Trigger
Point Sensitivity, Pain, 1986, 24: 313- 321.
16. Fischer AA, Documentation of Myofascial Trigger
Points, Arch Phys Med Rehabil, 1988, 69: 286-291.
17. Stuart Cathcart et al, Reliability Of Pain Threshold
Measurement In Young Adults: The Internet
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18. Leon Chaitow, Integrated treatment of myofascial
trigger points, http://www.healingpeople.com/
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19. Bovim G et al, Neck Pain in The General
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20. Van der et al,The Associations Of Neck Pain With
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And Personality Traits In A General
Population. J Rheumatol1991, 18: 1884-1889.
21. Peter D et al, Conservative Management Of
Mechanical Neck Pain: Systematic Overview And
Meta-Analysis, BMJ, 1996, 313: 1291-1296.
22. R. Lindman et al, Fiber type composition of the
human female trapezius muscle: Enzymehistochemical characteristics, Am J Anat, 2005,
190: 385-392
23. Kristen J. Light, Exertion Provokes Pain In Myalgia
Patients, BioMechanics Archives, 2008.
24. Irnich D et al, Is Acupuncture At Distant Points
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2/7/2013, 8:08 PM
Prevalence of Upper Limb Dysfunction in Subjects with

Chronic non Specific Neck Pain in Bangalore City,
Karnataka
Kinchuk DB1, Soumya G2, Payal D3
Student, MSc. Clinical Physiotherapy, International School of Physiotherapy, a Collaborative Programme of Gokula
Education Foundation and Coventry University, Bangalore, Karnataka, 2Lecturer, International School of Physiotherapy
GEF - CU Collaborative Programme Bangalore, 3Lecturer, International School of Physiotherapy GEF - CU Collaborative
Programme Bangalore.
1
ABSTRACT
Study design: Cross sectional study
Objective: To find out the prevalence of upper limb dysfunction in subjects with non specific neck pain.
Summary of the background data: Non specific neck pain is highly prevalent in women particularly
of working age. Upper limb disorder and disability/ dysfunction are one of the most important factors
that have been discovered in the management outcome for nonspecific neck pain. Single Arm Military
Press (SAMP) test has been used to measure the level of upper limb dysfunction in neck pain population.
With a high prevalence of non specific neck pain in India either due to their occupation or age it
becomes important to quantify the rate of upper limb dysfunction in Indian population in their working
environment so that further measures can be taken to address upper limb dysfunction in the course of
management of non specific neck pain.
Method: Seventy two (72) subjects fulfilling the inclusion criteria and exclusion criteria were taken up
for the study. The upper limb dysfunction was measured for all the subjects for both the hands. Descriptive
statistical analysis was carried out for this study. Results on continuous measurements are presented
on Mean SD (Min-Max) and results on categorical measurements are presented in Number (%) with
level of significance set at 0.05. The comparison between the categorical measurements has been analyzed
using one sample t- test.
Results: Of the 72 subjects 93.1% had upper limb dysfunction as determined by the test scores. The
mean and standard deviation of SAMP score for the right hand was 20.44 5.25 and for the left hand
it was 18.49 4.49. The comparison between the mean scores of right and left upper limb was done to
show a cumulative finding using one sample t- test and it was found to be statistically significant (p <
0.001).
Conclusion: Upper limb dysfunction has been found to be highly prevalent in subjects with non specific
neck pain working women in Bangalore city, India.
Keywords: Ischemic Compression, Upper Trapezius, Trigger Point.
INTRODUCTION
Non specific neck pain is a common occurrence in
general population and the incidence appears to be
rising1,2 .Most of the working aged women have been
complaining of neck pain to the physicians 3,4 and the
frequency has increased since past two decades 5,6.
Women are found to be having lower strength of their
neck muscles when compared to men 7,8,9,10.
There is evidence to understand the relationship
between the neck pain and upper limb dysfunction as
summarized by McLean et al. 11. Any mechanical
loading of the articular structures results in a protective
21. Kinchuk Dolma--105-109.pmd
105
spasm that invariably restricts the upper limb in

performing its functions. Static positioning of the upper
limbs during working like using computers could lead
to deconditioning of the upper limb eventually reducing
the strength and endurance 12.
The Single Arm Military Press (SAMP) test, which
is strength and endurance performance based outcome
measure, is more valid and reliable tool than DASH to
quantify the level of upper limb dysfunction 13. UK
Studies have found 67% of the population suffering
from non specific neck pain having problems regarding
upper limb functions14.
2/7/2013, 8:08 PM
Despite the high prevalence of neck pain in India,

limited literature is available regarding the presence of
upper limb dysfunction among neck pain population.
Thus, the present study intends to find out the
prevalence of upper limb dysfunction among subjects
with non specific neck pain by evaluating the strength
and endurance of upper limb using SAMP test.
Methods Of Data Collection
Convenience sampling
Method of sampling :
Type of the study
Sample size
Cross sectional
72 (seventy two)
Inclusion criteria
Mechanical/non specific neck pain
Chronic pain (i.e., should have had pain more than

3 months)
No disabling pain at the time of study
Working women (age 30-55 years)
No previous physiotherapy treatment taken
English speaking
Exclusion criteria
Traumatic neck pain e.g., whiplash associated

disorder
Old/recent trauma to the shoulder, elbow and hand
Acute neck pain (less than 3 months)
Cervical spondylosis
Radiculopathy
Neurogenic pain
Any other systemic illness
Psychological disorders
MEASURES
To assess the baseline dysfunction of upper limb in
subjects with neck pain a performance based outcome
measure was used viz., Single Arm Military Press
(SAMP) test. This SAMP test has a cut off point i.e. 25.
This means that the scoring less than 25 was considered
to be having upper limb dysfunction amongst the
subjects and a score of 25 and above meant the subject
did not have upper limb dysfunction.
MATERIALS REQUIRED
A set up was organized taking the participants
privacy into consideration in the various working
institutions for the study. Three kilogram dumbbell and
a stop watch along with documentation sheet were
arranged.
STATISTICAL METHOD
Procedure of data collection

A cross sectional study on 72 symptomatic subjects
with non specific neck pain was carried out in various
institutions in Bangalore city, India. The institutions
included primary and secondary school, private
workplace, private hospitals and clinical diagnostic
centres. An ethical clearance for Research study was
obtained from M S Ramaiah Medical College and
Hospital, Bangalore, Karnataka, India. Approval for
conducting the study was taken from the Principals of
the respective institutions. All the participants were

provided with a copy of the detailed informed consent
form. Purpose of the study was explained and a written
informed consent was obtained from the subjects.
Seventy two women of age ranging between 30 to 55
years fulfilling the inclusion criteria and exclusion
criteria were taken up for the study. Following a formal
introduction, a brief demographic data of the subjects
participating in this study was noted. The procedure of
the SAMP test was explained and demonstrated. This
test required the subjects to complete as many repetitions
of the SAMP technique as possible within 30 seconds
using a 3kg weight [see figures (1) and (2)] with both
the upper limbs separately. All participants were
instructed to do the test as fast as possible but could
stop and start at anytime during the 30 seconds, though
the timing continues. This was one time performed
technique and the cut off number of repetitions was 25,
the number of repetitions subjects were able to do was
documented.
106
Descriptive statistical analysis has been carried out

for the present study. Results on continuous
measurements (i.e. Age and score of right and left upper
limb) are presented on Mean SD (Min-Max).
Percentage enumeration has been carried out for
categorical measurements (presence of upper limb
dysfunction) as significance is set 0.05. The comparison
between the categorical measurements has been
analyzed using one sample t- test. The following
assumptions on data are made, Assumptions: 1.
Dependent variables should be normally distributed,
2. Samples drawn from the population should be
random, and 3. Cases of the samples should be
independent.
2/7/2013, 8:08 PM
Fig.1. Start position for SAMP test showing (a) anterior view and (b) lateral view
Fig. 2. Finish point for SAMP test showing (a) anterior view (b) lateral view
Table 2: SAMP score of right upper limb in

percentage.
RESULTS
The basic demographic characteristics of the study
population: All the seventy two subjects were working
symptomatic females of middle age ranging from 30 55 years (Mean 40.09 7.029 SD), right hand dominant.
Table 1: mean and standard deviation (MIN-MAX) of
age.
Age (years)
Mean SD
30- 55yrs
40.09 7.029
Table 1. Shows the mean and standard deviation of the age of

the subjects who participated in the study.
107
Right
SAMP Score
% of
subjects
with score
(d24)
Total number
of subjects
% of
subjects
with score
(e25)
57
(79.2%)
15
(20.8)
72
(100.0%)
Table 2. Shows the Percentage of scores of right upper limb of

the subjects who participated in the study. Out of 72 (100%)
subjects 57 (79.2%) of them had a score less than equal to 24
and 15 (20.8%) of them had score more than equal to 25.
2/7/2013, 8:08 PM
Table 3: SAMP score of left upper limb in percentage.
Left
SAMP Score
% of
subjects
with score
(d24)
Total number
of subjects
% of
subjects
with score
(e25)
65
(90.3%)
72
(9.7%)
(100%)
Table 3. Shows the Percentage of scores of left upper limb of

the subjects who participated in the study. Out of 72 (100%)
of the subjects 65 (90.3%) had score less than equal to 24 and
7 (9.7%) had scores more than equal to 25.
Table 4. Comparison of Mean score between right

and left upper limb.
Mean
Std. Error
p Value
(One sample
t- test)
Score Right
Total
(N = 72)
20.44
(SD 5.25)
0.619
<0.001
Score Left
Total
(N = 72)
18.49
(SD 4.49)
0.53
<0.001
Total
(72)
1.09
(SD 0.29)
0.03516
Table 4. Shows the Mean and Standard Deviation of the scores

in right and left upper limb of the study population. Since only
one group of subjects were there, one sample t- test has been
used to compare the Mean between the scores of right and left
upper limb. With Standard of error 0.619 and for right and left
upper limb respectively the p value is <0.001.
Table 5. Percentage enumeration of upper limb

dysfunction in subjects after combining both right and
left scores.
Total
Combination Score
Upper limb
Dysfunction
Present
Total
Count
72
(100%)
No
Dysfunction
of Upper Limb
67
(93.1%)
5
(6.9%)
Table 5. Shows the Percentage of presence of upper

limb dysfunction of the subjects who participated in
the study. 67 persons that accounts for 93.1% of the
total subjects had upper limb dysfunction and 5 persons
that amount to 6.9% of the total subjects had no observed
upper limb dysfunction.
DISCUSSION/CONCLUSION
In the present study 72 working women from various
occupations with chronic non specific neck pain were
taken up. These subjects were evaluated for their upper
limb dysfunction using SAMP test as an outcome
108
measure. The ones who performed repetitive action less

or equal to twenty four (d24) were considered to have
upper limb dysfunction and the ones who out performed
this test twenty five or more (e25) times were
considered to be not having any upper limb dysfunction.
The results suggests that middle aged working
women with chronic non specific neck pain presents
with upper limb dysfunction with the percentage
prevalence of 93.1% (67 subjects) and without upper
limb dysfunction percentage prevalence of 6.9% (5
subjects) after combining the mean scores of both right
and upper limb (Refer Table 5). This finding is in
accordance with the literature that concluded that
women older than 37 years of age independent of
occupation were susceptible of acquiring chronic neck
pain which could probably result in upper limb
dysfunction 15,16,17
Studies have shown that with increase in age there
will be a steady drop in SAMP test score11 and the
assessment of work and non work related factors
particularly in women is essential18. Since the present
study was just to find the prevalence of upper limb
dysfunction in non specific neck pain population, no
other outcome measures were used other than SAMP
test. This study suggests performing a detailed
biomechanical and functional analysis of the specific
area of problem (neck) as well as associated part (upper
limb) of the musculoskeletal system, in order to plan
out a rehabilitative protocol / strategy for any working
individual with neck pain.
Further studies can be done by
Considering larger subjects with similar condition.
Comparing upper limb dysfunction in dominant

and non dominant hand.
Further validating the clinical use of SAMP test as

an outcome measure of upper limb dysfunction/
disability.
ACKNOWLEDGEMENT
I would like to extend my gratitude towards our

Course Coordinator Prof. Savita Ravindra, Course
Director Dr. Sudha Suresh, Associate prof community
department Dr. Nanda Kumar B.S., internet search
engines Google Scholar, PubMed Central, Mendeley, my
colleagues and parents and the subjects who willingly
participated in my study
2/7/2013, 8:08 PM
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Rimpela M. Back, neck, and shoulder pain in
Finnish adolescents: national cross sectional
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Bot SD, Waal JM, Terwee CB, Windt DA, Schellevis
FG, Bouter LM, Dekker J. (2005) Incidence and
prevalence of complaints of the neck and upper
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Ferrari R, Russell AS. Regional musculoskeletal
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Staudte HW, Duhr N. Age- and sex-dependent
force-related function of the cervical spine. Eur
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8.
Ylinen J, Takala EP, Nykanen M, Hakkinen A,
Malkia E, Pohjolainen T, Karppi SL, Kautiainen
H, Airaksinen O. Active Neck Muscle Training In
The Treatment Of Chronic Neck Pain In Women.
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Taimela S, Takala EP, Asklf T, Seppl K. Active
treatment of chronic neck pain: a prospective
randomized intervention. Spine. 2000; 25(8):1021
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10. Bernard B. Musculoskeletal disorders and
workplace factors- A critical review of
epidemiologic evidence for work-related
musculoskeletal disorders of the neck, upper
extremity, and low back. Cincinnati (OH): United
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National Institute for Occupational Health and
Safety. 1997; 2.12.90.
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McLean SM, Taylor J, Balasoobramanien T,

Kulkarni M, Patekar P, Darne R, Jain V. Measuring
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and disability: a cross-sectional survey of the
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McLean S. Conservative management of nonspecific neck pain: Effectiveness of treatment,
predictors of treatment outcome and upper limb
disability. PhD dissertation, University of Hull;
Hull. 2007.
McLean SM, Moffett JK, Sharp DM, Gardiner E.
An investigation to determine the association
between neck pain and upper limb disability for
patients with non-specific neck pain: A secondary
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BT, Vaccaro AR, Albert TJ. Impact Of Neck And
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2/7/2013, 8:08 PM
Randomized Controlled trial of Group Versus Individual

Physiotherapy Sessions for Genuine Stress Incontinence
in Women
Komal Soni1, Harshit Soni2, Dhaval Desai1, Chintan Shah1, Hasmukh Patel3
(Lecturer), (Tutor), SPB Physiotherapy College, Surat, 3Clinical Therapist, U. N. Mehta Institute of Cardiology &
Research Centre, Ahmedabad
ABSTRACT
Background: Pelvic floor muscle exercises are used since 1948 as first-line treatment for management of
genuine stress incontinence in women. This pelvic floor muscle exercises can be delivered
simultaneously to a group of women or individually on a one to one basis.
Objective: The purpose of this study was to compare the effects of group physiotherapy and individual
physiotherapy sessions on the severity of incontinence & quality of life in patients with genuine stress
incontinence.
Materials and Methods: 40 women with chronic genuine stress incontinence were randomized into
Group A - where women were delivered the pelvic floor muscle exercises in a group of 10 (n=20) &
Group B - where pelvic floor muscle exercise on a conventional one to one basis, the individual approach
(n=20) were administered. Outcome measures which included VAS for measuring severity of
incontinence & King's health questionnaire for assessing quality of life were taken at baseline & at the
end of 3 months intervention program.
Results: Both the group A and group B showed improvement in severity of incontinence and quality of
life postintervention when compared with preintervention measurement and 't'calculated value for
pre-postintervention measures was statistically significant as it was above the 't' tabulated value.
Moreover, MeanSD of pre-post change in VAS for group A was 2.020.46 and for group B was 1.940.43
and King's Health Questionnaire scores for group A was 30.095.3 and for group B was 21.516.73.
't'calculated value for pre-post changes was statistically not significant as it was below the 't' tabulated
value of 2.576.
Conclusion: Both group and individual physiotherapy pelvic floor muscle exercises for women with
genuine stress incontinence are equally effective. One may choose anyone of it to gain benefits.
Keywords: Genuine Stress Incontinence, Pelvic Floor Muscle Exercise, Group Physiotherapy, Individual
Physiotherapy.
INTRODUCTION
GSI (Genuine stress incontinence); also known as
Stress urinary incontinence is defined as an involuntary
loss of urine that occurs during physical activity, such
as coughing, sneezing, laughing, or exercise.1 GSI is
found to be commonest, with its prevalence being
greatest in 5th decade of life.2 WHOs 1st International
Consultation on Incontinence estimated that bladder
Komal Soni
543, Jalaramnagar, GHB, Ganeshpura, Amroli,
Surat - 394107,
Gujarat, India, Mobile No: 9904157300
E-mail: sonikomal10@gmail.com
22. komal soni--110-115.pmd
110
problems affects approximately 200 million people

worldwide, with 10 to 30% of women between the ages
of 20 and 55 years, and in up to 40% of older women.3
Although not a life-threatening condition, GSI
causes various physical, psychological & sexual
problems for millions of women & their families. GSI
thus has a negative impact on Quality of Life (QoL) &
most affected domains are physical health & mobility.4
Hence the need for the effective management of this
condition is vital, not only for the relief of symptoms
but perhaps more importantly, for the prevention of
recurrent episodes of leakage, personal suffering, and
lost work productivity.
Studies have found out that women with
urinary incontinence have a significant reduction of
2/7/2013, 8:08 PM
pelvic floor function & following a 4-month pelvic floor

muscle exercise (PFME) training period, incontinence
of both stress type and with an urge component can be
alleviated in most of the women.5 NICE 2006 guidelines
for the management of women with GSI have also
outlined the evidence for the use of both pelvic floor
muscle training & bladder retraining as first-line
treatments for women with GSI.6 Used since 1948, PFME
when employed in the treatment of GSI may be expected
to give a significant improvement or cure about 50%
with exercises usually having a long lasting effect.7,8
This PFME can be given on a one to one basis
as with the conventional individual approach or can
be given simultaneously to a group of women; a group
approach. Promoting incontinence in group sessions
is suggested as an effective means to educate women &
to encourage active self-management. Approximately
20% of Womens Health Physiotherapists use group
approach.9 Despite this there has been few Randomized
Control Trials comparing the effectiveness of group
intervention against individual approach which
signifies the need of the present study. Thus the aim of
the study was to compare the effectiveness of pragmatic
group approach versus individual treatment sessions
on the severity of incontinence & QoL in patients with
GSI.
In this Experimental study, total of 40 subjects who
were sent to Bombay Maternity and Surgical Hospital,
Surat were assessed for their eligibility based on the
criteria for the study and following that they were
randomly assigned to Group A & Group B. After signing
the written informed consent (to participate in the study
and to allow reproduction of their photographs) they
were made to participate in study and baseline
measurements were recorded.
Group A: Consisted of 20 females who were
administered PFME in a group of 10 for 3 weeks.
Group B: Consisted of 20 females who were
delivered PFME individually on a one to one basis for 3
weeks.
Inclusion criteria
1. History of chronic (between 2 years to 5 years) GSI
with positive cough stress test.
2. Age group of 30 to 55 years.
3. Females who have undergone full-term vaginal
delivery.
2. Participation in Physiotherapy program for GSI in

the past 12 months.
3. Disease of central nervous system (e.g. MS, CVA) or
acute mental illness & dementia.
4. History of pelvic malignancy or pelvic surgery.
5. Vaginal or bladder grade 2 and 3 prolapses.
Outcome Measures
Visual Analogue Scale (VAS) for measuring severity

of incontinence
Kings Health Questionnaire (KHQ) for measuring

QoL
Exercise Regimens
Group intervention for female urinary incontinence
(Group A) (Figure 1 & 2)
Group met for nine, one-hour long sessions over a
three months period. Group sizes were planned to be
10 women in a group.
Session 1
Introduction to anatomy of lower abdomen & pelvic
floor, explanation of normal PFM & bladder function,
teaching and practice of PFMEs recruiting both fast &
slow twitch fibers, encouraged to maintain contraction
for 3-5 seconds, repeat 10 times.
Session 2
Discussion to motivate patient, PFME practice &
progression to 10 seconds with 10 repetitions plus upto
10 fast repetitions (2 sets) targeted for both slow & fast
twitch fibers. PFMEs during day to day activities taught.
The therapist instructed subjects to use the stress
strategy.
Session 3
PFME in standing position with different foot
positions taught.
Session 4
PFMEs progressed to 15 seconds with 10 repetitions
plus 10 fast contractions (3 sets). Lighthearted quiz to
reinforce knowledge gained.
Session 5
PFMEs progressed to include the step & lift
exercise & adoption of variety of postures.
Session 6
Exclusion criteria
Recruitment of transverse abdominus along with
PFME taught.
1. Pregnancy.
111
2/7/2013, 8:08 PM
Session 7, 8 & 9
PFMEs in different postures to 20 seconds with 10
repetitions plus 10 fast contractions (3 sets). The
maximum exercise prescription possible by session 9
was 60 repetitions (3 sets of 20 seconds).
Patients were asked to perform their respective
exercises taught at every session twice a day at home.
Pelvic floor exercise booklet explaining the above

procedures was given to patient in prior.
In Individual treatment (Group B), once a week 30
minute long session was delivered over a three months
period. The line of treatment progressed on the same
lines as described for group sessions. (Figure 3 & 4)
Figure 1 & 2 Delivery of Group Physiotherapy Sessions (GROUP A)
Figure 3 & 4 Delivery of Individual Physiotherapy Sessions (GROUP B)

among both the study groups.
112
All participants received full treatments and there
were no drop outs.
Data analysis was done by using SPSS 13.0 version
software. Unpaired t tests were used to find out
homogeneity of two groups for all the parameters at
2/7/2013, 8:08 PM
baseline and to compare the outcome measurement data

between two groups. Paired t tests were conducted to
determine whether VAS and KHQ scores were
significantly different before and after the intervention.
Each calculated t-value is compared with t-table value
to test two tailed hypothesis at 0.01 level of significance.
RESULTS
variables viz. general health perception, incontinence

impact, role limitations, physical limitations, social
limitations, personal relationships, emotions, sleep/
energy, severity measures for incontinence was -0.921,
-1.313, 0.000, -0.190, -0.305, -1.46, -2.53, -1.792, -0.384, 0.545 and -1.646 respectively. Hence, all the descriptive
data for both the groups was not significantly different,
so both the groups were homogenous for all possible
confounding factors and were valid for comparison.
Table-1. Demographic Data for both the groups

GROUP A
Graph 1: Comparison of pre-post Mean VAS

between both the groups
GROUP B
MeanSD
Range
MeanSD
Range
Age (years)
42.04.96
34-52
42.56.0
33-51
BMI
27.011.02
25.01-29.14
26.741.02
24.89-28.14
Duration of
the symptoms
(months)
39.257.18
26-57
38.58.88
27-54
Parity
2.350.67
1-4
2.50.97
1-4
tcal value at n1+n2-2 degree of freedom for age, BMI,

duration of symptoms and parity was 0.243, -0.693, 0.249 and 0.496 respectively. Also the t cal value at
n1+n2-2 degree of freedom among both the groups for
various preintervention measures like VAS, KHQ, KHQ
Table-2: Comparison of KHQ Scores between two groups
GROUP A
GROUP B
Variables
Pre
Post
t cal value
Pre
Post
KHQ Mean
52.437.78
22.345.05
17.01
47.059.50
25.544.04
t cal value
9.57
General Health Perception
57.518.31
25.011.47
12.36
57.512.07
27.57.90
9.00
Incontinence Impact
54.9922.36
28.3312.21
5.81
53.3223.3
26.6614.05
4.00
Role Limitations
53.3312.79
26.668.37
10.46
51.6616.57
28.328.05
6.33
Physical Limitations
54.1611.93
24.998.55
8.81
48.335.27
28.328.05
9.00
Social Limitations
55.2714.24
17.2211.09
9.12
41.1014.85
25.559.14
3.67
Personal Relationships
40.8316.64
14.997.45
7.21
29.9913.14
18.325.27
2.83
Emotions
54.9911.66
23.889.02
12.07
53.3210.20
31.14.68
7.74
Sleep/Energy
38.3316.31
15.417.29
7.75
34.9914.59
20.827.08
3.97
Severity Measures
62.4915.64
24.588.32
15.25
53.3311.25
23.336.57
10.30
As evident from graph 1 and table 2, t calculated

value of pre-post intervention VAS and KHQ scores were
above the t tabulated value of 2.576 and hence were
113
statistically significant, so both the treatments were

effective in improving the severity of incontinence and
QoL.
2/7/2013, 8:08 PM
Graph 2: Comparison of mean Pre-post change of

VAS between both the groups
TABLE 3 - Comparison of pre-post change in KHQ

scores between two groups
Variable
GROUP A
GROUP B
Pre-Post change Pre-Post change
t cal
value
KHQ
30.095.30
21.516.73
1.63
General Health Perception
32.511.75
3010.54
0.56
Incontinence Impact
26.6620.51
26.6621.08
0.00
Role Limitations
26.6612.56
23.3311.65
0.00
Physical Limitations
29.1614.17
20.0010.54
2.30
Social Limitations
38.0515.42
15.557.76
3.30
Personal Relationships
25.8315.74
11.6611.25
3.00
31.19.26
22.229.07
1.50
Sleep/Energy
22.9113.21
14.1612.45
0.80
Severity Measures
37.9111.93
30.011.24
0.80
Emotions
As shown in graph 2 and table 3, t calculated value

of pre-post intervention change in VAS and KHQ scores
were below the t tabulated value of 2.576 and hence
were statistically not significant (except for social
limitations and personal relationships), so both the
treatments were equally effective in improving the
severity of incontinence and QoL.
Moreover, both the strategies being equally effective,

group therapy can be considered as a convenient option
as it may be more cost effective, but the cost-effectiveness
of group therapy needs to be assessed. The findings of
studies done by LA Hill et al. (2007)13 and SE Lamb et
al. (2009)14 showed cost-effectiveness of group therapy
and hence gave preference towards it.
As seen from our study, while considering QoL it
can be seen that some domains of QoL like physical
limitations, social limitations and personal
relationships showed improvement better in group than
individual sessions. This can be attributed to better
delivery of information in group sessions and hence
high level of satisfaction associated with group therapy
as suggested by B Aston et al. (2007).15 Previous works
done by Frances Griffiths et al. (2009)16 showed that
women who had preference for individual therapy
when given group sessions exhibited their experience
of group sessions as good but also stated that for group
sessions, its effectiveness lies in its proper designing. If
the designing of group therapy is not proper than
embrassement associated with group sessions may lead
to failure in delivery of effective treatment.
Hence, both the treatments being equally effective,
either one can be used for benefit of the patients. But
factors should be sought that can predict the
effectiveness of therapy and thus better select those
patients most likely to benefit from specific treatment
program.
Limitations of the Study
1. This study only included women with GSI between
age group of 30-55 years as GSI is most common in
that age women & also a big age difference in
women receiving group therapy may lead to
improper delivery of exercise to patient.
DISCUSSION
Following a 3 months intervention with Group
Physiotherapy sessions & Individual Physiotherapy
sessions, the women showed significant reduction in
severity of incontinence & improvement in QoL.
However there were no significant differences found
between the two groups treated individually or in
group, thus suggesting that both individual & group
physiotherapy sessions are equally effective in
management of women with GSI. These findings are in
line with the findings of previous studies done by Sara
Demain et al. (2001),9 Janssen et al. (2001)11 & Flavia
Camargo et al. (2009).12
114
2. This study only included a smaller population as

study sample & also the time duration chosen was
limited, thus giving only short-term benefits.
Future Implications
1. Study can be explored for both the sex and for all
age groups & all types of incontinence to know the
effects of these exercise interventions.
2. In future study, a larger population can be studied
thus giving more standardized results.
3. In future studies, electromyography could be used
concurrently to provide additional information on
muscle activation associated with the Pelvic Floor
Muscle Exercises.
2/7/2013, 8:08 PM
CONCLUSION
This study concluded that both the
approaches group and individual are equally effective
to reduce severity of incontinence & improve quality of
life in women with GSI. However factors should be sort
for each specific patient so that they can benefit
maximum from the intervention.
ACKNOWLEDGMENTS
with full cooperation, extended thanks to Mrs. Dharti
Hingarajia for her valuable help. We are also grateful to
authors/ publishers of all those articles, journals and
books from where the literature for this article has been
reviewed and discussed.
9.
10.
11.
12.
REFERENCES
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8.
Stress Incontinence medlineplus. Available at:

http://www.nlm.nih.gov/medlineplus/ency/
article/000891.htm
Minassian VA, Stewart WF, Wood GC. Urinary
incontinence in women: variation in prevalence
estimates and risk factors. Obstet Gynecol. 2008
Feb;111:324-31.
Hunskaar S, Burgio K, Diokno AC, et
al. Epidemiology and natural history of urinary
incontinence. Urology October 2003;62(4):16-23.
Rehab Ali Mohamed, Ahmed Mahmoud Mostafa
The impact of urinary incontinence on quality
of life of women attending family practice center
at Fanara village Ismailia governorate. Available
from: http://www.scribd.com/doc/28184727/
Impact-of-Incontinence-on-Quality-of-Life
Marianne Gunnarsson, Pia Teleman , Anders
Mattiasson , Jonas Lidfeldt , Christina Nerbrand ,
Gran Samsioe . - Effects of Pelvic Floor Exercises
in Middle Aged Women with a History of Naive
Urinary Incontinence: A Population Based Study.
Eur Urol. 2002 May;41(5):556-61.
NICE guidelines for management of women with
urinary incontinence (NICE 2006), Journal of the
Association of Chartered Physiotherapists in
Womens Health, Autumn 2007;101:37-43.
H. Cammu & M. Van Nylen - Pelvic floor muscle
exercises in genuine urinary stress incontinence.
Int Urogynecol J, September 1997;8(5):297-300.
Chantale Dumoulin, Marie-Claude Lemieux
Physiotherapy for persistent postnatal SUI: a
randomized controlled trial. American College of
Obstetricians & Gynecologists, September
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Sara Demain, Jan Fereday Smith, Louise Hiller,

Krysia Dziedzic Comparison of group &
individual Physiotherapy for female urinary
incontinence in primary care. Physiotherapy, May
2001;87(5):235-42.
WMA Declaration of Helsinki - Ethical Principles
[59th WMA General Assembly Seoul, Korea, Oct
2008]. Available from: http://www.wma.net/en/
30publications/10policies/b3/
C. C. M. Janssen, A. L. M. Lagro-Janssen & A. J. A.
Felling the effects of physiotherapy for female UI
individual compared with group treatment. BJU
International(2001); 87:201-6.
Flvia de Oliveira
Camargo,
A n d r e a M o u r a R o d r i g u e s ,
Raquel Martins Arruda, Marair Gracio Ferreira
Sartori, Manoel Joo Batista Castello Giro and
Rodrigo Aquino Castro - Pelvic floor muscle
training in female stress urinary incontinence:
comparison between group training and
individual treatment using PERFECT assessment
scheme; Int Urogynecol J, December
2009;20(12):1455-62.
L. A. Hill, J. Fereday Smith, J. C. Knights, A. J.
Williams, S. E. Lamb, J. Pepper, M. Clarke
bladders behaving badly: a randomized controlled
trial of group versus individual intervention in
management of female urinary incontinence.
Journal of the Association of Chartered
Physiotherapists in Womens Health, Autumn
2007;101:30-36.
SE Lamb, J Pepper, R Lall, EC Jrstad-Stein, MD
Clark, L Hill, and J Fereday-Smith - Group
treatments for sensitive health care problems: a
randomised controlled trial of group versus
individual physiotherapy sessions for female
urinary incontinence. BMC Womens
Health(2009);9:26.
B. Aston & S. Moulder Is group treatment
acceptable in the management of women with
pelvic floor dysfunction? Journal of the
Association of Chartered Physiotherapists in
Womens Health, Autumn 2007; 101:37-43.
Frances Griffiths, Jo Pepper, Ellen C JorstadStein, Jan Fereday Smith, Lesley Hill & Sarah E
Lamb - Group versus individual sessions delivered
by a physiotherapist for female urinary
incontinence: an interview study with women
attending group sessions nested within a
randomised controlled trial. BMC Womens
Health 2009;9:25.
2/7/2013, 8:08 PM
A Study of Electromyographic Changes in Muscle Post

Exercise Induced Muscle Soreness
Manish Rajput1, Ankita Samuel1, Chhavi Gupta1, Sumit Kalra2
1
Student BPT, Banarsidas Chadiwala Institute of Physiotherapy,
2
Assistant Professor, Banarsidas Chadiwala Institute of Physiotherapy
ABSTRACT
Aim and objective: To analyze electromyographic changes in muscle post Exercise Induced Muscle
Soreness (EIMS).
Methodology: 80 subjects(age group 21-30yrs, BMI 18-29kg/m2) free of any musculoskeletal/
Neuromuscular/psychological disorder, took part in the study. After checking for leg dominancy and
calculation of BMI, the subjects were asked to perform one single squat up to 900 of hip and knee flexion
while an EMG of the Rectus Femoris and Vastus Medialis Obliqus (both parts of quadriceps muscle)
was recorded simultaneously. Another EMG reading was taken in the similar manner after confirming
the development of muscle soreness on a graphic pain rating scale following the exercise protocol.
Results: The mean value of peak EMG of Rectus Femoris pre exercise is 508.69mV (microvolt) and post
exercise induced muscle soreness is 686.60 mV. The mean of peak EMG amplitude of Vastus Medialis
Obliqus came out to be as 379.81 mV pre exercise and 472.70 mV post exercise induced muscle soreness.
The p value for RF pre and post was 0.000 and for VMO pre and post was 0.034.
Conclusion: The conclusion drawn from the study is that there is a significant increase in peak EMG
amplitude of the muscles (RF and VMO) post exercise induced muscle soreness.
Keywords: Exercise Induced Muscle Soreness (EIMS), RF, VMO, EMG
INTRODUCTION
At one time or another, each one of us must have
experienced muscle soreness following everyday
activities that are not associated with participation in
sports or in formal exercise programs for e.g.: downhill
walking etc. Although muscle soreness usually occurs
in less physically trained individuals, most people,
including elite athletes can experience this soreness as
well. Since the soreness is experienced in the time period
following any strenuous work, it is termed as exercise
induced muscle soreness (EIMS).
Exercise-induced muscle soreness is a common
occurrence in daily routine. It can be classified as acute
or delayed onset muscle soreness.1-4. Acute onset occurs
during exercise and may last four to six hours postexercise before subsiding. Delayed onset muscle
soreness (DOMS) typically appears approximately 12
hours after activity and may last for several days
following exercise.1,2 It is perhaps one of the most
common and recurrent forms of sports injury.2
23. Manish--116-120.pmd
116
All forms of exercise, if carried out vigorously

enough, can become painful. But only one form of
exercise, eccentric exercise5, 6, if we are unaccustomed
to it, leaves us stiff and sore the next day. In eccentric
exercise the contracting muscle is lengthened; in
concentric exercise it shortens. These eccentric actions
produce micro-injury to the active muscle fibers, 7-10
exhibiting muscular soreness, loss of joint range of
motion, swelling, and decreased force production.8, 11-16
The muscle soreness usually manifests as a dull,
aching pain combined with tenderness and stiffness.
Clinical signs of muscle soreness include increases in
plasma enzymes12, 14, 16 muscular fiber degeneration, 17
and the protein degradation18 that accompanies the
degeneration to favor sarcomere disruption as the
starting point for the damage. As well as damage to
muscle fibers there is evidence of disturbance of muscle
sense organs and of proprioception.19
Accompanying the muscle soreness is muscle
weakness20, 21 which persists long after the muscle
2/7/2013, 8:08 PM
soreness has receded, prolonged strength loss, a

reduced range of motion, and elevated levels of creatine
kinase in the blood. These are taken as indirect
indicators of muscle soreness, and biopsy analysis has
documented damage to the contractile elements.22
H1- (EXPERIMENTAL HYPOTHESIS)

There is significant change in EMG analysis of
quadriceps muscle post exercise induced muscle
soreness.
A measure to quantify muscle soreness is a Graphic

pain rating scale33 which is a 12 cm line between no
pain and unbearable pain. Pain was quantified by
measuring the distance (to the nearest 1/2 cm) from the
extreme left to the mark made by subjects to describe
their perception of pain. The length was multiplied by
two, yielding scores from 0 = no pain to 24 = unbearable
pain.
H0- (NULL HYPOTHESIS)
Electro-myography (EMG) is the study of

muscle function that involves recording the action
potentials (or electrical currents) that activate skeletal
muscle fibers23, 24.
Number and Source of subjects
After fatiguing muscle with exercise, there is a

decrease in maximal force production, which has been
observed as early as l hour after exercise. The surface
electromyographic (EMG) activity is modified during
muscle Fatigue (Big1and-Ritcgie, 1981).The EMG power
spectrum is shifted towards the lower frequencies as
exemplified by the fall in mean power frequency (MPF)
during static contractions as well as during dynamic
exercise. The EMG spectrum from eccentric, concentric
muscle contractions under human were studied as a
factor of mechanical damage of muscle fiber and
functional change of metabolic tissue. The primary
purpose of the study was to examine the relationship
between DOMS in after exercise and EMG change in
during exercise. A secondary purpose was to examine
their relationship to local muscle fatigue and perceived
scale of DOMS. We hypothesized that if exerciseinduced muscle soreness is associated with muscle
fatigue then the localized DOMS to muscle contractions
would be accompanied by attenuated response in index
of muscle fatigue.
The quadriceps Femoris muscle plays an important
role in explosive and powerful actions of the leg during
sport and daily activities. Eccentric contraction is
commonly used during training programs which often
leads to fiber injury and muscle soreness. The dominant
leg was chosen as there is enough evidence that injuries
are most common on the dominant limb.25
There is no significant change in the EMG analysis

of quadriceps muscle post exercise induced muscle
soreness.
METHODOLOGY
Research design- comparative
80 (male) college going students took part in the

study.
Inclusion Criteria
1. Body Mass Index(BMI)26 should be within the range
of 18-29 kg/m2
2. Asymptomatic male subjects between age group 213027 years.
3. Not involved in unaccustomed eccentric muscle
action over past 6 months.28
Exclusion Criteria
1. History of lower limb injury , surgery or any
implant28
2. All contraindications to EMG
3. Any visible deformity of the upper limb/lower limb
4. Obesity
5. Athletes
6. A diagnosed case of any musculoskeletal/
neurological/ psychological/ cardio-pulmonary
disorder and psychiatric disease
Instrumentation
1. Neurotrac EMG machine
2. Weighing machine
3. Measuring tape
4. Football
AIMS AND OBJECTIVE

To study the electromyographic changes in muscle
post exercise induced muscle soreness.
23. Manish--116-120.pmd
117
5. Barbell
6. Ice pack
2/7/2013, 8:08 PM
Variables
Dependent Variable
1. Peak value of EMG amplitude
squat exercises with the final set including continuous

squats as long as participants could complete an entire
repetition. The exercises were terminated when subjects
indicated that they were unable to perform the exercise
further
2. Graphic pain rating scale(GPRS)33

Independent Variable
1. Height
2. Weight
PROCEDURE
80 subjects volunteered for the study, out of which
61 subjects were fulfilling the inclusion criteria and 19
were excluded. The subjects who were fulfilling the
inclusion criteria were explained about the topic of the
research and its advantages and disadvantages. After
clearing their doubts regarding the study, a written
consent was obtained from them.
The subjects were asked to kick a ball to check for
leg dominancy29 and their body weight and height was
measured for calculating the body mass index. The
dominant leg was then prepared for the recording of
the EMG. The skin was carefully prepared by rubbing
with abrasive gel and alcohol. All standard precautions
were taken before recording EMG activity of the muscle.
The EMG activity of Vastus Medialis Obliqus (VMO),
and Rectus Femoris (RF) (both parts of QUADRICEPS)
was recorded with surface electrodes (5mm disk selfadhesive electrodes) placed approximately in parallel
with the muscle fibers over the muscle bellies, based on
a modification of standard proposed by Zipp30. The
distances and angles were measured for optimal
electrode placement.31
The subjects were asked to perform a single 2sec
down and a 2sec up squat while the EMG was recorded
simultaneously. After this the subjects were requested
to perform squat exercises, specifically chosen to induce
fatigue in the knee extensors (quadriceps) (William
Retailer et al). An intermittent exercise protocol(Navrag
B. Singh et al)32 was used and subjects were requested
to start in an upright position with feet shoulder-width
apart and with weights (approx. 40% body weight)
carried on a barbell over the shoulders, squat down to
approximately 90 knee flexion, and return to their start
position. Each set of squat exercises consisted of eight
repetitions and a 30 s rest period was provided between
sets. Each subject performed a minimum of 11 sets of
23. Manish--116-120.pmd
118
The subjects were then required to fill up Graphic

Pain Rating Scale33 after 8hrs of the exercise session to
assess for the induction of DOMS. Those in which
DOMS were established were again asked to perform a
2sec down and 2sec up squat and the EMG was
recorded. After recording the subjects were given ice
packs and were advised to take ice packs at home twice
daily for next five days for the treatment of the muscle
soreness.
The subjects were specifically not allowed to perform
any vigorous physical activities or quadriceps muscle
stretching or any form of treatment for muscle soreness
during the entire experimental period34.
RESULT
The Mean, standard deviation and two tailed Paired
T-test values were obtained with the help of SPSS
software (version16)
The mean value of peak EMG amplitude of Rectus
Femoris (RF) pre exercise is 508.69mV (microvolt) and
post exercise induced muscle soreness is 686.60 mV
whereas for Vastus Medialis Obliqus (VMO) it came
out to be as 379.81 mV pre exercise and 472.70 mV post
exercise induced muscle soreness.
The two tailed p value for RF pre and post is 0.000
and for VMO pre and post was 0.034. (Table 1&2)
The mean percentage for RF pre is 43% and post is
57% (Graph.1)
The mean percentage for VMO pre is 45% and post
is 55% (Graph.2)
Graph-1 Mean percentage of EMG of RF
2/7/2013, 8:08 PM
CONCLUSION
Graph-2Mean & standard deviation of RF
The p value for pre n post exercise induced muscle

soreness EMG recordings is less than 0.05 for both RF
& VMO, which by conventional criteria is considered
to be extremely statistically significant. Thus the
experimental hypothesis for the study holds true i.e;
there is significant change in the peak EMG amplitude
of the muscle post exercise induced muscle soreness.
The percentage increase in peak EMG activity of RF
is 14 %( Graph.1)
Graph-3 Mean percentage of EMG of VMO
The percentage increase in peak EMG activity of

VMO is 10 %( Graph.3)
A reduction in force output by an injured part
of a muscle may lead to compensatory recruitment from
an uninjured area of a muscle, or from other muscles35.
This leads to a marked increase in EMG activity
(hyperactivity), altered EMG ratios and increased force
production of the compensating muscles.
FUTURE RESEARCH
Graph-4 Mean & standard deviation of VMO
1. The EMG of the non-dominant leg can be recorded

after post exercise induced muscle soreness
2. A comparison can be carried out by recording the
EMG activity at the origin and insertion of the
muscle.
3. The same study can be carried on females.
REFERENCES
1.
Table-1 p value for RF pre-post

Paired Differences
Pre-post (RF)
2.
95% Confidence
Interval of
the Difference
3.
Lower
Upper
Sig
(2-tailed)
-266.11
-89.69
-4.03
.000
4.
Table-2 p value for VMO pre-post

Paired Differences
Pre-post (RF)
-178.57
23. Manish--116-120.pmd
95% Confidence
Interval of
the Difference
Lower
Upper
-7.21222
-2.16
119
5.
T
.034
Sig
(2-tailed)
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Effect of Pelvic Floor Muscle Strengthening Exercises in

Chronic Low Back Pain
Manisha Rathi
Associate Professor, Padmashree Dr. D. Y. Patil College of Physiotherapy, Pimpri, Pune
ABSTRACT
Low back pain (LBP) is a condition of localized pain to the lumbar spine. The pelvic floor muscle (PFM)
have an important role in proper muscular activation for lumbar stabilization and also in unloading
the spine. It was hypothesized that PFM exercise could be of benefit for patients with chronic LBP. After
ethical approval, a randomized controlled trial was carried out on 30 females with chronic LBP. Patients
were randomly allocated into two groups: an experimental and a control group. The control group was
given conventional physiotherapy treatment including modality and exercises; and the experimental
group received PFM strengthening with conventional therapy for 5 times per week upto 4 weeks. Pain
intensity and functional disability by Oswestry Disability Index were measured before and after
intervention . In both groups pain and functional disability were significantly reduced following
treatment (p < 0.01). Also the significant difference was found between the two groups (p > 0.05). It
seems that the PFM exercise combined with conventional treatment was effective over conventional
treatment alone in females with chronic LBP.
Keywords: Pelvic floor muscle, LBP.
INTRODUCTION
Low back pain (LBP) is a condition of localized pain
to the lumbar spine with or without symptoms to the
distal extremities whose etiology is commonly
unknown. 1 More than 80% of the population will
experience an episode of LBP at some time during their
lives. 2 For most, the clinical course is benign, with 95%
of those afflicted recovering within a few months of
onset. 3 Some, however, will not recover and will develop
chronic LBP (ie, pain that lasts for 3 months or longer).
Recurrences of LBP are also common, with the
percentage of subsequent LBP episodes ranging from
20% to 44% within 1 year for working populations to
lifetime recurrences of up to 85%. 4 In the United States
it is the most common cause of job-related disability, a
leading contributor to missed work, and the second
most common neurological ailment only headache
is more common.
Lower back pain may be classified by the duration
of symptoms as acute (less than 4 weeks), sub acute (4
12 weeks), chronic (more than 12 weeks).6 Causes of
lower back pain are varied. Most cases are believed to
be due to a sprain or strain in the muscles and soft
tissues of the back.8 Others may have pain from their
sacroiliac joint, where the spinal column attaches to
the pelvis, called sacroiliac joint dysfunction. Physical
24. Manisha Rath-121-125.pmd
121
causes may include osteoarthritis, rheumatoid arthritis,

degeneration of the discs between the vertebrae or a
spinal disc herniation, a vertebral fracture (such as from
osteoporosis), or rarely, an infection or tumor. In the
vast majority of cases, no noteworthy or serious cause
is ever identified. If the pain resolves after a few weeks,
intensive testing is not indicated.9
It has been suggested that the overall mechanical
stability of the spinal column, especially in dynamic
conditions and under heavy loads, is provided by the
spinal column and the precisely coordinated
surrounding muscles. 10 The spinal stabilizing system
of the spine was primarily suggested by Panjabi (1992),
consisting of three subsystems: the spinal column
providing intrinsic stability; spinal muscles,
surrounding the spinal column, providing dynamic
stability; and the neural control unit evaluating and
determining the requirements for stability and
coordinating the muscle response11,12 . Under normal
conditions, the three subsystems work in harmony and
provide the needed mechanical stability 13,14
Among various documented risk factors for LBP
such as smoking 15 obesity 16, pregnancy 17, physical
activity18, mental health 19, recent research done by Smith
et al. 2009 and Hodges et al., 2007 has focused on the
relationship between LBP and respiratory disorders,
2/7/2013, 8:08 PM
incontinence and gastrointestinal problems from the

Australia.20 A longitudinal study on womens health
reported that women with pre-existing incontinence,
gastrointestinal problems and breathing disorders
were more likely to develop LBP than women without
such problems. 21 This was considered to be a result of
changes in control of the trunk muscles following
involvement with incontinence, respiratory and
gastrointestinal problems. Changes in morphology and
altered postural activity of the trunk muscles including
muscles of respiration and continence which provide
mechanical support to the spine and pelvis has been
shown to be related to the development and occurrence
of LBP (Hides et al., 2001, Cholewicki et al., 2005).
Apart from the role of pelvic floor muscle (PFM) in
patients with urinary and faecal incontinence, the PFM
have also an important role in proper muscular
activation for lumbar stabilization and also in
unloading the spine (Sapsford and Hodges, 2001,
Sapsford et al., 2001). The pelvic floor forms the base of
the abdominal cavity and during different tasks that
elevate intra-abdominal pressure, muscles must
contract to maintain continence and contribute to
pressure increases (Gilpin et al., 1989). In a small
experimental trial of healthy subjects, strong voluntary
abdominal muscle contraction caused PFM activity at
the same intensity as maximal PFMs effort (Sapsford
and Hodges, 2001). Morkved et al. (2007) have
investigated the effect of group training during
pregnancy in prevention of lumbopelvic pain. Selfreported symptoms of lumbopelvic pain, sick leave, and
functional status were measured on 301 healthy
nulliparous women who were randomly allocated into
a training group (148) or a control group (153). The
control group received daily PFM training at home, and
the training group was given weekly group training
over 12 weeks including aerobic exercises, PFM and
additional exercises, and information related to
pregnancy. They reported that at 36 weeks of gestation
women in the training group were significantly less
likely to report lumbopelvic pain and had significantly
higher scores on functional status but there was no
difference in sick leave during pregnancy. However, they
concluded that a 12-week specially designed training
program during pregnancy was effective in preventing
lumbopelvic pain in pregnancy.
Sapsford et al. (2001) investigated the co-activation
pattern of the pelvic floor and the abdominal muscles
via needle electromyography (EMG) for the abdominals
and surface EMG for the pelvic floor. They found that
the abdominals contract in response to a pelvic floor
122
contraction command and that the pelvic floor contracts

in response to both a hollowing and bracing
abdominal command. The results from this research
suggest that the pelvic floor can be facilitated by coactivating the abdominals and vice versa.
However, very few published evidence was found
to assess the function of PFM in patients with LBP or to
evaluate the effect of PFM exercises in the treatment of
such patients. The need to carry out this study was to
investigate the effect of PFM exercise in the treatment of
patients with chronic Low back pain specially in
females . As PFM has an important role in lumbar spine
stability, and lumbar instability was suggested to be
one of the causes for LBP, it was hypothesized that PFM
exercise could be of benefit for patients with chronic
LBP.
This experimental study was carried out in
Physiotherapy OPD of Dr. D. Y. Patil College of
Physiotherapy, Pune. Ethical approval was taken from
Institutional Ethical Committee. 30 married females
with chronic low back pain fallowing in the age group
between 20 to 40 years were selected and divided by
random allocation into two groups- group A with 15
females and group B with 15 females. Pregnant females,
females with any Urogenital Dysfunction like UV
Prolapsed, Pelvic Inflammatory disease, Nerve injury
to pelvic floor muscle, any pathology of spine, lower
limb were excluded from the study. Informed consent
was obtained from all the females. Females from Group
A received conventional physiotherapy treatment which
included Short wave diathermy or Interferentional
therapy , Abdominals and back extensors strengthening
exercises, Stretching exercises along with core stabilizers
(Transverse abdominals and multifidus) for 5 times
per week upto 4 weeks.
Females from Group B received conventional
physiotherapy treatment as mentioned above along
with pelvic floor muscle strengthening exercises for 5
times per week up to 4 weeks.Pelvic Floor strengthening
exercises were given initially in supine position. Before
starting, patients were instructed to evacuate their
bladder, relax as much as possible, not to hold breathing
and concentrate only at pelvic floor muscles. Patient
was instructed to contract pelvic floor muscles, hold
the contraction for 5 seconds and then relaxation for 5
seconds. She was further instructed to repeat the
contraction for 10 times. As the strength was increasing,
contraction time was increased and relaxation time was
2/7/2013, 8:08 PM
reduced from time to time. All the pelvic floor exercises

were repeated 3 times in a day(21).
Pain was assessed by using Visual Analogue Scale
and Functional Disability was assessed by Oswestry
Disability Index on the 1 st day of visit to the
physiotherapy department and at the end of 4 weeks.
RESULTS
Graph 1 :- Showing pre and post score of VAS in
group A and B
Graph 2 :- Showing Pre and Post score of Oswestry

Disability Index in Group A and Group B
The Graph 1 showed that the mean difference in

pain in patients who received PFM strengthening
exercises along with conventional therapy was
3.8 + 0.96 whereas differences in pain at VAS in group
A was 2.867 + 0 .83 . This difference showed significant
improvement in reduction in pain as p < 0.05 with
CI at 95%.
The Graph 2 showed that the mean difference in
ODI in patients who received PFM strengthening
exercises along with conventional therapy was
19.73 + 3.58 whereas differences in ODI in group A
123
was 24.07 + 3 .24 . This difference showed significant

improvement in reduction in pain as p < 0.05 with
CI at 95%.
DISCUSSION
Present study showed the effect of pelvic floor muscle
strengthening exercises in chronic Low back ache. This
study showed that PFM exercise combined with
conventional physiotherapy treatment had a
significant effect over the conventional physiotherapy
program alone in the treatment of patients with chronic
Low back pain .
A study done by Eliasson et al. (2008) concluded
that the prevalence of urinary incontinence and signs
of PFM dysfunction were greatly increased in the LBP
group compared with the reference group. It appears
that LBP is a risk factor for urinary incontinence and
assessment of PFM function may be of value when
treating patients with LBP. Evidence suggest that the
exercise of the abdominal muscles may be beneficial in
maintaining PFM coordination, support, endurance,
and strength. Hence these exercise has the potential to
be useful in the rehabilitation of persons with
symptoms of PFM dysfunction. A few studies by
Sapsford et al., 2001 and Neumann and Gill, 2002 have
demonstrated the synergy between abdominal muscles
and PFM in healthy volunteers. EMG activity of PFM
and abdominal muscles showed that during voluntary
activity of PFM all abdominal muscles were activated
at different levels. The PFM seems to be an integral part
of trunk and lumbopelvic stability in addition to
contributing continence. As there are the strong evidence
supports the co-contraction of PFM and abdominal
muscles, the results of the present study showed the
consistent result that these co-contractions have an effect
on patients with chronic LBP and reducing disability.
One of the functions of PFM is to unload the spine.
The static pressure created by a rigid abdominal cylinder
can act to support the upper part of the body and
therefore unload the spine. This involves abdominal,
dorsal, diaphragmatic and PF muscles( Grillner et at
1978). Studies also indicates that the co-activation of
all these muscle is an essential prerequisite for
developing appropriate IAP, thus supporting the spine.
When strengthening of the PFM occurs, the load on the
lumbar spine decreases. This may be the cause for
reliving LBP in the present study.
Sapsford et al 2001 suggested that recruitment of
abdominal muscles function in association with
voluntary contraction of PFM may be affected by spine
2/7/2013, 8:08 PM
position. Placing the lumbar spine in flexion or

extension would change the length-tension properties
of the abdominal muscles and may have an influence
on their response to PFM contraction. As Sapsford et al.
(2001) highlighted that increase in Transverse
Abdominals activity with PFM activity was
significantly greater compared with External Oblique
and Rectus Abdominal in lumbar extension. It was
suggested that a neutral or extended lumbar spine
position is preferable for PFM exercise. In addition, these
findings indicate that contraction of the PFM may be
used to initiate contraction of the abdominal muscles.
A RCTby Richardson et al., 1999 indicates that specific
training of the Transverse Abdominals can assist with
the management of LBP. The results of their investigation
revealed that this could be best achieved by contraction
of the PFM with the spine positioned in either a neutral
or extended position. In the present study patients were
instructed to perform PFM exercise in supine position (
Neutral Position). This can results in improvement in
LBP by strengthening transverse abdominals.
3.
4.
5.
6.
7.
8.
9.
CONCLUSION
This study showed significant improvement in
chronic low back pain in females after giving pelvic
floor strengthening exercises with conventional therapy
than the conventional therapy alone.
LIMITATIONS
Objective outcome measures such as muscle activity
and muscle thickness using EMG or ultrasound was
not done. Also the measurement of pain intensity and
functional disability was done in subjective way in the
present study.
10.
11.
12.
ACKNOWLEDGEMENT
13.
The author acknowledges the Dr. D. Y. Patil

Vidyapeeth, Pimpri, Pune for financial support of this
study.
14.
The authors declare no conflict of interest.
15.
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Physiotherapy December 2001, volume 87, no. 12
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Comparing Hold Relax - Proprioceptive Neuromuscular

Facilitation and Static Stretching Techniques in
Management of Hamstring Tightness
Ali Ghanbari1, Maryam Ebrahimian2, Marzieh Mohamadi3, Alireza Najjar-Hasanpour4
Rehabilitation School, Shiraz University of Medical Sciences, Iran, 2Rehabilitation School, Shiraz University of Medical
Sciences, Iran, 3Rehabilitation School, Shiraz University of Medical Sciences, Iran, 4Student Research Committee,
Rehabilitation School, Shiraz University of Medical Sciences, Iran
ABSTRACT
Introduction: Hamstring tightness may result in several conditions of the knee and spine such as
anterior knee pain and low back pain. Stretching is a preventive and therapeutic technique in these
situations. The aim of this study is to compare the effectiveness of static stretching and hold-relax PNF
on increasing the extensibility of hamstring muscles.
Method & material: 51 male subjects in the age range of 18 to 30 entered to the study and randomly
assigned to one of the three groups of static stretching, hold-relax PNF and control. The extensibility of
hamstring was assessed by Active Knee Extension Test (AKET). The treatments in both static stretching
and PNF groups were applied for six sessions during the study.
Findings: At the end of the treatment period, we found a significant difference in hamstring extensibility
among the study groups. Hamstring extensibility was significantly larger in both treatment groups
compared to the control group (p<0.001). Moreover, the subjects in PNF group showed significantly
greater hamstring extensibility compared with the static-stretch group (p=0.015).
Conclusion: The present study suggests that hold relax - PNF is more effective than static stretching in
increasing the hamstring extensibility. Therefore, application of this technique and education of that
may be more useful for either patients with hamstring contracture or athletes.
Keywords: Hamstring Extensibility, Static Stretching, Proprioceptive Neuromuscular Facilitation (PNF), Hold
Relax
INTRODUCTION
The two-joint hamstring muscle group is the knee
flexor and hip extensor. The complete range of knee
flexion rarely occurs in activity daily living; therefore
the complete contraction and stretching of this muscle
group is rare. In this type of muscles, failure may be
occur under rapid and stressful situations(1).
Hamstring tightness may result in several
conditions of the knee and spine. The Resultant flexion
Marzieh Mohamadi
Rehabilitation School of Shiraz University of Medical
Sciences, Abiverdi Street, Chamran Boulevard,
Shiraz, Iran.
Email: mohamadipt@yahoo.com
Phone No.: 987116271551, Fax: 98711627249
25. marzeih iran-126-130.pmd
126
moment following hamstring tightness may cause

anterior knee pain owing to excessive patellofemoral
forces(1-2). Furthermore, decrement in rang of knee
extension may result in plantar fasciitis due to
abnormal loading on forefoot (3). In patients with
hamstring tightness, anterior pelvic tilt is decreased
during trunk forward bending(4); therefore mobility in
lumbar vertebrae would be increased(4), and lead to low
back pain(4-6). Because of these problems, it is important
to consider the length of the hamstring muscle group.
Stretching is a preventive and therapeutic
technique (7-8) which is applied musculotendinous
structures in order to change their length, improve joint
range of motion, reduce stiffness, improve performance,
decrease risk of injuries, improve posture and promote
relaxation(8-10). There are different types of stretching
2/7/2013, 8:08 PM
techniques including static, active, passive,

proprioceptive neuromuscular facilitation (PNF) and
ballistic(7, 10-11). Static stretching is the most common form
of stretching technique because of its safety,
effectiveness and easy performance(10). PNF stretching
involves active muscle contraction and neuromuscular
reflexes which decrease the resistance against
stretching(10, 12).
In spite of many research studies performed on the
issue of stretching, there are still disagreements about
the most effective and safe method, intensity, duration
and frequency of stretching(10, 13). Several studies have
focused on comparing the different methods of
stretching. Some of these studies have found that PNF
stretching and static stretching were equally effective
in improvement of muscle extensibility(7, 13-14). Others
have shown that PNF is more effective than static
stretching(9, 15). On the contrary, Davis et al reported that
static stretching is more effective(16).
The controversy around this issue was a motive for
conducting the present study. One limitation of the
previous studies, comparing the different techniques
of stretching, was that the intervention was applied
only for one Session. In this study, we aimed to compare
the effectiveness of several sessions of static stretching
and hold-relax PNF on increasing the extensibility of
hamstring muscles.
MATERIAL & METHOD
Subjects
We recruited a convenience sample of 51 male
subjects in the age range of 18 to 30, who were the
students of a local university. Exclusion criteria were
musculoskeletal or neuromuscular disorders, a history
of fracture or dislocation in lower extremity and active
participation in sports or exercise activities that
required regular hamstring stretching. We defined
active participants as those who were involved in
regular exercise activities in at least 2 sessions during a
week.
PROCEDURE
After signing a consent form, the subjects were
randomly assigned to one of the three groups of static
stretching, hold-relax PNF and control. At the beginning
of the first session, the extensibility of hamstring was
assessed for every participant. We used Active Knee
127
Extension Test (AKET) for this purpose. The subject lied

in supine position with his hip and knee in 90 degree
flexion and ankle in plantar flexion. Then, he was asked
to extend his knee as far as he could and in this position,
popliteal angle was measured by a goniometer. To
measure this angle, a long-arm goniometer was utilized.
One arm was located on the line connected the greater
trochanter and the lateral femoral condyle.The other
arm was along the line from the lateral malleolus to the
lateral condyle of tibia.
After the initial measurement, the subjects in either
of the two intervention groups (i.e. static stretching and
PNF groups) received the treatments as following:
Static stretching group
The subject was supine with his hip in 90 degree of
flexion. Therapist passively extended the subjects knee
up to a point where the subject reported a mild to
moderate stretching sensation without any pain. The
therapist held this position for 30 seconds and then
repeated the procedure three times with 10 seconds rest
between successive stretches.
PNF group
The subject was supine with his hip in 90 degree of
flexion. The Therapist extended the subjects knee until
the subject felt a very mild stretching sensation in his
hamstring muscles. Then, the therapist asked the subject
to flex his knee against the resistance applied by the
therapists hand. The subject was asked to use a force
around 50% of his maximal strength. No movement
was allowed to occur in the knee joint so that an
isometric form of contraction was gained in hamstring
muscles. The subject holds the contraction for 8 seconds
and then, on the command of the therapist relaxed the
hamstrings muscle. Immediately after the muscle
relaxation the therapist stretched the hamstring muscles
up to a point where the subject reported a mild to
moderate stretching sensation without any pain and
hold this position for 30 seconds. The therapist repeated
this procedure three times in every session.
The treatments in both static stretching and PNF
groups were applied for three sessions in one week with
one day rest between two sessions. The treatments
continued for two successive weeks, and thus every
subject received 6 sessions of treatment during the study.
At the end of the last session, the popliteal angle was
measured again in the similar way as that of the first
session.
2/7/2013, 8:08 PM
The subjects in the control group received no

treatment during a two weeks period. At the end of the
second week, the therapist measured the popliteal angle
similar to what he did for the other two groups.
Due to non-normal distributions of the study data,
we used Kruskal-wallis test with Bonferroni correction
to compare the hamstring extensibility among the three
study groups.
FINDINGS
The mean age of the subjects and the mean angle of
knee extension at the baseline of the study were
compared by Kruskal-wallis and ANOVA tests (Table1).
There were no significant differences between the three
groups in this regard. At the end of the treatment period,
we found a significant difference in the angle of knee
extension among the study groups (Table2). A post hoc
test using Mann-Whitney test with Bonferroni correction
showed significant differences in pair wise
comparisons of the study groups. Since there were three
pairs of comparison, the alpha level was set on 0.0167
( level =.05/3= .0167). The angle of knee extension
was significantly larger in both treatment groups
compared to the control group (p<0.001). Moreover, the
subjects in PNF group showed significantly greater
angle compared with the static-stretch group (p=0.015).
Table1: The mean age of the subjects and the mean
angle of knee extension at the baseline of the study.
Group
PNF
Static stretch
control
17
17
17
Age
23.592.26
22.712.56
22.061.29
0.117
Angle of
knee extension
150.296.98
147.478.69
152.188.08
0.231
number
P.Value
Table2: The comparison of the angle of knee extension

after treatment among the study groups
Group
Mean
difference
Median
difference
P.Value
PNF
4.591.94
<0.001
Static stretch
31.22
control
00.5
DISCUSSION
This study showed significant increases in the
hamstring extensibility in both static stretching and
hold relax PNF technique groups in comparison with
the control group.
128
Muscle, fascia, capsule and tendon are the primary

limiting factors of joint movement. Therefore, it is
necessary to consider the muscle spindle and Golgi
tendon organ in the ability of muscles to lengthen in
response to stretch, as well as the passive structures.
PNF stretching techniques focus on active components
and static stretching address the passive components
which limit the range of motion(17).
In static stretching, the inverse myotatic reflex results
in muscle relaxation and further stretch and range of
motion. In hold relax PNF, the neural inhibition
reduces reflex activity(13). An inhibitory interneuron
reduces -motoneuron activity of antagonist muscle(8)
which results in muscle relaxation and decreased
resistance to stretch(13).
Our study found that hold relax PNF was more
effective in increasing hamstring extensibility. The
previous studies on this issue, have found no difference
between these two methods of stretching (7). The
discrepancy between our study and the previous ones
could be explained by several issues. The subjects on
our study were relatively young (i.e. 18-30), compared
to the Felands study which were on 55 to 79 years old
people. Feland et al, has stated that PNF stretching in
the younger patients is more effective than in older ones.
This is due to the age-related neurophysiologic and
musculoskeletal changes such as motor neuron death
and increased collagen of the skeletal muscle, in older
people(13). In the OHoras study that was on 21 to 35
years old people, the results was similar to our study(15).
Another explanation for the disagreement between
this and the previous studies, could be that we
performed the intervention techniques in several
sessions, while, other studies used the techniques in
only one session(7-8, 13, 15). Probably, the effects of the
stretching techniques have been accumulated during
the six sessions of our study. We may propose that, if
there is a real difference between the two techniques of
stretching, one session of treatment might not be
enough in detecting that small difference. When the
treatment effects are accumulated during several
sessions, then, the difference between the two
techniques get larger and hence statistically significant.
The superiority of PNF technique on static stretching
observed in our study may be due to the different effects
of these techniques on the blood flow of muscles(11, 18).
The resultant muscle relaxation following PNF
techniques can cause changes in blood flow. PNF
technique increase motor activity that can affect
vascular function. The muscle activation may increase
2/7/2013, 8:08 PM
the release of vasoactive substances which results in

vascular dilation(18). On the other hand, the muscle
extension due to static stretching decreases muscle
blood flow(11, 19) because of two physical changes: 1)
longitudinal extension of blood vessels with the muscle
extension and 2) the increase of intramuscular pressure
during the stretching(19). Hyperactivity or hyperemia
can affects the muscular temperature(20). During the
exercise, muscle temperature increase from 35 to 40
degrees due to elevation in plasma ATP. The increased
temperature of collagen will increase tissue elasticity(21).
7.
8.
9.
CONCLUSION
The present study suggests that hold relax PNF is
more effective than static stretching in increasing the
hamstring extensibility. Therefore, application of this
technique and education of that may be more useful for
either patients with hamstring contracture or athletes.
10.
11.
ACKNOWLEDGEMENT
This work was based on the dissertation of the
Alireza Najar Hasanpour at Shiraz University of
Medical Sciences (SUMS), faculty of rehabilitation
sciences. The authors are thankful to Miss Yasaman
Khademolhoseini and the Rehabilitation Research
Center staff. Financial support from the SUMS 88-4649
grant made this research possible.
12.
13.
14.
The authors declare that there is no conflict of interest
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the hip and flexibility of soft tissues in individuals
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Norris CM. Back stability: integrating science and
therapy: Human Kinetics Publishers; 2008.
McGill S. Low back disorders: evidence-based
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of hamstring injuries in Australian Rules
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129
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17.
2005;13(1):4.
Puentedura EJ, Huijbregts PA, Celeste S, Edwards
D, In A, Landers MR, et al. Immediate effects of
quantified hamstring stretching: Hold-relax
proprioceptive neuromuscular facilitation versus
static stretching. Physical Therapy in Sport. 2011.
Schuback B, Hooper J, Salisbury L. A comparison
of a self-stretch incorporating proprioceptive
neuromuscular facilitation components and a
therapist-applied PNF-technique on hamstring
flexibility. Physiotherapy. 2004;90(3):151-7.
Rashad AK, El-Agamy MI. Comparing Two
Different Methods of Stretching on Improvement
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Feland JB, Myrer J, Merrill R. Acute changes in
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Shum GLK. Efficacy of Static Stretching and
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Session. The Journal of Strength & Conditioning
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Reliability and Feasibility of Community Balance and

Mobility Scale (CB&MS) in Elderly Population
NagaRaju1, Arun Maiya2, Manikandan3
MPT, Department of Physiotherapy, Manipal College of Allied Health Sciences, Manipal, Karnataka,
2
Associate Dean and Head of Physiotherapy Department, Manipal College of Allied Health Sciences,
Manipal, Karnataka, 3Associate Professor, Department of Physiotherapy, Manipal College of Allied Health Sciences,
Manipal, Karnataka
1
ABSTRACT
The objective was to determine the reliability and feasibility of Community Balance and Mobility Scale
(CB&MS) as a screening instrument for identifying balance dysfunction in elderly population in an
Indian situation. An observational study was conducted in community and old age homes residing
elderly population, involving 33 elderly individuals aged 60 years and above, selected by convenience
sampling method. CB&MS and Computerized Static Posturography measures were used for assessment.
Intraclass Correlation Coefficient and spearman's correlation coefficient were used for analysis. Results
showed high test-retest reliability (0.985) but no correlation with velocity moment measure of
Computerized Static Posturography. Our findings demonstrated that CB&MS is reliable and feasible
and hence could be applicable in the community for assessing balance and mobility of young old
elderly population.
Keywords: Test -Retest Reliability, Balance, Challenging Tasks, Community Setting.
INTRODUCTION
Ageing, in its broadest sense is the continuous and
irreversible decline in the efficiency of various
physiological processes2.The average life expectancy
is around 60 years now and the way health care facilities
are expanding with better income levels and access to
medicare, the life expectancy may rise between 70 and
75 by 20208.India had the second largest number of
elderly (60+) in the world.The size of Indias elderly
population aged 60 and above is expected to increase
from 77 million in 2001 to 179 million in 2031 and further
to 301 million in 2051. The proportion is likely to reach
12 per cent in 2031 and 17 per cent in 2051 17.
A decline in all the major systems for example,
cardiovascular, metabolic, respiratory, and
neuromuscular contributes to weakness, fatigue, and
slowing of movement that have been the hallmarks of
aging14.
Older adults have impaired balance recovery due to
an age-related decline in the ability to rapidly and
efficiently contract the muscles of the lower extremities
.These physiologic changes of normal aging may
increase the risk of falls13.This led to increase in the
number of older persons with disability9.
26. Naga Raju--131-135.pmd
131
Among community-dwelling older people over 64

years of age, 28-35% fall each year. Of those who are 70
years and older, approximately 32%-42% fall each year.
Older people who are living in nursing homes fall more
often than those who are living in the community.
Approximately 30-50% of people living in long term
care institutions fall each year, and 40% of them
experienced recurrent falls20. Balance disturbances
frequently cause elderly people to seek medical advice
and admission to hospitals and residential homes3.
Although a number of procedures have been
described to assess balance, many of these techniques
present difficulty in application due to cost, subjectivity,
specificity of assessment or other problems6. In spite of
laboratory measures of balance offer greater precision
and potential to detect subtle or sub clinical balance
impairments, Clinical and Functional tests of balance
(static and dynamic) share the advantages of ease of
administration, low cost and more directly interpretable
functional relevance16.
Computerized Posturography is the gold standard
tool to evaluate postural sway and quantify balance. It
is simple and efficient tool and offers technology for the
objective assessment and comprehensive
documentation of postural control7. Amplitude and
2/7/2013, 8:08 PM
velocity of anterior-posterior and medial-lateral sway

during standing in different positions are measured
using Posturography. The general census is that
computerized measures have a greater precision and
potential to detect sub clinical balance impairments1.
Role of Posturography in elderly population to detect
balance impairments has gained importance in the
recent years. However the balance measures were
assessed in clinical set up where the elderly individual
does not encounter barriers that challenge his balance
abilities. This necessitates the assessment of balance in
community environment.
CB&MS is a tool used to measure balance and
mobility of individual in the community setting. The
scale has been used and found to be valid and reliable
in high functioning patients with traumatic brain
injury10. This scale has not been tested for its usefulness
in Indian elderly population and no literature is
available to correlate this scale with the postural sway
measures of Posturography. Our study aims to find the
reliability and feasibility of CB&MS and its correlation
with postural sway measures using Static
Posturography.
MATERIAL AND METHOD
An observational study with convenience sampling
method was conducted at department of Physiotherapy,
MCOAHS, Manipal, India. The sample size for the
study was estimated from the previous existing study,
consisted of 33 (20 males and 13 females) elderly
persons aged above 60 years and were able to
understand and follow commands. Subjects who had
acute illness on the day of assessment, foot ulcers, acute
labyrinthine disorders, functional hearing & visual
deficits, cognitive impairments and non-cooperative
participants were excluded from the study.
PROCEDURE
The study protocol was presented and approval
was obtained to conduct the study by the ethical
committee of Manipal University. Elderly subjects in
the age group of 60 years and above were identified
from the community and old age homes after which
they were screened for inclusion and exclusion criteria.
The selected subjects were explained about the study
and informed consent was obtained for their
participation. The subjects were assessed for the
following measures as explained below.
Community Balance and Mobility Scale (CB&MS)
An 8 meter track with duct tape was made which is
of 5cm width on the floor with a perpendicular start
line and finish line. Markings done at 1m, 2m, 4m and
132
6m with a tape perpendicularly. A 40cm bare spot was

placed for item 3 and 4 after 6m mark. The visual target
for items 8 and 11 was placed at the 4m mark, at
individuals eye level and 1m from the outside edge of
the track. Individuals were advised to wear comfortable
clothes. All items (total 13) were scored in the first trail
after explaining each one task and ensuring rest periods
in between tasks as required.
The set up resembles as
Initial evaluation using CB&MS was done and

revaluation was done after a period of one week for
determining the test retest reliability.
Postural sway amplitude and velocity
After measuring the height, weight and age, subjects
were instructed to stand with normal base of support
on the force platform of Posturography machine with
arms folded in front of chest. Subjects were instructed
to stand relaxed on force platform, bare foot, with the
head in a straight head position. They were asked to
focus on specific point (2 m distance) at their eye level
during eyes open conditions and the timer is started.
After 30 seconds, the timer is stopped and the subject is
rested for two minutes.
The same procedure is repeated with subject
standing with normal base- eye closed for 30 seconds,
tandem stance the heel of one foot touches great toe of
other foot, the foot position according to convenience of
patient (eyes open and eyes closed) and both right and
left single leg stance while opposite leg flexed at knee
for 20 seconds. Two minutes of rest was given in
between each position. The subjects who did not stand
for 30 seconds in normal stance eyes open and eyes
closed and 20 seconds in remaining testing positions
even after two trials, the test is stopped and noted down
as unable to test. After all the testing positions were
done, velocity moment noted down from the computer.
These readings were used to correlate with CB&MS and
Tinetti POMA balance subscale measures.
Data analysis
Data was analyzed using SPSS version 16.Test retest
reliability of CB&MS was analyzed using Intraclass
Correlation Coefficient. Concurrent validity of CB&MS
with posturography measure (Velocity Moment) was
2/7/2013, 8:08 PM
analyzed using Spearmans correlation coefficient. The

level of significance was kept at P value less than or
equal to 0.05.
RESULTS
Descriptive statistic on the anthropometrics data,
balance subscale of Tinetti POMA and CB&MS total
scores of the study subjects is shown in table 1.
Above table shows high test-retest reliability of both

total score and individual items.
Phase 2: Correlation of CB&MS total score with
posturography velocity moment in different positions
Table 3: Correlation of CB&MS total score with
posturography velocity moment in different positions
Posturography
conditions
Correlation
with
CB&MS
r value
p value
Table 1: Demographic characteristics, median CB&MS

and POMA scores of elderly subjects (n=33)
Normal stance eyes open(NSEO)
0.078
0.672
Variables
Normal stance eyes closed(NSEC)
-0.033
0.859
Male
Female
13
Tandem stance eyes open(TSEO)
-0.092
0.617
Age in years (Mean + SD)
66.25+7.25
68.00+5.68
Tandem stance eyes closed(TSEC)
0.307
0.087
Height in cms (Mean + SD)
164.58+ 5.44
149.89+ 4.32
Single leg stance Rt eyes open(SL rt EO)
0.556
0.001
Weight in kgs (Mean + SD)
60.03+ 11.61
51.07+7.26
Single leg stance Lt eyes open(SL lt EO)
0.049
0.791
Single led stance Rt eyes closed(SL rt EC)
0.308
0.086
Gender
20
CB&MS score
(Median , IQR)
50.50 (43.25+57.00)
Balance subscale
of Tinetti POMA
16(16+16)
40.00 (34.50+46.00)
16(16+16)
Above table suggests that study group population

consist predominately males, scored higher in CB&MS
than females. It also shows all the all subjects scored
full on the balance subscale of Tinetti POMA.
Above table displays significant low positive

correlation of CB&MS total score with posturography
single leg stance right side in eyes open condition. In
addition to that it also shows negative correlation with
normal stance eyes closed and tandem stance eyes open
but not statistically significant.
Table 4: Correlation of individual items of CB&MS
with posturography velocity moment
Phase1: Test-retest reliability of CB&MS

Table 2: Intra-class correlation coefficient (ICC) values
for test retest CB&MS in elderly subjects (n=33).
Item No Item name
I
ICC value
Item
No
Item
name
Unilateral stance (Left)
SL lt EO
0.406
0.021
III
180 Tandem pivot
SL rt EO
0.500
0.004
IV
Lateral foot scooting (Left )
SL rt EO
0.542
0.001
Hopping forward
Unilateral stance right
0.871
Unilateral stance left
0.910
II
Tandem walking
0.994
III
1800Tandem pivot
0.960
VI
IV
Lateral foot scooting :Right
0.981
IX
Lateral foot scooting :Left
0.953
Hopping forward: Right
0.976
Hopping forward: Left
0.960
VI
Crouch and walk
0.959
VII
Lateral dodging
0.934
VIII
Walking& looking :Right
0.939
Walking& looking :Left
0.969
IX
Running and controlled stop
0.860
Forward to back ward walking
0.944
XI
Walk ,look & carry: Right
0.983
Walk ,look & carry: Left
0.981
XII
Descending stairs
0.889
XIII
Step ups 1 step: Right
1.000
Step ups 1 step: Left
0.973
Total
score
0.985
133
Posturography r value
conditions
P value
NSEC
-0.423
0.016
SL rt EO
0387
0.029
Crouch and walk
SL rt EO
0.492
0.004
Running with controlled stop
SL rt EO
0.389
0.028
Table shows significant positive correlation of

individual item of CB&MS with posturography velocity
moment except hopping forward with normal stance
eyes closed showed negative correlation.
DISCUSSION
The study participants were young-old with full
score in Tinetti POMA balance subscale, which implies
participants were highly functional. Males scored
significantly higher in CB&MS than females.
Our phase 1 results showed high test-retest
reliability of CB&MS in elderly subjects suggesting that
it could be a reliable tool to assess balance and mobility
function in them. CB&MS is simple and feasible test as
2/7/2013, 8:08 PM
it does not require any special equipment to be

performed in the community setting. Uneven surfaces
in community could be utilized since people would
have accommodated to that specific environment. This
also leads to evaluation in actual real life setting instead
of clinical setting. All subjects completed the test without
any adverse events and hence it is safe to be used in
young old elderly population.
CB&MS has items which represents the underlying
motor skills necessary for function within the
community. For example Single leg stance is necessary
during stance phase of gait cycle and for public
transportation.,etc.
In spite of being healthy elders, subjects could not
attain full score in CB&MS. A number of factors could
have contributed to the decrease in successful
performance and not attaining full score in CB&MS.
First, the tasks were challenging as certain items are
time scored, in which (item no I-right and left, VI, VIIright and left, IX,X,XI-right and left ,XIII-right and left)
they have to complete the tasks within the time limit in
order to attain full score. Second, the complexity of tasks
which include hopping forward, crouch and walk,
running with controlled stop, and lateral dodging
which requires good strength ,balance and
coordination. These observations were supported by
earlier study done by Scott J.Butcher et al 2004. Although
not tested in this study, the fact that women tend to
have lower muscle strength than men15 could explain
their lower performance on these items in the 60 to 72
year age category (table1). Slow speed of performance,
particularly for item 7(lateral dodging), could also be
attributed to slowness in reaction time with increasing
age5. A decrease in speed has previously been attributed
to age-related reduction in muscle fibre size, particularly
in type II fibres, which are primarily responsible for
speed of movement 20.
We observed that the subjects were motivated,
enthusiastic and enjoyed the part of the test, which
could be due to dynamic and challenging tasks
involved in the scale. This might be the reason for
adherence to retest evaluation of our study except nine
participants who could not attend the retest due to
personnel problems.
The average time taken to complete the test
administration was approximately 30 minutes.This is
more compared to other assessment measures in elderly
which could be explained by the progressive difficulty
in task items. Some of the items were scored based on
duration, which requires the subject to complete the
134
minimum time of 45 seconds (SLS).Some items need to

be performed four (Lateral dodging) or five (Step ups)
times and walk for seven consecutive steps (tandem
walking) which further increased the assessment time.
Rest periods given in between tasks could also have
increased the test duration.
In our phase results, we did not find any correlation
between items of CB&MS and Posturography measures
which could be explained by the difference in
measurement surface, environment and nonfamiliarization of Posturography. Posturography
measures were taken on force platform in well designed
and organized laboratory setting as against to CB&MS
which was performed in real setting.
Poor correlation between CB&MS and
Posturography could also be attributed to the different
components of balance being assessed by two tests, that
is Posturography measures static balance while,
CB&MS measures dynamic balance and mobility tasks.
LIMITATION
Our results were restricted to young-old elderly
population and hence cannot be generalized to oldold. However, we would like to recommend further
studies to test the feasibility of CB& MS in old-old
subjects.
CONCLUSION
CB&MS showed excellent test retest reliability
hence it could be feasible in the community for assessing
balance and mobility of young-old elderly population.
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19. Tinetti,M,et al (1988):Identifying mobility
dysfunction in elderly patients :standard
neuromuscular examination or direct assessment.
JAMA .259:119.
20. Vandervoort A (2002). Aging of the human
neuromuscular system. Muscle Nerve .25; 17-25.
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Core Stability Training with Conventional Balance

Training Improves Dynamic Balance in
Progressive Degenerative Cerebellar Ataxia
Khan Neha Tabbassum1, Nayeem-U-Zia2, Harpreet Singh Sachdev3, Suman K4
Student (M.P.T Neurology), Dept. of Rehabilitation Sciences, Hamdard University, New Delhi, 2Lecturer, Dept. of
Rehabilitation Sciences, Jamia Hamdard, New Delhi, 3Consultant physiotherapist, Neurology Dept.,
A.I.I.M.S., New Delhi, 4Co- Guide, Associate Professor, Neurology Dept., IHBAS hospital, New Delhi
ABSTRACT
Background and Purpose: Disorder of balance and gait is the commonest feature found in Cerebellar
ataxia patients. Purpose was to see the effect of Core stability training along with balance training on
dynamic balance in progressive degenerative Cerebellar Ataxia.
Methods: 20 subjects of progressive Degenerative condition (18 SCA subjects and 2 olivopontocerebellar
atrophy) were systematically assigned in two groups, group A (n=10) in core and balance training and
group B (n=10) in balance and relaxation training. Treatment was given 1 hour per session for each
group, 3 days a week for 4 weeks. The outcomes of the study were measured by Balance Evaluation
System Test (BESTest) and Modified falls efficacy scale (MFES).
Results: Core stability training group showed significant improvement on BESTest at follow up
compared to conventional balance training group. There was no statistical difference found in the
MFEscale among the two groups but the results were clinically significant till follow up for core stability
training group.
Conclusion: Core stability training can be included as an adjunct to conventional balance training in
improving dynamic balance in patients with progressive degenerative Cerebellar ataxia.
Keywords: Cerebellar Ataxia, Core Stability Training, Dynamic Balance, Falls
INTRODUCTION
Cerebellar ataxia indicates dysfunction of the
cerebellum. Ataxia literally means without order. The
term ataxia refers mainly to inaccuracy of movement
towards a target, to rhythmic limb movements either
during a sustained posture or when the patient attempts
to reach a target, inability to perform smooth alternate
movements and loss of coordination of muscle groups
in multi joint movements.1
Patients with degenerative cerebellar lesions show
global impairment of balance with greater instability
in anterior- posterior direction than medio- lateral
directions.2, 3 important factor contributing to instability
is decreased knee and ankle flexion when tested through
perturbations 3. Individuals with cerebellar ataxia show
more co-contraction modes of muscles resulting in
stiffness of muscles of major joints e.g. knee stiffness
and result in impaired coordination during feedback
and feed forward postural control 4Studies reveal
cerebellar gait ataxia is more related to balance deficits
than voluntary leg coordination deficits.5
27. Neha Tabussam--136-140.pmd
136
Systems approach describes, dynamic balance is a

result of interaction of the individual, task &
environment. Ankle, hip, suspensory and stepping
strategies keep centre of gravity over the base of support,
anticipatory postural adjustments occur before the
actual disturbance, volitional postural movements are
under conscious control are the motor components of
balance that support postural orientation & automatic
postural reactions.6
The muscles stabilizing lumbar spine form the core
muscles. This muscular control is required around
lumbar spine to maintain functional stability.7 Core
stability is defined as the ability of the lumbopelvichip complex to prevent buckling of the vertebral column
and return it to equilibrium following perturbation.8
Core stability (spinal stabilization)techniques
incorporated in Low Back Pain subjects have found to
improve the stability of spine by improving the cocontraction of trunk muscles, recovery in the size of
multifidus muscle, also resulted in motor learning by
retaining appropriate coordination of deep and
2/7/2013, 8:08 PM
superficial muscles for gaining spinal stability9,10,11.

Core strengthening improves dynamic postural control
in rehabilitation of athletic injury.12
The purpose of this study was to determine whether
the addition of Core stability training to conventional
balance training in patients with Progressive
degenerative cerebellar ataxia has any benefit on
dynamic balance as compared with conventional
balance training alone. Dynamic balance is a problem
in patients with Progressive Degenerative Cerebellar
Ataxia. The trunk muscles form the basis of core which
acts as the powerhouse for force production and coordinated limb movements during locomotion.13 Core
Stability training it is aimed to create awareness of
muscle contractions around the spine which have
eventually weakened due to chronic nature of disease.2,3
Also in progressive degenerative Cerebellar Ataxia the
synergies required for maintaining Dynamic Balance
are altered.4 The synergies can be strengthened through
training of Core muscles.14 If the study reveals positive
effects of core stability training on dynamic balance,
treatment protocols can be developed to improve
dynamic balance with ease in every clinical setting.
METHOD
A sample of 20 subjects with progressive
degenerative Cerebellar ataxia (18 subjects were SCA
and 2 were olivopontocerebellar atrophy) participated
in the study. Out of 20, 15 were male whereas 5 were
female. 18 subjects suffered from SCAs (type 1, 2, 3)
and two from olivo-ponto cerebellar atrophy. A sample
of convenience was taken.
Subjects in group A were treated with core stability
training which included back stabilization exercises,
single leg slides, leg loading, facilitation of Transversus
abdominis, bridging, Pelvic floor exercises and
diaphragmatic Breathing while balance training
included turning, walking sideways, heel to toe
walking, sit to stand, heel lifts, toe lifts, single leg
standing ,leg swings, stair climbing. Subjects in Group
B treated with balance training and relaxation
training15, 16,17,18,19 at Institute of Human Behaviour and
Allied Sciences Hospital, Delhi.
Subjects with Progressive degenerative ataxia of
cerebellar origin diagnosed by neurologist, age range
from 18-50, MMSE score e 24,Chronic cases having
symptoms more than a year, SARA score 15-23,20
Subjects should be able to walk minimum distance of
10 meters with or without walking aid were included
in the study.20
Subjects diagnosed as Afferent/ sensory ataxia, any
other neurological or orthopaedic disorder affecting gait
or balance, severe Low back pain, Already undergoing
137
physiotherapy intervention for last 3 months,

Uncorrectable visual or hearing loss, Subjects unwilling
to follow the exercise regime were excluded. It was a
prospective repeated measure experimental group
design. Instrument used for exercise regime was
pressure biofeedback device16, 21 (Chattanooga group).
A duly signed consent form was obtained from the
subjects. A detailed assessment of every subject was
done using neurological evaluation form. All the
subjects were assessed for inclusion and exclusion
criteria. The mini mental status examination was done.
Demographic data of the subjects were collected.
Subjects were assigned systematically into two groups
group A experimental and group B conventional
treatment groups.
The treatment sessions for both the groups were
given for 1 hour per day, 3 times per week for 4 weeks
The performance of the two groups was examined on
the following scales: Dynamic Balance was tested on
Balance Evaluation System Test(BESTest)22 and for fear
of Falls Modified Falls efficacy scale (MFES) 23was
used..The outcomes were taken 3 times during treatment
first before treatment, second immediately after the 4
weeks of treatment and third after a months follow up.
The treatment was given n the physiotherapy
department of the IHBAS hospital. The study was
reviewed by the ethical board of Jamia Hamdard
University, New Delhi.
DATA ANALYSIS
The data was analysed using SPSS software version
15. Independent T-test was used to see the difference
between the effects training between group A and
B.Effectiveness of treatment within the groups was
measured using repeated measure ANOVA. The results
were checked at P<0.05 level of significance.
RESULTS
The change in the Dynamic Balance and Fear of falls
was measured at three levels of the treatment phases,
initially at pre treatment, then post treatment and last
at follow up
BETWEEN GROUP
The Mean SD values for BESTest in experimental
group after 1 month of treatment was 63.50 15.757
and conventional group was 50.00 11.981.This
difference in values was statistically significant p=0.045.
The Mean SD values for experimental group from pre
intervention to Follow Up was 55.60 17.602 the result
was statistically significant (P=0.024) and conventional
group was 40.10 9.327.This difference in values was
statistically significant (p=0.024), indicating that the
2/7/2013, 8:08 PM
experimental group showed more improvement in

Balance than the conventional group. Although there
was no statistically significant improvement in the
scores at post treatment (p=0.433) and at follow up
(p=0.154) after treatment.
Table. 1.1 Comparison between pre, post and follow
up scores of experimental and conventional groups on
BESTest scale
Dependent
variables
Experimental
Mean SD
Conventional
Mean SD
P value
Pre BESTest total
35.60 12.616
38.10 10.503
0.636
Post 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 up

scores of experimental and conventional groups on
MFE Scale
Dependent
variables
Expt
Mean SD
Conv
Mean SD
P value
Pre MFES
52.80 20.137
59.10 14.395
0.431
Post MFES
77.80 30.724
68.80 17.725
0.433
Follow Up MFES
78.50 32.857
59.90 21.957
0.154
DISCUSSION
The key findings that emerged from the study were
that core stability training is effective in improving
Dynamic balance in progressive degenerative cerebellar
ataxia. Core stability training group showed significant
improvement on BESTest till follow up compared to
conventional balance training group. There was no
statistical difference found in the MFEscale among the
two groups but the results were clinically significant at
follow up for core stability training group.
Liebenson found trunk stabilization exercises
resulted in reduction of low back pain, by increasing
the kinaesthetic awareness necessary to maintain safe
neutral spine which is ideal for rehabilitation.24 Nicole
L et al. studied on dynamic balance testing among
young healthy adults and found that core strengthening
improves dynamic postural control during
rehabilitation of athletic injury.12 The diaphragm serves
as the roof of the core; stability is augmented on the
lumbar spine by contraction of diaphragm and
increasing intraabdominal pressure.13 Pelvic floor
musculature is co activated with the Transversus
abdominis contraction.13
The results found this study are supported by the
work of Paul W. Hodges which provided the rationale
of core stability training, that stability of spine depends
on both the muscle activation and CNS control.14 The
core stability training results in motor learning
sequentially through skill learning, precision training,
activation in variety of contexts, integration of skills
138
into tasks that includes coordination of deep and

superficial trunk muscles is maintained in functional
context balance.14 Konin JG et al. al described diagonal
orientation of core muscles resemble a serape,
producing a serape effect connecting the stability for
upper and lower extremities and maintaining muscular
control around the spine and maintaining functional
stability.25
In this study the pressure biofeedback was used for
core training including abdominal hollowing a basic
exercise taught initially and then hollowing associated
with lower limb movements. It activated Transversus
Abdominis (TrA) muscle, which is important muscle
forming core.26 It is found that the patient with cerebellar
ataxia uses restricted synergies i.e. stiffening of pelvis,
knees, and ankles during challenging tasks.27 It has also
been found that practice could lead to transition from
co-contraction to reciprocal patterns on the basis of
uncontrolled manifold (UCM) hypothesis.28 This study
included patients with chronic progressive disease, as
above study mentioned that these patients use restricted
synergies to maintain balance. Practice of core training
along with lower limb activities provided in this study
might have helped patients to develop reciprocal muscle
pattern rather than the stiffening of the joints.28 resulting
in reduction of synergies and their strengthening which
are essential for dynamic balance control.28
The rationale behind the fact that patients did not
return to pre treatment level or their condition did not
decline due to progression of disease, is that the natural
progression of degeneration in Cerebellar ataxia is 0.62.5 points 1 year as found on SARA scale depending on
genotypes (data of EUROSCA natural history. Thomas
Klockgether, 2008).5 Long term effects of intensive
exercise training have been proven in research on
progressive degenerative cerebellar disease even after
a year of training.29
There was no statistical significance in improvement
of the falls score at post treatment (p=0.433) and at
follow up (p=0.154).However experimental group
showed clinical improvement in falls score. When
baselines (fig.1.2) were compared for both the groups it
can be observed that the difference for improvement
was more in Experimental group than the conventional
group.
The results obtained may be attributed to the 1)
gender differences, in experimental group there were 3
females and conventional group there were 2 females,
because the females were seen to have less confidence
than males of same severity.23, 30 2) Considering age
differences, in conventional group 3 patients were of
age 45years and above, while in experimental there were
4 patients having age 45years and above. 3) Considering
2/7/2013, 8:08 PM
disease severity, in conventional group 4 subjects were

above 16 scoring of SARA scale, while in experimental
there were 5 subjects scoring more than 16. The above
factors may be the possible causes of difference of MFEs
score at pre treatment level that led to no statistical
significance even though the experimental group
improved more than conventional group.
CONCLUSION
The results obtained show that the core stability
training improves dynamic balance. However it was
seen that although there was clinical improvement of
scores on MFEScale, but no statistical significance was
observed. Thus it is concluded that in rehabilitation of
dynamic balance in patients with progressive Cerebellar
ataxia, core stabilization programme can be included
as an adjunct to conventional balance training.
LIMITATIONS OF STUDY
6.
7.
8.
9.
10.
11.
1. The subjects included in this study were moderately

disabled (rated on SARA scale). The results of this
study cannot be generalized to severely disabled
patients.
2. Scale for measurement of fear of falls taken was
subjective.
3. The sample size was smaller.
ACKNOWLEDGEMENTS
12.
13.
14.
Sincere thanks to Physiotherapy Dept. IHBAS, Jamia

Hamdard, New Delhi.
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Restoration of Normal Length of Upper Trapezius and

Levator Scapulae in Subjects with Adhesive Capsulitis
Pandit Niranjan Hemant1, Mhatre Bhavana Suhas2, Mehta Amita Anil3
Physiotherapist - Mumbai Cricket Association, Cricket Centre, Wankhede Stadium, 'D' Road, Churchgate,
Mumbai, - Jaslok hospital & Research Centre, 15 - Dr. Deshmukh Marg, Pedder Road, Mumbai,
2
Associate Professor, P.T School and Centre, Seth Dhurmal Bajaj Orthopaedic Centre, 3Professor and Head, P.T School and
Centre, Seth Dhurmal Bajaj Orthopaedic Centre, Seth G.S.Medical College and KEM hospital, Parel, Mumbai
1
ABSTRACT
Study Design: Prospective clinical trial of subjects with Adhesive Capsulitis
Objective: To find the effect of restoration of length of the shortened upper trapezius and levator
scapula muscle with muscle energy technique and sustained passive stretching techniques along with
Maitland joint mobilization for glenohumeral joint as compared to Maitland joint mobilization alone
on range of motion and scapular position at rest in subjects with unilateral adhesive capsulitis.
Background: The glenohumeral hypomobility in adhesive capsulitis causes excessive scapular motion
to compensate for the reduced gleno-humeral motion. The resulting tightness of upper trapezius and
levator scapula causes an altered scapular position at rest. Restoring normal length of upper trapezius
and levator scapulae will help to restore an optimal length-tension relationship and scapular position
resulting in better improvement of glenohumeral range of motion.
Methods and measures: 60 male subjects with unilateral adhesive capsulitis were divided into group
I and group II of 30 each. Baseline outcome measures assessed were shoulder ROM of flexion, abduction
and external rotation and resting position of the scapula using the Lennie test. Group I received Muscle
Energy Technique (MET) for upper trapezius and levator scapula along with Maitland joint mobilization
for the glenohumeral joint. Group II received Maitland mobilization for the gleno-humeral joint.
Outcomes were reassessed at 6 weeks.
Results: The results showed statistically significant improvement ROM in both groups with
improvement being more in group I as compared to group II. However scapular position showed
statistically significantly improvement only in group I with no improvement in group II.
Conclusion: Adding muscle energy techniques to the treatment of adhesive capsulitis gives better
outcomes compared to treating with joint mobilization alone.
Keywords: Adhesive Capsulitis, Muscle Energy Techniques, Upper Trapezius, Levator Scapula, Joint Mobilization
INTRODUCTION
Adhesive capsulitis is a condition causing painful
and restricted motion of the glenohumeral joint.
Normally the entire glenohumeral joint in the resting
position (arm dependent at the side) is surrounded by
a large, loose capsule that is taut superiorly and slack
anteriorly and inferiorly (redundant folds or axillary
pouch) 1. Hyaluronic acid with water is the lubricant
between the collagen fibres that allows the free gliding
to occur 2.The pathogenesis of adhesive capsulitis
involves the entire capsule with more involvement of
the antero-inferior axillary folds which are shrunken
and fibrosed 3,4.
28. Niranjan Pandit-141-147.pmd
141
The impairments are pain and loss of active and

passive mobility of the glenohumeral joint. Abnormal
scapular motion, such as excess elevation and increased
outward rotation of the scapula during elevation of the
arm, is generally thought to be a compensation strategy
for a limited glenohumeral motion, muscle imbalance
and pain 3. In a trial of ten patients with unilateral frozen
shoulder syndrome for 3 months early scapular lateral
rotation of the frozen shoulder during elevation of the
arm using an electromagnetic tracking device was
documented 5.
Research supports the view that patients suffering
from frozen shoulder syndrome compensate for
2/7/2013, 8:08 PM
impaired glenohumeral motion via the use of accessory

musculature i.e. increased trapezius muscle activity 6.
The upper trapezius and levator scapulae are
considered to be postural muscles and hence undergo
shortening in response to stress or overuse 7. The
scapula on the involved side is usually elevated,
laterally rotated and abducted 2. Studies on treatment
of adhesive capsulitis concentrate on treating
glenohumeral joint. But little attention is paid to
normalize scapular static and dynamic mechanics
which are essential for normal glenohumeral rhythm.
Hence the focus of this study was to find the effect of
restoration of length of the shortened upper trapezius
and levator scapula muscle with muscle energy
technique and sustained passive stretching techniques
along with Maitland joint mobilization for
glenohumeral joint as compared to Maitland joint
mobilization alone on pain scores, range of motion and
scapular position at rest in subjects with unilateral
adhesive capsulitis.
We begin with the null hypothesis that there is no
relation between combining muscle energy techniques
for upper trapezius and levator scapula and Maitland
joint mobilizations for glenohumeral joint as compared
to treating glenohumeral joint alone with Maitland joint
mobilization.
MATERIALS AND METHODOLOGY
Prospective clinical trial of 60 male subjects with

adhesive capsulitis from the outpatient department
of physiotherapy at Seth G.S. Medical college &
K.E.M. hospital Mumbai.
Patients with unilateral adhesive capsulitis.
Exclusion criteria
Bilateral adhesive capsulitis
Dorsal spine scoliosis as spine was taken as the

midline reference
Associated pathology of the cervical spine.
Post fracture stiffness
Rotator cuff tendinosis or tears
Shoulder instability
Complex regional pain syndrome
Neurovascular neoplastic or infectious conditions
Adhesive capsulitis along with neurological

conditions like hemiplegia
The material used
Universal goniometer
Vernier caliper
Wrist watch
Skin markers
Manual therapy table
10 centimeter visual analogue scale (VAS)
Assessment proforma.
Informed consent was obtained from subjects prior

to their inclusion in the study. Approval was taken
from Ethics Committee for Research on Human subjects
(ECRHS) of K.E.M. Hospital Mumbai.
The following outcome measures were assessed on
day 1 and at the end of 6 weeks (18th treatment session).
Flexion, abduction and external rotation ROM using

goniometer.
Position of the scapula on the thorax at rest using

the Lennie test 8 (Fig 1)
Markers were put on the skin overlying the affected

and non-affected scapulae for the superior
angle, root of the scapular spine and inferior angle.
Three measurements of scapular position in the
frontal plane were obtained for both sides.
Inclusion criteria
of or around shoulder
142
Midline to superior angle distance
Midline to root of the spine of scapula distance
Midline to inferior angle distance.
In addition, height difference between scapulae

(defined as difference between the vertical positions
of the inferior angles of the affected and the nonaffected scapula) was measured with the caliper
using the midline marks corresponding to the two
inferior angles.
Subjects were divided into group I and group II of

30 each and assigned alternately into groups i.e. even
numbers into group I and odd numbers in Group II.
Group I received: Muscle energy techniques for upper
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trapezius and levator scapulae along with Maitland

joint mobilization
Muscle Energy Technique for upper trapezius and

levator scapula 7: (Fig 2)
Subject performed a sub-maximal isometric

contraction in supine position for the respective muscle
against resistance commencing with the muscle at the
resistance barrier and maintained it for 10 seconds.
Following relaxation, muscle was stretched beyond the
barrier till a new barrier was reached and stretch was
maintained for 30 seconds. The sequence was repeated
3 times for upper trapezius and levator scapula.
Maitland joint mobilization: (Fig 3)
Anteroposterior (AP), posteroanterior (PA) and

inferior glide
Grade 3 and 4 Maitland joint mobilizations for the

gleno-humeral joint.
3 sets of 30 oscillations per minute per glide 9.
3 sets of 30 oscillations per minute per glide 9.
Both groups were given hydrocollator packs for the

shoulder joint for 10 minutes in sitting position before
treatment 10.
Home exercise program 11
Both the groups were given home exercise program
with the following exercises:
1) Shoulder girdle retraction and depression(scapular
setting).
2) Wand exercise to improve shoulder flexion and
shoulder rotation with both hands.
3) Active assisted shoulder extension in standing.
The subjects were asked to repeat each exercise ten
times twice a day.
They were told to take hot packs at home before
exercising to reduce pain and relieve spasm.
Data analysis and results
Group II received: Maitland joint mobilization.
Maitland joint mobilization: (Fig 3)
Anteroposterior (AP), posteroanterior (PA) and

inferior glide
Grade 3 and 4 Maitland joint mobilizations for the

gleno-humeral joint.
56 patients completed the study. Two subjects in

each group were lost to follow up before 6 weeks. So
there data was not taken into consideration in statistical
analysis. For the values of shoulder range of motion
and scapular position, paired t test (pre-post within
group comparison) and unpaired t test (inter-group
comparison) was used.
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
Significance
Mean
SD
Mean
SD
102.86112.14
13.5013.57
98.93108.57
12.3510.35
AbductionActivePassive
78.9388.75
14.3012.22
73.7585.36
10.8510.09
0.13270.2622
NS
External rotationActivePassive
7.1414.46
7.266.98
4.8212.14
4.615.17
0.15880.1632
NS
SA
6.3368
0.2099
6.2829
0.1700
0.2955
NS
IA
7.2882
0.3194
7.2261
0.2593
0.4276
NS
I I
0.9811
0.1765
0.9779
0.1734
0.9576
NS
ROM
FlexionActivePassive
0.26090.2731
NS
Scapular position
NS Not Significant, SA Superior angle, IA Inferior Angle, I I Difference in Inferior angle levels
143
2/7/2013, 8:08 PM
Analysis of scapular position change

Table 2. Inter-group comparison of reduction of distance of Superior and Inferior Angle from midline and
Difference between Inferior angles
Mean
SA Pre
SA Post
IA Pre
IA Post
II Pre
II Post
Group I
6.3368
6.2418
7.2882
6.7500
0.9811
0.3836
Group II
6.2829
6.2821
7.2261
7.2175
0.9779
0.9729
t- value #
1.05
1.39
0.79
6.43
0.05
15.66
p- value
0.2955
0.1697
0.4276
0.0001
0.4276
0.0001
* - Results analysed using paired t test

# - Results analysed using unpaired t test
These results indicate that only treatment received

by group I was effective in bringing about change in the
scapular position (p < 0.05) while no statistically
significant effect was seen in scapular position by

intervention given in group II (p > 0.05).
Analysis of abduction range of motion

Table 3. Intergroup comparison between abduction ROM before and after treatment.
Mean
Active Pre
Active Post
Passive Pre
Passive Post
Group I
78.93
110.54
88.75
121.07
Group II
73.75
100.00
85.36
111.79
t value #
1.52
2.70
1.13
2.81
p value
0.1327
0.0091
0.2622
0.0068

Shoulder ROM of abduction showed extremely

statistically significant improvement within both the
groups post treatment (p < 0.05). In intergroup
comparison, group I showed more highly statistically

significant improvement in abduction as compared to
group II (p < 0.05).
Analysis of flexion range of motion

Table 4 Intergroup comparison between flexion ROM before and after treatment.
Mean
Active Pre
Active Post
Passive Pre
Group I
102.86
137.86
112.14
Passive Post
146.96
Group II
99.64
114.82
108.57
125.89
t - value
1.13
6.21
1.10
6.42
p - value
0.2609
0.0001
0.2731
0.0001

Shoulder ROM of flexion showed extremely

statistically significant improvement within both the
groups post treatment (p < 0.05). In intergroup
144

significant improvement in flexion as compared to
group II (p < 0.05).
2/7/2013, 8:08 PM
Analysis of external rotation range of motion

Table 5 Intergroup comparison between external rotation ROM before and after treatment.
Mean
Active Pre
Active Post
Passive Pre
Group I
7.14
35.54
14.46
43.57
Group II
4.82
23.04
12.14
33.75
t value #
1.42
4.46
1.41
4.71
0.1588
0.0001
0.1632
0.0001
p - value
Passive Post

Shoulder ROM of external rotation showed

extremely statistically significant improvement within
both the groups post treatment (p < 0.05). In intergroup
significant improvement in external rotation as
compared to group II (p < 0.05).
DISCUSSION
Both the groups showed a significant improvement
shoulder range of motion. Intergroup comparison
indicates that group I showed significant improvement
post treatment at the end of 6 weeks (18th session) on
the above mentioned outcome when compared to group
II. However, the improvement of scapular position post
treatment was seen only in group I
Scapular position improvement was seen secondary
to the treatment of the upper trapezius and levator
scapula muscle using muscle energy technique could
be attributed to the therapeutic effects of muscle energy
techniques. Many authors have proposed that MET
techniques facilitate stretching by producing
neurological reflex muscle relaxation 7 following
isometric muscle contractions mediated by Golgi
tendon organs. Connective tissue elongation is time
dependent, and if a constant stretching force is loaded
on the tissue, the tissue will respond with slow
elongation or creep causing greater deformation i.e.
there is viscoelastic or muscle property change 7.
Myofascial structures have two distinct connective
tissue arrangements: elastic parallel fibres, arranged
parallel to the muscle fibres, and the stiffer in series
fibres that lie perpendicular to muscle fibres and found
mainly at the tendinous junctions. Passive stretching
would elongate the parallel fibres but have little effect
on the in series fibres; however, the addition of an
isometric contraction would place loading on these
fibres to produce viscoelastic or plastic change above
and beyond that achieved by passive stretching alone.
Literature suggests that MET methods produce a greater
change in stretch tolerance 7 than passive stretching by
decreasing an individuals perception of muscle pain.
145
Stretching and isometric contraction stimulate joint

muscle and joint mechanoreceptors and proprioceptors,
and it is possible that this may attenuate the sensation
of pain.
The above mentioned mechanisms contributed to
reduce over activity and increased length of the upper
trapezius and levator scapula muscle. This was
reflected on the scapular position in Group I on the
Lennie test. Literature supports the view that abnormal
compensatory scapular movements in patients with
shoulder stiffness can be reduced. In a particular study,
it was demonstrated that with simple motor control
instruction, the subjects reduced the amount of scapular
elevation and retained relative timing and control 12.
The primary role of mobilization is to restore joint
play and facilitate joint movement by restoring
arthrokinematics. The neurophysiologic effect is based
on the stimulation of the peripheral mechanoreceptors
and inhibition of nociceptors. The biomechanical effect
is based on breaking up adhesions in the capsule,
collagen fibre realignment and improving interfibre
glide 2. A multiple-subject case report concluded that
there seems to be a role for intensive mobilization
techniques in the treatment of adhesive capsulitis 13.
Hence there was increase in ROM of the shoulder over
a period of 6 weeks.
The underlying basis for the use of hot packs is the
ability of heat to elevate pain threshold, alter nerve
conduction velocity and change in muscle spindle firing
rate 10.
Thus the null hypothesis was rejected and the
experimental hypothesis was proved.
CONCLUSION
Restoring length of upper trapezius and levator
scapula is essential when treating patients with
adhesive capsulitis. While assessing patients with
adhesive capsulitis attention needs to be given to
assessment of abnormal scapular position. Treatment
2/7/2013, 8:08 PM
should be focused on treating the glenohumeral joint

alone but also incorporate techniques to restore altered
scapular mechanics.
The study did not take into account the strength of
muscles like middle and lower trapezius, rhomboids,
serratus anterior.
ACKNOWLEDGEMENTS
We are heartily thankful to the staff of PT School
and Centre, KEM hospital, who supported us from the
preliminary stages of the project.
Fig. 1. Lennie test
Also the influence of other muscles which become

tight in adhesive capsulitis like pectorals, subscapularis,
and teres major on glenohumeral range of motion was
not taken into account.
Implication for future studies
Studying the EMG activity before and post
intervention for the upper trapezius and levator
scapula would be helpful in understanding the
mechanism of improvement in the length of these
muscles post MET.
Interest of conflict: We, Pandit N, Mhatre B and
Mehta A state that there is no conflict of interests with
other people or organizations about our work.
Fig. 2. Muscle energy techniques

Upper trapezius
Levator scapula
146
2/7/2013, 8:08 PM
Fig. 3. Glenohumeral mobilization

Anteroposterior glide
Posteroanterior glide
Inferior glide
A study of the pathological findings in periarthritis

of the shoulder. JBJS Am. 1945;27:211-222.
5.
Vermeulen H.M. Stokdijk M. Eilers P.H.C. Meskers
C.G.M. Rozing P.M. Vliet Vlieland T.PM.
Measurement of three dimensional shoulder
movement patterns with an electromagnetic
tracking device in patients with a frozen shoulder.
Ann. rheum. Dis. 2002;61:115-120
6.
Jiu-Jenq Lin. Ying-Tai Wu. Shwu-Fen Wang. ShiauYee Chen. Trapezius muscle imbalance in
individuals suffering from frozen shoulder
syndrome. Clin Rheumatol 2005;24:569575.
7.
Chaitow L. Muscle energy techniques, 3rd edition;
Churchill Livingstone 2006.
8.
Sobush D. C. Simoneau G.G. Deitz K.E. Levene
J.A. Grossman R.E. Smith W.B. The Lennie Test for
measuring scapular position in healthy young
adult females: A reliability and validity study,
JOSPT Vol. 23 No. 1 Jan 1996.
9.
Maitland G.D. Peripheral manipulation, 3rd
edition.
10. Michlovitz S. Thermal agents in rehabilitation. 3rd
edition FA Davis Co. Philadelphia 1990
11. Kisner C. and Colby L. Therapeutic exercise, 5th
edition 2007.
12. 15 Babyar S. R. Excessive scapular motion in
individuals recovering from painful and stiff
shoulders: Causes and treatment strategies, Phys
Ther. 1996;76:3.226-238.
13. Vermeulen H.M. Obermann W.R. Burger B.J. Kok
G.L. Rozing P.M. van den Ende C.HM. End-range
mobilization techniques in adhesive capsulitis of
the shoulder joint: A multiple-subject case report.
Phys Ther. 2000;80:12.1204-1213.
REFERENCES
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2.
3.
4.
Norkin C. and Levangie P. 3rd edition. Jaypee

Brothers 2001.
Donatelli R.A. Physical therapy of the shoulder,
3rd edition; Churchill Livingstone 1997.
Reeves B. Arthrographic changes in frozen
shoulder and post traumatic stiff shoulders. Proc
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Neviaser J. S. Adhessive capsulitis of the shoulder:
147
2/7/2013, 8:08 PM
Comparison of VMO/VL Ratio in Patello-Femoral Pain

Syndrome (PFPS) Patients: A Surface EMG Study
Nishant H Nar
Consultant Physiotherapist Wockhardt Hospital, Rajkot
ABSTRACT
Background: PFPS describes anterior and retro patellar knee pain in the absence of other pathology.
PFPS is one of the most common disorders of the knee accounts for 25% of knee injuries in sports
medicine clinics. Prevalence rate is 20% in USA students and morbidity is directly related to activity of
patients. EMG studies of normal subject have revealed that VMO /VL ratio is about 1:1 (power CM et al)
Objective: To study the VMO/VL ratio during ECCENTRIC, CONCENTRIC, ISOMETRIC exercise and
Q-angle in PFPS patients and control groups.
Materials & Method: SUBJECTS; 25 diagnosed with PFPS and 25 asymptomatic control were recruited
for study. EMG activity of VMO VL was recorded by surface electrodes.EMG data were analyzed in
three activities for both groups, ISOMETRIC, CONCENTRIC and ECCENTRIC exercise. Outcome
measure was EMG MUAP amplitude and Q-angle.
Results: Results showed that VMO/VL ratio is lower in PFPS subjects. And static and dynamic Qangle is higher for PFPS groups.
Conclusion: There was significant difference in VMO/VL ratio and Q-angle in both groups.
Keywords: VMO, Surface EMG, Q-angle.
INTRODUCTION
PFPS describes anterior or retro patellar knee pain
in the absence of other pathology. PFPS which is one of
the most common disorders of the knee accounts for
25% of all knee injuries treated in sports clinics. [1]
Female patient are particularly more affected than
male [2]. Incidence rate is 7% and 10% in young male
and female. [2]
Prevalence rate is 20% in students in USA and
morbidity is directly proportional to activity of Patients
[3]
In one study done by Winslow et al 1995 out of 16,748

patients presenting with sports related musculoskeletal
problems, 11.3% had an anterior knee pain. Incidence
of PFPS in general population is reported in some
studies to be high as one in four with proportion
increase in athletes. (Levine 1979, Outbridge 1984)
29. Nishant--148-153.pmd
148
In orthopedics sports medicine, the most common

reasons for anterior knee pain are, [4]
Overuse
Mal-alignment
Trauma
Studies on the natural history of PFPS report that in
general it is a benign condition that may improve or
persist over time serious disability is uncommon. PFPS
is a condition of both malalignment and muscular
dysfunction.
Rehabilitation exercises can restore PF joint
homeostasis although the anatomical malalignment of
PFPS may not be corrected. [5]
Symptoms of anterior knee pain are brought on by
overuse stress; PFPS is an ideal condition for
prerehabilitation. [6]
Total or near total recovery was noted in 22% at 16
years ( Noman et al 1998)
70 % at 3 years (Kanmus et al 1994), 81% at 12 years
( jensssen et al 1990), 85% at 11 years (Karlsson et al
1996 ).
2/7/2013, 8:08 PM
The basic origin and exact pathogenesis of PFPS are

unknown but many predisposing factors have been
proposed including[7]
Acute trauma, knee ligament injury, instability,
overuse, immobilization, overweight, malalignment of
extensor mechanism.
In many cases, however there are no obvious reasons
for the symptoms, there is no clear association between
severity of the symptoms and the radiologic and
arthroscopic findings.
Some theories for the origin of non- traumatic
gradual onset of PFPS are [8]
Neuromuscular imbalance of VMO VL, Tightness
of lateral retinaculum, Hamstrings , Iliotibial band,
Overpronation of subtalar joint.
Several authors have exposed the theory that
abnormal patellar alignment is the root of pain [8]
Patients usually complain of insidious onset of
vague, activity related pain coupled with evidence of
wasting of Vastus medialis.[9]
EMG studies of normal subjects have revealed that
VMO/VL activity ratio is about 1:1,
Whereas EMG recording in patients having
PFPS has shown that the ratio of VMO/VL is le than
1:1. [10] [11].
Controversy exist in the literature as to the normal
relationship between the timing of EMG activity of the
VMO and VL and whether this difference in population
with PFPS.[12, 13]
Many rehabilitation strategies have implemented for
patients with PFPS. In general the goals of patella
femoral rehabilitation are to maximize quadriceps
strength while minimizing the patella femoral joint
reaction force and stress.[14, 15]
Also in outpatient department the cases of PFPS is

increasing day by day, and so the clinical assessment
and treatment of the condition are extremely
challenging because of the multiple forces affecting the
patella femoral joints.
MATERIALS AND METHODOLOGY
STUDY DESIGN
Cross sectional study
STUDY SETTING
This study was conducted at Physiotherapy Institute
of Ahmedabad. All the patients were referred from
Orthopedic Out patient Department of V.S Hospital,
Ahmedabad.
SAMPLE SIZE: 25 Subjects in each group
SUBJECTS: Male and Female with clinical
diagnosis of PFPS who were referred to physiotherapy
OPD
INCLUSION CRITERIA
1) Age between 25-40 year
2) Anterior knee pain more than 1 month
3) Knee pain atleast 2 of the following activities
Ascending stairs
Descending stairs
Squatting
Kneeling
4) Diagnostic tests were positive for PFPS
5) Subjects willing to participate in study
EXCLUSION CRITERIA
Recently EMG biofeedback is also useful method to

activate VMO muscle. Selina Lm Yip et al concluded
that EMG biofeedback + exercise programme is
beneficial than alone exercise in PFPS patients.[16]
1) Any trauma around knee joint
Other investigators [17, 18] have examined VMO and

VL EMG levels in the patients with PFPS, but have not
used control groups. Approximately 70% of patella
femoral disorder will improve with conservative
management.
4) Skin abrasion around knee
149
2) Any previous surgery around knee joint

3) Neurological disorder
5) Previous physiotherapy taken in past 6 months for

knee
2/7/2013, 8:08 PM
MATERIALS USED IN STUDY

Electrode, electrode gel, goniometer, measure tape,
micro pore, plinth, consent form, Pencil, Papers
assessment charts and recording sheets.
APPARATUS USED IN STUDY
EMG Machine with Neuro Perfect Plus Software
Computer System with printer
OUTCOME MEASURES
EMG amplitude
Q- Angle: static and dynamic
PROCEDURE
Twenty five subjects diagnosed with PFPS on the
basis of clinical examination and referred from
orthopedic OPD, and 25 asymptomatic controls were
recruited for the study. Subjects were selected on the
basis of inclusion and exclusion criteria. Detailed
assessment of patients with diagnostic tests for PFPS
and radiological examination was done. All subjects
were provided written informed consent. Then patients
data was entered to EMG programme (Neuro Perfect
plus Software) in computer. Then EMG surface
electrodes with gel were placed over the selected muscle.
Micropore tape was used to adhere the electrodes on
skin.
EMG parameters were SWEEP -10ms, SENSITIVITY
100micro volts, LOW CUT 100Hz, HIGH CUT 5 KHz,
PULSE/ SEC- 1, PULSE WIDTH-0.02ms
Averaged EMG Amplitude was taken for both VMO

and VL and then VMO/VL ratio was calculated
manually.
Static and Dynamic Q-angle was measured for both
groups. For static Q-angle measured with knee in full
extension with subject in supine position. ASIS (anterior
superior iliac spine), centre of patella and tibial
tuberosity was marked with pencil. The angle formed
by the intersection of line from ASIS to centre of patella
with centre of patella to tibial tuberosity was measured
in degrees with universal goniometer. [Fig-3]
Dynamic Q-angle was measured with static
quadriceps contraction in supine position with knee
extended. Procedure of measurement was same as for
static Q-angle.
VL electrode placement
Fig. 1. VMO electrode placement
VMO placed over the muscle belly approximately 4

cm superior to and 3 cm medial to the superomedial
patellar border and oriented 55 degrees to vertical. [19]
(Fig 2)
EMG amplitude was recorded during ISOMETRIC,
CONCENTRIC and ECCENTRIC exercises.
EMG MUAP Amplitudes were identified from
individual trials and averaged over the 5 repetition.
After that electrodes were removed and placed for
VL muscle and MUAP amplitude was recorded during
above described three exercises.
The electrode for VL was placed 10 cm superior and
6-8 cm lateral to the superior border of the patella, and
oriented 15 degrees to vertical. [19] (Fig 1)
150
Fig. 2. Q-angle measurement
2/7/2013, 8:08 PM
To analyze the dynamic Q-angle between groups

mann-whitney U- test was used as the data is non
parametric.
To analyze the value of VMO/VL ratio between
control and PFPS groups during isometric exercise
unpaired t-test was used, as the data is normally
distributed.
control and PFPS groups during concentric exercise
distributed.
control and PFPS groups during eccentric exercise
distributed.
Fig. 3
RESULTS
In this study all the tests were performed manually
as well as with the use of Graph pad software.
To analyze the value of static and dynamic Q-angle
within the groups for control and PFPS groups paired
t-test was used, as the data is normally distributed.
To analyze the static Q-angle between groups mannwhitney U-test was used as the data is non parametric.
Table-1 Age distribution of both group patients

Groups
Mean
SD
Control
32.56
5.324
Experimental
33.12
4.825
The mean age of the control group was 32.56 5.324

and in the PFPS patients, the mean age was 33.12
4.825 No significant difference was seen across the two
groups.
Table 2. Comparison of static and dynamic Q-angle in PFPS patients

Q-angle
mean
SD
Test used
t-value
p-value
significance
Static
16.12
2.789
paired t-test
t=3.663
P=0.0006
Extremelysignificant
Dynamic
19.52
3.709
Here the paired t-test was used as the data is normally distributed. Mean value for static and dynamic Q-angle
were respectively 16.12 2.789 and 19.52 3.709. t=3.663 and p=0.0006 so the difference was extremely significant
at 95% confidence interval.
Table -3 Comparison of static and dynamic Q-angle in control group
Q-angle
mean
SD
Test used
t-value
p-value
significance
Static
14.36
3.390
paired t-test
t=0.8088
P=0.4272
Not significant
Dynamic
15.12
3.321
Here the paired t-test was used as the data is normally distributed. Mean value for static and dynamic Q-angle
were respectively 14.36 3.390 and 15.12 3.321. t=0.8088 and p=0.4272 so the difference was not significant at
95% confidence interval.
Table -4 Comparison of static Q-angle in PFPS and control groups
Q-angle
mean
SD
Test used
U-value
p-value
significance
PFPS
16.12
2.789
Mann whitney
U test
U= 210
P=0.0475
Considered significant
Control
14.36
3.390
Here the Mann Whitney U test was used as the data is non-parametric. Mean value of static Q-angle for control
and PFPS groups respectively were 16.12 2.789 and 14.36 3.390. Difference was significant at 95% confidence
interval.
151
2/7/2013, 8:08 PM
Table -5 Comparison of dynamic Q-angle in PFPS and control groups
Q-angle
mean
SD
Test used
U-value
p-value
significance
PFPS
19.52
3.709
Mann whitney
U test
U= 120.50
P=0.0002
Extremely significant
Control
15.12
3.321
Here the Mann Whitney U test was used as the data is non-parametric. Mean value of static Q-angle for control
and PFPS groups respectively were 19.52 3.709 and 15.12 3.321. Difference was significant at 95% confidence
interval.
Table 6. Comparison of VMO/VL ratio during ISOMETRIC exercise in PFPS and control
Groups
mean
SD
Test used
t-value
p-value
significance
Control
0.9260
0.0482
Unpaired t-test
t=5.136
P=0.0001
Experimental
0.8124
0.0995
Here the un paired t-test was used. Mean value of VMO/VL in control group was 0.9260 0.0482 and PFPS
group was 0.8124 0.0995. t=5.136 and p < 0.0001. so the difference was extremely significant at 95% confidence
interval.
Table 7. Comparison of VMO/VL ratio during CONCENTRIC exercise in PFPS and control groups
Groups
mean
SD
Test used
t-value
p-value
significance
Control
0.9484
0.0300
Unpaired t-test
t=4.976
P=0.0001
Experimental
0.8336
0.1113
Here the un paired t-test was used. Mean value of VMO/VL in control group was 0.9484 0.0300 and PFPS
group was 0.8336 0.1113. t=4.976 and p < 0.0001. so the difference was extremely significant at 95% confidence
interval.
Table -8 Comparison of VMO/VL ratio during ECCENTRIC exercise in PFPS and control groups
Groups
mean
SD
Test used
t-value
p-value
significance
Control
0.9505
0.0374
Unpaired t-test
t=7.457
P=0.0001
Experimental
0.8126
0.0844
Here the un paired t-test was used. Mean value of

VMO/VL in control group was 0.9505 0.0374 and
PFPS group was 0.8126 0.0844. t=7.457 and p < 0.0001.
so the difference was extremely significant at 95%
confidence interval.
Graph 1. Comparison of mean of VMO/VL ratio
between control and experimental groups
CONCLUSION
This is a cross sectional study comparing the VMO/
VL ratio and Q-angle in PFPS and control groups on 50
total subjects.
There was a statistically significant difference in
VMO/VL ratio between control and PFPS subjects
during ISOMETRIC, CONCENTRIC and ECCENTRIC
exercise, so null hypothesis was rejected and
experimental hypothesis was accepted.
There was a statistically significant difference in
static and dynamic Q-angle in both groups. Static and
dynamic Q-angle value was higher in PFPS patients.
ACKNOWLEDGEMENTS
I would like to thank Dr Nehal shah (PG teacher)
and I am grateful to all my patients for their kind
cooperation and willingness to participate in this study,
without whom this study would not have materialized.
152
2/7/2013, 8:08 PM
Conflict of Interest : Nil

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Moller B, krebs B, Tidermand Dal c,aaris k,
isometric contractions in the patella femoral pain
syndrome.arch orthop trauma a surg,1986: 105:
24-27
Lam PL,Ng GYF: Activation of quadriceps muscle
during semisquatting with different hip and knee
positions in patients with anterior knee pain. Am
J Phys Med Rehabil,2001,80:804-808
2/7/2013, 8:08 PM
A Study to Check Added effects of Electrical Stimulation

with Task Oriented Training in Hand Rehabilitation
among Stroke Patients
Paras Joshi
Assistant professor, Shree K K Sheth Physiotherapy College, Rajkot
ABSTRACT
Back ground: stroke patients are having variety of disable functions, including limited hand functions
which has key role to do activities of daily living.
Objective: To determine the added effects of electrical stimulation combined with task oriented training
in stroke patients.
Methods: 30 subjects were selectively divided in to two groups. Group A received Eletrical stimulation
with Task oriented training while Group B received only task oriented training. Outcome measures
were grip strength, Box and Block test, 9 hole peg and ROM.
Findings: statistical significant difference found for all the variables used in methods in between the
groups.
Conclusion: Electrical stimulation with task oriented training improves hand functions more effectively
compared to only task oriented training in stroke patients.
Keywords: Electrical Stimulation, Task Oriented Training, Hand Rehabilitation
INTRODUCTION
involvement of focal areas of the brain. The term
cerebrovascular accidents (CVA) are used
interchangeably with stroke to refer to the
cerebrovascular conditions that accompany either
ischemic or hemorrhagic lesions. To be classified as
stroke, focal neurological deficits must persist for at least
24 hours. 1
Stroke is the third leading cause of death in
industrialized countries and the leading cause of adult
disability. Half of all stroke survivors are left with major
functional problems in their hands and arms.2
Although initial neurological loss in arm is generally
thought to be predictive factor for overall recovery it
has been reported that the recovery of the upper
extremity function is independent of the overall level of
stroke severity. 3
30. Paras Joshi--154-159.pmd
154
Numerous studies have suggested that electrical

stimulation improve muscle strength motor control
range of motion and reduced the spasticity of paretic
limb 4, 5
Electrical stimulation of spastic wrist flexor muscles
was compared with passive stretch of wrist flexor by
king who reported a significantly greater effect of
electrical stimulation on flexor spasticity.6 However
alfier10 stated that no direct stimulus must be allowed
to reach spastic muscle and he reported a reduction in
flexor spasticity after electrical stimulation of extensor
muscles.
Electrical stimulation at wrist in combination with
other rehabilitation strategies can result in increase grip
strength and improve motor function.7
The exact mechanism underline the action of
electrical stimulation has not been elucidated but
neurophysiologic models produce arguments in favor
of each strategy improvement in extensor muscle
strength through electrical stimulation of extensor
2/7/2013, 8:08 PM
might provide sufficient power to overcome flexor

spasticity.8
Its central tenet is the idea that the interacting
systems within the CNS are organized around essential
functional tasks and the environment in which the task
is performed. Thus an understanding of tasks, the
essential elements within each task, and the
environment is key to understanding and promoting
motor control. This approach is also based on the theory
that action system within the CNS are organized to
control function9.
Patients are instructed to practice those tasks that
present difficult for them, and to practice them in
varying environments. Different strategies may be used
by the different individual and should be allowed if
they achieve the desired functional outcome.11
So the aim of this study was to check the added
effects of electrical stimulation combined with task
oriented training in hand rehabilitation in stroke
patients.
METHOD AND MATERIALS
Sampling technique: Purposive sampling
technique.
Samples: A total of 30 subjects were included from
K K Sheth Physiotherapy center, Rajkot and
surrounding the city in 2 years framework.
Prior to participation in study the subjects were
explained about the procedure of physiotherapeutic
treatment with therapeutic electrical stimulation of the
muscle and task related training. Informed consent was
obtained from all the subjects.
Inclusion Criteria
Unilateral ischemic stroke
Grade 4 or 5 Brunnstrom assessment scale
MMT of muscle around the shoulder and elbow

joint minimum grade 3
Above 40 years of age, both the sexes
Exclusion Criteria
Sensory impairment
Chronic stroke patients. (> 1 year of stroke)
Uncontrolled blood pressure
155
Severely impaired cognition and communication
Traumatic brain injury
Clinical evidence of limited joint range of motion of

wrist joint
Clinical evidence of shoulder subluxation
The 30 subject selected were randomly divided into

the group (group A and B of 15 each).
Group A
Fifteen subjects received electrical stimulation along
with task related training.
Group B
Fifteen subjects received only task related training.
Subjects were kept blind about the different treatment
protocols for two groups
Measurements for grip strength was taken by hand
held dynamometer and hand functions were taken by
Box and block test12, 9 hole peg test13, wrist extension
and radial deviation pre intervention(baseline) and post
intervention (4th week)
Experimental procedure
Electrical stimulation technique: The researcher
himself performed the electrical stimulation of wrist
extensor. Subjects were seated in straight backed chair
with the feet flat on the floor. Subject was seated next to
the supported surface and the forearm rest on supported
surface. The wrist remains freely suspended at the edge
of the plinth to allow for movement due to electrical
stimulation.
The bipolar electrode placement was used to deliver
a motor level stimulus to the wrist and finger extension.
One electrode was placed over the lateral epicondyle of
humerus and active electrode was placed distally on
wrist and finger extensor (extensor carpi radialis longus
and bravis, extensor carpi ulnaris, extensor digitorum
communis). The electrode skin coupling medium was
an electrolytic gel. To fix the electrodes elastic Velcro
straps were used.
The stimulus was provided by an electrical
stimulation (vectorstim) providing a maximum output
intensity of 50 MA. This stimulator operated on pre
programmed protocols which were enlisted in the user
manual provided by the manufacture. The researcher
used protocol for the experimental group A protocol no
14 (50 HZ) was employed for stimulation of wrist and
2/7/2013, 8:08 PM
finger extensor. The intensity was gradually increased

as per the tolerance of each subject, achieving the
maximal intensity to produce motor response.
Goal is to push the glass along the table by extending

wrist with forearm in mid position.
Subjects were asked to practiced picked up

polystyrene cup around the rim without deforming
it between thumb and each finger.
Peg board exercises.
Electrical stimulation parameters
type of current : short interrupted direct current

(faradic)
waveform: monophasic
current modulation: surged
pulse duration: 0.7ms
inter pulse duration:19 ms (50 hz)
surge duration: 0.07ms
inter surge duration:3ms
on/off time:0.5 sec/3 sec (1:6)
intensity : as tolerated by patients
Duration of treatment: 30 min/day
Subjects performed their most difficult exercise for

10 repetitions each. Unsuccessful attempt was not
counted; however a subject is advised to change the
exercise if he/she is not able to do at al.
Treatment was given for 5 times in a week for 4
weeks.
Paired an unpaired t tests were used for the
statistical analysis.
FINDINGS
Treatment was given for 5 days in a week to each

subject for 4 weeks.
TASK RELATED TRAINNING
Subjects were asked to identify daily activities that
could be difficult to perform and that they would like to
improve.
The four or more of the following tasks were
administered / trained for the subjects.
manipulate tools for specific purpose ( tooth brush,

comb ,knife, fork, coin, clothpin ,button)
Grasp and release the different objects, or different

shapes, sizes.
Transport an object from one place to another.
Subjects were asked to lift glass up and to lower it

without loosing control at his wrist.
Graph 1. The female count in group A was 5 (33%)

and that of the group B was 6 (40%). The male count in
group A was 10 (67%) and that of the group B was 9
(60%). The total count of females in this study was about
11 (36%) and male was about 19(63%). The total count
of male and female subjects in this study was about 30
(100%).
Table I. Comparison of Strength scores within Group A and within Group B

Group
A
B
156
Intervention
Period
Mean
Standard
Deviation
t- value
Level of
significance
8.98 SS
SS at p < 0.05
8.93 SS
SS at p < 0.05
Pre
15
7.84
1.62
Post
15
9.46
1.50
Pre
15
7.79
1.62
Post
15
8.81
1.40
2/7/2013, 8:08 PM
Table II. Comparison of Box N Block and 9 Hole Peg Test Scores within Group A and within Group B
Group
Variables
Box N Block
9 Hole Peg Test
Box N Block
9 Hole Peg Test
Intervention
Period
Mean
Standard
Deviation
t- value
Level of
significance
17.83 SS
SS at p < 0.05
11.50 SS
SS at p < 0.05
7.17 SS
SS at p < 0.05
14.10 SS
SS at p < 0.05
Pre
15
16.53
2.41
Post
15
19.27
2.21
Pre
15
2.04
.33
Post
15
1.78
.30
Pre
15
16.80
2.24
Post
15
18.47
2.03
Pre
15
2.08
.31
Post
15
1.99
.31
Table III. Comparison of Wrist Extension and Radial Deviation Scores within Group A and within Group B
Group
Variables
Wrist extension
Radial deviation
Wrist extension
Radial deviation
Intervention
Period
Mean
Standard
Deviation
t- value
Level of
significance
13.25 SS
SS at p < 0.05
11.37 SS
SS at p < 0.05
8.08 SS
SS at p < 0.05
4.58 SS
SS at p < 0.05
Pre
15
26.93
2.46
Post
15
30.07
2.63
Pre
15
5.80
1.01
Post
15
7.87
.91
Pre
15
27.20
2.51
Post
15
29.00
2.29
Pre
15
7.13
1.06
Post
15
7.73
.79
Table IV: Comparison of Change in Strength, Box N Block , 9 Hole Peg Test , Wrist Extension and Radial Deviation
scores across the Intervention Period between Group A and Group B
Change in Variable
between Pre & Post
Intervention
Group
Change inStrength
Change in BoxN Block
Change in9 Hole Peg Test
Change in Wrist Extension
Change in Radial Deviation
Mean
Difference
Standard
deviation
t-value
Level of
significance
2.81 SS
SS at p < 0.05
3.83 SS
SS at p < 0.05
7.67 SS
SS at p < 0.05
4.11 SS
SS at p < 0.05
6.55 SS
SS at p < 0.05
15
1.62
.69
15
1.02
.44
15
2.73
.59
15
1.67
.90
15
.26
.08
15
.08
.02
15
3.13
.91
15
1.80
.86
15
2.07
.70
15
.60
.50
SS: Statistical significant
Graph 1. The female count in group A was 5 (33%)

and that of the group B was 6 (40%). The male count in
group A was 10 (67%) and that of the group B was 9
(60%). The total count of females in this study was about
11 (36%) and male was about 19(63%). The total count
of male and female subjects in this study was about 30
(100%).
DISCUSSION
Within the two groups, both electrical stimulation
combined with task related activity ( groupA) and task
157
related activity alone (group B ) proved to be effective.

This was reflected in the pre intervention and post
intervention measurements of grip strength, box and
block test, 9 hole pack test and active wrist extension
and radial deviation range of motion.
However between group comparisons of mean
scores of wrist extension and radial deviation ( AROM
), grip strength , box and block test , 9 hole peg test sub
scores and total percentage showed that subjects
receiving electrical stimulation combined with task
related training ( group A) had clinically and
2/7/2013, 8:08 PM
statistically significant improving in wrist extension

and radial deviation ( AROM) grip strength , box and
block test, 9 hole peg test sub score and total percentage
when compared to subjects receiving task related
training ( group B) across base line and 4th week
(table ) (p<0.05).
Electrical therapy has been applied as a therapy in
humans with central nervous system (CNS) injuries
although there is no conclusive direction as to which
technique works the best for a given indication. There
are convincing studies available to show that electrical
stimulation can strengthen atrophied muscles, change
in muscles property, increase the muscle bulk, and
improve the circulation and the change in the
metabolism.10
There is evidence that repetitive active movement,
mediated by neuromuscular stimulation can enhance
motor relearning after CNS damage. The additional
component of movement provides augmented sensory
feedback and propioceptive afferent stimulation. There
is reorganization of cortical representations for body
parts basal upon the afferent input that they contribute
as well as the amount of motor activation they undergo.
With electrical stimulation there is evidence that it
equally influence this reorganization. This can be highly
advantageous in limbs that are impaired to such a
degree that a voluntary movement could be impossible.
Because of significant amount of hemiparesis that is
caused by stroke, the use of electrical stimulation to
generate movement provides the means of inducing
positive motor changes associated with motion.16
Cauraugh14 et al focused on less severely affected
subjects, like those in the present trial spasticity were
not assessed; they reported improvement in sustained
contraction of wrist extensor muscles and in function
(box and block test) but no effect on motor control. From
the publication, it is not clearly whether there was no
gain in motor control or no difference in gain. In a letter
trail function improvement was confirmed but the
clinical relevance of this improvement was not
discussed. In this study it seems that functional
improvement can be clinically relevant for subjects.
People with a brain injury have deficit in motor
programmes, motor memory and associated feedback
and feed forward mechanism, which largely impede
their functional performance. 14 The motor relearning
approach promotes the regaining of normal motor skill
through task oriented training with appropriate
feedback and the active participants of the patients. In
this study, the motor relearning program was structured
158
in such a way that patient had ample opportunity to

gain this experience. First the patients were involved in
identifying their own problems in performance. These
problems are called the missing performance
component. The selection of task used for training was
meant to target those missing performance components
training in the functional tasks followed through on
the same missing components. The incorporation of
this strategy turned the programme into a client centered
intervention. The training thus become more
anticipatory for the patients and hence was more selfinitiated, targeted and effective.15 Limitation of the study
was absence of control group; neither patients nor the
therapist were blinded.
CONCLUSION
Both electrical stimulation along with task oriented
training and only task oriented training were useful to
improve hand functions.
Electrical stimulation with task oriented training
improves hand functions more effectively compared to
only task oriented training in stroke patients.
ACKNOWLEDGEMENT
I am sincerely thankful to Dr Saralaben Bhatt,
Principal K K Sheth Physiotherapy College, Rajkot for
their guidance and support
REFERENCES
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Susan B. OSullivan, Thomas Schmitz. Physical

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Wade DT, Langeton-hewer R et al; The hemiplegic
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Glanz M, Klawansky S ,et al; functional electrical
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JR de Kroon,J H Van der lee et al;theraputics
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King TI: The effect of neuro muscular electrical
stimulation in reducing tone.am j occupation ther
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Joanna Powell, MCSP; A. David Pandyan,et al;
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De Kroon JR, Ijzerman MJ, Lankhorst GJ, Zilvold
G.:electrical stimulation of upperlimb in
stroke:stimulation of extensors of the hand
vs.alternate stimulation of flexors and
extensors.Am.J.Phys.med.rehab. 2004;83:592-600
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Green p:prombles of organization of motor system
.In Rosan R,and Snell:Progress in theoretical
biology. Academic press.San Diego 1972.p 304
10. Alfieri V: Electrical treatment of spasticity Scand J
Rehabili med. 1982;14:177-82
11. Horak ,F:Assumptions underlying motor control
for neurologic rehabilition .In :contemporary
management of motor control problems.
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L. Validation of the Box and Block Test as a measure
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Mathiowetz, V., Kashman, N., et al. (1985). Grip
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June ;30 (6) :1360-1364
Catherine M . Dean, Carol L. Richards et al .Task
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intervention enhances walking distance and
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2/7/2013, 8:08 PM
Relationship of Cognition, Mobility and Functional

Performance to Fall Incidence in Recovering Stroke
Patients
Paras Joshi1, Hardik Trambadi2

Lecturer, Shree K K sheth physiotherapy college, Rajkot, 2Lecturer, Parul institute of Physiotherapy, Vadodara
ABSTRACT
Background: People with stroke are at risk of falls. The majorities of individual with stroke has some
degree of residual impairment, but regain walking ability and will be discharged home. Three quarters
fell in the first six month after their discharge from hospital. Identify increased knowledge of incremental
risk factors for falling and the assumption that some of the identified risk factors can be modified may
lead to development of intervention to reduce number of falls
Objective: To explore the relationship between cognition, mobility and functional performance with
respect to fall incidence in recovering stroke patients.
Methods: 110 subjects with stroke completed the study. Subjects were assessed on the basis of cognition,
mobility and functional performance during 4th week after stroke incidence. Information regarding
number of falls and characteristic of fall gained during a personal interview after six month from
stroke. Number of falls correlated with baseline scores.
Findings: There is a significant good correlation found between cognition, mobility, and functional
performance to number of falls in recovering stroke patients.
Conclusion: Cognition, mobility and functional performance might contribute to fall risk and fall
related injuries in recovering stroke patients.
Keywords: Stroke, Fall Incidence, Cognition, Mobility, Functional Performance.
INTRODUCTION
involvement of focal areas of the brain. The term
cerebrovascular accidents (CVA) are used
interchangeably with stroke to refer to the
cerebrovascular conditions that accompany either
ischemic or hemorrhagic lesions.1 Stroke is the most
common cause of chronic disability.2 People with stroke
are at risk of falls.3,4 The majority of individuals with
stroke will have some degree of residual impairment,
but will regain walking ability and will be discharged
home following hospitalization. Although impairment
is common, most people with stroke will regain walking
ability; however poor balance and impaired gait can
persist. 5
Studies reported that patients with stroke three
quarters fell in the first six months after discharge from
hospital. Stroke patients in acute care and rehabilitation
are at high risk of falling and remain a high-risk group
31. paras joshi--160-164.pmd
160
of the first few months after they are discharged to

home. 6-10 Apart from age, osteoporosis, previous
fractures, and falls are independent risk for hip
fractures.10 Side of the fracture is positively correlated
with the side of hemi paresis. 11
Patients with stroke have up to a 4 fold increased
risk of hip facture because of their high incidence of
falls.12 It has been shown that stroke patients in addition
have reduced bone mass in their paretic extremities,
that this development of hemi osteoporosis is extensive
and pronounced, and that begins early after stroke
onset.13
Furthermore, stroke has proved to be a factor for hip
fracture among women in case control study14, and
subjects with previous strokes have been over
represented in a sample of femoral neck fracture
patients.15
Stroke has a relative high risk for falling. Increased
knowledge of incremental risk factors for falling and
the assumption that some of the identified risk factors
2/7/2013, 8:08 PM
can be modified may lead to development of

intervention to reduce number of falls.16,17 Fall incidence
rates between 23% and 50% have been reported in
studies of people with chronic stroke (> 6 months post
stroke). 18-21 This rate is much higher than rates reported
for older community dwelling adults without stroke
(11%-30%). 22-24 but lower than rates for people with sub
acute stroke (1-6 months post stroke) (25%).25 Injury is a
frequent consequences of falls in people with chronic
stroke, with up to 28% reporting an injury.19
relationship existing between cognition, mobility,

functional performance with respect to fall incidence
among recovering stroke patients.
Studies shown that cognitive deficit 18,21,26 functional

impairments26 and impaired balance 7,26 are related to
fall history in people with acute stroke. 25 And
cognition 18 , balance impairment 18 and ADL 19,21
increased fall risk in people with chronic stroke.
A Prospective observational study was used with

purposive heterogeneous sampling technique.
The identification of fall- prone stroke patients is of

great importance. The issue has already been studied
to some extent, and a number of risk factors have been
suggested.27
8
Postural sway , increased motor response time to

visual stimuli28, and right ward orienting bias among
right hemisphere stroke patients29 have been associated
with an increased fall risk.
A multi factorial case control study concluded that
a history of falls, impaired decision making ability,
perceptual impairment, restlessness, generalized
weakness and abnormal hemocritic level were
independent fall risk factors among stroke patients in
acute care.29,30
Studies shown that 37% stroke survivors reported
at least one fall during the first six months after their
stroke. Among whom those fell, 37 percent suffered an
injury that require medical treatment, and 8 percent
suffered a fracture. Among those who fell, about half
fell only once, but 12 percent fell more than five times.
The study also found that 77 percent of patients fell at
home.31
Study showed that cognition, mobility and
functional daily activity tend to decline after stroke. 31
The purpose of this study is to correlate the
cognition, mobility and functional performance to fall
incidence in recovering stroke patients.
Alternate hypothesis (H 1 ): There will be a

significant relationship existing between cognition,
mobility, functional performance with respect to fall
incidence among recovering stroke patients.
One hundred and eighteen people with stroke were

recruited on a voluntary basis from vadodara city and
surrounding villages between oct 2009 to may 2011
A written consent was sought from subjects
participating in the study.
Selected one hundred and eighteen subjects met the
established criteria and one hundred and ten (77 male
and 33 female) out them completed the study. Five
subjects got an addition stroke and three of them were
died.
Subjects who were already diagnosed as stroke by
physician participated in the study. Subjects of both
sexes and either side of paresis, fulfilling the criteria
were taken for the study.
Inclusion Criteria
1. Above 50 years of age.
2. With ability to walk 8m (with assistive device, if
required).
3. Deemed to be fit for the study and mentally stable.
Exclusion Criteria
1. Major musculoskeletal problems (e.g. amputation
or recent joint replacement surgery).
2. Neurological disorder in addition to stroke.
3. More than one attack of stroke during study period.
4. Perceptual disorders.
5. Sever communication problem.
EXAMINATION
OBJECTIVES OF THE STUDY

To explore the relationship between cognition,
mobility and functional performance with respect to
fall incidence in recovering stroke patients.
HYPOTHESIS
Null hypothesis (H0): There will be no significant
161
Patients were assessed on the basis of cognition,

functional performance and mobility during 4th week
after stroke incidence.
Cognition, Mobility and Functional performance
were assessed by Mini Mental Status Examination
(MMSE), Performance Oriented Mobility Assessment
(POMA) and Barthel Index respectively.
2/7/2013, 8:08 PM
Patients and caretakers were asked to maintain the

chart for recording the number of falls, side of fall and
injury if any during the study period.
Numbers of falls were correlated with the baseline

scores
FINDINGS
Patients were informed that a fall was defined as

coming to rest on the floor or another lower level but
was not due to seizures, stroke or myocardial infraction,
or an overwhelming displacing force (e.g. earthquake.)
Table 1. Gender distribution
Number of falls recorded between one month post

stroke to six month post stroke (20 weeks).
Males
77
Females
33
Subjects participated in the study with mean age of

66.917.14. Pearsons correlation coefficient was used
to determine the relationship among cognition, mobility
and functional performance in relation to occurrence
of falls. P value was kept at 0.01 for statistical
significance. SPSS software was used for the statistical
significance.
Information regarding number of falls and

characteristic of falls were gained during a screening
interview with the patient, six month after stroke.
Assessment for the baseline score and interview for
the number and characteristics of falls were done by
different individuals.
Table 2. Variable analysis

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

Right 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%
DISCUSSION
Most of the patients with stroke are prone to fall
incidence during recovery stage. The purpose of this
study was to determine whether cognition, mobility and
functional performance could explain falls in
individual with recovering stroke.
It has been found that falls were common occurrence
in recovering stroke patients. Most of the patients
reported at least one fall during study period. Subjects
who experienced fall, most of them fell on the paretic
side.
In addition, fall related injuries were common,
although serious injury was less frequently reported. It
162
has been found that most of the falls occurred in home

during walking activities.
In this study measure of cognition, functional
performance and mobility were clearly able to explain
falls in this population or to discriminate between those
who had fallen and had not fallen.
It has been hypothesized that MMSE, POMA and
Barthel Index score would be associated with fall
incidence and be a risk factor for falls in recovering
stroke patients, and result supported the hypothesis.
Some authors32 have suggested that the recall method
of information gathering can produce recall bias but to
avoid that patients were asked to maintain chart in terms
2/7/2013, 8:08 PM
of calendar and similar explanation was given to the

caregivers.
Comparing age as a risk factor for fall, studies
showed that fall incidence rate is much lower in older
community dwelling adults without stroke (11%-30%)
than rates for people with subacute stroke (25%)4.
Reason behind that is pathophysiology of stroke that
changes the mental state dramatically.2
The scales which have been used for the study are
easily applicable to the patients within short time span,
having good reliability33-35 and found useful tool to
identify the subject who has more chances to fall
following hospitalization in this study. However
cognition, mobility and functional performance are not
the only factors responsible for fall incidence, other
factors needed to be rule out.
LIMITATIONS
The clinical information (cognition, mobility and
functional status) collected at the time of discharge may
have been different at the time of fall. But the study
outcome gave the predictive information about the
future fall incidence (i.e. six month) with these
measures.
During the 20 weeks time frame used for fall history,
participants could have experienced on illness (e.g. flu,
cold) or an exacerbation or worsening of an existing
condition (e.g. arthritis, dementia) that could have
negatively influenced their functional status at the time
of fall(s). In contrast, participants might have been in
worse physical or mental condition at the time of
examination that at the time of the fall(s).
Fallers who had fractures (11%) must have had
reduce mobility and affected the mobility component
and functional performance (our baseline scores)
With increasing age the cognition, functional status
and mobility level tend to decline, however stroke can
worsen the mental status dramatically. Factors such as
vestibular function, sensation, perception and home
environment have not been assessed in this population
in relation to fall risk.
Clinical implication
Cognition, mobility and functional status level are
able to explain the number of falls.
MMSE, POMA I and Barthel Index are easily
applicable tools and can be applied within minutes.
Patients with relative low scores can be advised to be
careful or to take further inpatient rehabilitation. Hip
protectors can be given to the patients in order to avoid
the fall related injuries.
163
Further recommendation
1. Factors such as sensation, perception and home
environment can be included in this population.
2. Combination of multiple risk factors can be checked
in relation to fall incidence.
3. Correlation of the variables studied can be done in
stroke subjects with and without physiotherapy
interventions.
CONCLUSION
MMSE, POMA and Barthel index are able to explain
the fall incidence in recovering stroke patients. There is
a significant relationship between cognition, mobility
and functional performance to fall incidence.
Cognition, Mobility and functional performance are
some of the factors responsible for falls in recovering
stroke patients, and might contribute to fall and fall
related injuries.
ACKNOWLEDGEMENT
Sincere thanks to Dr Praful Bamrotia for helping us
in data collection.
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Jocelyn E Harris et al. Relationship of balance and
mobility to fall incidence in people with chronic
stroke, Physical therapy. 2005; 85: 150-158.
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Jorgense HS et al. Stroke. Neurologic and
functional recovery- the cogenhagen stroke study.
Phy med rehabil clin N Am. 1999; 10: 887-906
6.
Anne Forster, John young. Incidence and
consequences of falls due to stroke, a systemic
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Nyberg L, Gustafon Y. Patients falls in stroke
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Sackely CM. Falls, sway and symmetry of weight
bearing after stroke. Int. Disabil Stud. 1991; 13:
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Byers V et al. Predictive risk factors associated with
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10. Tutuarima JA, Van der Mevlen Jhet al. Risk factors
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stroke on bone mass. Am J Phys Med Rehabil.
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Reliability of Modified Modified Ashworth Scale in

Spastic Cerebral Palsy
Divya Gupta1, Pooja Sharma2
Post Graduate student, Amity Institute of Physiotherapy, Amity University Uttar Pradesh, 2Assistant professor, Amity
Institute of Physiotherapy, Amity University, Noida, Uttar Pradesh,
ABSTRACT
Background & Objectives: In assessment of spasticity in the pediatric population, methods used in
practice are ordinal scales that lack reliability. Being a recent scale, Modified Modified Ashworth Scale
has not been used in pediatric population as yet. This study aimed to assess inter- and intra-rater
reliability of MMAS in assessing children with spastic cerebral palsy and also compare results with
those of AS and MAS.
Methods & Materials: The study included 40 children with spastic CP with mean age 7.75 yrs
.Functional levels of children were classified according to the Gross Motor Function Classification
System. Spasticity in wrist, elbow and knee flexors was assessed according to the AS, MAS, and
MMAS.
Results: Interrater reliability and intrarater reliability of MMAS varied from moderate to good.
Conclusions & Interpretations: The MMAS is a reliable tool in assessing children with spastic CP and
so are AS and MAS.
Keywords: Spasticity, Cerebral Palsy, Ashworth Scale
INTRODUCTION
Cerebral Palsy is defined as a non-progressive group
of disorders of movement and posture due to a defect or
lesion of the immature brain.1 It can be further defined
as a group of disorders of development of movement,
posture and coordination with varied etiological
associations and much phenotypic differences in the
clinical presentation.2 Of the many types and subtypes
of CP, none of them has a known medical cure and
treatment is mainly symptomatic .3,4 One of the major
manifestations of a sufficient intra-partum compromise
of fetal cerebral perfusion include abnormal tone.
However a study on the Indian population concluded
that spastic quadriplegia constituted the predominant
group ( 61%), followed by spastic diplegia (22%).5, 6, 7
Spasticity may be defined as velocity-dependent
increase in muscle tone with exaggerated stretch
reflexes.8,9 The nature of spasticity has prompted in a
Pooja sharma
Assistant professor
Amity institute of physiotherapy, Amity university, Noida
E mail: psharma1@amity.edu
32. Pooja Sharma-165-169.pmd
165
range of assessment and management techniques.

Different methods of spasticity assessment include
electrophysiological tests, electromyography, dynamic
flex meter, myometer, plasticity measurement system,
and pendulum test and is kinetic dynamometer.
However, they have limited clinical use. Methods most
commonly used in clinical practice are the Ashworth
Scale, the Modified Ashworth Scale, the Tardieu Scale
and the Modified Tardieu Scale.10 When using clinical
measures to assess spasticity, one assesses the
resistance to imposed passive movement when the limb
is briskly stretched through the full range of available
movement about a joint.10 The Ashworth scale was
created in the mid-1960s by Dr Bryan Ashworth as a
way of judging the effectiveness of anti-spastic drugs.11
It is a 5-point ordinal scale and has been used
extensively since then to assess increase in muscle tone
in a range of neurological disorders. The Modified
Ashworth Scale was created in 1987 by Bohannon and
Smith who introduced a 1+ grade to increase the
sensitivity of the original scale thus making it a 6-point
nominal scale.12 With the MAS grades of 1, 1+ and
2 having been questioned as hierarchical levels of
spasticity, recently the Modified Modified Ashworth
2/7/2013, 8:08 PM
Scale (MMAS) was created where grade 1+ was

omitted and the grade 2 redefined in the MAS.13 Valid
and reliable assessment tools are a pre-requisite in
establishing baseline functions and monitoring
developmental gains and also to contributing to an
increasing body of evidence-based recommendations
for CP. 14 Reliability of AS and MAS have been found to
be poor to good as assessed in patients with various
conditions.15,16, 17 18, 19 with values of MAS being slightly
higher. The existing data suggests that the reliability of
MMAS in patients with lower-limb muscle spasticity is
very good, and it can be used as a measure of spasticity
over time.20 21 . Although there are studies that conclude
both AS and MAS are not reliable for the assessment of
muscle spasticity, however experience and training
may improve agreement between the raters.22,23,24 There
is a need to standardize methods to apply these scales
in clinical practice and research.25, 26, 27 Being a recent
scale, the Modified Modified Ashworth Scale has not
been used in the pediatric population as yet. It provides
clearly defined and distinct grades to rate spasticity.
Also, the other two scales i.e. AS and MAS give arguable
results over their reliabilities in the same population.
The present study aims to assess and the inter- and
intra-rater reliability of the MMAS in three different
muscle groups i.e. the wrist flexors, elbow flexors and
knee flexors of children with spastic CP and also
compare the results with those of the AS and the MAS
which have already been used in the population under
consideration.
performed in a quiet environment . Subjects wore loose

and comfortable clothing which did not pose any
hindrance to the passive movements. Testing
commenced five minutes after the subjects had been
positioned. One repetition was done per joint. The
scores for AS, MAS and MMAS were determined
according to the level of resistance during the passive
movement of the antagonistic muscles. The muscle
groups tested were wrist flexors, elbow flexors, and knee
flexors in the same order. Each test movement was
performed over a duration of 1 second ( by counting
one thousand one). A separate recording sheet was
used for each session of each subject. As passive
stretching is considered to affect the measurement
results, measurements were repeated once on two
different days of the study. To minimize the
disadvantage of stretching of the spastic muscle, fast
stretching was avoided. The data obtained was later
statistical analyzed using the SPSS software.
METHODOLOGY
Subjects with spastic cerebral palsy belonging to age
group 4 to 14 years were recruited from Special schools
in Delhi and NCR whose informed consent had been
attained. All subjects with history of any orthopedic
surgery , botulinum toxin injection or those on oral or
intrathecal myorelaxant drugs , mentally retarded were
excluded. The procedure was explained to the subjects
and their parents. The functional level of participants
was classified according to the expanded and revised
Gross Motor Function Classification System ( GMFCS E & R ). Each subject was assessed by two raters in two
different sessions randomly . Both the raters are
physical therapists who are well-versed with the
procedure of the assessment and blinded to the results
of each other. For the inter-rater reliability component
of the study, a 30-minute interval period is added
between the assessments. For the intrarater reliability
component of the study, one of the raters repeated the
procedure the next day. The measurements were
166
Fig. 1. Testing wrist flexors
Fig. 2. Testing elbow flexors
2/7/2013, 8:08 PM
proximal to the ankle and applying a constant extensor

rotational force about the knee. Movement is from 90
flexion to full extension over 1 second.26
RESULTS
A total of 40 children were evaluated .AS, MAS, and
MMAS scores were considered ordinal and a value of
1.5 for MAS were assigned to ratings of 1+ to maintain
equal intervals.
TABLE 1 : Mean and standard deviation of age and
GMFCS level
Age ( years ) GMFCS level
Mean
7.775
2.375
Standard Deviation
2.823
1.147
TABLE 2 : Interrater reliability of A s,

MAS AND MMAS in wrist flexors, ELBOW FLEXORS
AND KNEE FLEXORS
As
Fig. 3. Testing Knee flexors
Patient positioned supine on a padded mat table.

The patients shoulder was in mid-rotation, forearm in
mid-pronation and hand was in functional position
with the distal limb held vertical. Passive movement
was achieved by the rater grasping the hand just
proximal to the MCP joints . Movement was from full
flexion to full extension over one second.26
Patient positioned supine on a padded mat table.
The patients shoulder was in mid-rotation, the forearm
in mid-pronation and the hand was in functional
position. The patients elbow was extended passively
from a position of maximal possible flexion to maximal
possible extension over a duration of about one second.
The lateral aspect of the forearm was grasped distally
while applying a constant extensor rotational force
about the elbow. While the elbow was extended, the
arm was also stabilized proximal to the elbow.26
The subject was in a seated position. The distal leg
was suspended vertically with the foot off the floor. The
trunk was stabilized by means of a padded strap drawn
comfortably tight around the pelvis and the hip was
stabilized by means of a padded strap comfortably tight
across the proximal legs, half-way between the knees
and the hips. Passive movement was achieved by the
rater grasping the posterior aspect of the distal leg just
167
Wrist
Flexors
(ICC)
Elbow
Flexors
(ICC)
Knee
Flexors
(ICC)
Single Measures
.750
.757
.359
Average Measures
.857
.861
.528
Single Measures
.397
.787
.738
Average Measures
.569
.881
.849
Single Measures
.336
.866
.605
Average Measures
.503
.928
.754
MAS
MMAS
TABLE 3: Intrarater reliability of AS , MAS ,MMAs in

wrist flexors, elbow flexors AND KNEE FLEXORS
As
Wrist
Flexors
(ICC)
ELBOW
Flexors
(ICC)
Knee
Flexors
(ICC)
Single Measures
.786
.890
.379
Average Measures
.880
.942
.550
Single Measures
.630
.910
.692
Average Measures
.773
.953
.818
Single Measures
.874
.986
.735
Average Measures
.933
.993
.847
MAS
MMAS
DISCUSSION
The results of the present study are in accordance
with the existing literature which demonstrate good
inter- and intra-rater reliability for AS, MAS has good
intra- and moderate inter-rater reliability, and MMAS
has good intra- and moderate inter-rater reliability in
wrist flexors.22,23 For the elbow flexors, all the three scales
AS, MAS, and MMAS have good inter-and intra-rater
2/7/2013, 8:08 PM
reliability. AS is found to be moderately reliable with

MAS and MMAS highly reliable in the knee flexors for
lower limbs. Various factors may affect the measurement
results of reliability. While investigating the reliability
of scales, related joints, anatomical and biomechanical
characteristics of muscle groups as well as interrater
and intrarater change and biological change should be
taken into consideration. Low reliability results of
ordinal scales are related to problems which occur
during the measurement of spasticity as well as the
environment and general condition of the patient. To
minimize this, the measurements were performed in a
quiet environment and screened from other patients and
therapists and one repetition was performed per joint.
The error with repeated measurements taken on
different days would be probably due to systematic
changes in the participant status leading to change in
the tone. However, we considered it was important to
document test-retest variability of repeated
measurements by inclusion of an intervening time
period because in clinical practice, results from repeated
measurements are rarely compared without an
intervening time interval. This interval has contributed
to an underestimation of intrarater reliability scores in
this study because fluctuations of tone during a single
day as well are well established. For this, grading on
the second day was done at the same time of the day as
on the first day. 24 Tone is not static and may change
with time,17 this factor may contribute to low agreement
between the raters. It is therefore essential that repeated
movements are kept to a minimum.25 It is not surprising
that the interrater reliability is higher than the intrarater
reliability indicating that these scales should be
interpreted with caution and even the same rater has
possibility of making an error. One possible reason could
be the clinical environment in the hospital. 26 Findings
of this study are consistent with the previous studies
showing very good inter- and intra-rater reliability
scores in elbow flexors for all the three scales AS, MAS,
and MMAS; scores for MMAS being the highest. The
current study does not observe any association between
the limbs, upper or lower, as well. This is probably due
to the fact that only one muscle group i. e. knee flexors
were investigated in the present study. Future studies
should include more muscle groups to investigate the
effect of limb, upper or lower, on the reliability scores.
The results of the present study are little variant from
the previous studies due to the age of the population
included .Younger kids would be easier to move due to
smaller limbs but would be harder to test due to reasons
of adherence. Out of a total of 40, 10 subjects were in
GMFCS level I, 14 in level II, 9 in level III, 5 in level IV,
168
and 2 in level V. MMAS shows moderate interrater

reliability in level II for wrist flexors, and moderate interand intra-rater reliability in level III for knee flexors.
Reliability of MMAS in levels I and II for all the muscle
groups under study was good. It could not be assessed
in groups IV and V owing to very small sample size.
Hence future studies should assess the reliability with
a large sample size of at least 40 in each level. The degree
of training and preparation to use the scales probably
exceeds the preparation of most clinicians using the
scales.
CONCLUSION
MMAS is a reliable tool in assessing spasticity in
elbow flexors, wrist flexors and knee flexors of children
as compared to AS and MAS in spastic CP.
Conflict of interest - Nil
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Samuel R Pierce, Richard T Lauer, Patricia A
Shewokis, Joseph A Rubertone, Margo N Orlin.
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cerebral palsy. Arch Phys Med Rehabil. 2006;
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Gracies JM, Williams M, Chia-Ho Lee, Turkel C.
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Evaluation of Pulmonary Function Tests in Patients

Undergoing Laparotomy
Nahar P S1, Shah S H2, Vaidya S M3, Kowale A N4
Assistant Professor, Department of Physiology, BJ Medical College, Pune, 2Assistant Professor, Department of
Physiology, BJ Medical College, Pune, 3Professor and Head of the Department, BJ Medical College, Pune, 4Professor and
Head of the Department, Government Medical College, Kolhapur
1
ABSTRACT
Background: Postoperative pulmonary complications are the most common cause of postoperative
mortality and morbidity. In this study we tried to identify patients at high risk of developing postoperative
pulmonary complication.
Objectives:
1. To compare and evaluate preoperative and postoperative values of pulmonary function tests
parameters.
2. To study the effect of gender difference, site of surgery and body mass index on postoperative
pulmonary function parameters.
Methods: Pulmonary Function Parameters were recorded preoperatively one day prior to surgery and
postoperatively on 5th day. PFTs were recorded using RMS Helios spirometer and all the tests were
conducted according to ATS/ERS guidelines.
Parameters recorded : TV,ERV,IRV,IC,VC,MVV,FVC,FEV1,FEV1/FVC,PEFR,PIFR
Statistical analysis were carried out by using t test
Results: We found statistically significant decrease in all the pulmonary function parameters in
postoperative period except that of FEV1/FVC. When we did intergroup statistical analysis, we found
more decrease in PFT parameters in Male patients, Patients undergoing Upper abdominal surgery and
in Obese patients.
Conclusion: Thus after laparotomy there are Restrictive type of ventilatory changes due to pain, altered
pattern of ventilation and diphragmatic weakness.
Male patients, patients undergoing upper abdominal surgeries & obese patients are high risk patients
for pulmonary complications.
Since these postoperative pulmonary changes can be easily diagnosed by spirometer, all patients
undergoing laparotomy should undergo preoperative and postoperative spirometry.
Also prophylactic preoperative physiotherapy and postoperative deep breathing exercises, incentive
spirometry and chest physiotherapy can be beneficial in patients of laparotomy.
Keywords: Laparotomy, Pulmonary Function Tests, Postoperative
Nowadays, the scope of surgery has widened

tremendously. But along with this, the increased toll of
complications has also come into focus. Even in the
face of good surgery, these post-operative complications
can tilt the balance between success and failure, and
among these, post-operative pulmonary complications

are especially notorious. Occurrence of these postoperative pulmonary complications can be easily
diagnosed by spirometry. Also these complications can
be prevented by simple pre-operative training and
regular postoperative physiotherapy in high risk
patients.
Nahar Pradeep
Department of Physiology, B.J. Medical College, Pune
Phone numbers - 08237010726
E-mail: pradeepnahar85@yahoo.com
In this study, we hypothesized that after laparotomy

in post-operative period there will be decrease in
Pulmonary function test (PFT) parameters. We also
believed that this decrease in PFT parameters is the
major culprit for post-operative pulmonary
INTRODUCTION
33. pradeep nahar--170-175.pmd
170
2/7/2013, 8:08 PM
complications. In order to indentify the high risk

patients we also studied the effect of gender difference
(Male, Female), site of surgery (Upper abdomen, Lower
abdomen) and BMI (Obese, Non obese) on postoperative PFT parameters.
Aims and objectives
1) To record various pulmonary function parameters
(TV, ERV, IRV, VC, IC, MVV FVC, FEV1, FEV1/FVC,
PEFR and PIFR) preoperatively and postoperatively
in patients undergoing laparotomy.
2) To compare and evaluate alterations between
preoperative and postoperative values of
pulmonary function parameters.
3) To study the effect of gender difference, site of
surgery and Body Mass Index on postoperative
pulmonary function parameters as compared to
their preoperative values.
The study protocol was approved by the
Institutional Ethics Committee. Patients were selected
from those admitted to Surgery and Gynaecology ward
of the Sassoon General hospital. 28 males and 22
females of the age group 30-60 years undergoing
planned laparotomy were selected for the study. The
study protocol was explained in detail to the selected
patients. All the patients willing to participate in the
study were asked to fill an informed consent form.
Pulmonary function parameters were recorded preoperatively on one day prior to surgery and the postoperative readings were taken on fifth post-operative
day. The PFTs were measured using a computerized
portable RMS Helios 702(Chandigarh) spirometer
(Photograph 1). This spirometer is automated and has
a flow sensor which converts the airflow signals to
digital signals. Values obtained were in litres and they
were compared with the existing database for the normal
healthy Indian population depending on age, sex,
height and weight. Patients with history of cardiorespiratory diseases, diabetes mellitus or hypertension
were excluded from the study. Also patients who had
intra-operative complications, post-operative
pulmonary, cardiac or surgical complications were
excluded.
The tests were conducted according to the American
Thoracic Society/ European Respiratory Society (ATS/
ERS) task force guidelines. The pulmonary functions
were recorded in the sitting position and before the
subject had lunch. The subjects were instructed to wear
loose clothes on the day of test. Name, age, sex, height
171
and weight were entered in the spirometer. The

procedures of all maneuvers were demonstrated to the
subject using disposable mouthpiece.
The Slow Vital Capacity (SVC) maneuver was
conducted in the following order:
Subjects were instructed to breathe normally through
the mouthpiece. After the three normal breaths, they
were asked to take deep inspiration followed by forceful
expiration. And again they were asked to take three
normal breaths without removing the mouthpiece.
Parameters recorded in this manoeuvre were Tidal
volume (TV) in litres, Expiratory reserve volume (ERV)
in litres, Inspiratory reserve volume (IRV) in litres,
Inspiratory capacity (IC) in litres, Vital capacity (VC) in
litres.
The Forced Vital Capacity (FVC) maneuver was
conducted in the following order:
Subjects were instructed to take slow and deep
inspiration. Then subjects were instructed to hold the
mouthpiece in the mouth with lips pursed around it
and asked to blow forcefully into the mouthpiece as
long as possible without hesitation and coughing. Then
without removing the mouthpiece from the mouth, they
were instructed to inspire maximally through the
mouthpiece. Parameters recorded in this maneuver
were Forced vital capacity (FVC) in litres, Force
expiratory volume in one second (FEV1) in litres, FEV1/
FVC in %, Peak expiratory flow rate (PEFR) in litre per
second and Peak inspiratory flow rate (PIFR) in litre
per second.
The Maximum Voluntary Ventilation (MVV)
maneuver was conducted in following order:
Subjects were instructed to breathe in and out as
rapidly and deeply as they can for a period of 15
seconds through the mouthpiece. All the recorded
maneuver results were analyzed for acceptability and
repeatability. Three acceptable readings were taken and
their mean values were calculated and analyzed.
Statistical analysis was carried out by Students t
test SPSS software( version 11).
FINDINGS
We found that post-operatively there is decrease in
TV by 21.87%, ERV by 22.01%, IRV by 23.64%, IC by
26.23%, VC by 25.54%, MVV by 26.28%, FVC by 26.32%,
FEV1 by 28.97%, FEV1/FVC by 3.48%, PEFR by 32.31%
and PIFR by 41.73%. All these differences were
statistically significant except that in FEV1/FVC. (Table
1, Figure 1)
2/7/2013, 8:08 PM
Intergroup statistical analysis between Male and

Female patients showed that post-operative percentage
decrease was more in Male patients as compared to
that in Female patients. (Table 2, Figure 2)
Intergroup statistical analysis between patients
undergoing upper abdominal surgery and patients
undergoing lower abdominal surgery showed that post-
operative percentage decrease was more in patients

undergoing upper abdominal surgery. (Table 3,
Figure 3)
Intergroup statistical analysis between obese and
non obese patients showed that post-operative
percentage decrease was more in obese patients as
compared to the non obese patients. (Table 4, Figure 4)
Table 1: Mean preoperative and postoperative values of pulmonary function parameters with postoperative
percentage decrease
Parameter
Mean
SD
Preoperative Postoperative mean

difference (Percentage %)
p value
0.077 (21.87%)
< 0.05*
0.168 (22.01%)
< 0.05*
0.610 (23.64%)
< 0.05*
0.759 (26.23%)
< 0.05*
0.930 (25.54%)
< 0.05*
24.000 (26.28)
< 0.05*
0.850 (26.32)
< 0.05*
0.820 (28.97)
< 0.05*
3.020 (3.48)
> 0.05
1.962 (32.31)
< 0.05*
2.534 (41.73)
< 0.05*
TV_PRE (in Lit.)
0.352
0.06
TV_POST (in Lit.)
0.275
0.04
ERV_PRE (in Lit.)
0.763
0.18
0.595
0.15
IRV_PRE (in Lit.)
2.580
0.26
IRV_POST (in Lit.)
1.970
0.21
IC_PRE (in Lit.)
2.893
0.34
IC_POST (in Lit.)
2.134
0.28
VC_PRE (in Lit.)
3.640
0.52
VC_POST (in Lit.)
2.710
0.30
MVV_PRE (Lit/min.)
91.320
7.91
MVV_POST (Lit/min.)
67.320
6.90
FVC_PRE (in Lit)
3.230
0.42
FVC_POST (in Lit)
2.380
0.36
FEV1_PRE (in Lit.)
2.830
0.42
FEV 1_POST(in Lit.)
2.010
0.32
FEV1/FVC_PRE (in %)
86.700
4.82
FEV1/FVC_POST (in %)
83.680
6.01
PEFR_PRE (Lit/sec.)
6.072
1.31
PEFR_POST (Lit/sec.)
4.110
1.04
PIFR_PRE (Lit/sec.)
6.072
1.31
PIFR_POST (Lit/sec.)
3.538
0.88
ERV_POST (in Lit.)
Pre: Preoperative
Post: Postoperative
*< .05: statistically significant
Table 2: Postoperative Percentage decrease in pulmonary function parameters in relation to the gender difference
Parameters
MALE, Postoperative
percentage decrease
FEMALE ,Postoperative
percentage decrease
TV
25.00
20.00
ERV
24.44
18.64
IRV
25.45
21.85
IC
28.01
23.30
VC
27.59
22.76
MVV
28.15
23.61
FVC
27.66
24.57
FEV1
30.23
27.41
FEV1/FVC
4.22
2.56
PEFR
34.31
29.44
PIFR
43.74
38.60
172
2/7/2013, 8:08 PM
Table 3: Postoperative Percentage decrease in pulmonary function parameters in relation to the site of surgery
Parameters
UPPER ABDOMAN,
Postoperative
percentage decrease
LOWER ABDOMAN,
Postoperative
percentage decrease
TV
26.47
20.00
ERV
24.32
20.77
IRV
25.09
21.40
IC
29.65
22.02
VC
29.47
21.85
MVV
27.81
24.19
FVC
29.79
23.05
FEV1
32.35
26.19
FEV1/FVC
3.69
3.28
PEFR
35.96
28.87
PIFR
45.70
37.90
Table 4: Postoperative Percentage decrease in pulmonary function parameters in relation to the BMI
Parameters
OBESE, Postoperative
percentage
decrease
NON OBESE,
Postoperative percentage
decrease
TV
23.52
19.44
ERV
22.97
21.51
IRV
24.80
22.48
IC
28.32
23.50
VC
26.40
24.86
MVV
27.98
24.53
FVC
28.52
24.08
FEV1
30.85
27.11
FEV1/FVC
4.50
2.34
PEFR
35.57
28.91
PIFR
43.80
39.58
DISCUSSION
To the best of our knowledge no one has studied all
the PFT parameters as a whole in postoperative period
as we did. Few authors have studied some parameters
in laparotomy patients. Beecher HK [2] found a greater
decrease in TV, ERV, IRV and VC as compare to our
study. This may be due to the fact that their study
measured PFT parameters on 2nd postoperative day
while ours was on 5th postoperative day. Similar study
conducted by Collins et al [3] on FVC, FEV1, FEV1/FVC
and PEFR showed lower decrease in PFT parameters
this may be due to they have studied it on 7 th
postoperative day. Very few authors have studied effect
of laparotomy on PIFR.
We found that post-operatively there was
statistically significant decrease in all PFT values except
that of FEV1/FVC. Thus post-operatively there is
restrictive type of ventilatory dysfunction which is
responsible for various post-operative pulmonary
complications. The various mechanisms responsible for
173
this post-operative pulmonary dysfunction are:

Impaired ventilation in post-operative period due
to diaphragmatic dysfunction which can be proved by:
a) Decreased diaphragmatic excursions [4] b)
Paradoxical motion of the diaphragm [5] c) Loss of the
diaphragms normal inspiratory - expiratory phasic
activity [6] d) Decrease in trans-diaphragmatic pressure
by almost 70% [7]
Adaptation of shallow breathing pattern without
periodic deep breathing in post-operative period results
in decreased surfactant secretion by type II alveolar
epithelial cells. This decrease in surfactant secretion
causes post-operative atelectasis, thus decreasing PFT
values.[8]
It has been proved that there is dysfunction of
intercostal muscles in post-operative period. Intercostal
muscles play an important role in forceful respiration.
So their dysfunction results in decrease in PFT
values.[8] The situation is further aggravated by certain
2/7/2013, 8:08 PM
post-operative factors such as prolonged recumbency,

supine position and tight dressing over abdomen.[9]
Intergroup statistical analysis showed that male
patients are more severely affected than female patients.
Various reasons that can be put forward for this
difference are
1) Type of breathing [10], Normally during quiet
respiration males show abdomino-thoracic type of
breathing, while females have thoraco-abdominal
type of breathing. Thus abdominal component is
predominant in males and this abdominal
component is mainly affected during laparotomy.
2) Progesteron, the female sex hormone, has its own
influence on chemoreceptor cells in medulla.
Progesterone increases sensitivity of respiratory
center to CO2. So whenever there are postoperative
ventilation abnormalities in females, it causes
stimulation of respiratory center due to progesterone
and this may improve postoperative pulmonary
function in them.[11]
Patients undergoing upper abdominal surgery are
more affected than that of lower abdominal surgeries
This can be explained by the fact that the
diaphragmatic weakness is the main cause of postoperative pulmonary dysfunction and this
diaphragmatic dysfunction mainly depends upon
proximity of operative site to diaphragm. The proximity
of operative site is inversely related to diaphragmatic
function. This finding has been supported by the
decrease in maximum inspiratory pressure, transdiaphragmatic pressure and expiratory muscle pressure
observed after upper abdominal surgery in several
studies. [ 12 13,14,15] This decrease is sustained for 48 hours
after surgery and may persist for a week. [16,17]
Furthermore, upper abdominal surgeries cause
predominantly rib cage breathing in post-operative
period, as shown by an increase in the ratio of
oesophageal to gastric pressure swings (Poes/Pga)
and by decrease in the abdominal to rib cage excursions.
This indicates that the intercostal inspiratory muscles
are more active after upper abdominal surgery. [12,14] This
is because the diaphragm is the muscle that is mainly
affected during upper abdominal surgery. The
mechanism that underlies the reduction in
diaphragmatic strength and the shift to predominantly
rib cage breathing is not fully understood, but
anaesthesia and pain are definitely responsible for this
dysfunction, some studies in animals and humans also
showed that an inhibitory reflex generated during the
174
surgical procedure is the major mechanism.

Manipulation of the splanchnic organs during
laparotomy causes reflex inhibition of the phrenic nerve
output decreasing diaphragmatic function. [15]
Thus upper abdominal operations are associated
with substantially worse diaphragmatic function
postoperatively than are lower abdominal operations,
and the risk of postoperative pulmonary complications
is accordingly higher by a factor of 1.5. [18]
CONCLUSION
We found after laparotomy in postoperative period,
there are restrictive type of ventilatory changes. All these
postoperative PFT decrease are more in male patients,
in patients undergoing upper abdominal surgeries and
in obese patients.
All these changes are favorable for producing
postoperative pulmonary complications. These changes
are mainly due to altered pattern of ventilation in
postoperative period.
Since these postoperative pulmonary changes can
be easily diagnosed by spirometer, all patients
undergoing laparotomy should undergo preoperative
and postoperative spirometry. Also prophylactic
preoperative physiotherapy and postoperative
interventions such as deep breathing exercises,
incentive spirometry and chest physiotherapy should
be advised to all patients undergoing laparotomy. These
simple and inexpensive procedures can make a
significant difference in patients outcome after
laparotomy.
This will definitely reduce mortality and morbidity
after laparotomy and will give very good results to
surgeon who had used good surgical technique and
alert mind for betterment of his patients.
REFERENCES
1.
2.
3.
Miller MR, Hankinson J, Brusasco V, Burgos F,

Casaburi R, Coates A et al. Standardization of
spirometry. Eur Respir J 2005;26:319-38
Beecher HK. Effect of laparotomy on lung volume:
Demonstration of a new type of pulmonary
collapse. J Clin Invest 1933;651:12.
Collins CD, Darket MD, knowelden J. Chest
complications after upper abdominal surgery:
Their anticipation and prevention. Brit Med J 1968;
1: 401-06.
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4.
Rehder K, Sessler AD, Marsh HM. General

anesthesia and the lung. Am Rev Respir Dis 1975;
112:541-63.
5.
Marsh HM, Rehder K, Sessler AD, Fowler WS.
Effects of mechanical ventilation, muscle paralysis
and posture on ventilation-perfusion
relationships
in
anesthetized
man.
Anesthesiology 1973; 38(1): 59-67.
6.
Russel WJ. Position of patient and respiratory
function in immediate postoperative period.BMJ
1981;283:1079-80
7.
Simonneau G, Vivien V, Saltine R. Diaphragmatic
dysfunction induced by upper abdominal surgery:
role of postoperative pain. Am Rev Respir Dis 1983;
128:899
8.
Rehder K. Anesthesia and the respiratory system.
Can Anesth Soc J 1979; 26(6):451-62.
9.
Brook lord. Abdominal operations.1969.5th ed.
New York. p 484-91
10. Guyton and Hall. Textbook of Medical Physiology.
11th ed. Elsevier Pvt. Ld.;2006: p 471-80.
11. Keele C, Neil E, Joels N. Samsung Wrights Applied
Physiology. 13th ed. Oxford University Press;2000
p 584
12. Ford GT, Whitelaw WA, Rosenal TW, Cruse PJ,
Guenter CA. Diaphragm function after upper
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abdominal surgery in humans. Am Rev Resp Dis

1983; 127: 431-36.
Celli BR, Rodriguez KS, Snider GL. A controlled
trial of intermittent positive pressure breathing,
incentive spirometry, and deep breathing exercises
in preventing pulmonary complications after
abdominal surgery. Am Rev Resp Dis 1984; 130:
12-15.
Ford GT, Rosenal TW, Clergue F. Respiratory
physiology in upper abdominal surgery. Clin
Chest Med 1993;14:23752.
Watters JM, Clancey SM, Moulton SB. Impaired
recovery of strength in older patients after major
abdominal surgery. Ann Surg 1993; 218:38090.
Putensen-Himmer G, Putensen C, Lammer H.
Comparison of postoperative respiratory function
after laparoscopy or open laparotomy for
cholecystectomy. Anesthesiology 1992; 77:67580.
Siafakas NM, Stoubou A, Stathopoulou M. Effect
of aminophylline on respiratory muscle strength
after upper abdominal surgery: a double blind
study. Thorax 1993; 48:6937.
Mitchell C, Garrahy P, Peake P. Postoperative
respiratory morbidity: identification and risk
factors. Aust N Z J Surg 1982; 52:2039.
2/7/2013, 8:08 PM
Evaluation of Standardized Backpack weight and its

Effect on Shoulder & Neck Posture
Pardeep Pahwa
Lect. in Physical Therapy, Composite Regional Centre for Persons with Disabilities (Ministry of Social Justice &
Empowerment , Govt of India) Sundernagar (HP)
ABSTRACT
The Backpack is one of several forms of manual load carriage that provides versality and is often used
by hikers, backpackers, and soldiers as well as school student. Students have emerged as another
population of backpackers who carry their school supplies in book bags which are backpacks. As the
students progress through the school grades the amount of homework and backpack loads of school
age children increases. We all want our children to do well in school.16 To initiate an educational
program regarding school backpack safety in our area, it is essential to know the 'weight' of backpack
students are currently carrying.
Keywords: Backpackpack, Craniohorizontal angle, Craniovertebral angle, Sagittal Shoulder posture, Anterior
Head Alignment.
INTRODUCTION
The Backpack is one of several forms of manual load
carriage that provides versality and is often used by
hikers, backpackers, and soldiers as well as school
student. The Backpack is an appropriate way to load
the spine closely and symmetrically, whilst
maintaining the stability. However, musculoskeletal
problems associated with backpack use have become
an increasing concern with school children.1
Students have emerged as another population of
backpackers who carry their school supplies in book
bags which are backpacks. Carriage of backpack applies
a substantial load to spine to school children.2
As the students progress through the school grades
the amount of homework and backpack loads of school
age children increases. As a result the students carry
all their materials in book bags. This has lead to physical
complaints in the form of muscle soreness (67.1%), back
pain (50.8%), numbness (24.5%) and shoulder pain
(14.7%). The most commonly reported medical problem
is plexus or peripheral nerve injury. Physical
examination can often reveal weakness, numbness and
possible muscle atrophy. 3 The Backpack loading
produce changes in standing posture when compared
with unloaded standing posture which has been related
to spinal pain.4
Although it is unclear whether backpacks can cause
permanent damage, the healthcare costs associated
34. Pradeep pehwa--176-184.pmd
176
with strain and pain could be enormous.5 School bags

are felt to be heavy by 79% of children, to cause fatigue
by 65.7%10.
We all want our children to do well in school.7 To
initiate an educational program regarding school
backpack safety in our area, it is essential to know the
weight of backpack students are currently carrying.
This information could be incorporated into school
curriculum or distributed as a handout for children to
take home to their parents. Many researches have been
done on amount of load carried by student and their
effect on shoulder and neck alignment is between 10%
and 17% of students body weight.1
Chansirinukor et al6 suggested that a backpack load
of 15% body weight is too heavy for adolescents to
maintain a prolonged standing posture.
Furjuouh el al5 reported that backpack carried by
majority of school students, in the sample are no longer
heavier than 10% of body weight which is associated
with complaints of pain in back, shoulder, neck or other
areas of body. Pascoe et al6 reported that mean weight
of school bags was 17% of students mean body weight.
The previous study done by Chansirinukor et al1
showed that carrying a load of less than 15% of body
weight should be recommended, but none of study has
shown the particular amount of backpack weight, from
where the change in craniohorizontal and
carniovertebral angle starts which leads to change in
cervical and shoulder posture.
2/7/2013, 8:08 PM
Aims and Objectives
To determine the particular amount of backpack

weight carried by students that does not change
the students cervical and shoulder posture.
This study was an observational study design.
To implement and recommend maximum weight of

backpack that should be carried by students.
All the subjects were tested in DIBNS gymnasium

To capture postural information on body segments,
clothing was rearranged so that shoulder and upper
half body exposed. With the subjects standing, adhesive
markers (Bindis) were placed on anatomical points
comprising :-
Statement of Question
Study Design
How much percentage of backpack weight should

be carried by students that does not change student
posture?
PROCEDURE
1. The External canthus of right eye.

METHODOLOGY
2. Right tragus of the ear.
Sample
3. Inferior margins of both ears.
A total of 10 school boys aged between 13 and 17

years old recruited as subjects. They were recruited from
the G.N.D public school, Dehradun. This study was
conducted at gymnasium of Dolphin Institute,
Dehradun.
4. A midpoint between greater tuberosity of humerus

and posterior aspect of acromion process of right
shoulder; and
5.
Spinous process of C7.
1. Subjects with postural abnormality , LLD, cervical

and shoulder pain
A small reflective ball was placed over the spinous

process of C7 The lateral malleoli were placed between
parallel lines, which are perpendicular to frontal Plane,
2 cm apart. The photographs were obtained using a
digital kodak camera that was attached to tripod. The
tripod was secured in correct position on floor by using
masking tape for the sagittal view photography, the
subject were placed 2.8 m from the camera and 1.8 m
from the camera for frontal view photography. Then
the subject were photographed from both lateral view
and from anterior aspect at same time with
2. Balance disorder
1. Unloaded
3. Congenital abnormality such as spina bifida,

cervical rib, deformity of spine.
2. Carrying a backpack weighing 8% to 20% of body

weight by adding 1% weight of body weight & so
on.
Inclusion Criteria
1. Subjects with in age group of 13-17years.
2. Height of subjects 90-160 cms .
3. Weight of subjects 30-60 kg.
Exclusion Criteria
4. Subjects with forward head posture, history of

recent fracture.
Instrumentation
1.
Metter Digital Electronic Scale
2. Digital Video Camera

3. Height Statuometer
4. Adhesive Markers
5. Book Bags
6. Educational Material
7. Motion Analysis Software
177
In order to evaluate posture of cervical and shoulder

region, motion analysis software (protrainer 6.1 sports
motion) was employed to calculate the angles from each
anatomical landmark from the photographs. The angles
in the lateral and frontal view thus calculated and
readings taken for the data analysis.
The four angles of measurement are
Craniohorizontal Angle1
The angle formed at intersection of a horizontal
line through tragus of ear and a line joining the tragus
of ear and external canthus of eye. It is believed to provide
an estimation of head on neck angle or position of upper
cervical spine
2/7/2013, 8:08 PM
Craniovertebral Angle1
DATA ANALYSIS
It is angle formed at the intersection of a horizontal

line through the spinous process of C7 and a line to the
tragus of ear. This is believed to provide an estimation
of neck on upper trunk position.
Sagittal Shoulder Posture1
The angle formed by intersection of horizontal line
through C7 and a line between the mid point of greater
tuberosity of humerus and posterior aspect of acromion.
This angle provides a measurement of forward shoulder
position
Anterior Head Alignment1
A line drawn between the inferior tip of left and right
ears, and the angle of this line to horizontal. This
measurement described how level the head was when
viewed from the frontal.
The significance of postural changes from where

the change starts in data were estimated by using paired
t-test on each postural angle within which planned
contrast were made of unloaded condition with loaded
backpack weight from pair 1 to pair 13 including 8%
upto 20% of body weight. The statistical significant level
of this study was set at 0.025.
RESULTS
The mean and standard deviation for physical
characteristics of all the 10 subjects were taken i.e. age
(14.1 + 1.19) yrs, weight (44.3 + 7.84) kg and height
(145.4 + 8.60) cms. The mean and standard deviation of
both unloaded and loaded CHA, CVA, SSP and AHA
from pair 1 to pair 13 were analysed by using paired t
test.
Table: 1 Showing comparison of mean and standard deviation for each unloaded and loaded condition of
Craniohorizontal angle at different percentages of body weight (8%-20%)
Variable
MeanSD
t-value
p-value
Pair 1
Variable
MeanSD
t-value
p-value
ULCHA
16.42.5
8.29
.000
LCHA 15
24.21.98
8.33
.000
15.73
.000
16.14
.000
12.75
.000
11.69
.000
Pair 8
ULCHA
16.42.5
LCHA 8
19.03.9
2.53
.032
Pair 2
Pair 9
ULCHA
16.42.5
LCHA 9
21.22.2
6.10
.000
Pair 3
ULCHA
16.42.5
LCHA 16
25.83.0
Pair 10
ULCHA
16.42.5
LCHA 10
21.34.3
3.86
.004
Pair 4
ULCHA
16.42.5
LCHA 17
27.42.3
Pair 11
ULCHA
16.42.5
LCHA 11
22.94.8
4.02
.003
Pair 5
ULCHA
16.42.5
LCHA 18
27.71.8
Pair 12
ULCHA
16.42.5
LCHA 12
24.14.9
4.81
.001
Pair 6
ULCHA
16.42.5
LCHA 19
28.02.1
Pair 13
ULCHA
16.42.5
LCHA 13
25.33.7
6.74
.000
ULCHA
16.42.5
LCHA 20
28.12.9
Pair 7
ULCHA
16.42.5
LCHA 14
25.03.0
178
7.20
.000
2/7/2013, 8:08 PM
Graph: 1 Showing comparison of backpack load at different percentage of body weight with unloaded condition for
Craniohorizontal Angle.
30
25
Degree
20
15
10
5
0
8
10 11 12 13 14 15 16 17 18 19 20
Percentage of body weight
Table: 2 Showing comparison of mean and standard deviation for each unloaded and loaded condition of
Craniovertebral angle at different percentages of body weight (8%-20%)
Variable
MeanSD
t-value
p-value
Pair 1
Variable
MeanSD
t-value
p-value
ULCVA
48.73.9
3.80
.004
LCVA 15
42.96.8
4.65
.001
3.75
.006
4.89
.001
4.311
.002
4.451
.002
Pair 8
ULCVA
48.73.9
LCVA 8
47.94.4
.937
.373
Pair 2
Pair 9
ULCVA
48.73.9
LCVA 9
47.26.4
.929
.377
Pair 3
ULCVA
48.73.9
LCVA 16
42.86.2
Pair 10
ULCVA
48.73.9
LCVA 10
46.76.6
1.27
.235
Pair 4
ULCVA
48.73.9
LCVA 17
42.06.6
Pair 11
ULCVA
48.73.9
LCVA 11
45.45.8
2.74
.023
Pair 5
ULCVA
48.73.9
LCVA 18
41.86.4
Pair 12
ULCVA
48.73.9
LCVA 12
43.46.9
3.32
.009
Pair 6
ULCVA
48.73.9
LCVA 19
42.36.9
Pair 13
ULCVA
48.73.9
LCVA 13
43.37.14
2.90
.017
ULCVA
48.73.9
LCVA 20
41.17.6
Pair 7
ULCVA
48.73.9
LCVA 14
43.06.737
179
3.47
.007
2/7/2013, 8:08 PM
Graph: 2 Showing comparison of backpack load at different percentage of body weight with
unloaded condition for Craniovertebral Angle
51
49
47
Degree
45
43
41
39
37
35
8
9 10 11 12 13 14 15 16 17 18 19 20
Table: 3 Showing comparison of mean and standard deviation for each unloaded and loaded condition of Sagittal
shoulder posture at different percentages of body weight (8%-20%)
Variable
MeanSD
t-value
p-value
Pair 1
Variable MeanSD t-value
ULSSP
59.1 6.2
LSSP 8
56.9 6.1
1.66
0.131
Pair 2
ULSSP
59.1 6.2
LSSP 15
58.6 6.3
.478
0.644
.599
0.564
.073
0.944
.209
0.839
.635
0.541
.082
0.936
Pair 9
ULSSP
59.1 6.2
LSSP 9
56.9 5.08
.246
0.811
Pair 3
ULSSP
59.1 6.2
LSSP 16
59.7 7.04
Pair 10
ULSSP
59.1 6.2
LSSP 10
57.8 5.5
.969
0.358
Pair 4
ULSSP
59.1 6.2
LSSP 17
59.2 6.3
Pair 11
ULSSP
59.1 6.2
LSSP 11
59.8 5.9
.793
0.448
Pair 5
ULSSP
59.1 6.2
LSSP 18
58.8 6.3
Pair 12
ULSSP
59.1 6.2
LSSP 12
59.3 7.1
.194
0.850
Pair 6
ULSSP
59.1 6.2
LSSP 19
60.0 7.2
Pair 13
ULSSP
59.1 6.2
LSSP 13
58.2 7.1
.588
0.571
ULSSP
59.1 6.2
LSSP 20
59.0 6.6
Pair 7
ULSSP
59.1 6.2
LSSP 14
59.2 6.4
p-value
Pair 8
180
.085
0.934
2/7/2013, 8:08 PM
Graph: 3 Showing comparison of backpack load at different percentage of body weight with unloaded
condition for Sagittal shoulder posture.
60
Degree
50
40
30
20
10
0
8
9 10 11 12 13 14 15 16 17 18 19 20
Table: 4 Showing comparison of mean and standard deviation for each unloaded and loaded condition of Anterior
head alignment at different percentages of body weight (8%-20%)
Variable
MeanSD
t-value
p-value
Pair 1
Variable
MeanSD
t-value
p-value
ULAHA
1.0 .66
4.9
0.001
LAHA 15
2.3 .82
4.8
0.001
4.7
0.001
8.5
0.000
9.7
0.000
7.2
0.000
Pair 8
ULAHA
1.0 .66
LAHA 8
1.2 .42
1.0
0.34
Pair 2
Pair 9
ULAHA
1.0 .66
LAHA 9
1.3 .48
1.9
0.081
Pair 3
ULAHA
1.0 .66
LAHA 16
2.2 .63
Pair 10
ULAHA
1.0 .66
LAHA 10
1.4 .51
1.8
0.104
Pair 4
ULAHA
1.0 .66
LAHA 17
2.6 1.07
Pair 11
ULAHA
1.0 .66
LAHA 11
1.5 .70
1.8
0.096
Pair 5
ULAHA
1.0 .66
LAHA 18
2.3 .67
Pair 12
ULAHA
1.0 .66
LAHA 12
1.6 .57
2.2
0.051
Pair 6
ULAHA
1.0 .66
LAHA 19
2.6 .51
Pair 13
ULAHA
1.0 .66
LAHA 13
1.8 .78
3.2
0.011
ULAHA
1.0 .66
LAHA 20
2.8 .42
Pair 7
ULAHA
1.0 .66
LAHA 14
2.0 .94
181
3.3
0.008
2/7/2013, 8:08 PM
Graph: 4 Showing comparison of backpack load at different percentage of body weight with Unloaded condition for
Anterior Head Alignment
3.0
2.5
Degree
2.0
1.5
1.0
0.5
0.0
8
9 10 11 12 13 14 15 16 17 18 19 20
DISCUSSION
For all three angles i.e craniohorizantal angle,

carniovertebral angle and anterior head alignment, the
change starts at 9%,11% and 13% respectively, which
is less than 15% of body weight. According to
Chansirinukor et al (2001), who recommended that 15%
of body weight represent an overload to this age of young
children support the present study.
According to National Back Pain Association (1997)
and Voll & Klimt11 (1997) who recommended that school
children should carry no more than 10% of their body
weight, supporting this study. But change in anterior
head alignment in present study starts at 13% of body
weight which is against the study done by Voll and
Klimt.
For sagittal shoulder position, the result of present
study shows insignificant difference from 8% to 20% of
body weight and so does not show any change in
sagittal posture at any percentage of body weight.
There is lot of controversy about the accurate
anatomical landmarks of this angle according to
different authors. Based on Rainey and Twomeys study
(1994)1,12, a more rounded shoulder is represented by a
smaller sagittal shoulder angle; provided the position
182
of C7 remains fixed. But study done by Chansirinukor

et al.,1 shows that sagittal plane shoulder posture
increases under load, when a marker was placed in
between greater tuberosity of humerus and posterior
aspect of acromion.
Braun and Amundson 8 in their study pointed
bicipital tendon groove as acromion angle for assessing
shoulder position in sagittal plane.
There might be reason that different position
adopted for measurement might have contributed to
contrasting outcome. So further studies using a 3dimensional approach is required to identify the
relationship between body landmark and their correct
placement for sagittal shoulder posture.
FUTURE RESEARCH
Future research is needed to investigate the effect of
backpack carriage on Unilateral side in dynamic
conditions on cervical and shoulder posture changes.
Girls students were not included in the study,
because of exposure. As the spine is maturing, there
may be gender based difference which can affect the
results of the study.
2/7/2013, 8:08 PM
Relevance to Clinical Practice

The carriage of heavy school bag coupled with long
carriage duration and lack of access of lockers in Indian
schools may represent an daily physical stress for school
students and could lead to musculoskeltal symptoms.
Therefore, if preventive measures can be introduced
with regard to safe load carriage in school students. It
will not only help to protect students while they are
still developing but it will also ensure that the
principles they learn now are carried through to
workplace as adults.
RECOMMENDATIONS
CONCLUSION
Previous studies suggest that postural response in
high school students are sensitive to load carriage
equivalent to 15% of body weight. The amount of weight
that does not change the students head and neck
posture, that can be recommended lies between 9-10%
of body weight. So, up to 10% of body weight, there is
safeguard limit for adolescents.
According to these results, teachers, children and
families should be equally involved in safe carrying of
backpack load. As a part of physiotherapy intervention,
students were often advised about their habitual
posture in relation to carrying backpack load.
REFERENCES
1.
2.
3.
4.
1. Wear padded, wide shoulder straps both sides.
5.
2. Backpack should not too heavy than 10% of student

body weight.
3. Advice the students to keep the load close to the
body.
Limitations of Study
6.
7.
1. If the number of subjects had been more, results

would have been better enhanced.
2. The study was limited to only one school and
particular age group. So, results may not be
generalized to the source population.
183
8.
Wunpen Chansirinukor, Dianne Wilson, Karen

Grimmer and Brenton Dansie., Effects of
Backpacks on students: Measurement of cervical
and shoulder posture. Australian Journal of
physiotherapy, 47, 110-116. 2001.
Yong Tai wang, D.D. Pascoe, W. Weimar. ,
Evaluation of Book Back pack load during walking
Ergonomics , 44 (9), 858 869, 2001
David D. Pascoe, Donna E. Pascoe, Yong Tai Wang,
Dong-Ming-Shim and Chang K. Kim., Influence
of carrying book bags on gait cycle and posture of
youths. Ergonomics, 40, (6 ),631-641, 1997.
Karen Grimmer, brenton dansie, S. Milanese, U.
Pirunson and Patricia trott., Adolescent standing
postural response to backpack loads: a
randomized controlled experimental study.BMC
Musculoskeltal Disorders, 3, 1-10, 2002
Forjuoh SN, Lane BL, Schuchmann J., Percentage
of Body weight carried by students in their school
backpacks.Am. J Phys. Med. Rehabil , 82, 261 266,
2003.
Youlian Hong, Chi-kin Cheung., Gait and posture
responses to backpack load during level walking
in children. Gait and posture, 17,28-33, 2003.
Richard- Pistolese., Backpacks- Your childs spine
at risk.
International chiropractic pediatric associationICPA, 3,1-2, 2000
Barbara lafferty brawn, Louis R. Amundson.,
Quantitative assessment of head and shoulder
posture. Arch. Phys. Med. Rehabil, 70, 322-329,
1998.
2/7/2013, 8:08 PM
9.
Daniel H.K. Chow, Monica L.Y Kwok, Alexander

C.K., A.V. Yang, Andrew D. Holmes, Jack Y Cheng,
Y.D. YAO. M.S Wong., The Effect of backpack load
on the gait of normal adoloscent girls. Ergonomics,
48 (6) , 642 656, 2005.
10. Stefano Negrini, Roberta carabalona., Back packs
on ! School Childrens
Perception of Load, Associations with Backpain
184
and factors determining the load. Spine, 27,

187-195, 2002
11. J.K. Whittfield, S.J. Legg, DI Hedderley., The weight
and use of school bags in Newzealand Secondary
Schools. Ergononics , 44 (9) , 819- 824, 2001
12. Raine S, Twomey Lt .,Posture of Head Shoulders
and thoracic spine in comfortable erect standing.
Australlian J. Physiotherapy , 40 (1) , 25-32, 1994.
2/7/2013, 8:08 PM
Effect of Abductor Muscle Strengthening in Osteoarthritis

Patients: A Randomized Control Trial
Nishant H Nar
Consultant Physiotherapist Wockhardt Hospital, Rajkot
ABSTRACT
Background: Osteoarthritis is a chronic, localized joint disease affecting approximately one-third of
adults, with the disease prevalence increasing with advancing age. OA affects many joints including
the large, weight bearing joints of the hips and knees and also the spine, hands, feet and shoulders. The
knee is the most common weight bearing joint affected by OA, with the disease predominantly affecting
the medial compartment of the tibio-femoral joint. Patients with knee OA frequently report symptoms of
knee pain and stiffness as well as difficulty with activities of daily living such as walking, stairclimbing and house keeping.
Objectives: To compare the effectiveness of hip abductor muscle strengthening exercises and
conventional physiotherapy treatment with conventional physiotherapy treatment alone in people
with unilateral medial compartment knee osteoarthritis.
Materials and Methodology: Study included 30 (Thirty) subjects with unilateral medial compartment
knee OA, aged 45 years or above. The subjects were randomly divided into 2 groups: Group -A and
Group -B. The subjects were treated for a period of 6 weeks, 6 days a week, once daily. Pain was
assessed by VAS score and physical function was assessed by WOMAC Index of Osteoarthritis.
Results: The results were analyzed by Wilcoxon Signed Rank Test. Group A showed significant
improvement in pain (T=120, p<0.05) and physical function (T=120, p<0.05). In Group B, results
showed significant improvement in pain (T=91, p<0.05) and physical function (T=120, p<0.05).
Comparison of Group A and Group B was done with Wilcoxon Sum Rank Test (Mann Whitney U Test),
Group A showed significant improvement in pain (z = -2.82, p<0.0052) and physical function (z = 3.56, p<0.0004).
Conclusion: Hip abductor muscle strengthening exercises showed over all improvement in pain and
physical function and is a useful adjunct exercise therapy in treating patients with unilateral medial
compartment knee osteoarthritis.
Keywords: Shortwave Diathermy (SWD), Visual Analoge Scale (VAS), WOMAC
INTRODUCTION
The term arthritis literally means inflammation of a
joint, but is generally used to describe any condition in
which there is damage to the cartilage. The cartilage
coats the joint surfaces to absorb stress, and allow
smooth joint movement. The proportion of cartilage
damage and synovial inflammation (the lining and fluid
in the joint capsule) varies with the type and stage of
arthritis. Usually the early pain is due to inflammation.
Later in the disease, pain is from the irritation of the
worn joint structures and inability of the joint to move
properly.
Osteoarthritis (OA) is a chronic, localized joint
disease affecting approximately one-third of adults, with
35. nishant--185-190.pmd
185
the disease prevalence increasing with advancing

age[1]. Concomitant with this high prevalence is a large
economic cost, with direct and indirect costs estimated
to be $23.9 billion in Australia in 2007[2]. Indeed, given
the changing demographics of the adult population[3],
expectations are for the prevalence of disease and its
burden on the health care system to increase in coming
decades[4].
The knee is the most common weight bearing joint
affected by OA, with the disease predominantly
affecting the medial compartment of the tibio-femoral
joint[5,6]. Patients with knee OA frequently report
symptoms of knee pain and stiffness as well as difficulty
with activities of daily living such as walking, stairclimbing and house-keeping[7].
2/7/2013, 8:08 PM
To date, most knee OA research examining treatment

for knee OA has focused on surgical or pharmacological
strategies. Although effective, these types of
interventions have many potential side effects and are
expensive[8]. Thus, recent knee OA clinical guidelines
reinforce the importance of non-pharmacological
strategies in the management of the condition[9,10].
However, there is an absence of high quality evidence
to support the use of such therapies[9].
There are several reasons for the development of OA
including age, being overweight, heredity factors, and
joint damage from a previous injury or during early
development of a joint. Increased loading across the
joint has been implicated in the progression of knee OA
severity [11]. In knee OA, the medial tibiofemoral
compartment is the most common site of disease. The
susceptibility of the medial compartment to OA
development may relate to greater load distribution (i.e.,
6080%) to the medial than the lateral compartment,
even in healthy knees, during gait. Excessive medial
compartment loading is widely believed to contribute
to medial OA progression. Because direct measurement
of knee load is invasive, external knee adduction
moment during gait, a correlate of medial load, has been
used in knee OA studies[12]. The role of gait analysis in
the quantification of dynamic joint load has received
much attention in the literature in light of the difficulty
in performing in vivo measurement of joint loading
during movement[13, 14, 15]. From the research, the external
knee adduction moment, an indirect measure of load in
the medial compartment of the tibio-femoral joint[16], has
emerged as an important and widely accepted
biomechanical marker of knee load.
Cross-sectional studies demonstrate that patients
with knee OA have a higher peak knee adduction
moment during walking when compared to healthy agematched controls[17, 18]. It is also likely that the higher
prevalence of medial compared with lateral tibiofemoral
joint OA is the result of differences in the relative loading
within the tibiofemoral joint. The external knee
adduction moment determines load distribution across
the medial and lateral tibial plateaus[12, 19, 20], with force
across the medial compartment almost 2.5 times that of
the lateral[16]. It has also been reported that for patients
with knee OA, the magnitude of the adduction moment
is predictive of clinical outcomes such as severity of
knee pain and radiographic disease[21, 22].
A variety of exercise programs for knee OA have been
described in the literature. These have included general
aerobic exercise programs such as walking or cycling
186
as well as more specific programs involving

strengthening of particular muscle groups and/or
flexibility exercises.
The primary aim of this study is to determine
whether strengthening of the hip abductor muscles in
people with medial compartment knee OA can reduce
knee pain and improve physical function. It is
hypothesized that a 6-week programme of
strengthening the hip abductor muscles will improve
pain and physical function in people with medial
compartment knee OA.
AIMS AND OBJECTIVE
1) To determine the effectiveness of hip abductor
muscle strengthening in people with medial
2) To compare the effectiveness of hip abductor muscle
strengthening and conventional treatment with
conventional treatment in people with medial
STUDY DESIGN AND MATERIALS
Study Design
An Experimental study was conducted to study the
effects of hip abductor muscle strengthening exercises
in patients with osteoarthritic knee joints.
Study Setting
All patients were referred from Orthopaedic Outpatient Department, Civil Hospital, Ahmedabad to B1
ward, Physiotherapy Department, Civil Hospital,
Ahmedabad where they all were treated during study
period.
Sample Selection
The sample size consisted of 30 (thirty) patients, who
were diagnosed with unilateral medial compartment
tibiofemoral OA, as per the Inclusion Criteria and the
Exclusion Criteria.
Study Duration
The total duration of the study was 6 months. The
subjects were treated for a period of 6 weeks, 6 days a
week, one session daily.
Sample Size
The sample size of 30 (thirty) patients was divided
in to two groups.
2/7/2013, 8:08 PM
Group A: 15 patients.
Description of the Tools
Group B: 15 patients.
Visual Analog Scale (VAS)
Age Group
WOMAC Index of Osteoarthritis
45 years or older.
Gender:
METHODOLOGY
Both sexes
Male: 14
Female: 16
SELECTION CRITERIA
Inclusion Criteria
Ethical clearance was obtained from the Ethical

Clearance Committee of wockhardt hospitals,rajkot
prior to the study. Those who fulfilled the inclusion
criteria were taken up for the study. The whole procedure
of the study was explained to all the subjects. A written
informed consent of all the subjects was taken prior to
the study. All the subjects were assessed as per the
assessment form.
1. Age greater than or equal to 45 years.

2. Unilateral medial compartment tibiofemoral OA
without involvement of any other compartment of
knee joint.
3. Duration of symptoms: Chronic according to IASP
classification.
4. At least some difficulty in daily function due to knee
OA.
30 (thirty) subjects were taken for the study with

diagnosis of unilateral medial compartment knee OA;
14 male and 16 female. They were randomly divided in
to two groups for the study. Each subject of the study
was treated for a period of 6 weeks, 6 days a week, one
session daily. An assessment was done prior to starting
of treatment and weekly assessment was taken for these
subjects.
EXERCISE PROTOCOL
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.
All the subjects were informed in detail about the

type and nature of the study. The subjects were divided
in to two groups; Group A and Group B, 15 patients in
each group. All the subjects were randomly selected
and assigned in to each group.
Exclusion Criteria
Group A
1. History of trauma within one year to affected knee
joint.
2. Associated with any other pathological condition
such as neoplasm, osteomyelitis, vascular problem
etc.
3. Low back pain radiating to knee joint.
4. Knee surgery or intra articular corticosteroid
injection within 6 months to affected knee joint.
MATERIALS USED IN THE STUDY
Consent form, universal goniometer, vas scale,
weight cuffs, WOMAC Index of Osteoarthritis,
Examination Table, Thera-bands, Short-wave
Diathermy Machine, Kodak C875 Zoom Digital Camera,
Paper, Pencil, Scale, Pins.
The subjects in Group A were given hip abductor

muscle strengthening exercises and conventional
physiotherapy treatment.
Group B
The subjects in Group B were given conventional
physiotherapy treatment.
Conventional Physioterapy Treatment for Both
Group -a & Group -b: - (Ref)
A. Short wave Diathermy
B. Stretching Exercises
1) Standing Calf Stretch
2) Supine Hamstring Stretch
3) Prone Quadriceps Stretch
187
2/7/2013, 8:08 PM
Table 1 Gender Distribution of the Subjects:
C. Range of Motion Exercises

1) In long sitting position, knee mid-flexion to end
range extension
2) In long sitting position, knee mid-flexion to end
range flexion
3) Stationary bicycle
D. Strengthening Exercise
1) Static quadriceps sets in knee extension
2) In high sitting position knee mid-flexion to end
range extension with weight cuff
Gender
Group A
Group B
Male count%
853.33%
640%
Female count%
746.66%
960%
15
15
Total
Table 2 displays the statistics of age distribution of

the 30 subjects. Among the 30 subjects, the mean age of
15 subjects in Group A was 51.33 with a standard
deviation (SD) of 5.2326, and the mean age of 15 subjects
in Group B was 52 with a standard deviation of 5.0142.
No significant age difference was seen across the two
groups.
Table 2 Age Distribution of the Subjects:
3) In prone position knee end range extension to midflexion with weight cuff
Hip Abductor Muscle Strengthening Exercises for
Group -a
Subjects in Group A were given a series of three
exercises designed to strength the hip abductor muscles,
6 days a week for 6 weeks.
Group
Mean
SD
Group A
15
51.33
5.2326
Group B
15
52
5.0142
Wilcoxon Signed Rank Test (1,2) was applied in

Group A and in Group B for with-in group analysis
and it is as follows:
In Group A, results showed significant improvement
on VAS score (T = 120 > 95, p < 0.05).
Type of exercise
1) Abduction in side lying
2) Abduction in standing
In Group A, results showed significant improvement

on WOMAC score (T = 120 > 95, p < 0.05).
Unilateral hip abduction performed in standing at

moderate resistance
In Group B, results showed significant improvement

on VAS score (T = 91 > 74, p < 0.05).
With the use of resistance band.
In Group B, results showed significant improvement

on WOMAC score (T = 120 > 95, p < 0.05).
3) Standing wall isometric hip abduction:

Performed in unipedal stance with the opposite limb
in 90 degrees of hip and knee flexion.
The whole study was extended for a period of 6
months. The duration of treatment programme for each
subject was 6 weeks. All the thirty (30) subjects
completed the whole treatment programme of 6 weeks
with out any discomfort.
RESULTS
Table 1 show the gender distribution of the 30
subjects who participated in the study. In the Group A
where the subjects underwent hip abductor muscle
strengthening exercises and conventional
physiotherapy treatment had 8 males and 7 females
and in the Group B where the subjects underwent
conventional physiotherapy treatment alone had 6
males and 9 females. There was no significant
predominance of sex.
188
Wilcoxon Sum Rank Test (Mann Whitney U Test)

(1,2) was applied for between-group comparison of
Group A and Group B, and it is as follows:
On comparing Group A and Group B for posttreatment VAS score, results showed significant
difference in improvement (z = -2.82, p = 0.0052).
On comparing Group A and Group B for posttreatment WOMAC score, results showed significant
difference in improvement (z = -3.56, p = 0.0004).
For Group A
Score
PreMean + SD
PostMean + SD
p<
7 + 1.690
2 + 1.463
120
0.05
66.66 + 6.986
27.66 + 4.237
120
0.05
PreMean + SD
PostMean + SD
p<
VAS
6.93 + 1.387
4.066 + 1.907
91
0.05
WOMAC
67.13 + 6.577
37.46 + 6.356
120
0.05
VAS
WOMAC
For Group B:
Score
2/7/2013, 8:08 PM
On comparing Group A and Group B:
Score
9.
z Value
p Value
VAS
-2.82
0.0052
WOMAC
-3.56
0.0004
The z values (corresponding to p) are highly

significant which suggest that hip abductor muscle
strengthening exercises are effective in reduction of pain
and improvement of physical function along with
conventional physiotherapy treatment.
Hence, Null Hypothesis of no significant effect of
hip abductor muscle strengthening exercises can be
rejected and Alternative Hypothesis of , there is an
additive effect of hip abductor muscle strengthening
exercises on reduction of pain and improvement of
physical function can be accepted.
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Effects of Scapular Stabilization Exercises and Taping in

Improving Shoulder Pain & Disability Index in Patients
with Subacromial Impingement Syndrome due to
Scapular Dyskinesis
Bhavesh Patel1, Praful Bamrotia2, Vishal Kharod3, Jagruti Trambadia4
Physiotherapist, Mahavir Physiotherapy Clinic, Mumbai, 2Tutor, Parul Institute of Physiotherapy, Vadodara, 3Junior
Lecturer, Shri K K Sheth Physiotherapy College, Rajkot, Gujarat, 4Physiotherapist, Shri Sai Physiotherapy and
Rehabilitation Center, Vadodara
ABSTRACT
Background & purpose: Shoulder disorders are among the most common of all peripheral joint
complaints1,2, with Subacromial Impingement Syndrome considered to be one of the most common
forms of shoulder pathology3, accounting for 44% to 60% of all complaints of shoulder pain during
arm elevation or overhead activities4. Researches for Subacromial Impingement Syndrome due to
Scapular Dyskinesis show that scapular stabilization exercises provide good results39. On the other
hand one of the study shows that effect of changing posture by taping will reduce the symptoms of
Subacromial Impingement Syndrome41. So the study is to compare the effectiveness of Scapular
Stabilization Exercises and Taping in improving shoulder pain & disability index in patients with
Subacromial Impingement Syndrome due to Scapular Dyskinesis.
Objective: To check the effect of Scapular Stabilization Exercises and Taping in improving shoulder
pain & disability index in patients with Subacromial Impingement Syndrome due to Scapular dyskinesis.
Method: A total of 60 patients were taken for the study. All subjects were diagnosed with Subacromial
Impingement Syndrome due to Scapular Dyskinesis. The purpose of the study was explained to all the
subjects and informed consent was taken from each subject. All subjects were randomly assigned to
either Scapular Stabilization Exercises group (Group A) and Taping group (Group B). The base line
data of SPADI was obtained to check for the pain functional outcome. SPADI was later taken at the end
of the treatment after 6 weeks on follow up.
Study design: Experimental design
Sampling technique: Purposive sampling technique
Outcome measure: Spadi Score Measurement
Result: Results show that Scapular Stabilization Exercises showed a significant improvement Shoulder
Pain and Disability Index (SPADI sub scores and total scores), when compared to Taping in individuals
with Subacromial Impingement Syndrome.
Conclusion: Scapular Stabilization Exercises showed a significant improvement Shoulder Pain and
Disability Index (SPADI sub scores and total scores), when compared to Taping in individuals with
Subacromial Impingement Syndrome.
Keywords: Subacromial Impingement Syndrome, Adhesive Tapes, Shoulder Pain and Disability Index.
INTRODUCTION
Shoulder disorders are among the most common of
all peripheral joint complaints1, 2, with Subacromial
Impingement Syndrome considered to be one of the most
common forms of shoulder pathology3, accounting for
44% to 60% of all complaints of shoulder pain during
arm elevation or overhead activities4.
36. Praful Bamrotia--191--195.pmd
191
The disorder was first recognized by Jarjavay in

1867, and the term Impingement Syndrome was
popularized by Neer in the 1970s5.
Subacromial Impingement Syndrome refers to
encroachment of the coraco-acromial arch on the
underlying mechanism of the rotator cuff 5. The
Impingement Syndrome can be diagnosed by certain
2/7/2013, 8:08 PM
impingement tests, that is, Neer test, Kennedy

Hawkins test and the Cross Over Impingement
(Horizontal adduction) test6.
Shoulder impingement disorders are currently
classified as primary or secondary7.
Primary shoulder impingement occurs when the
rotator cuff tendons, long head of the biceps tendon,
glenohumeral joint capsule, and/or subacromial bursa
become impinged between the humeral head and
anterior acromion8. Secondary shoulder impingement
is defined as a relative decrease in the subacromial space
due to glenohumeral joint instability or abnormal
scapulothoracic kinematics8.
Some evidence exists that; Scapular dysfunction is
associated with Shoulder Impingement9.
Scapular Dyskinesis is the alteration in the normal
static or dynamic position or motion of the scapula
during coupled scapula-humeral movements. Other
names given to this catch-all phrase include: Floating
Scapula and Lateral Scapular Slide10.
The scapular muscles facilitate upper extremity
movement via the scapular motions of protraction,
retraction, upward (lateral) rotation, and downward
(medial) rotation. The main muscles providing scapular
stabilization are the rhomboids, trapezius, and serratus
anterior17. Researches for Subacromial Impingement
Syndrome due to Scapular Dyskinesis show that
scapular stabilization exercises provide good results39.
One of the study shows that effect of changing posture
by taping will reduce the symptoms of Subacromial
Impingement Syndrome12. Taping is particularly useful
in addressing movement faults at the scapula-thoracic,
gleno-humeral and acromio-clavicular joints13. The
basic rationale for taping is to provide protection and
support for a joint while permitting optimal functional
movement. It is assumed that external support increases
joint stability by reinforcing the ligaments and restricting
motions14.
OBJECTIVES
1. To study the effectiveness of Scapular Stabilization
Exercises in improving Shoulder pain and
disability index in patients with Subacromial
Impingement Syndrome due to Scapular
Dyskinesis.
2. To study the effectiveness of Taping in improving
Shoulder pain & disability index in patients with
Subacromial Impingement Syndrome due to
Scapular Dyskinesis.
192
3. To compare the effectiveness of Scapular

Stabilization Exercises and Taping in improving
Shoulder pain & disability index in patients with
Subacromial Impingement Syndrome due to
Scapular Dyskinesis.
HYPOTHESIS
Null hypothesis (H0) There is no significant
difference between the effectiveness of Scapular
Shoulder pain and disability index in patients with
Subacromial Impingement Syndrome due to Scapular
Dyskinesis.
Alternative hypothesis (H1) There is a significant
difference between the effectiveness of Scapular
Shoulder pain and disability index in patients with
Subacromial Impingement Syndrome due to Scapular
Dyskinesis.
Study Design Experimental design
Sampling Technique Purposive sampling
technique
Samples 60 patients were taken for the study that
were diagonesed as having subarcromail impingement
syndrome and were randomly devided into two groups
of 30 each
Age Group 35 to 60 years.
Inclusion Criteria
Pain produced or increased during flexion and /

or abduction of the symptomatic shoulder.
And at least 4 of the following :
Positive Neer Impingement Sign.
Positive Hawkins Sign.
Pain produced during Supraspinatous Empty-Can

test.
Painful Arc of movement between 60 and 120

degrees.
Pain with palpation on greater tuberosity of the

humerus
Exclusion Criteria
Patient suffering with any shoulder fracture.
Patient suffering with Frozen Shoulder or Adhesive

Capsulitis.
2/7/2013, 8:08 PM
Patient suffering with any neurological condition.
3. Shoulder Pain And Disability Index.
Pregnancy.
Assessment of Pain and Disability Evaluation.
Known allergies to taping.
Presence of a Positive Sulcus Sign

METHOLOGY
A total of 60 patients were taken. The purpose of the

study was explained to all the subjects and informed
consent was taken from each subject. All subjects were
randomly assigned to either Scapular Stabilization
Exercises group (Group A) and Taping group
(Group B).
PROCEDURES
The patients were informed about the whole
procedure, the treatment merits and demerits and a
return consent were obtained from them for voluntary
participation in the study. They were randomly divided
into Group A and Group B of 30 subjects each. The base
line data of SPADI was obtained to check for the pain
functional outcome. SPADI was later taken at the end
of the treatment after 6 weeks on follow up.
Techniques of application
Group A Scapular Stabilization Exercises along.
The Scapular Stabilization Exercises are given for
the muscles that include Upper Trapezius, Middle
Trapezius, Lower Trapezius, Rhomboids, Serratus
Anterior.
Duration of Exercises : the scapular stabilization
exercises are given for six weeks.
SPADI SCORE MEASUREMENT

Pain and disability is evaluated by using SPADI. It
consists of 2 self report sub scales of pain and disability.
The items of both scales are VAS (Visual Analogue Scale)
and the 5 items pain subscales asks people about their
pain during ADLs (Activities of Daily Livings) and each
item is anchored by the descriptions no pain (left
anchor) and worst pain imaginable (right anchor).
The 8 disability items ask people about their difficulty
in performing ADL. Higher scores on the sub scale
indicate greater pain and greater disability. To obtain
the total score of SPADI both the pain and disability
subscales are averaged.
Study Duration: 6 weeks.
Procedures of Scapular Stabilization Exercises
For Upper Trapezius
It is done by Prone Row Exercise, where the patient
lies prone over the edge of the bed with the affected
limb out of the bed, and performs rowing movement.
For Lower Trapezius
It is done by, patient lying prone at the edge of the
bed, with the affected limb out of the bed and then
performs overhead arm raise in line with lower
trapezius
For Middle Trapezius and Rhomboids
Group B Taping
It is done by, patient lying prone at the edge of the

bed, with the affected limb out of the bed and then
performs horizontal abduction neutrally.
Taping is given for the muscles that include Upper

Trapezius, Middle Trapezius, Rhomboids, Serratus
Anterior
One of the functional exercise for Serratus Anterior

: The patient performs stepping alternating punch
exercise, with a resisted Thera tube.
Duration of Taping : Taping is given for two times

a week for six weeks.
Procedure of Taping target muscles
Ultrasound was given to both the groups once daily

5 times a week for six weeks. Pulsed mode was given at
a frequency of 1Mhz for 10 minutes.
From anterior aspect of upper trapezius just above

the clavicle over the muscle belly to approximately the
level of rib seven in a vertical line. Once partially
attached, a firm downward pull is applied and the tail
of the tape attached.
Tools used for the study

1. Ultrasound Therapy Unit
2. Adhesive Tapes
193
Taping for Upper Trapezius
Taping for Middle Trapezius and Rhomboids

From the anterior aspect of the shoulder, 2 cm medial
2/7/2013, 8:08 PM
to the joint line, around deltoid muscle just below

acromial level to T6 area without crossing midline. Tape
pull is into retraction.
Taping for Serratus Anterior
From 2 cm medial to the scapula border, following
the line of the ribs down to the mid-axillary line. Four
one-third overlapping strips are applied with the origin
and insertion pulled together and bunching the skin.
RESULTS
Table1: Average improvement in pain, disability and
total SPADI score in group A
SPADI
Average
improvement
Z-value
p-value
54
4.813
0.000
60
4.813
0.000
p<0.05 significant
56.93
4.800
0.000
p<0.05 significant
Pain
Disability
Total
Result
p<0.05 significant
Table2:- Average improvement in pain, disability and

total SPADI score in group B
SPADI
Average
improvement
Z-value
p-value
Pain
Result
40
4.832
0.000
P<0.05 significant
Disability
53.75
4.808
0.000
P<0.05 significant
Total
48.46
4.807
0.000
P<0.05 significant
Table 3:- Comparison of Pain, Disability and Total

SPADI before and after the treatment within Group-A
and Group-B using Mann-Whitney U test:SPADI
Average
Averag
improvement(A) improvement(B)
U-value
p-value
Result
Pain
54
40
263.50
0.005
P<0.05
significant
Disability
60
53.75
254.00
0.003
P<0.05
significant
56.93
48.46
239.00
0.002
P<0.05
significant
Total
DISCUSSION
Subacromial impingement syndrome is caused by
narrowing of the subacromial space with secondary
impingement of the bursal surface of the rotator cuff on
the undersurface of the acromion16. Some evidence
exists that, Scapular dysfunction is associated with
Shoulder Impingement9.
Clinical authorities have suggested that poor upper
body posture and muscle imbalance may cause or
perpetuate Subacromial impingement syndrome. The
aim of many conservative rehabilitation programs is to
correct posture and muscle imbalance using muscle
strengthening, muscle stretching, and joint mobilization
techniques. The evidence to support the efficacy of these
clinical practices is limited12.
194
Therapeutic exercises have previously been

determined to have long-term benefits for patients with
shoulder impingement syndrome8. The therapeutic
exercise stretches the anterior and posterior shoulder
girdle, relaxes the muscle, helps in motor learning to
normalize dysfunctional patterns of motion, and
strengthening the rotator cuff and scapular muscles,
which leads to improvements in pain, levels of disability
and functional loss, strength, shoulder range of motion,
pain with subacromial compression4.
A potential mechanism by which proprioceptive
shoulder taping may be effective is via augmented
cutaneous input. Tape is applied in such a way that
there is little or no tension while the body part is held or
moved in the desired position or plane. It will therefore
develop more tension when movement occurs outside
of these parameters. This tension will be sensed
consciously thus giving a stimulus to the patient to
correct the movement pattern. Over time and with
enough repetition and feedback, these patterns can
become learned components of the motor engrams for
given movements. It also causes increase in length and
decrease in tension thereby producing greater force
development in the inner range through optimised actinmyosin overlap during the cross-bridge cycle13. One of
the study demonstrated that taping was effective in
decreasing Upper Trapezius and increasing Lower
Trapezius activity in individuals with shoulder
impingement during overhead reaching tasks, thus
improving scapular dyskinesis15.
Here, both the groups had received Ultrasound
therapy as a modality in the treatment, as it is effective
in healing process, helps in decreasing inflammation
and swelling.
In present study, the results shows that Scapular
Stabilization Exercises is more effective than Taping in
patients with Subacromial Impingement Syndrome due
to Scapula Dyskinesis.
LIMITATIONS
1. In present study only SPADI is taken in outcome
measures.
2.
In this study there is no control group is present.
3. Its a short duration study as study duration is 6

weeks.
CONCLUSION
Scapular Stabilization Exercises and Taping
2/7/2013, 8:08 PM
produced significant improvement in Shoulder Pain

and Disability (SPADI Sub scores and Total scores)
values in patients with Subacromial Impingement
Syndrome due to Scapula Dyskinesis, when applied
individually. However Scapular Stabilization Exercises
showed a significant improvement Shoulder Pain and
Disability Index (SPADI sub scores and total scores),
when compared to Taping in individuals with
Subacromial Impingement Syndrome.
9.
10.
11.
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Herberts P, Kadefors R, Andersson G, Petersen I.
Shoulder pain in industry : an epidemiological
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Ashim Bakshi. A combination approach using
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Lori A Michener, Matthew K. Walsworth, Evin
Burnet. Effectiveness of Rehabilitation for patients
with Subacromial Impingement Syndrome : A
systemic review. Journal of Hand Therapy. 17:152164.2004.
David Morrison, Anthony.D.Frogameni and Paul
Woodworth. Non-Operative Treatment Of
Subacromial Impingement Syndrome. Journal of
Bone Joint Surgery Am. 79:732-737.1997.
Palmer LM and Epler ME : Fundamentals of
Musculoskeletal Assessment techniques 2nd ed.
Lippincott, Williams and Wilkins. 106-124.1998.
Fu FH, Harner CD, Klein AH. Shoulder
Impingement : a critical review. Clin Orthop.
269:162-173.1991.
Neer CS. Anterior acromioplasty for the chronic
impingement syndrome in the shoulder: A
preliminary report. J Bone Joint Surg Am. 54:41
50.1972.
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Philip W McClure, Jason Bialker, Nancy Neff,

Gerald Williams, Andrew Karduna. Shoulder
Function and 3-dimensional kinematics in people
with Shoulder Impingement Syndrome before and
after a 6-week Exercise Program. Physical Therapy.
84(9):832-848.2004.
W. Ben Kibler, John McMullen. Scapular
Dyskinesis And its Relation to Shoulder Pain.
Journal Of American Academy Of Orthopaedic
Surgery. 11:142-151.2003.
Farhad O Moola. Orthopaedic Surgery
Department. Scapular Stabilizing Muscles :
Rehabilitation Protocol. New West Orthopedic and
Sports Medicine Center. University Of British
Columbia.
Jeremy S. Lewis, Christine Wright, Ann Green.
Subacromial Impingement Syndrome : The effect
of changing posture on shoulder range of
movement. Journal Of Orthopaedic and Sports
Physical Therapy. 35:72-87.2005
Dylan Morrissey. Proprioceptive shoulder taping.
Journal of Bodywork and Movement Therapies.
4(3),189-194.2000.
A.M.Cools, E.E. Witvrouw, L.A. Danneels,
D.C.Cambier. Does Taping influence
electromyographic muscle activity in the Scapular
rotatorsin healthy shoulders?. Manual Therapy.
7(3)154-162.2002.
Selkowitz DM, Chaney C, Stuckey SJ, et al. The
effects of scapular taping on the surface of
electromyographic signal amplitude of shoulder
girdle muscles during upper extremity elevation
in individuals with suspected shoulder
impingement syndrome. J Orthop Sports Phys
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Benjamin Blair, Andrew S. Rokito, Frances Cuomo,
Kenneth Jarolem and Joseph D. Zuckerman.
Efficacy of Injections of Corticosteroids for
Subacromial Impingement. J Bone Joint Surg Am.
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2/7/2013, 8:08 PM
Effects of Osteopathic Manipulative Treatment in Patients

with Chronic Obstructive Pulmonary Disease
Praniti P. Bhilpawar1, Rachna Arora2
M. P. Th. from T.N. Medical College and B.Y.L. Nair Hospital, Mumbai, 2Asst. Professor in T.N. Medical College and
B.Y.L. Nair Hospital, Mumbai
ABSTRACT
Background: The study was carried out to assess the effects of osteopathic manipulative treatment in
patients with chronic obstructive pulmonary disease.
Subjects: 30 patients with chronic obstructive pulmonary disease were selected for the study.
Method: Patients were selected from the respiratory OPD at a tertiary care centre using convenience
sampling technique. The patients were recruited after signing the ethics approved consent forms.
Outcome measures: chest expansion, peak expiratory flow rate and respiratory rate were assessed and
documented prior to and following the intervention. The subjects were given seven osteopathic
manipulative techniques. The entire duration for osteopathic manipulative treatment session was
approximately 20 minutes for each subject.
Results: Significant improvements were found in chest expansion at axillary and xiphisternal level,
peak expiratory flow rate and significant decrease in respiratory rate after single session of osteopathic
manipulative treatment.
Conclusion: Osteopathic manipulative treatment increases chest expansion at both axillary and
xiphisternal level and peak expiratory flow rate and leads to reduction in respiratory rate in patients
with COPD.
Keywords: Chronic Obstructive Pulmonary Disease (COPD), Osteopathic Manipulative Treatment, PEFR
INTRODUCTION
Chronic obstructive pulmonary disease (COPD)
refers to a group of disorders characterized by chronic
airflow obstruction/limitation. It includes two distinct
patho-physiological processeschronic bronchitis and
emphysema1, 2, 3, 4. It is associated with an abnormal
inflammatory response of the lungs to noxious particles
or gases, especially tobacco smoke and air pollution both indoor and outdoor.
or the work of breathing, in COPD is markedly

increased.
The term COPD was accepted in the British Thoracic

Society (BTS) guidelines on management of this disease5.
Chronic obstructive pulmonary disease (COPD) is
currently the fourth leading cause of death worldwide.
The male to female ratio varied from 1.32:1 to 2.6:1 with
median ratio of 1.6:11.
Conventional management of COPD includes

smoking cessation, pharmacological therapy, long-term
oxygen therapy, and pulmonary rehabilitation. COPD
have been shown to decrease compliance of the chest
wall, force-generating capacity of the diaphragm,
residual volume (RV) increases, and forced vital
capacity (FVC). Therefore, the therapeutic intervention
commonly done for chest wall and related structures
are respiratory muscle stretching exercises. They have
been reported to improve chest wall mobility, improve
vital capacity, and decrease dyspnea6. However, COPD
is an important disease whose incidence is rising
worldwide and that there is a need to develop new
treatments to prevent the progression of the disease7.
The disadvantages of bio mechanical alterations of

hyperinflation are compounded by the increased
demand for ventilation in COPD. More work is required
of a less effective system. The energy cost of ventilation,
The osteopathic medical profession has developed

a variety of techniques for the specific purpose of
improving chest expansion, quality of life and
pulmonary function. These techniques are well
37. praniti--196-201.pmd
196
2/7/2013, 8:08 PM
described and target various aspects of the

musculoskeletal, neuronal and lymphatic components
of the pulmonary system. The efficacy of osteopathic
manipulative treatment (OMT) is thought to be
enhanced by using techniques in combination, where
one technique works synergistically with another to
achieve an overall therapeutic effect8.
Masarsky CS, Weber M, Virginia Chiropractic
Association Research Committee, Vienna 22180,
studied Chiropractic management of chronic
obstructive pulmonary disease. They noted that a
patient with a history of chronic obstructive pulmonary
disease going back more than 20 years was treated with
a combination of chiropractic manipulation,
nutritional advice, therapeutic exercises, and intersegmental traction. Improvements were noted in forced
vital capacity, forced expiratory volume in one second,
coughing, fatigue, and ease of breathing9.
The study was thus designed in order to determine
if one session of OMT treatment could produce
immediate changes on chest expansion, respiratory rate
and PEFR in patients with COPD.
MATERIAL AND METHOD
Study design: An Experimental hospital based study
Place of study: Physiotherapy OPD of Topiwala
National Medical College & Nair Hospital Mumbai.
Type of Sampling: convenience non-random sampling
Operational definitions were provided.
Inclusion criteria
Patients with Chronic Obstructive Pulmonary
Disease with FEV1/FVC < 70%.
Measurement tool
Measuring tape.
Peak flow meter.
Watch with seconds hand.
Outcome measures
Chest expansion at axillary, xiphisternal level
(using measuring tape).
Peak expiratory flow rate (using peak flow meter).
Respiratory rate (for 1 minute)
Thirty patients with COPD were selected and
included in the study after signing ethics approved
consent forms. The patients were evaluated prior to
treatment and data was documented. The subjects were
given seven osteopathic manipulative techniques. The
duration of entire osteopathic manipulative treatment
session was approximately 20 minutes for each subject.
The outcome measures were documented post
treatment. The patient was instructed to inform the
therapist immediately any discomfort during treatment
session. All the subjects in the study were able to tolerate
the manipulative techniques with no sign of any
discomfort.
Techniques of Osteopathic manipulation
1. Soft tissue kneading (paraspinal muscles in lower
cervical and thoracic region bilaterally)
2. Rib raising
3. Redoming the abdominal diaphragm (indirect
myofascial release)
4. Suboccipital decompression
5. Thoracic inlet myofascial release
6. Pectoral traction
7. Thoracic lymphatic pump with activation
DATA ANALYSIS
Exclusion criteria
Data analysis was performed by using Paired t-test

and Wilcoxon Sign rank test.
Unstable medical condition.
Acute bronchitis.
Pneumonia.
Acute Exacerbation within 1 month of data

collection.
Sex
Female
7%
Chest wall deformity.
Male
28
93%
Total
30
100%
197
Table No 1: Distribution of study group as per sex

shows the distribution of sex in the study group. Study
group consists of 7% female and 93% male.
Count
2/7/2013, 8:08 PM
Percent
Table No 2: Comparison of Chest expansion (axillary) before and after treatment: shows that there is statistically
significant improvement in chest expansion (axillary level) after single session of osteopathic manipulative
treatment, p value=1.17E-05 (<0.05)
Chest Expansion (Axillary)
Mean
SD
Median
Pre treatment
30
1.13
0.46
Post treatment
30
1.43
0.50
1.4
IQR
Wilcoxon Signed
Rank Test
p value
0.6
-4.383
1.17E05
0.65
Difference is significant
Table No 3: Comparison of Chest expansion (Xiphisternal) before and after treatment: shows that there is
statistically significant improvement in chest expansion (xiphisternal level) after single session of osteopathic
manipulative treatment, p value= 3.06E-05 (<0.05)
Chest Expansion
(Xiphisternal)
Mean
SD
Median
IQR
Wilcoxon Signed
Rank Test
p value
Pre treatment
30
1.19
0.45
1.2
Post treatment
30
1.48
0.51
1.6
0.6
-4.169
3.06E-05
0.8
Table No 4: Comparison of PEFR l/min before and after treatment: shows there is statistically significant improvement
in peak expiratory flow rate after single session of osteopathic manipulative treatment, p value= 2.84E-04 (<0.05)
PEFR l/min
Mean
SD
Median
Pre treatment
30
159.74
54.65
150
Post treatment
30
171.47
60.45
160
IQR
Wilcoxon Signed
Rank Test
p value
64
-3.629
2.84E-04
82.5
Table No 5: Comparison of RR/min before and after treatment: shows that there is statistically significant decrease
in respiratory rate after single session of osteopathic manipulative treatment, p value= 4.50E-03 (<0.05)
Respiratory Rate (per min)
Mean
SD
Median
IQR
Paired T test
p value
Pre treatment
30
25.37
7.50
24
3.08
4.50E-03
Post treatment
30
23.23
5.56
23
DISCUSSION
The results of the present study indicate that there
is statistically significant increase in chest expansion
at axillary and xiphisternal level. Also an increase is
seen in peak expiratory flow rate and decrease in
respiratory rate after osteopathic manipulative
treatment, thereby supporting the experimental
hypothesis. In this study, the mean age of the patients
ranged from 37-81 years of age. The distribution of
patients, according to sex is 93% male and 7% female.
The ventilation depends on the rib motion,
diaphragm function, muscles of respiration and
mechanical properties of the airways10. In COPD there
is hyperinflation of lungs and therefore chest wall is
fixed in inspiration (barrel shaped chest) 11. This results
in shortening of soft tissue of upper chest. COPD
patients generally have a kyphotic posture with
rounded shoulders (pectoral tightness) and elevated
shoulder girdle (trapezius tightness) to effectively use
accessory muscle of respiration. When the muscles are
in a shortened position, the fascia overlying the muscle
also gets shortened. Due to the barrel shaped chest, the
ribs are horizontally oriented. This further reduces the
198
excursion of ribs during inspiration. There by reducing

chest expansion.
According to handbook of osteopathic technique by
Laurie Hartman, kneading of paraspinal muscles relax
them by reducing fluid congestion and tonic irritability.
The underlying mechanism is thought to be due to reflex
balancing or from fluid interchange and lymphatic
drainage within the tissues12. Luce Helen and Robinson
Mark stated that soft tissue kneading decreases muscle
spasm, stretches and improves elasticity of soft tissues,
improves circulation, improves venous and lymphatic
drainage and promotes relaxation13.
Principles and practices of therapeutic massage by
Sinha states that kneading produces a local increase in
the flow of blood due to pumping action, liberation of
H substance and elicitation of axon reflex. This also
decreases the stagnation of fluid and oedema as well
as improves the nutrition of the area. It stretches the
tight fascia and helps in restoration of mobility of skin
and subcutaneous fascia. The intermittent pressure may
also stimulate tension dependent mechanoreceptor, i.e.
Golgi tendon organ, etc. and decreases the excitability
of motoneuronal pool in neurologically healthy
2/7/2013, 8:08 PM
individuals. This helps in decreasing the tension of

muscles.14
and Kuchera have this to say regarding lymphatic

drainage and the lungs.
Pectoral traction technique, a Myofascial release

technique, also helps in increasing chest expansion by
lengthening the tight structures12.The combination of
traction and respiratory motion releases the upper
anterior thoracic muscle tension15.
Myofascial release techniques such as diaphragm

release and thoracic inlet release also contributes to
increase in chest expansion and improves motion of
diaphragm. It releases connective tissue tension within
structures of thorax. It helps in removing restriction to
lymphatic flow. It releases tissue restriction, improves
lymphatic drainage and improves mechanics of
respiration.11, 14
In COPD there is increase in sympathetic nervous

system activity leads to release of catecholamines into
the blood stream and there is narrowing of airways
which leads to reduction in peak expiratory flow rate.7
Paraspinal muscle kneading and rib raising probably
stimulate Chapmans reflexes. Suboccipital
decompression probably improves parasympathetic
function by releasesing restricted tissues around vagus
nerves. 13, 16 This may lead to normalization of
sympathetic tone and which in turn may increase PEFR
and reduce RR.
The American Academy of Osteopathy states that
the rib raising technique improves movement of ribs
and thoracic cage by mechanical stimulation of
sympathetic chain ganglia and related structures. This
results in improved sympathetic tone in lung. This is
supported by the study done by Aaron T. Henderson
which shows that sympathetic nervous system activity
may decrease immediately after rib raising17.
Effective lymphatic drainage of the lungs is normally
achieved by contraction of the diaphragm and thoracic
cage movement during respiration. However, in patients
with COPD, both of these mechanisms may be
compromised, leading to impaired lymphatic drainage.
There are several OMT techniques which address the
problem of lymphatics such as rib raising, diaphragm
release, and lymphatic pumps18.
Numerous techniques are given in osteopathic texts
for controlling circulation and drainage. Chapmans
reflexes are one example that has already been
mentioned. Kuchera also gives ideas for detailed
treatment of lymphatic system dysfunction. The three
basic goals are:
a. To promote the free flow of lymph through its
lymphatic vessels and fascial pathways.
b. To improve function of the abdominal diaphragm,
the extrinsic pump for the lymphatic system.
c.
To reduce sympathetic outflow19.
Treatment techniques include manipulation of the

thoracic inlet, stretching the abdominal diaphragm,
fascial releases and thoracic lymphatic pump. Kuchera
199
According to handbook of osteopathic technique by

Laurie Hartman, myofascial release techniques
attempts to normalize these areas by allowing
improved circulation and re-setting of the neural
control of tendons and muscles. Its main action is on
connective tissues, fascia and muscle attachments10.
The reduction in RR could be attributed to
normalization of sympathetic tone through Chapmans
reflexes. The increase in chest expansion probably
suggests that the patients tidal breathing has increased
and therefore reflected as reduced RR.
Donald R. Noll studied the Efficacy of Osteopathic
Manipulation in Chronic Obstructive Pulmonary
Disease. He stated that OMT sessions are designed to
improve chest wall compliance and diaphragmatic
function which produce an immediate positive change
in pulmonary function parameters and chest wall
mobility20.
As this study supported our experimental
hypothesis OMT can be used as an adjunct treatment
in COPD along with pulmonary rehabilitation.
Conclusion: Osteopathic manipulative treatment
increases chest expansion at both axillary and
xiphisternal level in patients with COPD. There is
increase in peak expiratory flow rate following
osteopathic manipulative treatment in patients with
COPD. Osteopathic manipulative treatment leads to
reduction in respiratory rate in patients with COPD.
Small sample size
Patients are not divided according to GOLD

classification
Occupational background and socioeconomic

status were not considered
2/7/2013, 8:08 PM
SUMMARY
In order to investigate the effects of osteopathic
manipulative treatment in patients with chronic
obstructive pulmonary disease, 30 patients were
enrolled in this study. The patients were given single
session of Osteopathic manipulation techniques such
as soft tissue kneading, rib raising, Redoming the
abdominal diaphragm, suboccipital decompression,
thoracic inlet myofascial release, pectoral traction and
thoracic lymphatic pump with activation. The outcome
measures of chest expansion at axillary and
xiphisternal levels, peak expiratory flow rate and
respiratory rate were measured pre and post treatment.
The mean pre treatment and post treatment score of
chest expansion at axillary level were analysed using
the Wilcoxon signed ranks test and the improvement in
chest expansion was found to be significant, p
value=1.17E-05 (< 0.05).
chest expansion at xiphisternal level were analysed
using the Wilcoxon signed ranks test and the
improvement in chest expansion was found to be
significant, p value= 3.06E-05 (< 0.05).
peak expiratory flow rate were analysed using the
Wilcoxon signed ranks test and increase in PEFR was
found to be significant, p value= 2.84E-04 (< 0.05).
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

respiratory rate were analysed using paired t-test and
reduction in RR was found to be significant, p value=
4.50E-03 (< 0.05).
13.
Therefore these results support the hypothesis of

the study that Osteopathic manipulative treatment
shows improvement in Chest Expansion, Peak
Expiratory Flow Rate and reduction in Respiratory Rate.
14.
12.
Conflict of Interest Statement

I, Dr. Praniti P. Bhilpawar (PT) the primary
investigator hereby declare that there are no conflicts of
interest and the present study is an original work.
15.
16.
REFERENCES
1.
Murthy KJR, Sastry JG. Economic burden of

chronic obstructive pulmonary disease. NCMH
Background Papers Burden of Disease in India;
2005.
200
17.
Seaton Anthony, Seaton Douglas, Leith Gordon.

Crofton And Douglass Respiratory Disease 1. 5th
ed. London: Blackwell Science; 2000. p. 616-679.
Fishman Alfred, Elias Jack. Fishmans Pulmonary
Disease And Disorders. 3rd ed. US: McGraw-Hill;
1998. p. 645-681.
Boon Nicholas A, College Nicki R, Walker Brian
R, Hunter John. Davidsons Principles And
Practice Of Medicine. 20 th ed. Philadelphia:
Churchill Livingstone; 2006. p. 678-684.
British Thoracic Society. Guidelines For The
Management Of Chronic Obstructive Pulmonary
Disease. Thorax 1997; 52.
Celli BR, MacNee W. Standards for the diagnosis
and treatment of patients with COPD: a summary
of the ATS/ERS position paper. Eur Respir J 2004;
23: 932946.
Barnes Peter J. Chronic Obstructive Pulmonary
Disease. NEJM 2007 Jul 27;343(4):269-280.
Noll Donald R, Brian F Degenhardt, Jane C
Johnson, Selina A. Burt. Immediate Effects of
Osteopathic Manipulative Treatment in Elderly
Disease. JAOA 2008 May;108(5):259.
Masarsky CS, Weber M. Chiropractic management
of chronic obstructive pulmonary disease. J
Manipulative Physiol Ther. 1988 Dec;11(6):505-10.
Halma Kelly D. The Osteopathic Approach to the
Chest Pain Patient.
Rosenow Edward C. Barrel chest. MFMER. 2010
Aug 7.
Hartman Laurie. Handbook of Osteopathic
Technique. 3rd ed. UK: Chapman & Hall; 1997.
Luce Helen, Robinson Mark. Integrating
Osteopathic Manipulative Treatment into Clinical
Care. University of Wisconsin Department of
Family Medicine STFM Annual Meeting Denver,
CO;April 29, 2009.
Sinha Akhoury. Principles and practices of
therapeutic massage. 1st ed. New Delhi: Jaypee;
2001. p. 57.
Hruby Raymond J, Hoffman Keasha N. Avian
influenza: an osteopathic component to treatment.
Osteopath Med Prim Care 2007;1.
American Academy of Osteopathy. An Overview
of Osteopathic Manipulation Techniques.3500
DePauw Boulevard, Suite 1080 Indianapolis,
Indiana 46268-1136(317) 879-1881.
Henderson Aaron T et al. Effects of Rib Raising on
the Autonomic Nervous System: A Pilot Study
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Using Noninvasive Biomarkers. JAOA 2010

Jun;110(6):324-330.
18. Sutphin Dean, Chair Kerry Redican, David
Harden, Billie Lepczyk. The Use of Osteopathic
Manipulation in a Clinic and Home Setting to
Address Pulmonary Distress as Related to Asthma
in Southwest Virginia: 2009 Jan.
19. Mein Eric A. Physiological Regulation Through
201
Manual Therapy. Philadelphia: Physical

Medicine and Rehabilitation; 2000.
20. Noll Donald R et al. Efficacy of osteopathic
manipulation as an adjunctive treatment for
hospitalized patients with pneumonia: a
randomized controlled trial. Osteopath Med Prim
Care. 2010;4:2.
2/7/2013, 8:08 PM
Comparison of Stretch Glides on External Rotation Range

of Motion in patients with Primary Adhesive Capsulitis
Paras Joshi, Bhavesh Jagad
Lecturer, Shree K K Sheth Physiotherapy College, Rajkot
ABSTRACT
Back ground: Adhesive capsulitis, most commonly referred to as frozen shoulder (FS), is an idiopathic
disease with 2 principal characteristics: pain and contracture, affecting the external rotation most. In
contrast to traditional mobilization technique andrea et al found posterior glide more effective in
improving external rotation ROM and pain.
Objective: To find out the effective stretch glide for external rotation ROM and pain in patients with
primary adhesive capsulitis.
Methods: 30 subjects were divided into two groups called Anterior stretch glide (ASG) and Posterior
stretch glide (PSG). Each group received ultrasound, same exercise protocol along with their designated
glides for 2 weeks. Outcome measures were External Rotation ROM and VAS. Data was analyzed by
using the SPSS software. Wilcoxon signed rank and rank sum tests were used to measure the differences
in VAS and Paired and unpaired t tests were used for ROM evaluation.
Findings: There was a significant difference in External Rotation ROM and VAS in both the groups
after the intervention, even there is a significant difference between the groups.
Conclusion: anterior stretch glide is very effective in reducing pain or unpleasantness intensity and
increasing external rotation range of motion at shoulder in patients with primary adhesive capsulitis.
Keywords: Primary Adhesive Capsulitis, Stretch Glides, External Rotation
INTRODUCTION
Frozen shoulder, or idiopathic adhesive capsulitis
is a condition of uncertain etiology characterized by
substantial restriction of both active and passive
shoulder motion that occurs in the absence of a known
intrinsic shoulder disorder1
Although adhesive capsulitis is generally
considered to be a self-limiting condition that can be
treated with physical therapy, the best treatment has
been the subject of extensive investigation2
The types of treatment have included benign
neglect, chiropractic manipulation, oral corticosteroids,
injection of corticosteroids, physical therapy exercises
and modalities, manipulation under anesthesia,
mobilization and arthroscopic and open releases of the
contracture2-6
Adhesive capsulitis is caused by inflammation of
the joint capsule and synovium that eventually results
in the formation of capsular contractures. The capsule
202
does not become adhered to the humerus, as the term

adhesive implied, but the contracted capsule holds the
humeral head tightly against the glenoid fossa.
Clinically, there is global loss of both passive and active
ROM of the glenohumeral joint, with external rotation
usually being the most restricted physiologic
movement.2,7,8
In physiotherapy exercises, massage and modalities
have been shown effective to improve ROM at shoulder
joint, except rotational components. 9
Traditionally anterior glide of GH joint is used to
improve External Rotation ROM based on convex
concave concept.10 Where as Roubal11 and Andrea J12 et
al have found posterior glide more effective based on
capsular constrain mechanism.13
Purpose of this study was to find out the direction
of movement for GH joint glide that would result in
significant improvement in shoulder External rotation
ROM in individual with primary adhesive capsulitis.
2/7/2013, 8:08 PM
OBJECTIVES
1. To check the effectiveness of anterior stretch glide
on External Rotation ROM and pain or
unpleasantness in patients with primary adhesive
capsulitis.
2. To check the effectiveness of posterior stretch glide
on External Rotation ROM and pain or
capsulitis.
3. To compare the effectiveness of anterior and
posterior stretch glide on External Rotation ROM
and pain or unpleasantness in patients with
primary adhesive capsulitis.
HYPOTHESIS
Null Hypothesis: There will be no significant
difference between Anterior Stretch Glide and Posterior
Stretch glide on External Rotation ROM and pain or
capsulitis.
Alternate Hypothesis: There will be significant
difference between Anterior Stretch Glide and Posterior
Stretch glide on External Rotation ROM and pain or
capsulitis.
Total 55 Subjects with primary adhesive capsulitis,
fulfilling the criteria of the study were selected between
march 2011 to February 2012 from Shree K K Sheth
Physiotherapy Center, Rajkot. 30 Subjects have
completed the study and taken for final analysis.
Inclusion criteria
1. Idiopathic or Primary Adhesive Capsulitis
(insidious onset, no history of trauma)
2. Age between 30 to 55 years
3. Unilateral condition
Exclusion Criteria
4. History of steroid injection

5. Muscular tightness affecting the study (i.e
subscapularis)
Consent forms were signed by the Subjects before
participation in the study.
Subjects were randomly (by using the random
number, i.e. 1, 2) assigned to one of the two treatment
groups:
Group 1: Anterior Stretch Glide (ASG), (6 male, 9
female =15)
Group 2: Posterior Stretch Glide (PSG), (5 male, 10
female =15)
3 subjects have reported having diabetes and taking
medications for the same (2 from ASG and 1 from PSG)
Subjects were advised not to do exercises at home
nor were any written guidelines given.
MEASURES
Subjects were exclusively evaluated for only External
Rotation ROM and unpleasantness on VAS.
External Rotation ROM
External Rotation ROM was assessed at the baseline
and at the end of the 6th treatment session by Hjelms
protocol.15 All Measurements were taken in supine
position.
Baseline: Humerus was placed in full available
Abduction passively, and active External Rotation ROM
was measured. Available abduction at baseline was
recorded for each subject.
At the end of 6th session: Passively the humerus is
abducted to baseline abduction and active External
Rotation ROM was measured again.
All measurements were taken by therapists having
more than 5 years of clinical experience by standard
goniometer. Therapists were kept blind about the groups
and to avoid subjective bias Subjects were instructed to
look opposite side during measurements.
1. Any previous history of surgery to affected side

2. Cervical radiculopathy affecting the study
3. History of neurological conditions affecting the
study (i.e stroke, Parkinsons)
203
VAS
Subjects were asked to mark VAS before the 1st
treatment and after the last treatment; we asked the
subjects to mark on 10cms vertical line the relative
unpleasantness.16
2/7/2013, 8:08 PM
Targeted capsule (anterior or posterior) was

preheated before glide by 1 MHz 19Ultrasound, in order
get the maximum effect of stretch glide.17 Ultrasound
were applied at 1.5 w/cm2 in continuous mode for 10
minutes (Electroson 608, 35mm diameter of head, 12
acoustic watts max). Capsule region was effectively
covered and subjects were asked to report discomfort if
any. However no such reports were found during the
study.
In this study we used Kaltenborn grade III technique,
applying the force to stretch tissues crossing the joints.18
We used stretch glide like Andrea J and al; no oscillatory
motions were performed, only end range stretch
position was held for 1minute at least. During each
treatment session total 15 repetitions were given. Each
subject was treated for 6 sessions on alternate days, in
2 weeks.
Group 1: ASG group
Subjects were positioned in prone; with maintained
lateral humeral distraction (mid range position), while
anterior stretch glides was performed to end range, at
the end range of abduction and external rotation.
DATA ANALYSIS
For each subject, the number corresponding to the
subjects mark on the visual analogue scale was
recorded. Raw score means and standard deviations of
the visual analogue scale score and external rotation
range of motion were calculated. In order to determine
whether there was a significant difference within the
two groups between the pre-treatment visual analogue
scale scores and the post treatment visual analogue
scale scores, Wilcoxon Signed Rank Test was
performed. The difference between pretreatment visual
analogue scale scores and post treatment visual
analogue scale scores in ASG group was compared with
that of PSG group using Wilcoxon Rank Sum Test. This
analysis was done to determine whether the difference
in the scores between the two groups is significant or
not. The pretreatment external rotation range of motion
was compared with the post treatment external rotation
range of motion within two groups using two tailed
Students paired t-test. Between groups comparison of
difference in external rotation range of motion was done
by performing two tailed students unpaired t-test. The
paired and unpaired t-tests were performed using spss
statistics 14.0.
RESULTS
Group 2: PSG group

Subjects were positioned in supine; with maintained
lateral humeral distraction (mid range position), while
posterior stretch glide was performed to end range, at
the end range of abduction and external rotation.
Followed by the stretch glides subjects were
participated in traditional ROM exercises which
include rope and pulley, finger ladder, wand exercises,
pendular exercises 20 repetitions for each exercise.
Table 1. Gender distributions of 30 subjects who

participated in the study
Gender
ASG GROUP
PSG GROUP
Male
6 (40%)
5 (33%)
Female
9 (60%)
10 (67%)
15
15
43.09511.38
44.29510.6
Total
Mean age with SD
Table 2. MeanSD for External Rotation ROM and VAS.

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

Calculated
Observed
ASG Group (t14)
5.37
2.14
PSG Group (t14)
2.54
2.14
P<0.05
Significant
Between groups ASG & PSG
2.86
2.05
P<0.01
Significant
204
2/7/2013, 8:08 PM
P<0.005Highly significant
Table 4. T value and z value calculated by Wilcoxon
Signed Rank Test and Rank sum test respectively for
VAS
VA S
T value
Probability (P)
ASG Group(within group)
110
<0.01 S
PSG Group (within group)
60
<0.05 S
Between groups ASG & PSG 3.21 (z value)
<0.001 HS
Table 1 shows the gender distributions and mean

age with standard deviations respectively. ASG group
contained 6 (40%) male and 9 (60%) female with mean
age of 43.09511.38 years, where as PSG group
contained 5 (33%) male and 10 (67%) female with mean
age of 44.29510.6 years.
There was no significant age difference seen across
two groups.
Table 2 and Table 3
Shows pre treatment, post treatment and difference
means and standard deviations of visual analogue
scale score for pain or unpleasantness intensity and
the external rotation range of motion values of each
group. Scores reflect greater improvement for ASG
group than for PSG group on all variables.
The two tailed paired t-test has showed significant
difference between pre and post-treatment external
rotation range of motion in ASG and PSG group at 5%
significant limit. Comparison showed significant
difference between these groups. Calculated t values
for the difference of External rotation ROM within ASG
& PSG groups at 5% significance limit and t values for
comparison of difference between two groups and value
of probability of occurance by chance.
Table 4
Wilcoxon signed rank test was applied in ASG and
PSG group for within group comparison of visual
analogue scale score and the result showed significant
improvement in visual analogue scale scores in ASG
(T=110>105, P<0.01) and PSG (T=60, P<0.05)
Wilcoxon Rank Sum Test (Mann Whitney U Test)
was applied for comparison between ASG and PSG for
post treatment visual analogue scale scores. The result
reflects significant difference in the improvement
between ASG and PSG Groups
Above results suggests that anterior stretch glide is
more effective in improving shoulder external rotation
and pain or unpleasantness as compared to posterior
stretch glide.
205
Hence, the null hypothesis of no difference within

and between groups is rejected and alternative
hypothesis is accepted.
DISCUSSION
Study was done to investigate the effectiveness of
anterior versus posterior stretch glide on External
Rotation ROM and pain or unpleasantness in patients
with adhesive capsulitis. We found that anterior stretch
glide combined with ultrasound and exercises were
superior in treating External Rotation ROM deficits
commonly found in patients with adhesive capsulitis.
We have excluded the patients who have muscular
tightness affecting the study. i.e. subscapularis.
Glenohumeral external rotation ROM deficit was
attributed to muscle flexibil-ity deficit (eg, subscapularis
flexibility deficits) if the glenohumeral external rotation
ROM deficit became less as the shoulder was
abducted.12
These findings are against of Roubal11 et al and
Andrea12 et al, who found marked increase in External
Rotation ROM with posterior glide. Our findings
support the traditional convex concave rule.13, 18
Andrea et al have chosen flexion as additional
component to increase effectiveness for mobilization
using posterior stretch glide which could have affected
their outcome; where as we have not added the flexion
in posterior glide no matter whatever the progression
is. Present study includes only those patients who have
finished the protocol despite having vigorous stretch
protocol for 1 min at least without compromising the
intensity of stretching; where as Andrea et al have used
the vigorous protocol in a minimal number of patients
only.
Novotny et al7 studied the gleno-humeral joint in
vitro using techniques in which only the capsule and
articular surface contact controlled the motion of the
humerus. They found that at low mo-ments the humeral
head initially trans-lates across the glenoid surface in
the direction opposite to the motion, due to the joint
surface geometry, as consistent with the concave-convex
rule. Then, with increasing moment and angle of
rota-tion, the humeral head changes direc-tion as the
capsule tightens, pushing the humeral head back
along the glenoid surface. Thus, it is thought that the
tension in the capsular tissues rather than joint surface
geometry controls the translatory movements of the
humeral head. Asymmetrical capsular tight-ness has
the potential to impact humeral head motion, especially
2/7/2013, 8:08 PM
when tension in the capsule increases as the arm is

tak-en further into elevation, which supports the andrea
et al results however we dint get such results and not
able to clearly explain the why this mechanism has not
been taken place in our patients.
We found anterior stretch glide more effective based
on traditional covex concave rule and naturally
elongated anterior capsule provide more space for head
of humerus when subject actively externally rotate the
arm in contrast to capsular constrain mechanism.13
Moreover in adhesive capsulitis fibrous adhesion takes
place surrounding the joint capsule, we believe that
anterior stretch glide may be more effective in breaking
those adhesion and allow normal kinetics when patient
attempts active external rotation.7
Joint mobilization techniques are assumed to induce
various beneficial effects. The neurophysiologic effect
is based on the stimulation of peripheral
mechanoreceptors and the inhibition of nociceptors. In
addition obermann et al found high grade traditional
mobilization found effective to treat the patients with
primary adhesive capsulitis.20 Our results supports it
in terms of pain and ROM.
LIMITATIONS
Dominance of hand is of much importance in
adhesive capsulitis, we have not considered it in our
study.
Abduction and Internal Rotation could have
included in this study as outcome measures.
Functional outcome measure was not included in
this study.
Further recommendations
Multi angle glides should be checked in larger
population.
Effects of glides can be checked with thickness of
capsule and movement pattern in further studies.
CONCLUSION
The ASG group showed significant improvement
in the External Rotation ROM as well as VAS score
compare to PSG group. The results of this study indicate
that anterior stretch glide is very effective in reducing
pain or unpleasantness intensity and increasing
external rotation range of motion at shoulder in patients
with primary adhesive capsulitis.
206
ACKNOWLEDGEMENTS
We would like to thank management of Shree K K
Sheth trust and Dr. Sarala bhatt for their support and
guidance.
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Matsen, F. A., III; Lippitt, S. B.; Sidles, J. A.; and
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Novotny JE, Nicholoas CE. Normal kinematics of
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Wamer et al. Adhesive capsulitis of shoulder. J
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Jurgel J, Rannama L, et al. Shoulder functions in
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week rehabilitation. Medicina 2005;41:30-38
10. Curl LA, Warren RF. Glenohumeral joint stability.
Selective cutting studies on static capsular
restraings
11. Roubal PJ et al. Glenohumeral gliding
manipulation following interscalene brachial
plexus block in Subjects with adhesive capsulitis.
12. Andrea J, Joseph J et al. The effect of anterior versus
posterior glide joint mobilization on external
rotation range of motion in Subjects with adhesive
capsulitis. JOSPT 2007;37;3.
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13. Donatelli RA, Wooden MJ. Orthopaedics physical

thera. 2nd edi. :Churchill Liningstone; 1994
14. Harryman DT et al. translation of the humeral head
on the glenoid with passive glenohumeral motion.
J Bone joint Surg Am. 1990;72:1334-43
15. Hjelm, Draper C et al. anterior inferior capsular
length sufficiency in the painful shoulder. J ortho
Sport Phys Ther. 1996;23:216-22
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visual analogue scales as ratio scale measures for
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45-56
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17. Reed B, Ashikaga T. The effects of heating with

ultrasound on knee joint displacement. J Ortho
Sports ther. 1997;26:131-7
18. Kaltenborn FM. Manual Therapy of the Extremity
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19. Gann N. Ultrasound: current concepts. Clin
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Low-Grade Mobilization Techniques in the
Management of Adhesive Capsulitisof the
Shoulder: RandomizedControlled Trial. Phys
thera. 2006; 86:355-368.
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A Study of Electromyographic Activity of Masseter

Muscle After Gum Chewing in Young Adults
Preeti Baghel1, Nidhi Kalra2, Sumit Kalra2
BPT Student, Assistant Professor, Banarsidas Chandiwala Institute of Physiotherapy (Maa Anandmai marg,
Chandiwala estate, Kalkaji, New Delhi
ABSTRACT
Background: Habitual gum chewing is considered as one of the causes which can lead to the
development of Temporomandibular disorder (TMD). Previous studies have compared the effect of
chewing induced masticatory muscle pain in females and males using different methods but this study
compares the electromyographic behaviour of masseter muscle in females with males who do gum
chewing.
Aims and Objective: To compare the effect of gum chewing on masseter muscle in females with males
by analyzing its electromyographic behaviour.
Subjects: 60 young adults (30 females and 30 males) who do gum chewing took part in this study
which was allotted to two groups: Group A- Females and Group B- Males.
Research Design: Comparative study
Methodology: The device used in this study is a single channel EMG. The subjects were given chewing
gum and asked to chew gum at least one hour before coming for the study. All monitoring was performed
with the patients in a sitting position. Two self-adhesive surface electrodes were utilized and placed on
the midsubstance of muscle belly of right masseter muscle in line with muscle fibers. The EMG recording
of masseter muscle was done at most comfortable position of jaw i.e., at rest position and the EMG
activity was recorded after 30 seconds.
Data Analysis: Data are expressed as mean, standard deviation and 95% confidence interval. The
independent t- test or Levene's test for equality of variances was used to determine the normal distribution
of the variance (P < 0.05).
Results: The independent t-test indicates a significant increase in the motor activity of the masseter
muscle in females than in males as t-test reveal statistically reliable difference between the mean number
of POST TEST - A has (M = 2.171, s = 101.76) and that the POST TEST - B has (M = 1.62, s = 75.57), t(58)
= 2.367, P = .05.
Conclusion: Electromyographic behaviour of the masseter muscle in individuals who do gum chewing
is found to be significantly increased in females than in males. This can result in the development of the
signs and symptoms of the temporomandibular disorders. Therefore, it can be concluded from the
present study that one should avoid gum chewing especially females on the regular basis so as to
prevent their jaw from the risk of developing TMD at an early age.
Keywords: Electromyography, Mastication, Muscle fatigue, Chewing.
INTRODUCTION
Chewing is an oral function that is of vital
importance for the biological and social life of human
beings. As a pre-requisite for this function, a healthy
masticatory system characterized by the absence of pain
at rest and during functional movements of the
mandible is required.1, 2
The Masseter muscle is an integral part of the oral
facial complex and one of the major muscles of
mastication. It functions with other masticatory muscles
39. Preeti Bhagel-208-212.pmd
208
in moving and posturing the mandible. When a patient

has temporomandibular dysfunction (TMD) or a
myogenic disorder, the integrity of the masseter muscle
can be compromised resulting in pain, malfunction,
inflammation and swelling. TMJ syndrome occurs in
younger patients mostly women, typically between the
ages of 20 and 40. A careful evaluation of the masseter
muscle is necessary in facial pain patients since the
pain can originate from a distant site and be referred to
this area.3, 4, 5, 6
2/7/2013, 8:08 PM
Gum Chewing like any product has positive and

negative effects. Surprisingly, the positive effects of gum
chewing are many; however excessive use can present
problems. The type and duration of chewing are what
determine how healthy or unhealthy gum chewing will
be for an individual.6
Women are more likely to experience disability due
to TMDs, and they represent over 80% of the patients
who receive treatment of TMDs.9, 10 In 2003; H. Karibel,
G. Goddard and R. W. Gear11 studied the sex differences
in masticatory muscle pain after chewing. They tested
the hypothesis that physiologically relevant exercise
(i.e., chewing bubble gum for 6 min) increases
masticatory muscle pain in patients, but not in
asymptomatic control subjects, and that female patients
experience a significantly greater increase than males.
These results suggested greater susceptibility in
women.
Inclusion criteria (4, 12, 13)
Age group of 20 to 25 years.
Free of dental pathologies.
Individuals who chew gum regularly. (3-5 sticks of

gum a day)
Exclusion criteria(1, 14, 15, 16)
TMJ Dysfunction.
Sleep rated or waking bruxism.
Medical systemic problems that could affect

muscular function such as myalgia, myositis and
fibromyalgia of masseter muscle.
History of severe head and neck trauma (fractures

or whiplash injury).
History of orthognatic surgery.
Obviously, further research must be done on these

possible negative side effects of constant gum chewing.
But for now, the idea of research is to study the longterm effects of gum chewing on motor activity of the
masseter muscle by comparing its electromyographic
behaviour in females with males who do gum chewing.
Using any medication that could interfere in muscle

activity such as antihistamines, sedatives etc.
Receiving any kind of treatment during the course

of study that could directly or indirectly interfere in
muscle activity such as speech therapy and
otorhinolaryngology treatment.
AIMS AND OBJECTIVE
Subjects having any neurological, psychological or

psychiatric disorder.
To compare the effect of gum chewing on masseter

muscle in females with males by analyzing its
electromyographic behaviour.
Instrumentation
NULL HYPOTHESIS (H0): Effect of gum chewing

on masseter muscle in males is same as that of females
as EMG indicates almost similar motor activity in both
the males and females.
Electromyography machine -NeuroTrac TM

MyoPlus4 attached with an desktop display.
Two Self-adhesive surface electrodes, round shaped

with a diameter of approximately 30mm.
A chair (Adjustable in height).
EXPERIMENTAL HYPOTHESIS (H1): Effect of

gum chewing on masseter muscle in females is more
than that of males as EMG indicates greater motor
activity in females.
Research design
Comparative Design.
Variables
ALTERNATE HYPOTHESIS (H2): Effect of gum
chewing on masseter muscle in males is more than that
of females as EMG indicates greater motor activity in
males.
METHODOLOGY
The subjects for the present study were selected from
various colleges of Delhi. 60 young adults (Group A30 females and Group B- 30 males) took part in this
study on the basis of following criteria:
209
Dependent variable: EMG activity.
Independent variable: Gum chewing.

PROCEDURE
Subjects fulfilling the inclusion criteria were taken

subjects regarding study.
2/7/2013, 8:08 PM
EMG RECORDING
The device used in this study is a single channel
EMG. The subjects of both the groups were given
chewing gum and asked to chew gum at least one hour
before coming for the study. All monitoring was
performed with the patients in a sitting position. The
subjects were seated comfortably upright in a chair of
adjustable height at a desk of 30-inch height on which
the EMG attached to an desktop display is placed.17
Back of their heads were supported and their feet was
insulated from the floor.18 The subjects were asked to
make no head or body movements during the
recordings.19 Position of the head was kept vertical and
no movement was allowed as jaw muscles respond to
change in head position 20, 21 and facial muscles should
be relaxed, keeping lips closed. Questions were
answered after the instructions were given to be certain
that the instructions were understood. Two selfadhesive surface electrodes were utilized and placed
on the midsubstance of muscle belly of right masseter
muscle in line with muscle fibers. 22, 23 One electrode
was at the level of the lower border of the mandible,
and the other 25 mm above this, close to the motor point.
Preliminary experiments showed that with this
placement, the waveform obtained by triggering an
average of the surface EMG on the spikes of a single
masseter motor unit was biphasic and approximately
symmetrical. 23 The EMG recording of masseter muscle
was done at most comfortable position of jaw (i.e., at
rest position which is the habitual postural position of
the mandible when at rest is in the upright position
and the condyles are in a neutral unstrained position
in the mandibular fossae). It was made sure that proper
electrode placement is done and then EMG activity was
recorded. The recording time for each analysis was 30
seconds.
DATA ANALYSIS
Data are expressed as mean, standard deviation and
95% confidence interval. The independent t- test or
Levenes test for equality of variances was used to
determine the normal distribution of the variance (P <
0.05).
RESULTS
All the subjects who took part in this study

were analyzed.
A t-test reveal statistically reliable difference

between the mean number of POST TEST A has (M =
210
2.171, s = 101.76) and that the POST TEST B has (M =

1.62, s = 75.57),t(58) = 2.367, P = .05.
The independent t-test indicates a significant

increase in the motor activity of the masseter muscle
in females than in males.
Graph 1: Right masseter muscle mean and standard

deviation
CONCLUSION
Electromyographic behaviour of the masseter muscle
in individuals who do gum chewing is found to be
significantly increased in females than in males. The
independent t-test indicates that females show higher
electromyographic activity of masseter muscle than
males which means masseter muscle functions at a
higher pace in females who chew gum continuously
which may lead to the wear and tear of the
temporomandibular joint. This can result in the
development of the signs and symptoms of the
temporomandibular disorders.1 Therefore, it can be
concluded from the present study that one should avoid
gum chewing especially females on the regular basis
so as to prevent their jaw from the risk of developing
TMD at an early age.
DISCUSSION
In this study, the effect of gum chewing on motor
activity of the masseter muscle which is considered as
the primary chewing muscle was compared in females
with males who do gum chewing using EMG since it is
well known that the amplitude of EMG is related to
certain extent to the force a muscle may generate.15, 24
The temporomandibular joint is used throughout the
day to move the jaw, especially in biting, chewing,
talking and yawning. Slow and painful failure of jaw
joint function is termed as temporomandibular
syndrome/disorder. Habitual gum chewing is
considered as one of the causes which can lead to the
development of TMJ disorders.25 In this study we found
2/7/2013, 8:08 PM
significant increase in the activity of masseter muscle

in females who do gum chewing for prolonged time.
For most people, pain in the area of the jaw joint or
muscles does not signal a serious problem. Generally,
discomfort from these conditions is occasional and
temporary, often occurring in cycles. The pain
eventually goes away with little or no treatment. Some
people, however, develop significant, long-term
symptoms.4,9 Many studies have also shown that women
show a tendency to report significantly elevated levels
of muscle pain after a heavy chewing exercise, while
men do not.11 But, still neither the etiology of muscle
related temporomandibular disorders nor the reason
for the disproportionate number of women suffering
from these disorders is well established.
3.
4.
5.
6.
7.
Further research is of course required but the present

study suggests that one should avoid gum chewing on
the regular basis especially females as continuous
chewing has a harmful effect on the masseter muscle
activity. In individuals who do continuous chewing,
masseter muscle continues to function at a higher pace
getting no time to recover between the meals. Thus,
gradually it can lead to the development of signs and
symptoms of temporomandibular disorders.
8.
CLINICAL RELEVANCE
11.
Many other conditions can cause similar symptoms

to TMD including a toothache, sinus problems,
arthritis, or gum disease. Therefore, health professional
needs to conduct a careful patient history and clinical
examination to determine the cause of the symptoms.9
Researchers throughout the health sciences are working
together not only to gain a better understanding of the
temporomandibular joint and muscle disease process,
but also to improve the quality of life for people affected
by these disorders. Simple self-care activities are often
effective in maintaining oral health and also preventing
jaw from the risk of developing TMDs. Nowadays, gum
chewing is considered as the major culprit as it leads to
the over usage of the jaw therefore it should be avoided.
9.
10.
12.
13.
14.
15.
REFERENCES
1.
2.
M. Koutris et al: Effects of intense chewing exercises

on the masticatory sensory-motor system. JDR
2009; vol.88 (7), pg.658-662.
Paul Ingraham: Massage therapy for Bruxism, jaw
clenching and TMJ syndrome, 2010.
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16.
John S.Dupont, Christopher E. Brown: Masseter

tenomyositis, The J. cranio. Prac.2009/July.
Temporomandibular joint syndrome: chew on this:
your jaw joint can be a source of painful arthritis.
Arthritis today 2007/july-aug.
Renata Cunha Matheus Rodriques Garcia:
Influence of female hormonal fluctuation on
maximum bite force and masticatory efficiencycomparison between subjects with and without
temporomandibular disorder. Virtual library
2008/july 08/03106-6, 01.
Robert P Sheon, MD: Temporomandibular joint
dysfunction syndrome. Uptodate 2012/Jan.
http://www.ehow.com/list_6457095_effectsexcessive-gum-chewing.html (Gail Sessons: The
effects of excessive gum chewing).
http://www.askmen.com/sports/foodcourt/
foodcourt11.html (Health and sports: Lose weight
by chewing gum).
National Institute of Dental and Craniofacial
research: TMJ & Muscle disorders 2010/March,
pub no. 10-3487.
De Rossi SS, Stoopler ET, Sollecito TP:
Temporomandiblar disorders and migraine
headaches: co-morbid conditions? The internet
journal of dental sciences 2005; vol.2, no.1.
H. Karibel, G. Goddard, R.W Gear (2003): Sex
differences in masticatory muscle pain after
chewing. JDR 2003/Feb, vol.82, no. 2112-116.
A. Gavish, M. Halachmi, E. Winocur and E. Gazit:
Oral habits and their association with the signs
and symptoms of temporomandibular disorders
in adolescent girls. J. oral rehab. 2010; vol.27,
22-32.
Regiane
Cristina
Mendonca
et
al:
Electromyographic assessment of chewing
induced fatigue in TMD patients- a pilot study.
Braz. J.oral sci. 2005/oct-dec, vol.4, no.15.
Macarena Venegas et al: Clenching and grinding:
Effect on masseter and sternocleidomastoid
electromyographic activity in healthy subjects. J.
Cranio. Prac.2009/july.
Dahlstrom L: Electromyographic studies of
cranimandibular disorders- a review of the
literature. J. oral rehabil 1989/Jan, vol.16 (1),
pg.1-20.
Selma Seissere et al: Electromyographic activity of
masticatory muscles in women with osteoporosis.
Braz Dent. J. 2009; vol.20, no.3.
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17. Robert H. Jebsen, Neal Taylor et al: An objective

and standardized test of hand position. Archives
of physical medicine & rehab 1969/June.
18. Marie- Agnes Peyron et al: Influence of age on
adaptability of human mastication. J. neurophysio.
2004/Aug; vol.92 (2), pg.773-779.
19. Simona Tocco, Stefano Teta and Felice Festa :
Electromyographic evaluation of masticatory, neck
& trunk muscle activity in patients with posterior
crossbites. European J. orthodontics, vol.32,
issue.6, pg.747-752.
20. HD Adhikari et al: Electromyographic pattern of
masticatory muscles in altered dentition-part II. J.
conserv. dent. 2011; vol.14, issue.2, pg. 120-127.
21. Ray La Touche et al: The influence of
craniomandibular posture on maximal mouth
opening and pressure pain threshold in patients
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25.
with myofascial temporomandibular pain

disorders. Clinical journal of pain 2011/Jan, vol.27,
no.1.
Paul Canavan and Jessica Capurso: Protocol for
use of EMG and tactile biofeedback in treatment
of temporomandibular disorders and orofacial
pain.
Timothy S. Miles, Andrew V. Poliakov and Michael
A. Nordstrom: Responses of human masseter
motor unit to stretch. The journal of physiology
1995/Feb, vol.483, pg.251-264.
Claudia Maria de felicio et al: Reliability of
masticatory efficiency with beads and
correlational with the muscle activity. Pro-Fono
R. Atual. Cient 2008; vol.20, no.4, 225-30, oct/dec.
William C. Sheil Jr. MD, FACP, FACR:
Temporomandibular joint disorder.
2/7/2013, 8:08 PM
A Study to Evaluate the effect of Fatigue on Knee Joint

Proprioception and Balance in Healthy Individuals
Purvi K. Changela1, K. Selvamani2, Ramaprabhu3

Lecturer, Shri K K Sheth Physiotherapy College, Rajkot, 2Assoc. Prof., Srinivas College of Physiotherapy, Mangalore,
3
Assoc. Prof., Srinivas College of Physiotherapy
ABSTRACT
Introduction: Balance and proprioceptive testing is more commonly used in clinical settings to evaluate
injured athletes to return to activity. Muscle fatigue produces neuromuscular deficiency within the
muscle , thus predispose a joint to injury and decrease the athletic performance. A finding of previous
studies shows contradictory findings of effect of muscle fatigue on proprioception and balance.
Aims & Objectives: A study to investigate the effect of fatigue on knee joint proprioception and balance
in healthy individuals.
Materials & Methods: An observational study was conducted on 30 healthy subjects ( age 18-30 years)
from Srinivas college of physiotherapy, Mangalore. Subjects was selected by simple random sampling
techniques. Fatigue was induced in the subjects by cycling upto level of exceeding 60% of predicted
HRmax (14-17 PRE). Subjects were tested to estimate reproduction error by using weight bearing joint
position sense test at 30 0 of knee flexion , by goniometric evaluation accompanied by photographic
method and the balance assessment was done on force platform with the measurement of anteroposterior,
lateral CoP excursion and stability score in single limb stance, before and after fatigue protocol.
Results: After inducing fatigue,significant reproduction error was found for perception of joint position
sense (t=-4.103) with significant changes were found in AP (t=3.997), lat CoP excursion (t=10.949) and
stability score (t=11.785) at p>0.05.
Conclusion: A study revealed that moderate exercises can reduce proprioception which affects the
neuromuscular control of joint making individual more suspectible to injury.
Keywords: Fatigue, Proprioception, Balance, Dynamic Stability.
INTRODUCTION
Muscular fatigue is most often defined as an exercise
induced reduction in the ability of a muscle to generate
force. 1 It is caused by a combination of different
physiological mechanisms occurring at both the central
through the impairment of central drive and peripheral
level through the impairment of muscle function.2 The
high incidence of injuries occur during later session of
sports suggest that fatigue may predispose a joint to
injury and decrease the athletic performance.3 The study
of fatigue relative to performance of different skills in
the sports has long been a subject of practical interest.4
Since sports activities are strongly promoted, the risk
of sport injuries is likely to increase. It is reported that
knee joint injuries are the common injuries among all
sports injury, 39.8% of all sports injuries involve the
knee.5 It has been suggested that a higher incidence of
injuries at the last third of match could be related to
alteration of the lower limb neuromuscular control and
40. purvi --213-217.pmd
213
altered ability to dynamically stabilize the knee joint

but exactly how this impairment comes about is less
clear. 6 It is possible that one factor is reduced
proprioceptive acuity.7
In 1906, Sherrington defined Proprioception as
the perception of positions and movements of the body
segments in relation to each other, without the aid of
vision, touch or the organs of equilibrium. 7 The
importance of the proprioception in knee function,
stability, injury prevention has been studied extensively
in literatures. The current consensus is that the sense of
proprioception originates in the simultaneous activity
of a range of different types of receptors located in
muscles, joints, and skin.8 Some of these receptors have
been shown in animal studies to be affected by muscle
fatigue 9 and/or by increased intramuscular
concentrations of substances (Arachnoid acid, KCL, 5HT, Bradykinin) released during muscle contractions10
which have a direct impact on the discharge pattern of
muscle spindles that represent the peripheral
2/7/2013, 8:08 PM
component of fatigue and efferent as well as afferent

neuromuscular pathways are modulated with
excessive fatigue via reflexes originating from smalldiameter muscle afferents (group III and IV afferents)
could modify the central processing of proprioception.11.
Although it is reasonable to assume that these receptors
are affected in a similar way in humans, comparably
little is known about the fatigue effects on human
proprioception.12
The perception of movement or joint position in
clinical measurements reflects the status of the whole
system, or that measured proprioceptive defects are
connected to functional disability.13 It is believed that
the Central Nervous System (CNS) links together
afferent proprioceptive feedback from multiple joints of
a limb segment and redundancy of the afferent
information can be used as an error check to improve
proprioceptive feedback in order to maintain function.8
Reproduction ability is decreased; possibly due to
increased sensitivity of capsular receptors from muscle
fatigue-induced laxity.3 The assessment of potential
injury risk before sports participation followed by
intervention may decrease the relative injury incidence
in athletes.14
The integrity and control of the proprioceptive acuity
is essential for the maintenance of balance.15 Balance is
defined as persons ability to maintain an appropriate
relationship between the body segments and between
the body and the environment and to keep the bodys
center of mass over the base of support when performing
a task.16 It is assumed that some form of muscle spindle
desensitization or perhaps ligament relaxation and
Golgi tendon desensitization occurs with excessive
fatigue which leads to decreased efferent muscle
response and poorer ability to maintain balance.17
Balance testing is more commonly used in the clinical
setting to establish gains in the proprioceptive capacity
of injured limbs and helps to evaluate injured athlete to
return to activity.15 Measures of postural control such
as center of pressure (CoP) excursion which may be a
more sensitive measure of postural control that
incorporates proprioception have been used clinicaly.18
In humans, the effect of fatigue on proprioception
has been investigated at various joints. Findings of
disturbed proprioception and balance are frequent in
the literatures, but together they are not conclusive. So
the purpose of this study is to investigate the effect of
muscular fatigue on proprioception and balance in
healthy individuals.
40. purvi --213-217.pmd
214
METHODOLOGY
Study design: Observational study design
Sampling Technique: Simple Random Sampling
Sample collection: 30 healthy subjects in age group
of 18-30 yrs of both sex were taken for the study from
Srinivas College of Physiotherapy, Mangalore.
Inclusion Criteria
1.
Age group: 18-30 years
2.
Both male and female were included.
Exclusion Criteria
1. Knee joint pathology
2. Musculoskeletal disease of lower limb
3. Neurological condition
4. Respiratory and heart problem
Materials used
Static cycle
Reference markers
Universal Goniometer
Video camera
HR assessment apparatus (cardio-vigil)
Two dimensional digitizing software of the peak

measurement system (UTHSCSA Image Tool version
3)
Force Platform (BERTEC, Columbus, OH 43229,

U.S.A.)
TESTING PROCEDURE
The proposed title and procedure was being

approved by ethical committee members , written
consent was taken from subjects who fulfilled the
inclusion and exclusion criteria and they were
randomly selected. Subjects age, sex, height, weight,
body mass index (BMI), resting heart rate was recorded
prior to the test. Borg scale of perceived rate of exertion
(PRE) was clearly explained to all the subjects before
cycling. Right lower limb was used for measurement of
proprioception and balance test.
Fatigue was induced by asking the subject to perform
cycling on a static cycle as fast as possible, the level of
2/7/2013, 8:08 PM
fatigue was indicated and measured by using Borgs

Rate of Perceived Exertion (RPE) scale and HR was
monitored using cardio-vigil. Fatigue was induced in
the subjects by cycling. When subjects reached upto
level of exceeding 60% of predicted HRmax and a level
of exertion of 14-17 on the RPE scale, immediately the
subjects were asked to discontinue cycling.19
Proprioception and balance tests were performed
before and after fatigue protocol and scores were
recorded.
excursion and Stability score in single-limb stance on

the force platform after the JPS test following fatigue
protocol.21
DATA ANALYSIS
The demographic data were analyzed using paired
t-test for comparison of pre and post fatigue
measurement.The data analysis was done using SPSS
softwear package version 14.level of significance was
set at d 0.05 with Cl of 95%
Subjects were tested to estimate reproduction error

by using weight bearing joint position sense test at 30 0
of knee flexion , by goniometric evaluation accompanied
by photographic method.The subject was given three
trials to identify and reproduce knee joint position (300
knee flexion) initially with eyes open followed by eyes
closed. After trials of test positions, reference markers
were placed along the lateral aspect of the lower limb
for photographic evalution: a) over the greater
trochanter, b) over the iliotibial tract proximal to the
superior border of the patella and c) over the neck of
fibula.20
RESULTS
Table 1: Distribution of age groups
Age
Frequency
Percent
Valid Percent
19
10.0
10.0
20
16.7
16.7
21
13
43.3
43.3
22
20.0
20.0
23
10.0
10.0
Total
30
100.0
100.0
Table 2: Gender Proposition
The balance assessment was done on force platform

while the leg was flexed to 90at the hip and knee joints,
with both arms hanging relaxed at the sides in singlelimb stance with the measurement of AP, Lat CoP
Frequency
Percent
male
21
70.0
female
30.0
Total
30
100.0
Table 3: Comparison of pre and post fatigue joint position sense (JPS) test score, AP CoP excursion, Lateral CoP
excursion and stability score.
Mean
Std. Deviation
Std. Error Mean
df
Pre fatigue JPS test score
6.7370
3.04761
.55641
-4.103
29
.000VHS
Post fatigue JPS test score
8.7197
3.04767
.55643
Pre fatigue AP CoP excursion
1.2777
.27712
.05060
-10.949
29
0.000VHS
Post fatigue AP CoP excursion
1.7620
.32318
.05900
Pre fatigue LAT CoP excursion
.4590
.32341
.05905
-3.997
29
.000VHS
Post fatigue LAT C oP excursion
.6820
.44055
.08043
Pre fatigue stability score
86.6090
2.84795
.51996
11.785
29
.000VHS
Post fatigue stability score
81.7803
2.75167
.50238
VHS=very highly significant
The above table shows the mean of pre JPS test score
i.e. 6.7370 3.04761 (SD) and post JPS test score i.e.
8.71973.04767 which shows significant differences (t
= -4.103, p<0.05) (figure 1), mean of pre AP CoP
excursion i.e. 1.2777 0.27712 (SD) and post AP
excursion i.e. 1.76200.32318 which shows significant
difference (t = -10.949, p < 0.05) (figure 2), mean of pre
Lat Cop excursion i.e. 0.4590 0.32341 (SD) and post
Lat excursion i.e.0.6820 0.44055 (SD) which shows
significant difference (t = -3.997, p < 0.05) ( figure 3),
40. purvi --213-217.pmd
215
mean of pre stability score i.e. 86.6090 2.84795 (SD)

and post stability score i.e. 81.7803 2.75167 (SD) which
shows significant difference for pre and post stability
score (t = 11.785, p < 0.05) (figure 4) for the present study.
DISCUSSION
The results of the present study indicated that
fatigue reduces knee joint proprioception i.e. higher
reproduction error was found for perception of joint
2/7/2013, 8:08 PM
position sense (t = -4.103, p < 0.05) thereby supporting

the experimental hypothesis.
The findings of David Roberts et al. (2003) on
healthy young persons, to estimate threshold for
perception of movement before and after fatigue shows
statically significant difference in threshold value, after
inducing fatigue which support the results of our
study.22 However, Marks and Quinney (1993) provided
contradictory findings suggested that muscle fatigue
had a negligible effect on knee JPS. However, they
induced fatigue by having the subject contract the
quadriceps muscle 20 times, which likely was less
fatiguing and that mainly affected the anterior
structures of the thigh. Therefore, the posterior
structures, which are of afferent importance during
extension, were probably less affected by fatigue.23
An important issue here in this present study is,
whether the effects of fatigue on position sense of knee
can be attributed to central fatigue or to muscle fatigue.
Central fatigue may have accompanied peripherally
elicited effects, but there is a chain of evidence indicating
that alterations in the proprioceptive inflow from
peripheral muscle receptors have contributed
considerably to the central fatigue effects. 10
Djupsjobacka M. et al. (1995) suggested that muscle
spindles are strongly affected by metabolic products ,
such as bradykinin, 5-HT, and lactic acid, the
proprioceptive inflow from spindle afferents during the
JPS test is likely to have been affected by fatigue.24
Different methods have been used to assess
proprioceptive acuity in various studies. Amongst them,
Goniometric evaluation for measuring the angle
accompanied by video films is an adequately accurate
method of measuring the joint angle. Berry C. Stillman
et al. (2001) explained that WB assessments of
proprioception which is more functional might have
greatest relevance in the area of sports medicine .
Theoretically, fatigue may increase the time of reaction,
which, in the present study, would be seen as higher
reproduction error scores. 20
The results of the present study also indicated that
fatigue reduces balance performance (t= 11.785; p <
0.05). There are several possible reasons why muscular
fatigue affects balance performance. It seems plausible
that some form of muscle spindle desensitization or
perhaps ligament relaxation and Golgi tendon
desensitization occurs with excessive fatigue. The
increased AP and Lat CoP excursion observed after
cycling in the present study may be explained by a
40. purvi --213-217.pmd
216
decrease in muscle response and a delay in muscle

reaction and poorer ability to maintain balance.17 Eva
Ageberg et al. (2003) found that short-term cycling
decrease ability to maintain balance in single limb
stance in healthy subjects 30 support the result of present
study . 21
We found that a short period of moderate exercise
can reduce proprioception, which may affect the
neuromuscular control of the knee joint and
significantly affects the ability of an individual to
maintain balance on force platform device, thus, may
make it more susceptible to injury.
CLINICAL IMPLICATION
Balance and Proprioceptive testing can be used in
the clinical setting to evaluate injured athlete to return
to activity.
CONCLUSION
The knee joint proprioception and balance are
affected after fatigue in healthy individuals.
ACKNOWLEDGEMENT
I wish to express my thanks to respectable Principal
Ramprasad M. Srinivas College of Physiotherapy,
Mangalore , to my respected Guide Assoc. Prof. K.
Selvamani and all my respected teachers for their help
and valuable suggestions.We gratefully acknowledge
our respected principal Dr. Sarla Bhatt for their kind
support and guide in the journal publication.
1.
2.
3.
4.
5.
REFERENCES
Vollestad NK. Measurement of human muscle
fatigue. J Neurosci Methods June 1997; 74 (2):
219-227.
Noakes TD. Physiological models to understand
exercise fatigue and the adaptations that predict
or enhance athletic performance. Scand J Med Sci
Sports June 2000; 10 (3): 123-145.
Hiemstra LA., Lo IK., Fowler PJ. Effect of fatigue
on knee proprioception: implications for dynamic
stabilization. J Orthop Sports Phys Ther Oct 2001;
31(10): 598-605.
Mark Lyons, Yahya Al-Nakeeb, Alan Nevill. The
impact of moderate and high intensity total body
fatigue on passing accuracy in expert and novice
basketball players. J of Sports Sci and Med June
2006; 5: 215-227.
Majewski M., Susanne H., Klaus S. Epidemiology
2/7/2013, 8:08 PM
6.
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10.
11.
12.
13.
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of athletic knee injuries: A 10-year study. J Knee

June 2006; 13(3): 184-188.
Ribeiro Fernando1, Santos Fernando2, Oliveira
Jose. Effects of a volleyball match induced fatigue
on knee joint position sense. 12th Annual
Congress of the ECSS, 1114 July 2007, Jyvaskyla,
Finland.
Martin B. Jorklund. Effects of repetitive work on
proprioception and of stretching on sensory
mechanisms. Umea university medical
dissertation, new series no. 877 91. 2004; 90:
7305-604.
Grigg P. Peripheral neural mechanisms in
proprioception. J. Sport Rehab Feb 1994; 3 (1):
2-17.
L. Hayward, U. Wesselmann and WZ. Rymer.
Effects of muscle fatigue on mechanically sensitive
afferents of slow conduction velocity in the cat
triceps surae. J Neurophysiol 1991; 65 (2): 36070.
Pedersen, Jonas, Lonn, Johan, Hellstorme, Fredric,
Djupsjobacka, Mats, Johansson, Hakan. Localized
muscle fatigue decreases the acuity of the
movement sense in the human shoulder. Williams
and Wilkins July 1999; 31(7): 1047-52.
Solomonow M., R. Baratta, BH. Zhou. The
synergistic action of the anterior cruciate ligament
and thigh muscles in maintaining joint stability.
Am J Sports Med May-June 1987; 15 (3): 207-13.
Meral Bayramoglu, Reyhan Toprak and Seyhan
Sozay. Effects of osteoarthritis and fatigue on
proprioception of the knee joint. Arch of Phys Med
and Rehab Mar 2007; 88(3): 346-50.
Ashton Miller JA., Wojtys EM., Huston LJ., FryWelch D. Can proprioception really be improved
by exercises? Knee Surg Sports Traumatol Arthrosc
May 2001; 9 (3): 128-136.
Chandy TA. and Grana WA. Secondary school
athletic injury in boys and girls: A three-year
comparison. Phys Sports Med 1985; 13: 10611.
Peggy A. Houglum and David H. Perrin.
Therapeutic exercises for athletic injuries.United
217
States. First edition. Human Kinetics 2001: 272-3.

16. Shumway Cook A. and Woollacott M. Control of
posture and balance. Motor control. Theory and
practical application. Second edition. Baltimore,
Williams and Wilkins 1995; 120-121.
17. Johnston, Richard B., Howard, Mark E., Cawley,
Patrick W., Losse, Gary M. Effect of lower extremity
muscular fatigue on motor control performance.
Med Sci Sports Exerc Dec 1998; 30 (12): 1703-1707.
18. Gandevia SC. Spinal and supraspinal factors in
human muscle fatigue. Physiol Rev Oct 2001; 81
(4): 1725-1789.
19. J.E. Bullock Saxton, WJ. Wong, N. Hogan. The
influence of age on weight-bearing joint reposition
sense of the knee. Exp Brain Res Jan 2001; 136(3):
400-406.
20. Barry C. Stillman and Joan M. McMeeken. The role
of WB in the clinical assessment of knee joint
position sense. Austr J of Physiotherapy 2001; 47:
247-253.
21. Eva Ageberg, David Roberts, Eva Holmstrom,
Thomas Friden. Balance in single-limb stance in
healthy subjects - Reliability of testing procedure
and the effect of short-duration Sub-maximal
Cycling. BMC Musculoskeletal Disorders June
2003; 4: 14.
22. David Roberts, Eva Ageberg, Gert Andersson,
Thomas Friden. Effects of short-term cycling on
knee joint proprioception in healthy young
persons. Am J of Sports Med 2003; 31: 990-994.
23. Marks R., Quinney HA. Effect of fatiguing maximal
isokinetic quadriceps contractions on ability to
estimate knee-position. Percept Mot Skills Dec
1993; 77 (3 pt 2):1195-202.
24. M. Djupsjobacka, H. Johansson and M.
Bergenheim. Influences on the -muscle spindle
system from muscle afferents stimulated by
increased intramuscular concentrations of
arachidonic acid. Brain Res Nov 1994; 663 (2):
293302.
2/7/2013, 8:08 PM
Effect of Core Stabilization and Balance-Training Program

on Dynamic Balance
Rabindra Basnet1, Nalina Gupta2
BPT Student, HOD Department of Physiotherapy, College of Applied Education and Health Sciences,
Meerut, Uttar Pradesh
ABSTRACT
Introduction: Over the years, injury rehabilitation has changed from strengthening the body using
strength training to achieve functional kinetic chain movements using neuromuscular training, which
includes balance and proprioception. Neuromuscular control is the motor response to the sensory
input of the muscles, whereas balance is a state of bodily equilibrium. The purpose of this study was to
find out the effect of core stabilization and balance training on dynamic balance.
Method: subjects were randomly assigned to one of the two groups: Group A-core stabilization group
and Group B-Balance training group. Both groups were given exercise program for six days per weeks
for two weeks. Pre and post analysis was done by using Star Excursion Balance Test.
Result: Paired T-test was used within the group and p value was found to be less than .05 in both the
groups and independent sample T-test was used between the groups where p value was found to be
more than .05.
Conclusion: Our study concluded that there was no statistical significant difference between core
stabilization group and balance training group.
Keywords: Core-Stability Training, Balance Training, Neuromuscular Control
INTRODUCTION
Balance is a key component of normal daily
activities. In the simplest terms, balance can be defined
as the ability to maintain the bodys centre of gravity
within the limits of stability as determined by the base
of support. Balance, or postural control, can be
described as either dynamic or static. Static postural
control is attempting to maintain a base of support while
minimizing movement of body segments and the centre
of mass; while dynamic postural control involves the
completion of a functional task with purposeful
movements without compromising an established base
of support.1
To maintain balance, it is necessary to have a
functional awareness of the base of support to better
accommodate the changing centre of gravity. The goal
of balance training is to improve balance through
perturbation of the musculoskeletal system that will
facilitate neuromuscular capability, readiness, and
reaction.2
41. Rabindra--218-222.pmd
218
Panjabi describes clinical instability as the loss of

the spines ability to maintain its patterns of
displacement under physiologic loads so there is no
initial or additional neurologic deficit, no major
deformity, and no incapacitating pain. The spine
stability system consists of the following interacting
elements Neuromuscular control (neural elements),
Passive subsystem (osseous and ligamentous elements)
& Active subsystem (muscular elements).3
The human core is described as the human low backpelvic-hip complex with its governing musculature. The
core is important because it is the anatomical location
in the body where the centre of gravity is located, thus
where movement stems. The core functions to maintain
postural alignment and dynamic postural equilibrium
during functional activities, which helps to avoid serial
distortion patterns. Core stability is the motor control
and muscular capacity of the lumbopelvic-hip complex.4
The core is split into two different regions, the local
and global musculature. The multifidus, transverse
2/7/2013, 8:08 PM
abdominus, internal oblique and quadrates luborum

constitute the local stabilizing system. The longissimus
thoracis, rectus abdominus and external oblique make
up the global system. The local system is responsible
for segmental spine stability while the global system is
responsible for isometric and isotonic contraction in
the spine. Both of these regions play a role not only in
daily and athletic movement but also potentially in
injury prevention.6
A useful method of measuring dynamic balance is
the Star Excursion Balance Test.1 The test provides a
quantifiable way to measure dynamic balance. This
single leg standing and contralateral reaching test can
be used to determine the dynamic stability of an
individual as they perform a functional movement task.
SEBT requires a participant to maintain a base of
support with one leg while maximally reaching in
different directions with the opposite leg without losing
balance or significantly altering the base of support in
the stance leg.6
According to Kibler et al, core stability and strength
is an important component to maximize efficient
balance and athletic function in upper and lower
extremity movements. The same authors suggest that
the core acts as a base for motion of the distal segments,
or proximal stability for distal mobility.7
Logically, strengthening core muscles will improve
stability of the lumbar spine. What has been researched
in much less detail is the effect core strengthening will
have on tasks that encompass whole body movement
and dynamic postural control.7
Thus, the aim of this study was to find out the effect
of core stability and balance training on dynamic
balance.
It was an experimental study. Thirty normal healthy
subjects of CAEHS, Meerut of both the gender with age
18 to 25 years were included in the study. Subjects
219
having injury and pathology of Hip, Knee and Ankle,

deformities such as Genu valgum & varum etc, Sharp
acute pain, recent hematoma of knee, hip & ankle and
any acute inflammatory condition, history of LBP with
sciatica and subject with neurological impairments
were excluded from the study.
All the subjects were explained about the procedure
and were made to fill the consent form. Subjects were
divided into two groups: Group A (n=15) - Core
stabilization group and Group B (n=15) - Balance
training group. Pre evaluation was done by using Star
Excursion Balance Test.
Group A received core stability exercises of 3 sets for
30 seconds/session once a day 6 days a week for 2
weeks. Exercises given to this group were Plank Jao,
Side Plank, Bridge, Superman, Sideline Hip Abduction,
Oblique Crunch, Straight Leg Rise and Lying
Windscreen Wipers Wipers.
Group B received Balance Training exercise of 3 sets
for 30 seconds/session once a day 6 days a week for 2
weeks, exercises are Tandem Standing, One Limb
Balance, Hip Rise, Knee Band, Standing Kick, Side Kick,
Standing On Foam, One Leg Standing On Foam, Back
Kick with Band and Side Kick With Band Band.
After two weeks, both the groups were evaluated
again using SEBT.
DATA ANALYSIS AND RESULT
Data analysis was done by using SPSS software.
Paired T-test was used within the group and p value
was found to be less than 0.05 in both the groups. There
was significant difference within the groups as seen in
Table 1 & 2.
Independent sample T- test was used between the
groups where p value was found to be more than 0.05.
There was no statistical significant difference between
the groups as seen in table 3.
2/7/2013, 8:08 PM
Table 1 Mean and Pre-Post analysis of Group A
Mean
Sig.
58.9333
.000
Pair 1
RtANTpreB
RtANTpostB
73.7333
.000
Pair 2
RtALpreB
54.4000
RtALpostB
74.1333
53.8000
Pair 1
RtANTpreA
RtANTpostA
80.8667
Pair 2
RtALpreA
60.2667
RtALpostA
80.0667
Pair 3
RtLATpreA
61.5333
RtLATpostA
77.5333
Pair 4
RtPLpreA
60.3333
RtPLpostA
75.8667
Pair 5
RtPOSTpreA
54.2667
RtPOSTpostA
70.7333
Pair 6
RtPMpreA
49.0000
RtPMpostA
70.0667
RtMEDpreA
48.2000
RtMEDpostA
66.8667
RtAMpreA
55.6000
RtAMpostA
74.8000
LtANTpreA
58.5333
LtANTpostA
85.0000
Pair 7
Pair 8
Pair 9
Pair 10
Pair 11
Pair 12
Pair 13
Pair 14
Pair 15
Pair 16
LtALpreA
55.8000
LtALpostA
75.2000
LtLATpreA
47.6000
LtLATpostA
65.6000
LtPLpreA
50.6000
LtPLpostA
70.8000
LtPOSTpreA
52.9333
LtPOSTpostA
71.5333
LtPMpreA
58.6000
LtPMpostA
73.6000
LtMEDpreA
60.8000
LtMEDpostA
76.7333
LtAMpreA
61.6000
LtAMpostA
78.8667
220
Table 2 Mean and Pre-Post analysis of Group B

Mean
Sig.
56.0000
.000
.000
Pair 3
RtLATpreB
RtLATpostB
69.8667
.000
Pair 4
RtPLpreB
51.2667
RtPLpostB
66.0667
49.3333
.000
Pair 5
RtPOSTpreB
RtPOSTpostB
64.6667
.000
Pair 6
RtPMpreB
48.2000
RtPMpostB
61.4667
RtMEDpreB
46.1333
RtMEDpostB
58.0667
RtAMpreB
54.5333
RtAMpostB
71.5333
LtANTpreB
57.0000
LtANTpostB
71.6667
LtALpreB
52.1333
LtALpostB
69.2000
LtLATpreB
47.6667
LtLATpostB
64.0667
47.0667
.000
.000
.000
.000
.000
Pair 7
Pair 8
Pair 9
Pair 10
Pair 11
.000
Pair 12
LtPLpreB
LtPLpostB
62.6667
.000
Pair 13
LtPOSTpreB
52.4667
LtPOSTpostB
64.4667
LtPMpreB
54.9333
.001
Pair 14
.000
Pair 15
.000
Pair 16
LtPMpostB
66.3333
LtMEDpreB
53.7333
LtMEDpostB
67.2000
LtAMpreB
53.2667
LtAMpostB
71.6000
2/7/2013, 8:08 PM
.000
.001
.001
.000
.000
.000
.000
.000
.000
.000
.000
.000
.000
.003
.005
Table 3 Independent T-Test between the Groups
Sig.(2-tailed)
RtANTpre
.482
RtANTpost
.105
RtALpre
.188
RtALpost
.215
RtLATpre
.082
RtLATpost
.133
RtPLpre
.034
RtPLpost
.033
RtPOSTpre
.132
RtPOSTpost
.157
RtPMpre
.818
RtPMpost
.075
RtMEDpre
.632
RtMEDpost
.086
RtAMpre
.767
RtAMpost
.555
LtANTpre
.733
LtANTpost
.008
LtALpre
.443
LtALpost
.204
LtLATpre
.988
LtLATpost
.745
LtPLpre
.460
LtPLpost
.052
LtPOSTpre
.892
LtPOSTpost
.092
LtPMpre
.458
LtPMpost
.069
LtMEDpre
.108
LtMEDpost
.103
LtAMpre
.048
LtAMpost
.151
DISCUSSION
This study was an attempt to find out the effect of
core stabilization and balance training on dynamic
balance. In our study we found significant difference
within the group and we did not find any significance
between the groups. This is in agreement with the study
done by Kimberly et al. in 2005. They also specified in
their study that, although the results of study between
groups were not significant, enhancement of dynamic
balance may result if the core stabilization training
program is applied in the clinical settin.4
Core stability improves static and dynamic balance
and could be beneficial for improving balance by
strengthening those muscles most often associated with
lumbar spine control.
221
By just training the core, overall dynamic stability

can be positively affected with strong magnitude of
change. There is also evidence that a 4 week intervention
might be enough to cause a significant training effect,
with a strong magnitude of change in core global
muscular endurance.6
When the transverse abdominus contracts, the intraabdominal pressure increases and tenses the
thoracolumbar fascia. These contractions occur before
initiation of limb movement allowing the limbs to have
a stable base for motion and muscle activation. The
rectus abdominus and oblique abdominals are
activated in specific patterns with respect to limb
movement that also provide postural support.9
Piegaro et al in 2003 stated in their study that there
is a trend towards improving dynamic balance with
core stability exercises and balance training exercises.8
Zech A, et al in 2010 concluded that Balance training
is effective at improving static postural sway and
dynamic balance in both athletes and non-athletes. But
balance training exercises should be given for longer
duration for finding it to be effective.21
Limitation of the study: Sample size was small and
study was done in a shorter duration.
Future research: In future, combined effect of core
stability and balance training exercises on dynamic
balance can be done. Study can be done on geriatric
population. Bio feedback can also be incorporated in
the study. Study can be done for longer duration.
CONCLUSION
Our study concluded that there was no statistical
significant difference between core stabilization and
balance training program.
REFERENCES
1.
2.
3.
4.
Kahle N. The Effects of Core Stability Training on

Balance Testing in Young, Healthy Adults.2009.
Available at [http://etd.ohiolink.edu]
Yaggie, JA, and Campbell BM. Effects of balance
training on selected skills. J. Strength Cond. Res.
2006;20(2):422-428.
Akuthota V, Ferreiro A, Moore T, and Fredericson
M. Core stability exercise principles. Curr. Sports
Med.Rep., 2008;7(1)39-44.
Samson KM, BS, ATC, PES. The Effects of a FiveWeek Core Stabilization-Training Program on
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5.
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8.
Dynamic Balance in Tennis Athletes.2005

Available at [http://wvuscholar.wvu.edu.]
Akuthota V, Nadler SF. Core strengthening. Arch
Phys Med Rehabil 2004;85(3 Suppl 1):S86-92.
McCaskey A,The Effects of Core Stability Training
on Star Excursion Balance Test and Global Core
Muscular Endurance,2011 Available at [http://
etd.ohiolink.edu]
Bashiri J, Hadi H, Razavi SD, Bashiri M. Effect of
Resistance-Balance training on dynamic balance
in active elderly males. Annals of Biological
Research, 2011; 2(5):689-695.
Piegaro AB, JR., BS, ATC. The comparative effects
of four-week core stabilization & balance-training
programs on semi dynamic & dynamic
222
balance,2003
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at
[http://
www.portalsaudebrasil.com]
9.
Robinson R, Gribble P. Support for a reduction in
the number of trials needed for the Star Excursion
Balance Test. Arch Phys Med Rehabil. 2008;
89(2):364-370.
10. Hessari FF, Norasteh AA, Daneshmandi H,
Ortakand SM. The effect of 8 weeks core
stabilization training program on balance in deaf
students. Medicina Sportiva, 2011;15 (2): 56-61.
11. Zech A. Balance training for neuromuscular
control and performance enhancement: a
systematic review. J Athl Train, 2010 JulAug:45(4):392-403.
2/7/2013, 8:08 PM
A Retrospective Analysis of Disability-Related Data on

Disabled Children and their Families in Turkey
Rasmi Muammer
Assistant Professor, Yeditepe University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation
TR-34755, Istanbul, Turkey
ABSTRACT
Purpose: The aim of this study was to investigate and analysis the data and records of disabled
children and their families.
Materials and Methods: Records and data of 116 patients with different neurological conditions seen
at the Physiotherapy Department at a special education centre between August 2004 and August 2008
were investigated. Obtained data and records included: age, gender, mode of delivery, diseases
distribution , types of cerebral palsy and related factors, education level and job status of the parents,
intermarriage, therapy interest rate.
Results: The most prevelant mode of delivery was as a vaginal delivery in 68 (59%) cases while a
caesarean section seen in 47 (41%) cases in addition to one adoption case with unknown delivery type.
29 (25%) of this deliveries were as a premature while 2 (2%) deliveries were as late deliveries. Cerebral
palsy was the most prevalent (61%) cause of physiotherapy attendance. The spastic type also represented
the most type of cerebral palsies with prevelant of 57%. The most prevelant parents educational level
included the primary school (mothers-fathers, 56%-47%). There was also intermarriage betweeen 33
pairs with cousin relation in 28 pairs and 5 pairs with distant relation. Most of the mothers were
housewifes (%97) and attendance to therapy realized by 91% of the mothers.
Conclusion: Many factors are related to physiotherapy attendance of the paediatric neurological
conditions. Parents low educational level, intermarriage, high percentage of housewifes, free- worker
position of fathers and high percentage of mothers who attend to children care may reflect socioeconomic level of this population.
Keywords: Cerebral Palsy; Parents
INTRODUCTION
A wide spectrum of motor impairments affect
function in children and adolescents which may be
congenital and acquired conditions such as cerebral
palsy, traumatic brain injury, myelomeningocele, spinal
cord injury, Down Syndrome, and neuromuscular
disease. Many of these disorders result from dysgenesis
or injury to developing motor pathways in the cortex,
basal ganglia, thalamus, cerebellum, brainstem, central
white matter, or spinal cord. These conditions are
associated with motor impairments including muscle
weakness, abnormal muscle tone, decreased joint range
of motion, and decreased balance and coordination.
There are variations in severity within each of these
conditions. Many children with impairments
attributable to these conditions will have some degree
of disability that may limit their normal development
and functions and should benefit from physical,
42. Rasmi Turkey-223-227.pmd
223
occupational, and/or speech-language therapy

services.1,2 The amount of the physiotherapy may be
intensive or routine amounts with long or short term
therapy3 and a specific and measurable goals of the
therapy are essenetial for evaluation of improvement
in motor function.4,5 Also the goal of treatment of
children with motor disorders mirrors the management
of other forms of chronic disease and disability 2.
Establishing such goals are related to many factors and
to each condition of the wide spectrum of the diseaes in
which cerebral palsy is the most frequent diagnosis of
children who receive physiotherapy.6 However having
a sufficient knowledge about rare cases related to
pediatric physiotherapy has a key role of setting the
objective goals.
This retrospective study was conducted at a special
2/7/2013, 8:08 PM
education centre, Istanbul, Turkey. The centre provides

physiotherapeutic services as well as a special
education according to the patients needs who were
reffered from guidance and research centers with a
diagnosis from an official institution. Records and data
of 116 infant, children and young with different
neurological conditions seen at the physiotherapy
department between August 2004 and August 2008
were investigated. Obtained data and records included:
age, gender, mode of delivery, diseases distribution ,
types of cerebral palsy and related factors, education
level and job status of the parents, intermarriage,
therapy interest rate. Physical therapy a patient received
was based on the evaluation of the physical therapist
and the severity of the problems including classic
physiotherapy in addition to neurodevelopmental
therapy. Data were analyzed using descriptive statistics
of mean and standard deviation. Range and
percentages, and the frequency distributions of the
various data were calculated and presented in tables
and figures.
RESULTS
One hundred and sixteen paediatric patients were
managed at the physiotherapy department of a special
education centre between August 2004 and August
2008. 44% of the cases were females while the males
represented 56% with mean age of 22.3529.95 months
for females and and 24.3533.56 months for males at
the entry. The most prevelant mode of delivery was as a
vaginal delivery in 68 (59%) cases while a caesarean
section seen in 47 (41%) cases in addition to one case
adoption with unknown delivery type. 29 (25%) of these
deliveries were as a premature while 2 (2%) deliveries
were as late deliveries (Table 1a,1b).
Table 2: Diseases distribution (CP: Cerebral Palsy, DS:

Down Syndrome, SB: Spina Bifid, Myopathy:
Myopathy, Polio: Poliomyelitis
Diseases
CP
71
61%
DS
14
12%
SB
18
16%
Myopathy
12
10%
Polio
1%
The spastic type also represent the most type of

cerebral palsies with prevelant of 57%, hypotonic type
prevalent 21%, mixed type 7%, athethoid type 6%,
ataxic type 6% and unknown 3% (Table 3).
Table 3: Types of Cerebral Palsies
Type
Spastic
41
57%
Hypotonic
15
21%
Mixed
7%
Athethoid
6%
Ataxic
6%
Unknown
3%
Result of factors related to cerebral palsy showed

that the widespread prenatal, perinatal and postnatal
factors as causes of cerebral palsy showed a rate of 41%
were seen in 29 cases, Kernicterus (6%) was seen in 4
cases, Rett Syndrome (1%) was seen in 1 case, Mapple
Syrup Urine disease (3%) was seen in 2 cases,
Cytomegalovirus infection (3%) was seen in 2 cases,
Pelizaeus-Merzbacher (1%) was seen in 1 case, trauma
(6%) was seen in 4 cases, West syndrome (8%) was seen
in 6 cases and others related to genetic factors,
chromosome anomalies or unknown factors (31%) seen
in 22 cases (Table 4).
Table 4: Result of factors related to cerebral palsy
N
Pre, peri, post natal Factors
29
41%
Kernicterus
6%
Rett Syndrome
1%
Mapple Syrup Urine disease
3%
Cytomegalovirus Infection
3%
Table 1a: Mode of Delivery

Mode of Delivery
Vaginal Delivery
68
59%
Caesarean Section
47
41%
Unknown(Adoption)
< 1%
Table 1b: Mode of Delivery

Premature
29
25%
Late Delivery
2%
Diseases distribution is presented in Table 2.

Cerebral palsy was the most prevalent (61%) cause of
physiotherapy attendance, Down Syndrome prevalent
12%, spina bifida 16%, myopathies 10%, while
Poliomyelitis comprised the least frequent (1%).
224
Pelizaeus-Merzbacher
1%
Trauma
6%
West syndrome
8%
Others
22
31%
The parents educational level is seen in (Figure 1)

and the most prevelant included the primary school.
2/7/2013, 8:08 PM
Figure 1: The figure shows the parents educational

level and the most prevelant included the primary
school for both mothers (56%) and fathers (47%). The
other levels respectively are: None-education (4%, 3%),
Secondary School (22%,22%), High School (13%, 24%)
and Collage (5%, 4%).
Figure 3: Most of the fathers were workers (%94), the

rate of the state officers is 3% and fathers of none-job is
3%.
There was also intermarriage betweeen 33 (28%)

pairs with cousin relation in 28 pairs and 5 pairs with
distant relation (Table 5).
Attendance to therapy realized by 105 (91%)

mothers, 7 fathers (6%) and 4 others (3%) (Figure 4).
Table 5: Intermarriage betweeen pairs
Non- intermarriage
intermarriage
83
72%
33
(28 pairs cousin,
5 pairs distant
relation)
28%
(85% cousin,
15% distant
relation)
Figure 4: Attendance to therapy realized by 105

(91%) mothers, 7 fathers (6%) and 4 others (3%).
Most of the mothers were house wifes (%97), while

most of the fathers were workers (%94) (Figure 2, 3).
Figure 2: Most of the mothers were house wifes
(97%), the rate of the state officers is 2% and mothers of
free job is 1%.
DISCUSSION
Paediatric Neurological diseases affect the mental
motor development of the patients resulting in various
impairments of the ability to co-ordinate muscle action
to maintain normal posture and movement.7 Muscle
weakness, abnormal muscle tone, restricted joint range,
and decreased balance and coordination are associated
with motor impairments. Cerebral palsy, Down
syndrome and central nervous system infections are
some of the pediatric neurological condition. Cerebral
palsy is the most common condition responsible for
physiotherapy attendance8 and affects as estimated
225
2/7/2013, 8:08 PM
500,000 Americans.9 Furthermore spastic type was

found to be the most common type.8,10 In this study we
found that cerebral palsy was the most prevalent cause
of physiotherapy attendance. The spastic type also
represents the most type of cerebral palsies. These
findings correlated with findings in the literature.
Brain damage causing cerebral palsy may develop
during the prenatal, perinatal or postnatal periods.
Prenatal factors have a significant role in the cases.
Prenatal factors lead to premature birth and/or
intrauterine retardation of the infant.11 This research
showed that 29 (25%) of these deliveries were as a
premature while 2 (2%) deliveries were as late deliveries.
It is also found that factors related to central nervous
system infection, metabolic, storage disorders,
congenital, developmental disorders, hereditary,
familial genetic and chromosome anomalies disorders
included a several conditions with different rates that
caused brain damage and retardation such as
Kernicterus, Rett Syndrome, Mapple Syrup Urine
disease, Cytomegalovirus infection, and PelizaeusMerzbacher. Trauma, West syndrome and others
unknown factors was recorded. In addition to the
previous factrors of course the widespread prenatal,
perinatal and postnatal factors such as pregnancy rsik
factors, delivery risk factors, asphyxia, infections and
injuries are common causes.12
Down Syndrome, spina bifida, and miopathies
accounted for 12%, 16%,10% respectively of cases
reviewed. Although these children experience postural
and movement abnormalities which benefit from
physiotherapy and rehabilitation 13,14,15 , the low
prevalence seen in this study may be due however to
the low prevalence of the condition in general
population.8.Poliomiyalitis has the least percentage
between the conditions which reflects its termination
in the public.
The negative impact of socioeconomic deprivation
has been shown for many aspects of child
mortality and morbidity but the relation between
socioeconomic status and the risk of cerebral palsy is
not clear. Low birth weight and prematurity are the
strongest risk factors for cerebral palsy. Given the
observed association between these factors and
socioeconomic status, an increased prevalence of
cerebral palsy with low socioeconomic status is
expected. A strong association was observed between
socioeconomic status and the risk of cerebral palsy.16
Other factors in child disability include poverty, lack of
exercise, bad housing and poor diet are being
226
important.17 Marrying within family; genetic risks

increase the chance of children being born with
disabilities.
Parents low educational level, intermarriage
betweeen the family, high percentage of housewifes,
free- worker position of fathers and high percentage of
mothers who attends to children care may reflect a low
socioeconomic level.
ACKNOWLEDGEMENT
The auther appreciate the cooperation of Prof. Dr.
Erturul KILI at Yeditepe University-stanbul, and
M.Yldrm Special Education centre and all
physiotherapists at department of physiotherapy,
stanbul, Turkey.
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Bower E, Michell D, Burnett M, Campbell MJ,
McLellan DL Randomized Controlled Trial of
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Kolobe H A, Palisano R J, Stratford PW
Comparison of Two Outcome Measures for Infants
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Delays, Physical Therapy 1998; 78 (10): 1062-1072.
Bower E, McLellan DL, Arney J, Campbell MJ A
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Nelson K B, Grether J K Causes of Cerebral palsy,
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Eur J Pain 2004; 8 (1): 55-61.
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Disturbances in the Motor Behavior of Children
with Downs syndrome: The Need for a Theoretical
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retrospective cohort study, Arch Dis Child 2005;
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2/7/2013, 8:08 PM
Effect of Postural Brace for Correcting Forward Shoulder

Posture and Kyphosis in Patients with Chronic
Obstructive Pulmonary Disease: A Pilot Study
Ravi Savadatti1, Gajanan. S. Gaude2, Prashant Mukkannava3

Principal, SDM College of Physiotherapy, Dharwad, 2HOD Respiratory Medicine, JNMedical College Belgaum, KLE
University, 3Assistant professor, SDM College of Physiotherapy, Dharwad
ABSTRACT
Objectives: 1.To evaluate the effect of postural brace in correcting forward shoulder posture and kyphosis
in patients with chronic obstructive pulmonary disease.( COPD)
2. To evaluate the effect of postural correction on inspiratory muscle strength in COPD patients.
Design: A Pilot study comparing baseline values with post-test values.
Subjects: A total of 30 subjects between age group of 45-60 years of either gender, diagnosed to have
COPD with forward shoulder posture and Kyphosis were studied.
Methods: Daily inspiratory muscle training(IMT) sessions of 30 minutes' duration and weekly training
load increments of -2 to -4cmH2O over a 8-week period with the training device at loads of >30% of
baseline maximal inspiratory pressure (PImax) was given. Posture was corrected by a brace and patients
were asked to wear it throughout the day for 8 weeks.
Outcome measures: Posture was assessed by Plumbline (PL), intra scapular distance(ISD) and
percentage of kyphotic index(KI). Inspiratory muscle strength was measured by deriving maximal
inspiratory pressure (PIMax)
Results: All subjects tolerated the training load, improved their inspiratory muscle strength, and reported
correction of posture.
Conclusion: A combination of posture correction by a brace and inspiratory muscle training using
TIMT is beneficial in improving posture and the strength of inspiratory muscles of COPD patients.
Keywords: COPD, Posture, Kyphosis, Forward Shoulder Posture, Maximal Inspiratory Pressure
INTRODUCTION
There is decreased strength and endurance of
diaphragm in COPD.1,2 The inspiratory muscles are
placed at a suboptimal length for generation of muscle
tension due to overinflation.3 Hence the diaphragm is
susceptible to fatigue as a result of increased loading
and diminished capacity to produce inspiratory
force.3,5,6 Inspiratory muscle strength and endurance
have been shown to be reduced in COPD.4,7 Patients
experiencing dyspnea in COPD benefit from IMT, as
strong inspiratory muscles help decrease dyspnea.8
However the efficacy of IMT is controversial and its use
in a clinical setting is limited in patients with COPD.
Patients with COPD will attend forward head, rounded
and elevated shoulders. Posture such as Kyphosis, and
43. Ravi Savaddati--228-233.pmd
228
forward shoulder posture (FSP) affects the respiratory

values in COPD.1,11 There is excessive thoracic flexion
in kyphosis and thoracic supportive device such as
postural brace can be used to prevent excessive thoracic
flexion, thus correcting posture. 14 Taking into
consideration, the beneficial effects of IMT on strength
of inspiratory muscles and the ill effects of bad posture
in the form of dorsal Kyphosis and FSP on respiratory
values in COPD, It is legitimate to question whether
addition of postural correction with IMT has any
beneficial effects in rehabilitation patients with COPD.
Till date to our knowledge, none of the studies have
reported weather IMT along with upper thoracic
posture correction by a brace can have an additional
effect on the strength of the inspiratory muscles in
COPD. Hence the aim of this study was to evaluate the
2/7/2013, 8:08 PM
effect of adding postural correction to IMT in patients

with COPD.
METHODOLOGY
Subjects: 30 subjects between age group of 45-60
years of either gender, diagnosed to have COPD with
FSP and Kyphosis, from Physiotherapy OPD of S.D.M.
Hospital, were studied and taken as per their inclusion
and exclusion criteria.
Inclusion and exclusion criteria: Inclusion criteria:
Subjects having mild to moderate COPD (as per GOLD
standards)9with FSP and Kyphosis. Subjects were
excluded if they had any respiratory conditions other
then COPD, cardiovascular, neuromuscular, or
orthopedic diseases. All the individuals with fixed
deformities of shoulder girdle and upper quadrant were
also excluded from the study.
Procedure: A routine method of evaluation and
collecting data on COPD with FSP and kyphosis was
done. Outcome measures such as Plumb line (PL), ISD
(inter scapular distance) was assessed to know FSP.
Kyphotic index(KI) was derived to know the percentage
of kyposis and maximal inspiratory pressure (PI Max)
was measured to know the strength of the inspiratory
muscles. After briefing the subjects about the study, their
written consent was taken and ethical clearance was
obtained prior to the study. A plumb line was hung 3
feet in front of a wall with the plumb bob approximately
a quarter inch off the floor anterior to the lateral mellolus.
This point was considered as a reference point for
assessing posture in lateral view. The subjects were in
bare feet, wearing clothing that allowed for visual
observation of body landmarks and standing between
the wall and the plumb line. Subjects were asked to
expose the external auditory meatus. The tip of the
acromian process was marked with a skin marker. The
distance from the tip of the shoulder (acromion processes
and is termed as landmark) and the plumb line was
measured with a scale. For the purpose of analysis,
FSP was graded as normal or mild that is considered to
be within normal limits(WNL) or grade 1 and was
measured from center of landmark in line with or up to
1cm anterior to the plumb line, moderate deviations or
grade 2 was measured from posterior border of
landmark in line with or displaced up to 1 cm anterior
to the plumb line , and severe or grade 3 was measured
from posterior border of bony landmark displaced more
than 1 cm beyond the plumbline.13,15 For measuring ISD
the subject was made to stand in his or her relaxed
posture with back exposed.The horizontal distance
229
between T3 spinous process and the vertebral border of

both the scapulae was measured by an cloth inch tape.
The distance was calculated in inches.15,16 Measurement
of kyphotic index was done using a flex curve ruler of
60 cms. Initially, the subjects were asked to expose their
spine and adopt their normal posture. C7 spinous
process and posterior superior iliac spine(PSIS) level
were marked.17 The flexicurve ruler was pressed against
their back with the top end placed against the C7
spinous process in the midline. The ruler was molded
into the shape of the subjects spine in the midline to
the level of the PSIS. The flexicurve ruler was removed
and the shape of the spine was then traced on a paper
consisting of the horizontal line.The cervical end of the
flexi curve was placed on the line and the distal end of
the ruler was made to coincide with the other end of the
horizontal line .The curvatures were then traced on the
paper. Thoracic height (H) and thoracic length (L) was
measured. The KI (%) was calculated as18
KI (%)= Thoracic height X 100
Thoracic length
The larger the KI, the more marked is the Kyphosis.
Inspiratory muscle strength was derived as PI Max
which was measured with a Magnehelic pressure
gauge(No. 2000-200cm) at residual volume (RV) with
the highest pressure generated in five trials taken as
PIMax. Initially the subject was made to sit and asked
to exhale slowly and completely (to RV). Then he/she
was asked to seal the lips firmly around the mouthpiece
(to prevent air leak), and then inhale forcefully through
the mouthpiece (as if he/she is trying to pull in hard,
like you are trying to suck up a thick milkshake). The
largest negative pressure sustained for 1 second on the
pressure gauge was recorded. The participant was
allowed to rest for about 1 minute, and then repeated
the maneuver 5 times. The highest value recorded, was
taken for the study. The mechanical pressure gauge has
minor tick marks at 5cmH2O increments, so results were
rounded to the nearest 5cmH2O19,20
Intervention: Threshold inspiratory muscle training
device (TIMT) was used to training the inspiratory
muscles. Subjects inhaled through the spring-loaded
TIMT device that provides resistance to inspiratory
muscles. The pressure settings are adjustable in 2cmH2O increments (range, -7cmH2O to-41cmH2O).The
subjects were asked to inspire hard enough through
the mouth piece to open the valve in the device and
permit inspiration against that force. Nose clip were
used to occlude nasal air flows. The initial training load
2/7/2013, 8:08 PM
intra-rater reliability, the measurements from all the

outcome parameters obtained in the first evaluation of
rater 1 and in the second evaluation of the same rater at
baseline, 8weeks and 3 months were analyzed using
(ICC1,1)21. Utilizing data from SPSS, Standard Error of
Measurement (SEM)22 as a measurement of the within
subject re-test variation (
)23
were obtained.
(resistance) was attempted at 30% of the patients

baseline PI Max. As the strength improved to the point
where subject were exercising for continuous of 30
minutes, then the pressure load was increased by2cmH2O. The advance in the pressure was up to, -40
cm H2O. TIMT was given with an intensity of 30% of
PIMax for 30 min/ day for 8 weeks10
Posture was corrected with subject standing in
upright posture and was asked to wear the brace (Vissco
posture brace) that fitted best in upper thoracic region
for a whole day (except while lying down) for 8 weeks.
The outcome measures were measured at baseline
(before intervention)and at the end of 8 weeks and 3
months of intervention.
Table 1: Discrpitive analysis and baseline

characterstics:
Mean SD
n
30
Age in years
52.87 5.04
Sex M/F
20 (67%)/10(33%)
ISD in inches
Data analysis: All analyses were done using SPSS

Ver-sion 16. Descriptive statistics are reported as means
and SD (standard deviation). A repeated measures
analysis of variance for each individual outcome
measure time was performed to determine if there was
any change in scores at three time periods. The repeated
measures of time were baseline, 8 weeks post
intervention and 3 months post intervention. The data
sphericity was tested using the Mauchly test. When the
test results were statistically significant, the data were
corrected using the Greenhouse-Geisser correction to
determine if significant differences existed between
conditions. For significant main effects, pairwise
comparisons were performed between levels using t
tests with a modified Bonferroni procedure. Significance
was set at p < 0.05.
5.35 0.71
Plumb line in grades
1.97 0.76
Kyphotic index (%)
11.20 0.90
PI Max in cm H2O
60.33 12.79
For values ranged from 1.0 to 0.81, the reliability

was conside-red excellent; from 0.80 to 0.61, very good;
from 0.60 to 0.41, good; from 0.40 to 0.21, reasonable
and, finally, from 0.20 to 0.00, poor1
RESULTS
Descriptive statistics of all subjects is given in Table
1.The means and standard deviations for all outcome
measures at baseline, 8 weeks and 3 months are shown
in Table 2. The Repeated measures ANOVA for the ISD
scores revealed a significant difference((F1.03,30.01)=
71.08,p<0.000) among three time periods. A post hoc
pair-wise t test showed means of ISD scores for all
three time periods(at baseline, 8 weeks post intervention
and 3 months post intervention) were significantly
different from one another (Table 2).
To determine inter-rater reliability, the measurements

from all the outcome parameters obtained by rater 1
and rater 2 at baseline, 8weeks and 3 months were
sub-jected to statistical analysis using Intraclass
Correlation Coe-fficient type 3,1 (ICC3,1)21. To determine
Table 2 Descriptive statistics [mean & SD] for the outcome measures for forward shoulder posture, kyphosis and
inspiratory muscle strength between three time periods
Outcome
Measures
ISD (Inches)
PL Scores(Grade)
Baseline
8WeeksPost intervention
3 MonthsPost intervention
Mean
SD
Mean
SD
Mean
SD
5.35
(0.71)
4.73
(0.54)
5.08
(0.61)
1.97
(0.76)
1.27
(0.64)
1.53
(0.63)
p-value*
0.000
(1-2, 1-3,2-3)
0.000
(1-2, 1-3)
0.090
(2-3)
KI Scores(%)
11.20
(0.90)
10.38
(1.11)
10.85
(0.98)
0.000
(1-2, 1-3,2-3)
PIMax Scores(Cm H2o)
60.33
(12.79)
90.67
(19.82)
81.17
(18.41)
0.000
(1-2, 1-3,2-3)
230
2/7/2013, 8:08 PM
*Repeated measures analysis of variance .Post-hoc

t tests with a modified Bonferroni procedure p < 0.05
statistically significant.
ISD=Intrascapular Distance; PL= Plumbline;
KI=Khyphotic index; PiMax=Maximal Inspiratory
pressure
There was 11.5% significant reduction (p<.000) of
ISD scores after 8 weeks post intervention. The Repeated
measures ANOVA for the PL scores revealed a
significant difference ((F 2,58)= 22.06,p<0.000) among
three time periods. A post hoc test showed means of PL
scores differed at all three time periods (Table2).There
was a statistical significant reduction(p<.000)of
plumbline measurement after 8weeks of intervention
with improvement scores of 35.53%. The Repeated

measures ANOVA for the KI scores revealed a
significant difference ((F1.56,45.39)= 62.05,p<0.000) among
three time periods. A post hoc pair-wise t test showed
means of KI scores for all three time periods were
significantly different from one another (Table 2).
Kyphotic index scores reduced 7.3% significantly
(p<0.000) following 8 weeks of post intervention. The
Repeated measures ANOVA for the PIMax scores
revealed a significant difference ((F 1.21,35.22 )=
195.78,p<0.000) among three time periods. A post hoc
pair-wise t test showed means of PIMax scores for all
three time periods were significantly different from one
another.
Table 3 Inter-Rater Reliability (ICC 3,1) for all OutcomeMeasures

Outcome
Rater 1
Measures
Rater 2
Mean
SD
Mean
SD
ICC 3,1
95%CI
Baseline
5.34
0.71
5.48
0.69
0.946
(.873; .976)
0.16
8th week
4.73
0.54
4.72
0.49
0.942
(.878; .972)
0.12
3months
5.08
0.61
5.18
0.68
0.929
(.850; .966)
0.18
PL Scores
Baseline
1.96
0.76
1.96
0.76
0.943
(.938; .986)
0.18
(Grades)
8th week
1.26
0.63
1.36
0.61
0.933
(.857; .968)
0.16
3months
1.53
0.62
1.63
0.66
0.937
(.867; .970)
0.17
0.33
ISD (Inches)
SEM
KI
Baseline
11.2
0.89
11.5
0.81
0.835
(.678; .966)
(%)
8th week
10.37
1.11
10.3
1.05
0.944
(.883; .973)
0.26
3months
10.85
0.97
10.77
0.96
0.993
(.981; .997)
0.09
PIMax
Baseline
60.3
12.7
61.5
10.5
0.923
(.840; .963)
3.3
(Cm H2O)
8th week
90.66
19.8
88.16
18.21
0.927
(.847; .965)
5.38
3months
81.16
18.41
79.16
15.09
0.914
(.821; .959)
5.05
ISD=Intrascapular Distance; PL= Plumbline; KI=Khyphotic Index; PiMax=Maximal Inspiratory Pressure;SEM= Standard Error
of Measurement
(Table 2).The maximal inspiratory pressure

increased significantly by 50.29% following 8 weeks
(p<0.000).The improvement was carried over till 3
months of followup in all variables except for PL
scores(table 2).Inter-rater and intra-rater reliability
estimates of all outcome measures at baseline, 8weeks
and 3 months are shown in Table 3 and Table 4
respectively. Interrater ICC scores were Excellent,
ranging from 0.83 to 0.94 for all measures with SEM
ranging from 0.09 to 5.38 (table 3).Similarly Intra rarter
ICC scores were Excellent, ranging from 0.956 to 0.999
for all measures with SEM ranging from 0.02 to 1.84
(table 4).
Discussion: COPD is the leading cause of morbidity
and mortality worldwide.12 Patients with COPD tend
to develop FSP and Kyphosis.1,11, 24 these postural
deviations affect the respiratory values1. This study
demonstrates an 8-week intervention program with a 3
231
month follow up. Following intervention, both posture

and inspiratory muscle strength improved in adult
COPD patients after 8 weeks and the improvement was
retained till 3 months of followup. Posture was corrected
by a brace and correction of posture was associated
with decrease in the intra scapular distance, kyphotic
index and plumb line. IMT was given by a TIMT device
and improvement in the inspiratory muscle strength
was associated with increase in the maximal
inspiratory pressure. Previous report 10 have
demonstrated the use of TIMT device for training
inspiratory muscles. IMT of 5 to 30 minutes for 6 weeks
at loads of >30% of baseline PIMax improved patients
inspiratory muscle strength, similar effects were found
with 8 weeks of intervention and 3 months of follow up
in this study (table 2).Poor posture along with weak
back muscles, causes inability to straighten the upper
back, which in turn limits the ability to raise and expand
the chest and maximize the lung capacity.13
2/7/2013, 8:08 PM
Table 4 Intrarater Reliability (ICC 1,1) for all Outcome Measures
Outcome
Rater1 (day1)
Measures
Rater1 (day2)
Mean
SD
Mean
Baseline
5.34
0.71
5.35
8th week
4.73
0.54
4.73
3months
5.08
0.61
5.11
PL
Baseline
1.96
0.76
(grades)
8th week
1.26
3months
1.53
KI
Baseline
(%)
PiMax
(Cm H2O)
ISD (inches)
SD
ICC 3,1
95%CI
SEM
0.7
0.999
(.997; .999)
0.07
0.54
0.997
(.995; .999)
0.02
0.61
0.998
(.996; .999)
0.02
1.93
0.78
0.957
(.909; .979)
0.17
0.63
1.26
0.63
0.956
(.907; .979)
0.13
0.62
15.3
0.62
0.956
(.908; .979)
0.14
11.2
0.89
11.2
0.89
0.999
(.997; .999)
0.08
8th week
10.37
1.11
10.38
1.1
0.999
(.998; 1.00)
0.11
3months
10.85
0.97
10.88
0.97
0.999
(.998; .999)
0.09
Baseline
60.3
12.7
60.5
12.6
0.999
(.997; .999)
1.27
8th week
90.66
19.8
90.83
20.3
0.997
(.995; .999)
1.09
3months
81.16
18.41
81.5
18.38
0.999
(.997; .999)
1.84
ISD=Intrascapular Distance; PL= Plumbline; KI=Khyphotic Index; PiMax=Maximal Inspiratory Pressure;SEM= Standard Error
of Measurement
We assume that correction of posture with brace,

would have aided in straightening the upper back and
expanding the chest, thus having an additional
beneficial effect on inspiratory muscle force generated
by the inspiratory muscles. Hence postural correction
might have influenced the increase in the PIMax values
along with inspiratory muscle training. In this study
we found a high inter rater(ICC 3,1)and intra rater (ICC
1,1) reliability ( table 3,4) for all measurements to
evaluate posture and strength of the inspiratory
muscles in COPD patients.
CONCLUSION
The results of this pilot study suggest that, TIMT
device can be used to improve the strength of the
inspiratory muscles. With addition of postural
correction by a brace, not only improved posture but
also aided in increasing the inspiratory muscle strength.
Hence, posture correction needs to be given adequate
importance in pulmonary rehabilitation of patients with
COPD, however, despite the lack of a control group and
the small size of the sample studied, we suggest that
further study is warranted.
REFERENCE
1.
2.
Hillegass and Sadowsky. Essentials of cardio

pulmonary physiotherapy, 2nd ed. WB Saunders
company,2001.p. 742.
Verheul AJ, Dekhuizen PN.Diaphragm
dysfunction in patients with COPD. Ned Tijdschr
Geneeskd.2003;147(18): 855-60.
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Roussos CS, Macklem PT. The Respiratory

Muscles. N Engl J Med 1982;307:786-97.
4.
Arora NS, Rochester DF. COPD and human
diaphragm muscle dimensions. Chest
1987;91:719-24.
5.
Rochester DF, Braun NMT, Arora NS. Respiratory
muscle strength in chronic obstructive pulmonary
disease. Am Rev Respir Dis 1979;199(suppl):
151-154.
6.
Bellemare F, Grassino A. Force reserve of the
diaphragm in patients with chronic obstructive
pulmonary disease.J Appl Physiol 1983;55:8-15.
7.
Morrison NJ, Richardson J, Dunn L, Pardy R.
Respiratory muscle performance in normal elderly
subjects and patients with COPD. Chest 1989; 95:
9091.
8.
Hamilton AL, Killian KJ, Summers E, Jones NL.
Muscle strength, symptom intensity, and exercise
capacity in patients with cardio respiratory
disorders. Am J Respir Crit Care Med
1995;152:2021-31.
9.
Global Initiative for Chronic Obstructive Lung
Disease. Global strategy for the diagnosis,
management, and prevention of chronic
obstructive pulmonary disease 2010. Available at
(http://www.goldcopd.org/uploads/users/
files/GOLDReport_April112011.pdf).October 19,
2011.
10. Nield MA. Inspiratory muscle training protocol
using a pressure threshold device: effect on
dyspnea in chronic obstructive pulmonary
disease. Arch Phys Med Rehabil. 1999;80:100-2.
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11.
12.
13.
14.
15.
16.
17.
Kisner C, Colby LA. Therapeutic exercise:

Foundations
and
techniques.
3rded:Philadelphia:FADavisCo;1996.p.111-710
Gaude G S, Nadagouda S. Nebulized
corticosteroids in the management of acute
exacerbation of COPD. Lung India.2010 octdec;27(4): 230-235.
Kendall FP, Kendall E, Provance PG, Rodgers
MM,RomaniWA. Muscles testing and function
with posture and pain. 5th ed. Baltimore,MD
:Lippincott Williams and Wilkins;2005.p.49-244.
Hall MC,BrodyTL. Therapeutic exercise. Moving
toward function. Philadelphia: Lippincott
Williams &Wilkins. Publ;1999:.p.557-60
Peterson DE, Blankenship KR, Robb BJ, Walker
MJ, Bryan JM, Stetts DM, Mincey LM, Simmons G.
Investigations of the validity and reliability of four
objective techniques for measuring forward
shoulder posture. JOSPT.(25).1997.p.34-41.
Sobush DC, Simoneau GG, Dietz KE, Levene JA,
Grossman RE, Smith WB. The Lennie test for
measuring scapular position in healthy young
adult females: A reliability and validity study.
JOSPT.1996;23(1):39-50.
Ensurd KE, Black DM, Harris F, Ettinger B,
CummingS SR, Colrelates of Kyphosis in older
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18. Bembalgi V. A cross sectional study of skeletal

deformities in post menopausal women in urban
and rural areas.Indian journal of physiotherapy
and occupational therapy,2010 june; 4(2): 87-88.
19. Sachs CM, Enright LP ,Hinckley Stukovsky KD,
Rui Jiang and R Graham B, for the Multhi-Ethnic
Study of Atherosclerosis Lung Study. Performance
of Maximal Inspiratory Pressure Tests and
Maximal Inspiratory Pressure Reference
Equations For 4 Race/Ethnic Groups. Respiratory
Care 2009;54(10):1321-1328,
20. Wen AS, Woo MS, Keens TG. How many
maneuvers are required to measure maximal
respiratory pressure accurately? Chest 1997;
111:802-807.
21. Weir JP. Quantifying test-retest reliability using the
intraclass correlation coefficient and the SEM. J
Strength Cond Res. 2005;19(1):231-40.
22. Peat JK, Mellis C, Williams K, Xuan W. Health
science research: a handbook of quantative
methods. London: SAGE Publications; 2002.
23. Harvill L. Standard error of measurement. Educ
Meas. 1991;10:33-41.
24. OSullivan BS, Schmitz JT. Physical rehabilitation
assessment and treatment. 4th ed. Philadelphia:
FA Davis Company. publ; 2001:445-465.
2/7/2013, 8:08 PM
Effect of Neck Extensor Muscles Fatigue on Postural

Control Using Balance Master
Reshma S.Gurav1, Rajashree V.Naik2

Lecturer, MGM College of Physiotherapy, Kamothe, Navi Mumbai, 2HOD and Professor, L.T.M.C. and Sion Hospital,
Sion, Mumbai
ABSTRACT
Background: Poor postural performance is observed in patients suffering from neck pain and following
Whiplash injuries. Fatigued muscles following the neck pathology are unable to transmit somatosensory
information to the central nervous system, and hence upright postural control may be compromised.
Hence there is need to investigate neck muscles fatigue and balance.
Objectives: 1.To assess the dynamic endurance of neck extensors till fatigue sets in.
2. To study the postural control pre and post fatigue in neck extensors.
Methods: 50 healthy students participated in the study. Balance assessment was done on balance
master with modified clinical test of sensory interaction and balance. Fatigue was induced in neck
extensor muscles using pressure biofeedback apparatus in supine position. The posturographic data
of sway velocity was obtained pre and post fatigue & analyzed with paired't' test.
Results: Postural sway velocities in mCTSIB test showed significant difference after inducing fatigue in
neck extensors (mean 0.14+0.22, P<0.001)
Conclusion: It is speculated that from the fatigued neck muscles, altered sensory input leading to
abnormal central processing may compromise balance, thereby reflecting a notable change in postural
sway.
Keywords: Fatigues, Postural Control, Sway Velocity.
INTRODUCTION
Balance, both literally and figuratively, is one of the

most important concepts and functions in life.
Historically balance has not been considered a critical
factor in rehabilitation of orthopedic patients or perhaps
the impact of these deficits on high-level functional
outcomes had not been sufficiently documented. Yet
balance deficits in orthopedic patients exist are often
persistent, impede the return of normal function and
increase the risk of re-injury.1
The crucial role of the sensory systems and the brain
in producing skilled, co-ordinated movement is
recognized by orthopedic physical therapist as
evidenced by closed chain testing and training.1, 2
Neuromuscular re-education is necessary for
efficient co-ordinated movement, which in turn is
necessary for skilled function on the job or on the playing
field.1,2,3
Balance a highly integrative process involving
multiple afferent pathways, depends on somatosensory,
44. RESHMA--234-237.pmd
234
visual and vestibular inputs for the reception of intrinsic

(body) and extrinsic (environment) information.
The brain for the integration of this information and
the formation of a motor plan and musculoskeletal
system for the production of adequate movements to
execute the plan. Problems in any of these areas can
lead to the imbalance. The known presence of
proprioceptive deficits and musculoskeletal
impairments in orthopedic patients should arouse the
suspicion that balance problem may exist in these
patients and research confirms these suspicions.1,2,3,4
Poor postural performance is observed in patients
suffering from neck pain and following whiplash injury
in which there is hyperextension injury and too much
rotation at the cervical spine.Especially those who have
had injuries or disruption of joint surface in the
peripheral joints or spine such as whiplash injuries to
the neck. The small intrinsic, deep dorsal and
suboccipital cervical muscles show a high density of
muscle spindles that are likely to provide a main
contribution to neck proprioception.
2/7/2013, 8:08 PM
If fatigued muscles are unable to transmit

somatosensory information to the CNS, then upright
postural control may be compromised. Therefore there
is need to use a specific testing method to determine the
correlation between the neck extensors fatigue and
balance1, 5
In the erect standing posture, the body undergoes a
constant swaying motion called postural sway or
sway envelope. Physiological postural sway is defined
as the continuous corrective movements around the
center of gravity of a body designed to maintain postural
control in the upright position while stand still.6, 7
Shumway- cook and Horak in 1986 suggested a
method for clinically assessing the influence of sensory
interaction on postural stability in the standing
position. The purpose of the test is to identify
abnormalities in the three sensory system contributing
to postural control- somatosensory, visual and
vestibular.
In mCTSIB (Modified Clinical Test of Sensory
Interaction of Balance) the level of challenge is increased
by altering the support surface from the firm level
forceplate to a complaint foam pad.
Mean COG sway velocity assessed under four
conditions: - In all conditions, low sway scores are good
and high sway scores are worse.8
Eyes open, firm surface.
Eyes closed, firm surface.
Eyes open, foam surface.
Eyes closed, foam surface.
MATERIAL AND METHODOLOGY

Study Design: -Experimental within subject design.
Selection Criteria -The study was carried out on
subjects selected from physiotherapy department, K.E.M
Hospital. The study was approved by the ethical
committee, Seth G. S. Medical College and K.E.M
Hospital and subjects gave informed consent to the
work.
50 Normal healthy students volunteered for the
study.
Subjects of either sex within the age group of 20-25
years were included.
There were no dropouts during the course of study.
EXCLUSION CRITERIA
Any history of cervical spine trauma.
Neck pain or any type of musculoskeletal treatment
taken for neck complaints in the past three months.
Any balance disorders.
Visual impairments not corrected by glasses.
H/o ankle sprains / knee ligament injuries.
STUDY MATERIAL
Pressure biofeedback apparatus.
Blood pressure apparatus (sphygmomanometer)
and stethoscope.
Balance master and foam
It was hypothesized that the balance would be

significantly changed when the fatigue sets in neck
extensors muscles.
Personal computer. Pentium 3, 128 MB, Neurocom

software
AIMS AND OBJECTIVES
STUDY PROCEDURE
AIM
Balance Assessment
To study the effect of neck extensor muscles fatigue

on postural control using balance master.
Balance master was connected to the personal

computer for obtaining digital recording of postural
sway. The subject was asked to stand still on the force
plate as per the foot placement displayed on the
computer screen.
OBJECTIVES
To assess the dynamic endurance of neck extensor

muscles till fatigue sets in.
To study the postural control on stable and unstable

surfaces pre and post fatigue in neck extensor
muscles.
44. RESHMA--234-237.pmd
235
The four test conditions of modified CTSIB (m CTSIB)

test administered each test for 10 seconds duration.
2/7/2013, 8:08 PM
The four test conditions were always administered

in chronological order Eyes open, firm surface (FIRM-EO)
Eyes closed, firm surface (FIRM-EC)
Eyes open, foam surface (FOAM-EO)
Eyes closed, foam surface (FOAM EC)
Posturographic data of sway velocity obtained for
each test.
Procedure for inducing fatigue in neck extensor
muscles.
The subject assumed a supine position on the plinth
with head and neck placed in neutral position such
that tragus of the ear and tip of the shoulder are in the
same horizontal plane. Layers of towels were placed
under the head to achieve the neutral position as
needed. The air bag of the stabilizer was folded into
three and placed behind the neck suboccipitally. The
airbag was inflated to 20 mmHg as baseline.
The subject was asked to perform the static neck
extension over the inflated cuff. The maximal neck
extension contraction was noted on biofeedback

apparatus. 60% of maximal voluntary isometric
contraction was calculated and subject was asked to
repeat that submaximal contraction as many times as
possible and no. of contractions were counted. The
biofeedback was held such that the performer and
subject both can see the fluctuations on the pointer.
When the subject was unable to exert the pressure at
given sub maximal pressure values against the cuff he
or she was allowed to stop and made to stand.
The blood pressure was measured to rule out the
effect of postural hypotension on balance. Again the
subject was taken on the balance master and
posturographic data obtained as earlier. The collected
posturographic data was analyzed statistically with
paired t test.
Results and Graphical Representation
Every condition of test and composite of all
conditions of the test were analyzed witht test in which
pre and post posturographic recordings were
compared.
TABLE -1 - Comparison of Postural sway velocities in four test conditions of mCTSIB pre and post neck extensors
fatigue
Sway Velocity
(in degrees/sec)
Firm
EO
Firm
EC
Foam
EO
Foam
EC
Composite
0.23
0.27
0.60
1.50
0.61
PRE
Mean
POST
Mean
0.32
0.34
0.68
1.56
0.73
DIFFERENCE
Mean
0.11*
0.07*
0.08*
0.06*
0.12*
P<0.001
P<0.1
P<0.01
P<0.05
P<0.001
P Value
*statistically significant
Observation Postural sway velocities before and

after neck extensors fatigue were compared using the
pairedt test. There was significant difference between
the Postural sway velocities demonstrated by subjects.
In eyes open on firm surface the difference was highly
significant (p value <0.001) whereas even though the
postural sway velocities were high in eyes closed on
foam surface the difference was significant. (p value
<0.05). The difference between the postural sway
velocities in composite of all test conditions was highly
significant at p value <0.001.
DISCUSSION
As observed in this study, there was maximum
increased postural sway in Eyes open, firm surface test
condition, in spite of all the three sensory inputs were
44. RESHMA--234-237.pmd
236
available, which can be explained as because of neck

muscles fatigue, the proprioceptors could not provide
the accurate somatosensory inputs to the CNS, required
for maintaining postural control and hence there was
increase in postural sway. It can also be said that as
this test was done immediately after the fatigue was
induced hence the postural sway was maximum in this
particular test condition as seen in graph 2.
In Eyes closed on firm surface, when the visual
information was unavailable, the postural sway was
increased and the difference between pre and post sway
velocity was statistically significant as in this condition
subjects relied more on somatosensory and vestibular
inputs.
In test conditions on foam surface, there was
additional challenge to musculoskeletal systems
2/7/2013, 8:08 PM
because of inaccurate somatosensory information. As

shown in table 3, the postural sway velocity was
increased definitely and the difference pre and post
fatigue was statistically significant.
So it can be inferred that mechanoreceptors of
the synovial facet joints and surrounding soft tissues
of the cervical spine if affected by a spinal injury such
as whiplash injury or chronic neck pain due to cervical
spondylosis can alter postural control. Stampley et al
(2006) in their study, Neck muscles fatigue and postural
control in patients with whiplash injury showed that
patients with whiplash injury show identifiable
increase in neck muscle fatigability and associated
increase in postural sway after contractions of dorsal
neck muscles and physiotherapy treatment reduces
these effects9.
CONCLUSION
The submaximal isometric contraction of the neck
extensor muscles for maximal no. of repetitions
produced changes in displacement of center of gravity
and velocity of postural sway in young healthy subjects.
Therefore this study accepts the hypothesis that the
neck extensor muscles fatigue significantly affects the
balance, which was confirmed by mCTSIB test.
Abnormal central processing of sensory input may
compromise balance in the setting of postural
perturbations to a greater degree in patients with neck
muscles weakness as in case of chronic neck patients
and whiplash injuries.
Ultimately, this may help us in developing objective
evaluation procedure and the priority treatment goal
for subjects suffering from neck complaints, thus taking
care of all aspects of functional rehabilitation of the
patients with neck complaints.
Department, my Guide, the Bio statistician, the

Departmental Staff and to all my subjects. I wish to
express my heartfelt gratitude to Mr. Vivek Nadkarni
and Mrs. Tanuja Nadkarni and whole team of
Neurocom international Ltd. I thank them for providing
me balance master equipment and their valuable
guidance and technical expertise in analyzing data.
Their special interest and assistance has been guiding
force in every step during the preparation of my study.
I thank Dr.Yesha Pandya (PT) for technical help.
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
9.
Kauffman, Nashner Lewis. Balance is critical

parameter in orthopedic rehabilitation.
Orthopadic Physical Therapy Clinics of North
America.New Technologies in Physical Therapy.
March 1997;(6-1)
Lewis Nashner. The anatomic basis of balance in
orthopedics. Orthopedic physical therapy clinics
of North America. March 2002;(11-1)
Blackburn TML, Voight , A matter of balance.
Rehabilitation Therapies. June 2001.
Guyton C, Hall JE. Textbook of medical physiology.
Chapter 49, 50, 51, 52, 55, 9th Edition
Mark Morningstar. Reflex control of the spine and
posture, a review of literature from a chiropractic
perspective. Chiropractic Osteopathy journal
2005; (13-16).
Sharon Thomas. Functional Efficiency of the
vestibular system in the performance of standing
balance Sept. 2004.
Shumway Cook, Motor control: Theory of
practical Application, 2nd edition, 1995.
Neurocom Internantional The clinical test for
the sensory interaction of balance Description
and definations.
Stapley D.J. Neck muscle fatigue & postural control
in patients which whiplash injury. Clinical
Neurophysiology March 2006, (117-3): 610-622.
ACKNOWLEDGEMENT
This is to acknowledge the help and support
extended to me by Head of the Physiotherapy
44. RESHMA--234-237.pmd
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2/7/2013, 8:08 PM
Aerobic Capacity in Regular Physical Exercise Group and

Indian Classical Dancers: A Comparative Study
Rupali B. Gaikwad1, Vijay Kumar R. waghmare2, D.N. Shenvi3
Assistant Professor, Dept. of Physiology, Govt. Medical College, Miraj Dist. Sangli, Maharashtra, 2Assistant Professor,
Dept. of Anatomy, Govt. Medical College, Miraj Dist. Sangli, Maharashtra, 3Associate professor, Dept. of Physiology,
Seth.G.S.M.C. & K.E.M.H., Parel, Mumbai, Maharashtra
ABSTRACT
Introduction: Dance in its many forms has recently received much attention in medical literature and
considerable promotion in the lay press. This has been in keeping with current awareness of physical
fitness, which has been the result of increasing evidence linking cardiovascular disease to physical
inactivity, lack of cardiopulmonary fitness and obesity.
One such program is aerobic or cardiovascular training program. Cardiovascular fitness is one of the
most important health component required for performing more physical work with many health
benefits. It is common notion that, only physical exercise provides fitness and is beneficial to health.
Attempts have been made in the past to correlate other physical activities like ballet (western dance)
with established physical exercise routines in gymnasium.1, 2. Indian classical dance is one of the
physical activities as it is performed regularly.
Material and Methods: The study group consists of 30 female subjects aged 17-30 yrs from each group
who had received training in their respective physical exercise/ activity for a minimum duration of 6
months. Aerobic power was determined by simple exercise step test (Queen's College step test). Grading
of aerobic capacity was done by using indirect estimation of VO2 Max.
Results: Comparison in the given study groups showed that; not only conventional aerobic exercises
but also any physical activity (Indian classical dance) performed regularly improved cardiovascular
endurance of an individual. This improvement in endurance was statistically proved.
Discussion: Comparison in the given study groups showed that; not only conventional aerobic exercises
but also any physical activity (Indian classical dance) performed regularly improved cardiovascular
endurance of an individual. This improvement in endurance was statistically proved.
Conclusion: The mean value of the vo2 max in ml/kg/min was found to be higher in Indian classical
dancers than females engaged in gymnasium.
The number and percentage of females falling into good and average category was more in Indian
classical dancers than females engaged in gymnasium. The percentage of Indian classical dancers
from Bharatnatyam type falling into good category was more than Indian classical dancers from Kathak
type.
This concludes that the vo2 max in ml/kg/ml and aerobic capacity under grading into "good" and
"average" category was more in Indian classical dancers than females engaged in gymnasium.
Keywords: VO2 Max (Aerobic Power), Aerobic Capacity, Indian Classical Dance, Physical Exercise Group.
INTRODUCTION
Less physical activity with relative sedentary life
style habits leads to gradual deteriorations of physical
wellbeing or even disability. Sports, exercise or everyday
chores will help us to live longer.
Today people are more aware of the fact that physical
exercise will not only decrease the incidence of health
problems but also lead to an improved quality of life
and longevity. Subsequently a new fitness trend has
45. Rupali --238-242.pmd
238
gradually developed over the last two decades which

has led to a tremendous increase in the number of
individuals who participates in fitness and wellness
programmers.
One such program is aerobic or cardiovascular
training program. Cardiovascular fitness is one of the
most important health component required for
performing more physical work with many health
benefits. It is common notion that, only physical
exercise provides fitness and is beneficial to health.
2/7/2013, 8:08 PM
Attempts have been made in the past to correlate other

physical activities like ballet (western dance) with
established physical exercise routines in gymnasium.1,
2
. Indian classical dance is one of the physical activities
as it is performed regularly. There are very few studies
3, 4, 5,6,7,8
showing that Indian classical dance (BharatNatayam, Kathak) can provide health related fitness
and endurance.
Study was done in 2 groups
First study group (engaged in physical exercise in
gymnasium): comprising of 30 female subjects of age
group 17 to 30 years.
Second study group (Indian classical dancers):
comprising of 30 female subjects of age group of 17 to
30 years.
of VO2 max/ aerobic power in ml/kg/ min between

Indian classical dancers & females engaged in
gymnasium. The VO2 Max/ aerobic power in ml/kg/
min was to be higher in Indian classical dancers than
females engaged in gymnasium. The difference was
found to be highly significant with the p value of 0.
The Table No. II show Comparison of actual &
predicted VO2 Max/ aerobic power (ml/kg/min) in
Indian classical dancers. There was difference in means
of actual VO2 Max & predicted VO2 Max. The difference
was found to be significant with the p value of 0.05.
The Table No. III show Comparison of actual &
predicted vo2 max / aerobic power VO2 Max (ml/kg/
min) in females engaged in gymnasium. There was no
difference in means of actual VO2 Max and predicted
VO 2 Max. The difference was found to be nonsignificant with p value of 0.05.
1) Subjects ages 17-30 years.
The Table No. IV show comparison of aerobic

capacity/fitness in both study groups; Indian classical
dancers and females engaged in gymnasium.
2) Minimum regular six months training (with at least

one session of one & half to two hours duration &
minimum three days in a week.)
The total number and percentage of females from

both study groups falling into average category was
more compared to good and fair category.
Exclusion criteria
The total number and percentage of females falling

into good and fair category was more in Indian
classical dancers compared to females engaged in
gymnasium.
Inclusion criteria
1) Subjects without regular 6 months training.

2) Subjects having any type of cardiopulmonary
diseases like myocardial infraction, unstable
angina, aortic stenosis, cardiac arrhythmia, acute
endocarditis, myocarditis and pericarditis. Such
subjects are excluded by history, general & systemic
examination.
The total number and percentage of females falling

into fair category was more which was from study
group of females engaged in gymnasium only.
DISCUSSION
METHODOLOGY
Cardiovascular endurance assessment by Queens
college step test:
The equipments used: Stepping bench of height
16.25 inches, Metronome set at 88 beats / min or 22
steps ups / min for women. Stop watch, Scale for
measuring height, weighing scale.
Prior to testing, required pretest instructions
will be given & test was properly explained &
demonstrated to each subject. Calculations were done
to obtain the results.
Observations & results
The Table No. I and the Fig.1 shows the Comparison
45. Rupali --238-242.pmd
239
It is common notion that only physical exercise

provides physical fitness & is beneficial to health. But
it is found that any type of physical activity done
regularly can improve cardiovascular endurance.
Indian classical dance is one of the physical activities
as it is done regularly. The VO2 max in ml/kg/ml and
aerobic capacity under grading into good and
average category was more in Indian classical
Following are the reasons.
a) Muscle group involved
The total muscle mass involved in Indian classical
dance was much more and variable, moment to
moment, in the entire duration of the activity in
2/7/2013, 8:08 PM
comparison to females engaged in gymnasium.

Predominantly the lower extremity is involved in the
exercises performed by the females engaged in
gymnasium. Thus higher the VO 2 Max in Indian
classical dancers.
The organism (inclusive heart) could tolerate a
prolongation of the exercise period when larger mass
of skeletal muscle were activated. The subjective feeling
of strain was more related to metabolism. Therefore a
training of the oxygen transporting system was more
efficient and psychologically less strenuous, the larger
the muscular mass involved in dynamic activities. 9
b) Duration
Indian classical dancers were practicing for an
average duration of 45-60min daily. In addition, they
were also learning the skills for 3-4 days in a week.
This might be classified as intermittent type of training
method. (Teacher teaches dance step for 5 min then
student dances for learning that step for 5 to 10 min.)
Compared to Indian classical dancers, females
engaged in gymnasium did the exercise for an average
duration of 60 min. (15 to 20 minutes- treadmill, cross
cycling, stepper; 30 min strength and flexibility
exercise.) females did this training for 5-6 days on an
average in a week.
No threshold duration per workout exists for optimal
aerobic improvement. If threshold exists, it probably
depends on the interaction of total work accomplished
(duration or training volume), exercise intensity,
training frequency and initial fitness level. Generally,
the more frequent and longer the endurance training
programme is, the greater will be the fitness benefits10.
c) Effect of Nritta, specific position, Natya, Nritya and
music in Bharatnatyam.
Bharatnatyam comprises three aspects, Nritta,
Nritya and Natya.
action. The solar plexus at the naval forms the centre

from which all movements originate and are controlled
by breath. The vibrations generated by Nritta lead to
correction of energy imbalance in the body by acting
upon nervous flexes or chakras a result of biochemical
changes. Natya, Nritya and music were helpful in
reducing the stress and increasing the functions of
limbic system, reticular activating system, probably by
releasing the neurotransmitters. This might help to
elevate the mood and to keep the mind calm and alert.
d) Effect of Kathak
In Kathak physical activity is based on bhav (mood),
raga (melody) and tala (rhythmic beat) mainly. Kathak
dance is an art which has mainly vigor of dynamic foot
work and pin point spins the subtle movements of the
face and blended with miming of stories of all kinds. In
Kathak workload was by bells around the ankles,
leg exercise by tapping of feet in a high speed rhythm
called Tatkar. Kathak dance improves and maintains
cardiovascular endurance and respiratory fitness.
Females engaged in gymnasium were performing
exercises on treadmill, cross cycling and stepper with
strength and flexibility exercises. Females engaged in
gymnasium had speed, inclination variation while they
were performing exercises on treadmill.
e) Training period
Training period varies among dancers & among
females engaged in gymnasium.
f)
Goal
The goal of most of the Indian classical dancers is to

attain expertise in a dance form, some of them wanted
to make career in dance and few of them were dancing
as a hobby. But the goal of the females engaged in
gymnasium was to reduce weight to maintain figure,
while some of them wanted to achieve for physical
fitness.
Nritta are rhythmical and repetitive elements, i.e.

it is dance proper.
CONCLUSION
Natya (Abhinaya) is the dramatic art, and is a

language of gestures, poses and mime.
.This concludes that the VO2 max in ml/kg/ml and

aerobic capacity under grading into good and
average category was more in Indian classical
Nritya is a combination of Nritta and Natya.

Nritta in Bharatnatyam type includes complex steps
in different postures with expressions which involve
each and every part of the body of the dancer. In Nritta
the whole body was made the instrument to produce
45. Rupali --238-242.pmd
240
Thus physical activity like Indian classical dance

done regularly improved aerobic capacity/
cardiovascular endurance in dancers.
2/7/2013, 8:08 PM
Table I. Comparison of VO2 max/ aerobic power in ml/kg/ min between Indian Classical dancers & females
engaged in gymnasium.
Samplesize
VO2 max in ml/kg/ min

mean
S.D.
Indian classical
dancers
30
38.5975
2.2798
0.4162
Females engaged
in gymnasium
30
33.7707
2.5108
0.4584
S.D. = standard deviation,
Indian classical
dancers vs. females
engaged in gymnasium.
S.E. of
mean
t value
p value
7.7952
P< o.oo1Highly
significant
S.E. of mean = standard error of mean the unpairedt test was used for the test of significance.
Table II. Comparison of actual & predicted VO2 Max/ aerobic power (ml/kg/min) in Indian classical dancers.
Sample
size
Actual VO2
Max (Mean)
Predicted VO2
Max (Mean)
S.D.
30
38.5975
42.6068
4.0093
4.5042
IndianClassical dancers
Actual vs.
predicted VO2 Max
t' value
p' value
4.875
<0.05 significant t
d= mean difference, S.D. = standard deviation. The pairedt test was used for the test of significance.
Table III. Comparison of actual & predicted vo2 max / aerobic power (ml/kg/min) in females engaged in gymnasium.
Sample
size
Actual VO2
Max (Mean)
Predicted VO2
Max (Mean)
S.D.
30
33.7707
33.2747
0.4959
2.5188
Females engaged in
gymnasium.
Actual vs.
predicted VO2 Max
t' value
p' value
1.0784
<0.05Nonsignificant t
d= mean difference, S.D. = standard deviation the pairedt test was used for the test of significance.
Table IV. Comparison of aerobic capacity/fitness in both study groups; Indian classical dancers
and females engaged in gymnasium.
Aerobic capacity based on
age, gender and maximal
oxygen consumption
(VO2 Max) in ml/kg/min
Good (%)
Average (%)
Indian classical dance- Kathak
06(9.99%)
11(18.33%)
Fair (%)
0
Indian classical dance-Bharatnatyam
06(9.99%)
07(11.67%)
Females engaged in gymnasium
01(1.66%)
09(15%)
20(33.33%)
Total (%)
13(21.64%)
27(45%)
20(33.33%)
1.
2.
REFERENCES
COHEN JL, S EGAL KR, Witrol I, et al., Cardio
respiratory responses to ballet exercise and VO2
Max. of elite ballet dancers. Med Sci Sports Exerc.
1982; 14: 212-217.
ROBIN D. CHEMELAR, BARRY B. SCHULTZ, ROBERt O.
RUHLING, TERRY A. SHEPHERD, MICHAEL F. ZUPAN, SALLY
S. FITT., A physiologic profile comparing levels
and styles of female dancers. The Physician and
Sports Medicine. July 1988; Vol.16, No. 7: 87-97.
45. Rupali --238-242.pmd
241
3.
4.
5.
GABER C. E., MCKINNEY J. S. and CARTETON R. A., Is

aerobic dance an effective alternative to walk jog
exercise training? Indian Journal of Medical
Research. 1968; 56, No.6, June: 845-849.
HANNA J.L., the power of dance: health and
healing. J Altern Complement Med. 1995; winter,
1(4): 323-331.
MILLBURN S., BUTTS N. K., A comparison of the
training responses to aerobic dance and jogging
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6.
7.
8.
in college females, Med Sci Sports Exerc. 1983;

15(6): 510-513.
N OVAC L. P., M AGILL L. A. and S CHUTTE J. E.,
Maximal oxygen intake and body composition
of female dancers. Eur J Appl Physiol Occup
Physiol. 1978; Oct 20, 39(4):277-282.
PEPPER M. S., Dance a suitable form of exercise?
A Physiological appraisal. S Afr Med J. 1984; Des
8, 66(23):883-888.
Changes in selected cardio respiratory responses
45. Rupali --238-242.pmd
242
to exercise and in body composition, following 12

week aerobic dance programme. Jr Sports Sci;
winter, 4(3): 189-199.
9.
ASTRAND P.O. and RODAHL K., Textbook of Work
Physiology. 1988; Third edition, (London:
MacGraw Hill), pp. 311,356,361.
10. Merle L. Foss.,Steven J Keteyian , Foxs
Physiological basis for exercise & sports. 1998;
Sixth edition, (MacGraw Hill), pp. 301-303.
2/7/2013, 8:08 PM
Comparative Study to Determine the Hand Grip Strength

in Type-II Diabetes Versus Non-Diabetic Individuals - A
Cross Sectional Study
Jayaraj C. Sindhur1, Parmar Sanjay2
Associate Professor, Dept. of Medicine, 2Assistant Professor, Dept. of Physiotherapy,
S.D.M. College of Medical Sciences & Hospital, Dharwad
ABSTRACT
Abstract: Background and objective: The diabeties is increasing in developing countries, many
complication have been studied hand getting affected is one of them. As hand is major in human
function. So objective of this study was to evaluate the grip strength in diabetic group and compare
with non-diabetic individuals.
Materials & Method: After obtaining ethical clearance, a pilot study was conducted and total 274
subjects 137 in each group that is diabetic and non-diabetic were assessed for hand grip strength and
compared with each other. The standard method of assessment by using hand dynamometer and Body
Mass Index was assessed by using stadiometer and weaning machine. After obtaining of the data
analysis was done.
Results: The mean age of diabetic group was 57.63 + 6.76 year, non diabetic mean age was 57.70 + 6.48.
The mean Body Mass Index was 22.81 +2.04 kg/m2 and 24.62+3.06 in non-diabetic and diabetic group
was respectively. The mean grip strength for the diabetic left hand was 13 kgs while non-diabetic it was
15kgs while right hand was 14kgs in diabetics and 16kgs was in non-diabetic individuals.
Conclusions: We concluded that there is significant reduction in grip strength in diabetic group. It was
increased as the duration of diabeties was increased. There fore incorporating grip strength evaluation
and treatment at the earlier stages may help in preventing complication, which will also reduce the
impact on functional disability in diabetic population.
Keywords: Diabetes Mellitus, Grip Strength, Hand Dynamometer
INTRODUCTION
As per word health organization (WHO), diabetes
mellitus is a heterogeneous metabolic disorder
characterized by common feature of chronic
hyperglycemia with disturbance of carbohydrate, fat
and protein metabolism is a leading cause of morbidity
and mortality1.
India leads the world with largest number of diabetic
subjects earning dubious distinction of being termed
the diabetic capital of world according to diabetes
atlas 2006 published by the international diabetes
federation, number of people with diabetes in India
currently around 40.9 million is expected to rise to 69.9
million by 2025 unless urgent preventive steps are
taken.2
46. Sanjay parmar--243-246.pmd
243
Diabetes causes various system dysfunction and

which leads to disabling function which include
musculoskeletal disorder although other complication
of diabetes are better recognized as cause of the
morbidity and mortality. The musculoskeletal
syndromes associated it with it may be very
debilitating.3
The prevalence of connective tissue disorder in these
patient has increased in the recent years affecting
significantly their quality of life. Approximately 82.6%
of individual with diabetes have been found to exhibit
musculoskeletal abnormalities, mainly of the
degenerative, non-inflammatory type musculoskeletal
disorder are the common finding among patient with
type II diabetes. It causes connective tissue in many
ways which leads to different alteration in periarticular
and skelectur system.4
2/7/2013, 8:08 PM
The hand of human is remarkable instrument,

capable of performing countless actions owing to its
function as prehension and precision. The functional
view point of the hand is the effectar organ of the
upperlimb which supports it mechanically and allows
it adopt the optimal position for any given action.
However hand is not only motor organ but also a very
sensitive and accurate sensory receptor, which feeds
back information essential for its own performance.5
Grip strength is one of the many components to be
considered in the examination of the hand function.
The grip strength measurement can provide objective
the quantifiable information regarding hand function.6
Inclusion Criteria
Subjects of either gender of any age with type-II
diabetics as diagnosed according to American Diabetic
Association Criteria.8
Exclusion Criteria
1. Any musculoskeletal, Neurological, Disorder/
Injury
2. Subjects unwilling and not comfortable during
procedure or before.
Less importance has been given to hand in diabetes

mellitus, though hand function is crucial for
productivity and quality of life.7
Sampling: Convenient Sampling as all included.

Earlier as diabetic group which were diagnosed. The
sample derived from pilot study which came upto 274
individuals divided as 137 diabetic individuals and
than age matched and gender, BMI matched individuals
were taken for the study.
OBJECTIVE OF STUDY
PROCEDURE
To study the hand grip strength in type II diabetes

mellitus as compare to non-diabetes age matched
individuals.
The study was approved by the SDM College of

Medical Science & Hospital Ethical committee. Subjects
with diabetics mellitus were screened by doing routine
blood test and previous record which followed to the
Principal Investigator. Grip strength was collected
using Hand Dynamometer9,10. Inter- rater and intra
rater reliability were assessed by a pilot study and r
values were found to be 0.95 and 0.94 respectively.
HYPOTHESIS
Null Hypothesis: There will not be difference in
Hand grip strength in non-diabetic to diabetic
individuals.
Alternative Hypothesis: There will be difference in
Hand grip strength in non-diabetic to diabetic
individuals
MATERIAL AND METHODOLOGY
Department of medicine S.D.M. College Medical
Science & Hospital Dharwad.
Before testing vitals were noted and the procedure

was explained and demonstrated in local language.
The position prescribed by the American Society of
Hand Therapist was used. The dynamometer reading
taken was mean was three trials for each hand. The
dynamometer was reset to zero prior to each reading
and was read to be nearest increment of the 2 scale
division. 60 second rest was given between each trial.
Each contraction was held for 3 seconds. 11
RESULTS
MATERIAL
1. Data collection sheet including conset form
2. Hand dynamometer (IMI-1417)
3. Straight backed chair without armrest
4. Sphygmomanomenter (Diamond)
5. Steltho Scope (Littman)
6. Weighing machine (Koups)
Table I . Distribution of Study Subject according to

study groups and gender
Groups
Male
Female
Total
Diabetic
64
46.72
73
53.28
137
Non-Diabetic
64
46.72
73
53.28
137
Total
128
46.35
146
53.65
274
Table 2. Mean and standard Deviation or study

samples according to groups
Groups
Mean age (Years)
Standard Deviation
7. Stadiomeler
Diabetic
57.63
6.76
Non-Diabetic
57.70
6.48
8. Goniometer (IMR: 1432)
Total
57.66
6.61
244
2/7/2013, 8:08 PM
Table 3.Comparison of diabetic and
non-diabetic groups with respect to grip
strength (Kg) by unpairedt test.
FUTURE SCOPE
Variables
Groups
Mean
SD
t value
P-value
Grip strength
kgs in left hand
Diabetic
Non diabetic
12.820
15.006
3.93
3.21
-5.034
0.000
Grip strength
in Kgs on right
hand
Diabetic
Non diabetic
13.868
15.960
4.06
3.22
-4.71
0.000
CONCLUSION
Significant at 5% level of significance (P<0.05)
DISCUSSION
Hand is an important target for diabetic
musculoskeletal complication. Much less attention has
been given to the hand. Hand function is crucical for
productivity and quality of life.12,13 The mean BMI was
25.18 kg/m2 in diabetic and 25.69 kg/m2 in non diabetic
thus no significant difference was found. As BMI (Body
Mass Index) said to influence grip strength. That is
individual with higher BMI has higher grip strength.
The Systolic Blood Pressure (SBP) & Diastolic Blood
Pressure (DBP) was changed significantly this was true
for both group. The recommended 3 second duration of
hold and repetition of three times was used in study so
as to register maximum reading. However isometric
muscle contraction can cause in blood pressure and
heart rate which was monitered by physician. The blood
pressure values came to normal in 3 minutes.11
Hand grip values were significantly lower in
diabetic group compared with control non diabetic
group. This finding is in accordance with studies by
Cetinus et al and Sayer et al, in there study evaluated
muscle strength and physical function in 1391 diabetic
subjects it was found that mean grip strength in diabetic
was 41.8 kgs while as in normal non- diabetic it was
44.7 kgs. (P=0.002).14
Also reduction in grip strength is associated with
power glycemic control with increased systemic
inflammatory cytokines such as Tumor Necrosis Factor
(TNF-) and interleukin-6(IL-6) have detrimental
effects on muscle function. Distal symmetrical
neuropathy which may present sebclinically is also
responsible for distal muscle weakness and therefore
attributes to low grip strength15.
LIMITATIONS
Work profile /level of physical activity were not
taken into considerations
245
To study correlation between duration of diabetic

and grip strength as a longitudinal study
The objective of this study was to determine grip

strength between diabetic and non- diabetic
population. Thus we conclude that be grip strength gets
reduction and early medical and physical therapy
intervention may show better out come in hand function
REFERENCES
Mohan H. Textbook of pathology 5th ed New Delh:
Jaypee Brothers Medical publisher 2005. P 842-48
2.
Mohan V. Sandeep S.; Epidemiology of Type -2
Diabetes: Indian scenario Indian J. Med Res (serial
online) 2007 March (cited 2008 Oct. 23); 25:
217-230
3.
Joslin E. Joslins diabetes mellitus 14th ed Boston:
Lippincott Williams and Wilkins: 2004,
P. 1061-1121.
4.
Browne D, Mc care F. Musculoskeletal disease in
diabetes 18 (2); 62-64; 2009
5.
Magee D. Orthopedic physical Assessment 4th
edition penny sylovania Elsevier science; 2002, p
355-418
6.
Kuzala EA, Vargo MC. The Relationship between
elbow position and grip strength. Am J occup Ther
1992; 46 (6): 509-512
7.
Cosanova JE, Young MS, Hand function in patient
with diabetic mellitus, southern medical journal
(serial online) 1991 September (citied 2008
September 10); 84 (9): 1111-1113
8.
Stewart P. Diagnosis and classification of Diabetes
mellitus. Diabetes care (serial online) 2008 Jan
(cited 2008 Sept. 4); 31 suppl 1:55-60
9.
McAradle WD, frank IK, victor L. Exercise
physiology Energy, Nutrition and Human
performance 6th ed Baltimore: Lippincott Williams
and Wilkins: 2007 P 774-775.
10. Brown SC, Millor WC, JC ME: Exercise
Physiology: Basis of Human Movement in health
disease 6th ed London Lippincott Williams and
Wilkins; 2007 P 529-530
11. Innes E. Hand grip strength testing: A review of
the literature. Australian occupational therapy
Journal (serial online) 1999 (cited 2008 August
2011); 46 ; 120-140
1.
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12. Casanopva JS, Young MJ. Hand function in patient

with diabetes mellitus. Southern medial Journal
(serial online) 1991 Sept. 2008; 84 (9) ; 1111-1113
13. Savas, Hakanc, et al: The effects of the diabeties
related soft tissue hand legion and the reduced
hand strength on function disability of hand in
type 2 diabetic patient. Diabetic Research and
clinical practice 2007; 77: 77-83
14. Sayers, Dennison E- Type 2 diabetes, muscle
246
strength and impaired physical function. Diabetes

care (serial online) 2005 (cited 2008 August 2011);
28 (10): 2541-2.
15. Goodpaster BH, Decreased muscle strength and
quality in older adults with type 2 diabetes: The
Health ageing and body composition study
diabetes (serial online) 2006 Jun (cited 2008
October 2008); 55:1813-1818
2/7/2013, 8:08 PM
Study of Correlation between Hypermobility and Body

Mass Index in Children aged 6-12 Years
Parmar Sanjay1, Praveen. S. Bagalkoti2, Rajlaxmi Kubasadgoudar2
Assistant Professor, Department of Physiotherapy, 2Associate Professor, Department of Pediatrics,
SDM College of Medical Sciences And Hospital, Dharwad, 2Consultant Pediatric Physiotherapist,
Regional Neuroscience Centre, Hubli, Karnataka
1
ABSTRACT
Objectives: Joint hypermobility indicates an increase in the range of joint movement among normal
individuals. Joint hypermobility commonly occurs in school age children (8-39%). Weight gain may
precipitate the onset of symptoms of hypermobility syndrome. This study was done to assess the
correlation between hypermobility and body mass index in children aged 6-12 years.
Design: Cross sectional study
Methods: Beighton score was used to evaluate 420 healthy children. One point was scored for each
positive result (maximum: 9). Scores >4 were considered to be generalised hypermobility. Body mass
index was calculated using height and weight of the children. Then, the data was evaluated statistically
using SPSS 16.0 version statistical software and results were obtained.
Results: The result showed that 57.14% of hypermobile children were under weight, 35.93% of
hypermobile children had normal weight, 19.15% of hypermobile children were at risk of being
overweight where as 16.67% of hypermobile children were overweight. A negative correlation (-0.0008)
between hyper mobility and BMI was found.
Conclusion: Hypermobility was more prevalent (57.14%) among under weight children aged 6-12
years.
Keywords: Hypermobility, Beighton Score, 6-12 Years Aged Children, Body Mass Index
INTRODUCTION
Generalised joint hypermobility indicates an
increased range of motion in general compared with
the mean range of motion. Generalised joint
hypermobility is claimed to be present in 515% of
general population.1 There is clear evidence that factors
such as gender, age group, ethnic group, certain physical
activities and their intensity, and the presence of certain
pathological conditions, may be associated with joint
mobility.2 Greater range of motion is inherently present
in children than adults.3
The most widely used scale for hypermobility is the
Beighton hypermobility score. It can be conducted
easily and requires less time. A study done by van der
Giessen LJ showed that Beighton score is valid in
healthy children aged between 4 to 12 years.4 It is a
practical and reliable method for defining
hypermobility in children.
247
Ancedontal evidence suggests that sudden and

substantial weight gain may precipitate the onset of
symptoms, notably arthralgia, in previously
asyptomatic hypermobile individuals. Despite the fact
that no study has yet demonstrated an improvement in
symptoms following weight loss, it would seem
advisable to recommend such a measure to obese adults
or children with the symptoms.5
There is no study done on correlation between
hypermobility and body mass index in children aged
6-12 years. There is need for identifying body mass index
in hypermobile children who are at risk of developing
musculoskeletal complications. Education and
therapeutic interventions can be targeted to this specific
group of children before they become symptomatic and
prevent further sequelae.
In this study we assessed the correlation between
hypermobility and body mass index in children aged
612 years.
2/7/2013, 8:08 PM
METHOD
Before commencement of the study, an ethical
clearance from Shri Dharmastala Manjunatheshwara
Institutional Ethical Committee, Dharwad was taken.
Children from various schools of Dharwad were
included in the study. Prior to the commencement of
the study, a written consent letter was obtained from all
parents.
SUBJECTS
420 children aged 612 years were included, of
which there were 252 boys and 168 girls. At first, all the
children were screened by a paediatrician and children
with skeletal problems such as fracture, neuromuscular
disorder like cerebral palsy, rheumatic disorders,
metabolic dysfunctions or disorders such as
homocystinuria, developmental delay and genetic
disorders such as downs syndrome were excluded.
PROCEDURE
Joint hypermobility was measured in five body areas
using Beighton score. One point was scored for each

positive result (for each side), and scores of 4 or more
points were considered to be generalised hypermobility.
The children were categorized according to the scoring.
Along with scoring the hypermobility, even height
and weight of the children were taken. Body mass index
(kg/mt2) was calculated using these height and weight
measurements. According to CDC growth charts, the
children were categorized as underweight, normal
weight, at risk of being overweight and overweight
groups.
SPSS 16.0 version statistical software was used for
statistical analysis. The investigator used Chi square
test to evaluate the descriptive statistics that is
distribution of study subjects by BMI and generalised
hypermobility. Then, the Correlation between hyper
mobility scores (i.e. only scores are greater than or equal
to 4) with BMI scores was found out using Karl
Pearsons correlation method.
RESULTS
Table1. Distribution of study subjects by BMI and hyper mobility.
BMI
Normal mobility
Hyper mobility
Total
42.86
12
57.14
21
5.00
Normal weight
214
64.07
120
35.93
334
79.52
At risk of being overweight
38
80.85
19.15
47
11.19
Overweight
15
83.33
16.67
18
4.29
276
65.71
144
34.29
420
100.00
Underweight
Total
Chi-square=12.5291
df=3 p=0.0057, S
Table1 shows the distribution of study subjects with

respect to BMI and hyper mobility. This table shows
that 57.14% of hypermobile children were under weight,
35.93% of hypermobile children had normal weight,
19.15% of hypermobile children were at risk of being

overweight where as 16.67% of hypermobile children
were overweight.
Table 2. Correlation between hyper mobility scores with BMI scores by Karl Pearsons correlation method
Correlation between Hyper
mobility scores (i.e. only scores are
greater than or equal to 4) with
BMI scores
Table 2 shows correlation between hyper mobility

scores (i.e. only scores are greater than or equal to 4)
248
Correlation coefficient
t-value
p-value
-0.0008
-0.0099
0.9921
with BMI scores. There was negative correlation

coefficient of -0.0008 between hypermobility and BMI.
2/7/2013, 8:08 PM
DISCUSSION
The purpose of this study was to assess the
correlation between hypermobility and body mass index
in children aged 612 years.
A study was done to know the prevalence of joint
hypermobility in children from Mumbai, India and its
association with malnutrition. 829 children of the lower
urban socio-economic strata, between 3 and 19 years of
age were evaluated independently by two observers for
hypermobility using the Beighton 9-point scoring
system. Their nutritional status was stratified using
standard Indian growth charts and hypermobility was
quantified in various nutritional groups.
Musculoskeletal symptoms were assessed by a
questionnaire given to parents. They found
hypermobility in 58.7% of population. Near equal sex
incidence was noted. A higher incidence of finger signs
was noted in comparison to elbow hyperextension,
knee hyperextension and hands to floor. 26% of the
hypermobile population had musculoskeletal
symptoms as compared with 17.2% of the non
hypermobile population. A positive Beighton score was
found in children with grade 3 and 4 malnutrition and
26.1% of those hypermobile had musculoskeletal to
symptoms in comparison 17.7% of their non
hypermobile counterparts.6
A population-based evaluation of generalized joint
laxity (Hypermobility) in fourteen-year-old children
from the UK was studied. Among the 6,022 children
evaluated, the prevalence of hypermobility (defined as
a Beighton score of >4 [i.e., >4 joints affected]) in girls
and boys age 13.8 years was 27.5% and 10.6%,
respectively. 45% of girls and 29% of boys had
hypermobile fingers. There was a suggestion of a
positive association between hypermobility in girls and
variables including physical activity, body mass index,
and maternal education. Girls who were obese were
2.7 times more likely to be hypermobile (adjusted OR
2.70 [95% CI 1.245.88]) compared to girls who were
underweight.7
Our study showed that 57.14% of hypermobile
children were under weight, 35.93% of hypermobile
children had normal weight, 19.15% of hypermobile
children were at risk of being overweight where as
16.67% of hypermobile children were overweight.
249
The limitations to our study was that further follow

up regarding any complication secondary to
generalised hypermobility was not carried out.
Moreover, hypermobile children were screened
subjectively and individual hypermobility were not
documented (example, elbow hyperextension). No
correlation between socioeconomic factor and
hypermobility was studied.
Future scope of this study will be long term follow
up of any secondary problem in hypermobile group of
various body mass index.
CONCLUSION
From this study, we can conclude that hypermobility
is more prevalent (57.14%) among under weight
children aged 6-12 years.
REFERENCES
1.
2.
3.
4.
5.
6.
7.
Russek LN. Hypermobility syndrome. Phys Ther

1999 Jun;79(6):591-599.
Lamari NM, Chueire AG, Cordeiro JA. Analysis
of joint mobility patterns among preschool
children. Sao Paulo Med J 2005 May 2;123(3):
119-123.
Juul Kristensen B, Rogind H, Jensen DV, Remvig
L. Inter-examiner reproducibility of tests and
criteria for generalized joint hypermobility and
benign joint hypermobility. Rheumatology
(Oxford) 2007 Dec;46(12):1835-1841.
van der Giessen LJ, Liekens D, Rutgers KJ,
Hartman A, Mulder PG, Oranje AP. Validation of
Beighton score and prevalence of connective tissue
signs in 773 Dutch children. J Rheumatol 2001
Dec;28(12):2726-2730.
Peter Beighton, Rodney Grahame, Howard Bird.
Hypermobility of joints. 4th ed. Springer Verlag
London Limited; 2012. p. 82.
Hasija RP, Khubchandani RP, Shenoi S. Joint
hypermobility in Indian children. Clin Exp
Rheumatol 2008 Jan-Feb;26(1):146-150.
Clinch J, Deere K, Sayers A, Palmer S, Riddoch C,
Tobias JH, Clark EM. Epidemiology of generalised
joint laxity (hypermobility) in fourteen year old
children from the UK. Arthritis Rheum. 2011
Sep;63(9):2819-2827.
2/7/2013, 8:08 PM
Comparison of Reaction Time in Older Versus Middle-aged

Type II Diabetic Patients - An observational Study
Shruti Bhat1, Sanjiv Kumar2
MPT, Dept of Neuro Physiotherapy, 2PhD Principal and Professor, Institute of Physiotherapy,
KLE University, Belgaum
ABSTRACT
Introduction: Diabetes mellitus affects the various systems of the body like the somatosensory, auditory
system and slows psychomotor and cognitive responses all of which together may affect the reaction
time. Reaction time is the time taken by the individual to react or respond to a applied stimuli. Slowing
of these reaction times affects the everyday tasks such as balance, increasing probability of a slip or a
fall.
Objective: The objective of the study was to evaluate and compare the reaction time of the middle aged
and old age individuals with type II diabetes mellitus.
Methodology: Thirty individuals having diabetes mellitus of age 40 to 60 were randomly allotted in
two groups. The individuals between 40 to 60 years were allotted to Group A and those between 60 to
80 years were allotted to Group B. The reaction time of both the groups were evaluated by using Drop
Ruler Test and compared.
Results: Results showed that the reaction time in Group A was 0.19 seconds (0.01) and in group B it
was 0.21 seconds (0.01). The reaction time was more in group B compared to group A but was not
statistically significant. The co-relation co-efficient between age and reaction time of the two groups
combined was r=0.605
Keywords: Diabetes Mellitus, Reaction time, Drop Ruler Test, Middle aged, Old age.
INTRODUCTION
Diabetes mellitus a metabolic disorder of multiple
aetiology. It is characterized by chronic hyperglycaemia
associated with disturbances of carbohydrate, fat and
protein metabolism. This may result due to defect in the
production of insulin or its action or due to both the
mechanism.1 India ranks first in the list of top 10
countries estimated to have the highest numbers of
people with diabetes in 2000 and 2030. 2 The
International Diabetes Federation (IDF) estimates the
total number of people in India with diabetes to be
around 50.8 million in 2010, rising to 87.0 million by
2030.3 Diabetes mellitus may present with characteristic
symptoms such as thirst, increased frequency of
urination, visual disturbances, and decrease in body
mass. The condition is symptomless in initial stages
but may give rise to various complications affecting
various organs of the body like eyes, kidneys, nerves
giving rise to conditions like retinopathy, nephropathy,
and neuropathies respectively. Diabetes also affects the
48. Sanjeev Kumar--250-253.pmd
250
central nervous system and Type 2 diabetes has been

associated with cognitive impairments4
Reaction time is the time taken by an individual to
react or respond to an applied stimulus. It is the time
lapse between the stimuli and response shown by the
individual. Reaction time is considered to be a putative
component of higher cognitive functions 5 this reaction
time is found to be increased in individuals with type II
diabetes6. The reaction time depends on both the
peripheral and central components of the nervous
system. Impaired peripheral sensations and declined
cognitive function, due to affection of central nervous
system are the important factors for increased reaction
times in diabetic individuals. One of the largest
implications of increased reaction time is in the area of
slips and falls. Falls are incurred by most of the diabetic
population and are a common source of morbidity and
mortality. Hence the assessment and improvement of
reaction time constitutes an important part of
management of individuals with type II diabetes.
2/7/2013, 8:08 PM
Various studies are done to assess the reaction time

in diabetic individuals by comparing with the healthy
individuals but no study is done on comparison of these
reaction times between patients with diabetes mellitus
of different age group. Hence objective of this study was
to compare the reaction time in middle age and old age
type II diabetic patients.
So is the initial distance (zero). Substituting in zero for

vo and So simplifies the equation as Sf=1/2at2. Solving
this equation for t yields dt=(2Sf/a)
As the intra subject variability is high in this method
10 trials were conducted for each subject and the mean
reaction time was taken for statistical analysis.
PARTICIPANTS
30 subjects diagnosed with type II diabetes from
KLEs Dr. Prabhakar Kore Hospital And Medical
Reasearch Centre, Belgaum and Vrudhashram were
recruited in this study and divided in to two groups
according to their age. Those between age 40 to 60 were
allotted to group A and those between age 60 to 80 were
allotted to group B. Group A had 15 patients (9 females
and 6 males with mean age 50.4 yrs +/- 6.16 yrs) and
Group B also had 15 patients (7 females and 8 males
with mean age 70.2 +/- 4.73 yrs).
PROCEDURE
The participants were explained about the test to be
performed and written consent was obtained from each
participant. After obtaining the consent the patient was
allotted to one of the groups according to his/her age.
The reaction time in all subjects was tested using the
Drop Ruler Test.7 A 30cm wooden ruler was used to
perform the test. The subject was made to sit on a chair
or stool with elbow supported on a table with wrist
outside the table. The forearm was placed in midprone
position. The ruler was then placed between the thumb
and the index finger such that the finger and thumb are
close but not touching the ruler. The 0cm mark on the
ruler coincided with the borders of the fingers. The ruler
was then dropped between two fingers without prior
intimation and the subjects were asked to grasp it at
their earliest. The distance at which the ruler was
grasped was noted down and reaction time was
calculated. The standard equation for freely falling
bodies is Sf=1/2at2+vot+So.8 Where Sf is the average
distance that the ruler fell, a is the acceleration of gravity
(980 cm/sec2),t is the time that it takes the ruler to fall
(the reaction time), vo is the initial velocity (zero) and
Mean baseline demographic values were calculated

for the continuous variables and analysis was done to
find the co-relation between age and the reaction time.
The data was analysed in SPSS 16 using independent
t-test to estimate the difference between groups in each
outcome. The significance level was set at p<0.05.
RESULT
The data were collected from group A and group B
which was analysed and assessed for the significance.
(Table-1) The gender distributions among the groups
were as follows; in group A there were 6 males and 9
females with mean age 50.4 (+/-6.16) years and in group
B 8 males and 7 females with mean age 70.2 years (+/4.73) were included. The mean height of group A was
1.65 meter (+/-0.14) and group B the mean height was
1.61 meters (+/-0.13). Hence there were no significant
difference between the groups and within the group as
far as height was concerned. The weight of participants
of group A was 65.21kg (+/- 4.17) whereas in group B it
was 65 kg (+/- 11.02). Within the group there were
moderate difference whereas inter group comparison
does not show any significant difference hence it may
be concluded that the group was homogenous. BMI was
assessed and for group A mean BMI were 23.62 (+/2.38) thus signifies that there were hardly any
overweight individuals included in group A. In group
B mean BMI was 25.03(+/- 1.98) suggestive of presence
of overweight individuals in this group. The reaction
time was calculated in group A and found that mean
reaction time was 0.19 seconds (+/- 0.01) and in group
B 0.21 seconds (+/- 0.01). The reaction time of groups
might be related to the BMI of the groups. The co-relation
co-efficient between age and reaction time of the two
groups combined is r=0.605
Table 1. Demographic details and outcome result

Age
Height(m)
Weight(kg)
BMI
Reaction time(s)
Gender
6 males9 females
50.46.16
1.650.14
65.214.17
23.62 2.38
0.19 0.01
8 males7 females
70.24.73
1.610.13
6511.02
25.03 1.98
0.21 0.01
0.970
0.058
1.574
2.872
DF
28
28
28
28
P<0.05
0.340
0.955
0.127
0.008
251
2/7/2013, 8:08 PM
DISCUSSION
A reaction time measurement includes the latency
in the sensory neural code traversing peripheral and
central pathways; perceptive, cognitive and volitional
processing; a motor signal again traversing both central
and peripheral neuronal structures; and finally, the
latency in end effector (e.g., muscle) activation5. Many
studies have been done to evaluate the reaction times
in healthy individuals. A study on human reaction
times found that in almost every age group, males have
faster reaction times than females and also that while
men were faster than women at aiming at a target, the
women were more accurate.9 Here in the present study
the difference of reaction times in females and males
with diabetes was not calculated. A longitudinal study
was done on 1,265 community-dwelling volunteers
(833 males and 432 females) who ranged in age from 17
to 96 and cross-sectional analyses revealed slowing of
simple reaction (SRT) and relatively greater slowing of
disjunctive reaction time (DRT) across decades for both
males and females. Repeated testing within
participants over eight years showed consistent
slowing and increased variability with age 10. In our
study similar results were shown with group B having
more reaction time compared to group A. Holmes et al.
reported significant slowing of visual reaction time
during a hospital clamp study at a blood glucose level
of 16.7 mmol/l but were unable to replicate this
subsequently using an auditory reaction-time task.11 The
present study showed that hyperglycaemia is
associated with increase in reaction time in diabetic
individuals. There is increasing evidence that
hypoglycaemic episodes are also critical factor in type
2 diabetes and older subjects aged more than 65 years,
who represent the majority of type 2 diabetic patients,
appear at a particularly high risk of experiencing severe
hypoglycaemia. Hypoglycaemia unawareness in the
presence of pronounced hypoglycaemia, induced
reaction time prolongation in older type 2 diabetic
patients 12. Earlier study on diabetic individuals
concluded that middle-aged individuals with type 2
diabetes showed a greater decline in cognitive function
than middle-aged individuals without diabetes 3.
Another study on the effect of metabolic syndrome on
cognitive function showed that subjects with metabolic
syndrome showed poorer cognitive performance than
subjects without metabolic syndrome, especially those
with high levels of inflammation and hyperglycaemia
was the main contributor of the association of metabolic
252
syndrome with cognition 13 . Study done on 20

individuals with type 2 diabetes with mean age 61.5
years concluded that during acute hyperglycaemia,
cognitive function was impaired and mood state also
deteriorated.14 These evidences show that the delay in
the reaction time may be the consequence of
somatosensory affection, cognitive decline and
hypoglycaemic unawareness.
In the present study there is increase in the reaction
time in the second group but is not statistically
significant. This increase may be due to age factor or
episodes of severe hyperglycaemia. Another reason may
be the increased BMI in the second group i.e group B.
study on middle aged individuals concluded that
increased BMI was associated with poor cognitive
functions15. Comparison of type 2 diabetic subjects with
normal individuals concluded that patients with long
standing diabetes showed improved cognitive capacity
with restoration of glycaemic control16. Hence it can be
said that the decline in cognitive function in diabetes
mellitus is rapid in the first few years after diagnosis
and with progression of the condition the process of
this decline is slowed down. This might be a reason
why there was no significant difference in the reaction
times between the middle aged and old aged diabetic
individuals. The reaction time in Group B did not show
statistical increase because the increased reaction time
in them may be attributed to the old age more than
presence of the condition.
The further scope of this study is to evaluate large
population of diabetic individuals and to take into
account the duration of the condition which was not
considered in the present study.
CONCLUSION
Our present study concludes that the slowing of
reaction time in individuals with type II diabetes is more
pronounced in the early stages of the condition and
does not significantly worsen with the progression of
the disease.
REFERENCES
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Definition, Diagnosis and Classification of

Diabetes Mellitus and its Complications, Report
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A Ramachandran, AK Das, SR Joshi, CS Yajnik, S

Shah, KM Prasanna Kumar. Current Status of
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Astrid C.J. Nooyens, Caroline A. Baan, Annemieke
M.W. Spijkerman, W.M. Monique Verschuren.
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Ian J. Deary and Geoff Der. Reaction Time, Age,
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Samantha J Richerson, Charles J Robinson and
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Mohammad. Can We Promote Physical Fitness
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a Response to Delays in Control Systems. Kajaani
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Reynolds, P. A. Hancock and Reginald E. Quilter.
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Kevin J. Grimm,William L. Clarke. Relationships
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Miranda G. Dik, Cees Jonker, Hannie C. Comijs,
Dorly J.H. Deeg, Astrid Kok, Kristine Yaffe, Brenda
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H. Fonds, J. Ferrires, J. B. Ruidavets. Relation
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2/7/2013, 8:08 PM
Effect of Rehearsal Digit-Span Working Memory

Intervention on Sensory Processing Disorder in children
with Autism: A Pilot Study
Smily Jesu Priya V1, Jayachandran V1, Noratiqah S2, Vikram M3, Mohamad Ghazali M1, Ganapathy Sankar U4
Lecture, Department of Occupational Therapy, 2Student, Department of Occupational Therapy, 3Lecturer, Department of
Physiotherapy, Universiti Teknologi MARA (UiTM), Malaysia, 4Associate professor, SRM University, Kattankulathur
ABSTRACT
This pilot study investigated the effect of rehearsal digit span WM training on Sensory processing
disorder (SPD). Twenty children's with autism (6-9 years) were participated. The experimental group
received combination modalities of rehearsal digit span WM training to SPD, while the control group
did not receive. The duration of training was one hour, twice per day for ten sessions. The finding
indicate that rehearsal digit Span WM intervention has significant changes in the auditory filtering
and no changes in tactile sensitivity, movement sensitivity, low energy, visual/auditory sensitivity
taste/smell sensitivity, seeks sensation and total score, since training was not conducted with controls.
The study discusses consideration for future WM intervention on SPD for children with ASD.
Keywords: Autism; Working Memory; Digit Span; Sensory Processing Disorder
INTRODUCTION
Sensory processing disorder (SPD) is quite common
among children with autism; literature reports a range
of occurrence from 42% to 80% 1. Children with evidence
of sensory processing dysfunction, such as those with
autism, often have difficulty regulating their response
to sensation and specific stimuli and may use selfstimulation to compensate for their limited sensory
input or to avoid overstimulation2. These atypical
sensory reactions suggest poor sensory integration in
the central nervous system and could explain
impairments in attention and arousal1.
One area of executive function (EF) is which is
frequently discussed in autism is working memory
(WM). Among the many potential areas of deficit in
autism is related with executive function3. The clinical
presentation of sensory processing disorder in autism
has been linked to deficits in executive functioning5.
Executive function is an umbrella term for a set of
subfunctions that are integrated throughout cortical
and subcortical areas of the brain and used to carry out
higher order cognitive tasks. Overall the evidence is
mixed about the relationship between sensory
processing disorder and executive deficits in autism,
and it is unlikely that executive dysfunction is the
primary explanatory model of these behaviors4. Still it
is important to examine if executive function (working
49. smily jesipriya-254-258.pmd
254
memory) intervention also could account for the

improvement of sensory issues in autism. This will
allow researchers to determine whether working
memory intervention will solve the sensory processing
disorder in children with ASD.
Despite the documented deficits in working memory
(WM) in autism, relatively little research has been
published on procedures for remediating these deficits.
A small number of studies have evaluated approaches
to improving working memory, often focusing on
children with attention deficit hyperactive disorder
(ADHD), fetal alcohol spectrum disorder (FASD) or
Down syndrome. The rehearsal training program
effectively improved the mnemonic performance of a
child with down syndrome7. This finding was later
replicated with typically developing peers. For example,
authors found that WM span scores increased as a
result of using a rehearsal strategy and positive
reinforcement improves the WM in autism8.
Sensory symptoms in autism also are impacted by
cognitive maturation, at least in preschool-aged
children. Researchers have found that lower mental
ages are predictive of aberrant sensory features in young
children with autism or other developmental
disabilities9. Based on the previous studies there was a
relationship between executive functions and sensory
processing disorder in individuals with ASD, virtually
2/7/2013, 8:08 PM
no research has been published in cognitive

intervention to sensory issue problems. Therefore, the
purpose of this was to examine the rehearsal digit span
working memory intervention on sensory processing
disorder in children with ASD.
METHOD
Research design
We used a pretestposttest, control group design.
This study was approved by the ethics committee as
required (Institutional Review Board), and all parents
provided consent for their childrens participation.
Participants and setting
Participants in the study were a convenience sample
of children diagnosed with autism (n=20) on the basis
of the Diagnostic and Statistical Manual of Mental
Disorders criteria10. All participants were between ages
6 and 9 (mean [M] age = 7.4) (See Table 1). All
participants with autism were selected from the
Occupational Therapy Department and they were
assigned to an experimental (n=10) and control (n=10)
group.
Inclusion criteria for this study included: Nonverbal
intelligence scores within the average range on the
Wechsler Intelligence Test11, language scores below the
average range on the Clinical Evaluation of Language
Fundamentals-Fourth Edition (CELF-4) 12, and no
known auditory, neurological, or physiological basis
for their difficulties. Exclusionary criterion included:
A significant history of hearing problems or speech/
language difficulties, a diagnosis of dyspraxia, a core
language standard score outside the range of 85 to 115
on the CELF-412, and for all participants, an inability to
recognize the numbers 1 to 9 in English.

Table 1. Distribution of Demographic Characteristics
Variables
Respondents
Group
Experimental
10
Control
10
Gender
Male
13
Female
Diagnosis
Autism
20
Age (year)
MeanSD
7.401.155
Range
69
INSTRUMENTATION
Short Sensory Profile (SSP): This study used the SSP
to assessed SPD (according to parent observation). The
SSP, which is based on the Sensory Profile13,14, is a 38item caregiver questionnaire that was specifically
designed to be used as a research instrument and
screening tool to identify children with SPD (age 3 -10).
The 7 sections of the SSP found in a normative sample
are Tactile Sensitivity, Taste/Smell Sensitivity,
Movement Sensitivity, Under-responsive/Seeks
Sensation, Auditory Filtering, Low Energy/Weak, and
Visual/Auditory Sensitivity.
TASK DESIGN
The four digit recall tasks were designed using the
different combinations of visual and auditory
modalities for both the input presentation and the
childs response (output), as described in Table 2. All
four tasks used digit sequences, which ranged from two
to seven digits. In order to minimize the use of a
chunking strategy, sequences did not include repeated
or consecutive numbers. The four task types were used
for both the DF and DB recall conditions. The digit recall
tasks are available on the journals website at (http://
www.informaworld.com/ijslp).
Table 2. Outline of task designs used for digits forwards (DF) and backwards (DB) conditions
Task
Input
Visual Support
Output
Visual Support
Abbreviation
Description
Auditory
Verbal
Aud/Verb
Participant listens to a digit sequence says

the numbers aloud. No visual information
is available.
Auditory
Verbal and motor
Aud/Verb-Mot
Participant listens to a digit sequence and

says the numbers aloud while pointing to
them on a full digit grid.
Auditory and visual
Verbal
Aud-Vis/Verb
Participant listens to a digit sequence while

watching it on the screen and says the
numbers aloud.
Auditory and visual
Verbal and motor
Aud-Vis/ Verb-Mot
Participant listens to a digit sequence while

watching it on the screen and says the
numbers aloud while pointing to them on
a full digit grid.
255
2/7/2013, 8:08 PM
PROCEDURE
Control group was not received training and
experimental group received rehearsal training of four
digit recall tasks using different combinations of
auditory and visual input and output for a DF and DB
recall. The duration of intervention was one hour, twice
per day and total ten sessions.
Prior to each task, the participants were given a
short explanation outlining what they were required to
do and some reminders. The tasks that used visual
input or required gestural output included a 3-second
presentation of the full digit grid before the task began,
to familiarize the participants with the designated
locations of the numbers. Each task began with four
training items (two trials at a length of two digits and
two trials at a length of three digits). This allowed the
participants to become familiar with the demands of
the task and receive feedback if they were a difficulty.
The test sequences began at a length of two digits and
progressed to a length of seven digits, with two trials at
each length. The participant was required to score at
least one of the two trials correct at each digit length to
progress to a longer sequence. This design was adapted
from Pickering.15. For each digit sequence, the tester
controlled when it was presented and said go after
its completion. The participants then gave a response
and the tester recorded this online. A 3-second
animation reward was then revealed on the screen.
The tasks for both the DF and DB conditions were

presented in the following order: Task 1 (Aud/Verb), 2
(Aud/Verb-Mot), 4 (Aud-Vis/Verb-Mot), 3 (Aud- Vis/
Verb). Tasks with auditory only input were presented
first, followed by those with mixed modality input. The
DF and DB tasks were completed in separate sessions,
with the DF tasks first and the DB tasks in the last
session. Before starting the DF condition, each child
was shown a full digit grid and asked to name the
numbers. The tester pointed to each number in a random
order to ensure automatic speech patterns were not
used. If the child unable to recognize and name one or
more of the numbers, they were excluded from further
testing. Production of a correct sequence was given a
score of 1, and a sequence where any number was
incorrect was scored 0. If there was a discrepancy
between the number the child pointed to and the
number said aloud (regardless of whether one of these
was correct), a score of zero was given for that sequence.
RESULT
Table 3 shows the pre- and post-test score for all
participants for the SSP. The Wilcoxon Signed Rank test
was to determine whether any differences in pre and
post test for experimental and control group on SSP in
children with ASD. The result showed that there was
no significant changes were found in both experimental
and control group (P > 0.05).
Table 3. Pre and post test scores for all participants on the SSP for both groups
Group
Variable
Experimental
Control
Pre test
Median (IQR)
Post test
Median (IQR)
Z-statistic
P-value
Tactile sensitivity
27.50 (9.00)
30.50 (4.00)
-1.604
0.109
Taste/smell sensitivity
15.00 (3.00)
15.50 (5.00)
-1.342
0.180
Movement sensitivity
12.00 (2.00)
13.00 (4.00)
-1.414
0.157
Seeks sensation
24.50 (7.00)
28.50 (7.00)
-1.826
0.068
Auditory filtering
18.50 (5.00)
24.00 (4.00)
-1.826
0.068
Low energy
28.50 (3.00)
28.50 (2.00)
-1.00
0.317
Visual/auditory sensitivity
20.50 (8.00)
22.50 (4.00)
-1.604
0.109
Total
149.00 (17.00)
162.00 (15.00)
-1.826
0.068
Tactile sensitivity
24.50 (14.00)
30.00 (11.00)
-1.342
0.180
16.00 (9.00)
14.50 (9.00)
-0.184
0.854
11.00 (2.00)
11.50 (5.00)
-0.816
0.414
Seeks sensation
27.00 (14.00)
29.00 (12.00)
-0.552
0.581
Auditory filtering
21.50 (9.00)
17.00 (5.00)
-1.105
0.269
Low energy
25.00 (5.00)
25.50 (7.00)
-0.447
-0.447
17.00 (2.00)
17.00 (9.00)
-0.365
0.715
143.00 (34.00)
146 .00 (35.00)
-1.826
0.068
Total
256
2/7/2013, 8:08 PM
Table 4 present Mann Whitney test was used to

analysis post test between experimental group and
control group in children with ASD. The experimental
group displayed significant changes in auditory
filtering than the control group, as measured by a SSP
(P < 0.05, Z = 0.041), indicating that rehearsal digit span
working memory interventions were having impact on

ASD. No significant changes were found between the
two groups on tactile sensitivity, taste/smell sensitivity,
movement sensitivity, seeks sensation, low energy,
visual/auditory sensitivity and total (p > 0.05).
Table 4. Comparison between experimental and control group on SSP

Variables
Experimental
(n=10)Median (IQR)
Control
(n=10)Median (IQR)
30.50 (4.00)
30.00 (11.00)
0.00
1.00
15.50 (5)
14.50 (9.00)
-0.577
0.564
13.00 (4.00)
11.50 (5.00)
-1.169
0.243
Seeks sensation
28.50 (7.00)
29.00 (12.00)
0.00
1.00
Auditory filtering
24.00 (4.00)
17.00 (5.00)
-2.045
0.041
Low energy
28.50 (2.00)
25.50 (7.00)
-0.899
0.369
22.50 (4.00)
17.00 (9.00)
-1.162
0.245
162.00 (15.00)
146.00 (35.00)
-1.732
0.083
Tactile sensitivity
Total
DISCUSSION
Results identified significant post-intervention
changes in auditory filtering (see Table 4) between the
groups, as determined by SPP scores in the area of
sensory processing. The findings of this study show
that auditory short-term memory performance can be
improved in children with ASD through rehearsal
strategies. Previous study suggested that since shortterm memory skills are strongly related to language
acquisition, it is very important to improve these skills
in children with ASD17. The rehearsal working memory
intervention improved auditory filtering in
experimental group. In this study, an experimental
group applied rehearsal training on working memory
with animation reward in children with autism. A
reward is one type of positive reinforcement. Positive
reinforcement provided motivation to the respondent
to perform the digit span tasks. Researcher suggested
that basic intervention (positive reinforcement) may be
successful in improving working memory in children
with autism8.
No significant changes in the experimental and
control groups were found in the scores on the SSP or
from pretest to posttest. Many reasons could exist for
the non significant results, ranging from a lack of
rehearsal working memory and sensory memory
training. With regard to the effectiveness of intervention,
it may not fully reflect common clinical sensory
processing disorder because recommendations for
rehearsal into other working memory span were not
provided. A previous study supported digit forward
task involving central executive of Baddeley model of
257
Z-statistic
P-value
working memory16 and increase cognitive demand of

digit backward recall. The study stated that rehearsal
training improves working memory capacity18. Children
who not receive some specific training they do not show
any significant changes in their performance. In
addition, the sensitivity of the measurement tools may
have influenced their ability to detect the changes.
LIMITATIONS
To fully interpret and apply the results of this study,
several limitations should be considered. As with
pretestposttest control group designs, a small sample
was used; we had only twenty participants.
Conclusions from the study should be interpreted and
applied in the context of the small number of
participating individuals. To increase external validity
and generalizability of results, future researchers
should include a larger sample size. Second, this study
involved digit span task only as intervention and
duration of treatment was short. Working memory
involved many tasks such as listening recall, counting
recall, word list matching, word list recall, Non-word
list recall and others. Future researches to need to be
examined all the combined tasks of activities to WM
skills on sensory processing disorder. Third, this study
was not used sensitive of outcome measures for sensory
processing disorder in ASD.
CONCLUSION
This study provides preliminary support for using
rehearsal digit span working memory intervention in
children with ASD, although further research is
2/7/2013, 8:08 PM
necessary. Results identified significant progress

towards auditory filtering after rehearsal digit span
working memory interventions, although no significant
changes were found on the other components. Results
suggest implementing intervention, that are generalized
to home and community setting, using interventions
that allow for individualized improvement in further
studies, and completing future studies with a large
sample. Moreover, WM is an essential skill for everyday
life, and is an important link to skills, such as word
learning and mathematics.
6.
7.
8.
ACKNOWLEDGMENT
9.
The authors would like to thank all parents or care
taker for their co-operation with data collection.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of
interest with respect to the research, authorship, and/
or publication of this article.
10.
11.
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Baranek GT: Efficacy of sensory and motor

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Roberts JE, King-Thomas L, Boccia ML: Behavioral
indexes of the efficacy of sensory integration
therapy. American Journal of Occupational Therapy
2007; 61, 555562.
Hughes,C: Executive dysfunctions in autism: Its
nature and implications for the everyday problems
experienced by individuals with autism. In: J.
Burack and T. Charman, Editors, The development
of autism: Perspectives from theory and research
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OHearn K, Asato M, Ordaz S, Luna B:
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Lopez BR, Lincoln AJ, Ozonoff S, Lai Z: Examining
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Farb J, Throne J: Improving the generalized
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11, 413419.
Baltruschat L, Hasselhorn M, et al: Further
analysis of the effects of positive reinforcement on
working memory in children with autism.
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855 863.
Baranek GT et al:Hyperresponsive sensory
patterns in young children with autism,
developmental delay, and typical development.
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American Psychiatric Association: Diagnostic and
statistical manual of mental disorders 2000; (4th
ed., text rev,). Arlington, VA: Author.
Wechsler, D: Wechsler Preschool and Primary
Scale of Intelligence-Revised. Cleveland, OH: The
Psychological Corporation 1989.
Semel E, Wiig E, Secord W: Clinical Evaluation of
Language Fundamentals fourth edition. San
Antonio, TX: Psychological Corporation, 2006.
Dunn, W: The sensory profile: Users manual. San
Antonio, TX: Psychological Corporation, 1999.
McIntosh, DN et al: Development and validation
of the short sensory profile. In W. Dunn (Ed.),
Sensory profile manual (pp. 59-73). San Antonio,
TX: Psychological Corporation, 1999.
Pickering S, Gathercole S, Peaker M: Verbal and
visuo-spatial short-term memory in children:
Evidence for common and distinct mechanisms.
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Gathercol SE, Baddeley AD: Working memory and
language. Hove: Erlbaum, 1993.
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Development 2007; 78, 1068 1082.
2/7/2013, 8:08 PM
Evaluation of Inter-Rater Reliability to Measure Hand and

Arm Function in Reaching Performance Scale for Stroke
Patients
SureshKumar T.1, Leo Rathinaraj A.S.2, Jeganathan A.3, Vignesh waran Vellaichamy4
Assistant Professor, Maharashtra Institute of Physiotherapy, Latur, 2Professor, Maharashtra Institute of
Physiotherapy, Latur, 3Professor, MAEER's Physiotherapy College, Talegaon, Pune, 4Lecturer, Santosh
College of Physiotherapy, Ghaziabad
ABSTRACT
Objective: This study is to assess the inter-rater reliability of Reaching Performance Scale test in hand
function evaluation.
Introduction: Stroke is defined as a rapidly developing clinical sign of focal or global disturbance of
cerebral function lasting for more than 24 hours or leading to death due to no other reason than
vascular origin. As there is high incidence of middle cerebral artery stroke, upper limb is more affected
than the lower extremity and about 20% of the individual fail to regain any functional use of affected
upper extremity. When a stroke patient attempts to move and encounters all the deficits the natural
reaction is to compensate with available motor strategies. The measurement of the performance of the
affected arm and hand of the patient with hemiplegia is important for determining the goal of intervention
as well as outcomes of rehabilitation. So there is a need to have a scale that measures the quality of
motor performances specific to the task and identify which elements of the task are missing and how
they are compensated. Reaching performance scale is for the identification and quantification of
movement pattern and their compensation during reach to grasp task in patients with upper extremity
involvement after a stroke.
Materials & Methodology: 30 Hemiplegic patients between age group of 40-60 years who met the
inclusion criteria were selected and explained about the study and procedure, and the consent for the
study was taken. The Type of study is Inter-rater reliability study (correlation). The Materials used were
card board cone, Table, inch tape and a chair.
Procedure: The patients were examined by two Physiotherapists respectively. The patient was seated
in a chair with backrest but no arm rest. Reaching performance scale evaluated six components. For all
patients both close target [Task I] and Far target [Task II] were assessed and graded. Only reach to grasp
component of task are taken into account. The inter-rater reliability to measure the hand and arm
function in Reaching Performance scale was statistically analysed by the Mann-Whitney test with
P<0.05.
Result & Conclusion: In this study the reliability between the investigators is very highly significant
correlation of closed target (0.951) and P <0.05, Far target (0.946) and P<0.05. So we can conclude that
inter rater reliability of RPS scale in assessing arm and hand function is high and hence RPS can also
be used to assess the compensatory strategies in stroke patients for an effective intervention.
Keywords: CVA, Stroke, Arm and hand function, Reaching Performance scale, Inter-rater Reliability,
Compensatory strategies.
INTRODUCTION
Stroke is the third leading killer on western countries
after heart disease and cancer. Among all neurological
disease of adult life, the cerebro-vascular disease ranks
first in frequency and importance. 1 Stroke or
cerebro-vascular accident CVA is defined as a rapidly
developing clinical sign of focal or global disturbance
of cerebral function lasting for more than 24 hours or
50. Suresh Kumar--259-263.pmd
259
leading to death due to no other reason than vascular

origin.2 The term CVA is used interchangeably with
stroke of either ischemic or hemorrhagic lesions and
affects approximately 7,00,000 individual a year out of
them 75% have weakness in the upper extremity.3 With
an estimated number of 5, 00,000 stroke survivors and
the incidence of stroke increases dramatically with age,
doubling every decade after 55 years of age. In India,
the prevalence range is 20 per 1, 00,000 population and
2/7/2013, 8:08 PM
in south India, the incidence of stroke is 56.9 per

1, 00,000 population.4
The most common insult to the brain results from
middle cerebral artery lesion. More than two third are
within the distribution of middle cerebral artery5. Owing
to high incidence of middle cerebral artery strokes,
upper limb is more affected than the lower extremity,
about 20% of the individual fail to regain any functional
use of affected upper extremity. Typically distal muscles
more affected than proximal muscles.6 Grip strength
changes accordingly to the size of object being grasped.
In hemiplegics commonly grasp an object and then
initiate the movement from the shoulder which places
the hand in a non functional position 7 . Recent
movement analysis studies shows that the patient with
hemiparesis due to stroke, use excessive trunk and
shoulder girdle displacement, when pointing to targets
or attempting to reach and grasp objects placed within
and beyond the reach of the arm8. Such excessive
displacement is thought to be compensatory behaviour
emerging from the efforts of spared cortical and
subcortical system to compensate for lost control over
motor function such as elbow extension and shoulder
elbow inter joint co-ordination.9
Studies of motor recovery following stroke have
shown that improvement in outcome measures such as
speed, precision and variability of arm movement may
be accomplished by compensatory strategies. For
example in patients with severe hemiparesis,
compensatory trunk movements that are used to extends
the reach of the arm may limit the recovery of shoulder
adduction and elbow extension needed for
independent arm movement.10 A compensatory strategy
used by stroke patients is the fixation of body segments.
This may decrease the number of motor elements (degree
of freedom).11 A negative consequence may be the lack
of girdle mobility, which may limit the normal
kinematics of upper and lower limb movement.12
The measurement of the performance of the affected
arm and hand of the patient with hemiplegia is
important for determining the goal of intervention as
well as outcomes of rehabilitation.13 Functional outcome
scale access the performance of daily living at the
activity level and quantify whether task is performed
with in the constraint specified by the test, while little
attention is paid how the movement performed.
Impairment scales assess the underlying impairment
such as decreased range of motion or muscle weakness
or how well the specific movement performs. Thus test
evaluate movement or movement pattern having no
260
functional goal. Impairment scales identify the factor

that may affect the performance of the task.14 So there is
a need to have a scale that measures the quality of motor
performances specific to the task and identify which
elements of the task are missing and how they are
compensated.15 Reaching performance scale is for the
identification and quantification of movement pattern
and their compensation during reach to grasp task in
patients with upper extremity involvement after a
stroke. These scales particularly focus on the transport
phase of reaching, defined as the beginning of the
movement until the object is grasped. This scale also
includes a measure of compensatory strategies used
for grasping.
METHODOLOGY
The purpose of the study is to assess the inter-rater
reliability of Reaching Performance Scale test in hand
function evaluation. 30 Hemiplegic patients between
age group of 40-60years who met the inclusion criterias
were selected by simple random sampling from various
hospitals and rehabilitation centers. They were
explained about the study and procedure, and the
consent for the study was taken. The Inclusion Criteria
include patients who Sustained with single Cerebro
vascular accident, aged between 40-60 years, with
duration of one month to five years, having good
cognitive function, both the right and left side
involvement. The Exclusion criterias were Patients who
are not able to follow simple instructions, having any
musculoskeletal condition that prevent test procedure,
Non co-operative patients, flaccid stage and Mental
retardation. The Type of study is Interater reliability
study (correlation). The Materials used were card board
cone [7 cms base & 17.5 cms height] , Table [72 cm
height], inch tape and a chair [seat height 42 cms] to
evaluate hand and arm function by using Reaching
Performance Scale.
PROCEDURE
As the test procedure is to find the inter-rater
reliability, the patients are been examined by two
Physiotherapists respectively. Prior to performance, the
patient were been instructed briefly how to carry out
the test procedure. The patient was seated in a chair
with backrest but no arm rest. The chair kept facing the
table. The table and chair placed one arm distance of
patients arm, keeping wrist on the table. Patient seated
without leaning on the back support and patient feet
flat on the floor. A card board cone kept on the table.
Reaching performance scale evaluates six components
2/7/2013, 8:08 PM
As a procedure is a double blind one time study, in

order to prevent scoring error, 3 successive readings is
noted and a separate recording sheet is used for the
two examiners and examiners were unaware of each
others results. The inter-rater reliability to measure the
hand and arm function in Reaching Performance scale
was statistically analysed by the Mann-Whitney test
with P<0.0
Shows the correlation of grasp between the 2

investigators. Statistical analysis reveals that
spearmans rank correlation co-efficient is r = 0.946 [Far
target] and the level of significance p = 0.000. Since
the correlation is between the values -5 and +5 and
level of significance is < 0.05, the correlation between
the raters is very highly significant.
Graph 1:
SCATTER DIAGRAM FOR CLOSED

TARGET
INVESTIGAT
OR B
namely Trunk dissplacement, Movement smoothness,

Shoulder movements, Elbow movements, Prehension
and Task accomplishments. This is an ordinal scale
and graded according to the patient performance. For
all patients both close target [Task I grasping the cone
placed 1 cm far from the front edge of the table] and Far
target [Task II - grasped the cone placed 30 cm far from
the front edge of the table] were assessed and graded.
Only reach to grasp component of task are taken into
account.
20
15
10
5
0
0
RESULTS
Median
Quartile
deviation
11.5
1.25
SCATTER DIAGRAM FOR FAR

TARGET
Quartile
deviation
12.0
1.50
Table 3. Correlation between Investigator I and

investigator II
Close target
r-value
P-value
Result
0.951
0.000
P<0.05[Very
highly
significant]
Shows the correlation of grasp between the 2

investigators. Statistical analysis reveals that
spearmans rank correlation co-efficient is r = 0.951
[Close target] and the level of significance p = 0.000.
Since the correlation is between the values -5 and +5
and level of significance is < 0.05, the correlation
between the raters is very highly significant.
Table 4. Correlation between Investigator I and
investigator II
Far target
261
r-value
P-value
Result
0.946
0.000
P<0.05(Very
highly
significant)
INVESTIGATO
R B
Median
20
Graph 2:
Table 2. Median and Quartile deviation for Far target

Far target
15
INVESTIGATOR A
Table 1. Median and Quartile deviation for Close

target
Close target
10
20
15
10
5
0
0
10
15
20
INVESTIGATOR A
DISCUSSION
This study was aimed at determining the inter rater
reliability of Reaching performance scale test in
assessing the arm and hand functions of stroke patients.
The data analysis and statistical inference has
reinforced the reliability of Reaching performance scale
test. This study indicates reaching performance scale
test is extremely reliable for each of the subscales as
well as the total score when performed by different
raters. Different users of RPS test achieved consistent
2/7/2013, 8:08 PM
result. Recent movement analysis studies have shown

that patient with hemiparesis due to stroke use
excessive trunk and shoulder girdle displacement when
pointing targets or attempting to reach and grasp object
placed within and beyond the reach of the arm. Such
excessive displacement is thought to be compensatory
behaviour emerging from the efforts of spared cortical
and subcortical system to compensate for lost control
over motor function such as elbow extension and
shoulder-elbow interjoint coordination.
In the flaccid extremity as a result of CVA there is
insufficient muscle tone to hold the glenohumeral joint
in proper alignment due to the force of gravity and
weight of the arm. The scapula placed in a downwardly
rotated and abducted position (Ryerson and Levitt
1997). In the extremity with the spasticity unbalanced
muscle activation can contribute to downward
depression and retraction of scapula (O Sullivan 2001).
Difficulty with Reach, and grasp occurs often in the
patient with CVA. The factors that may cause changes
in upper extremity function are unbalanced muscle
pull, paralysis, decrease in sensation, secondary joint
changes, pain and odema. These factors restrict the
reach and grasp due to increase tone of muscle, the
pattern that develops include internal rotation and
elevation of shoulder, elbow flexion, fore arm supination
or pronation, wrist and finger flexion. If this position of
fingers and wrist flexion continues for longer periods,
flexor tendons shorten. This cause increased difficulty
in active or passive opening of the hand.16
To mask the impairment the patient always
compensate with the other movement to accomplish
the task. For example a patient with severe hemiparesis,
compensatory trunk movements are used to extend the
reach of the arm. This may limit the recovery of shoulder
adduction and elbow extension needed for
independent arm movement. Compensatory strategies
in reaching activities of stroke patients are adaptive
one. It invariably lead to other problems by causing
altered movement or joint glides. Hence it is important
for then to be evaluated and corrected. This scale
particularly focuses on transport phase of reaching i.e.
the beginning of movement until the object is grasped.
This scale also includes measure of compensatory
strategies used for grasping.
Reaching performance scale test is constructed for
assessing upper limb functional recovery. Performance
evaluated for close and far targets. A wide range
varying from acute stroke to chronic strokes were
included in this study. The duration of the samples
262
included ranged from a minimum of 1 month to 5 years

of post stroke. Mindy F Levin concluded that the interrater reliability of reaching performance scale in
assessing arm and hand function was significantly
high.17
In this study the reliability between the investigators
is very highly significant correlation of closed target
(0.951) and P <0.05, Far target (0.946) and P<0.05. So
we can conclude that inter rater reliability of RPS scale
in assessing arm and hand function is high and hence
RPS can also be used to assess the compensatory
strategies in stroke patients for an effective intervention.
CONCLUSION
This study led to the inference that the Reaching
performance scale test used in assessment of hand
function in stroke patient has got very high significant
inter-rater reliability. The current study being an
evaluative study, have assessed the functional recovery
of affected upper limb, and the inter-rater reliability, so
that it can be used for clinical and research purpose.
The inter-rater reliability is found to be high, the clinical
implication of this study is that this scale can be used
either when two therapists treat the same patient or
when the clinical data is shared and they will be able to
interpret each other score without assessing the patient
again. Though the inter-rater reliability of Reaching
performance scale test was already proved but it was
less compared with that of intra rater reliability and
further studies was recommended.
To conclude, the inter-rater reliability of Reaching
performance scale test was analyzed and found that it
is highly reliable, with high level correlation and
significance in measuring hand function of stroke
patients.
ACKNOWLEDGEMENTS
The authors are thankful to, Prof Dr.Koti Reddy
M.P.T, Principal, Maharashtra Institute of
Physiotherapy for kindly providing laboratory facilities
to carry out this work. A special thanks to my senior
Dr.Lenin, for being source of inspiration.
There is no conflict of interest between the authors
SOURCE OF FUNDING
Nil
2/7/2013, 8:08 PM
ETHICAL CLEARANCE
This research study is given clearance under Ethical
committee headed by Prof Dr.Koti Reddy, Principal,
Maharashtra Institute of Physiotherapy, Latur.
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balance scale: Reliability assessment with elderly
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Lawrence ES, Coshall C, Dundas R. et al, Estimate
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rehab 1992 nov ,73 11. 1073-80.
Catherene M, Dean M, Robeta B Sheaperd ,Task
related training improve performance of seated
reaching task after stroke 1997 ,28 ,722-728.
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Chapter17;532-para3.
Horak HB: The effect of movement velocity, mass
displaced, and mass certainty on associated
postural adjustment made by normal and
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movements in hemiparetic patients. Stroke.2002;

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for neurologic rehabilitation. In Contemporary
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Cirstea CM, Ptito A, Forget R, Levin MF. Arm motor
improvement in stroke patients may depend on
type of training.Soc Neurosci Abtstir.2000; 26:162
Brunnstrm S. Motor testing procedures in
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Phys Ther.1966; 46:357375.
Levin MF. Interjoint coordination during pointing
movements is disrupted in spastic hemiparesis.
Brain.1996; 119:281294.
Fisher B. Effect of trunk control and alignment on
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2:72,1987.
Mindy F Levin, Johanne Desrosiers, Danielle
Beauchemin, Nathalie Bergeron and
Annie
Rochette. Development & Validation of a scale for
rating moto Compensation used for reading in
patients with Hemiparesis: The Reaching
Performance scale. Physio therp Vol 84, Number
1, Jan 2004.
Roby-Brami A, Fuchs S, Mokhtari M, Bussel B.
Reaching and grasping strategiein hemiparetic
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Dolores B Bertoti. Functional Neuro rehabilitation
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2/7/2013, 8:08 PM
Effect of Incentive Spirometry on Cardiac Autonomic

Functions in Normal Healthy Subjects
Trupti Ajudia1, Pravin Aaron2, Subin Solomen3

Lecturer, Professor, Assistant Professor, Padmashree Institute of Physiotherapy, Bangalore
2
ABSTRACT
Objective: Objective of the study was to examine the effects of Incentive Spirometry on cardiac autonomic
functions in normal healthy subjects in 18-25 years age group.
Material & Method: 30 subjects (n=15 in Study group and n=15 in Control group) were included in
this study. The duration of study was 3 months. Primary outcome measures included cardiac autonomic
function tests. Outcome measures were recorded before and 3 months after the study.
Result: 3 months practice of Incentive Spirometry resulted in statistically significant change (p < 0.05)
in following parameters - Basal heart rate, Immediate maximum heart rate, Steady state heart rate,
Steady State heart rate (time in seconds) during heart rate response to Standing test; Minimum heart
rate and Deep Breathing Difference (DBD) during heart rate response to Deep Breathing test.
Conclusion: 3 months practice of Incentive Spirometry changes autonomic function response.
Keywords: Breathing Exercise, Pranayama, Incentive Spirometer, Autonomic Functions.
INTRODUCTION
Breathing exercise is defined as the therapeutic
intervention by which there is purposeful alteration of
a given breathing pattern.1 Breathing exercises are
fundamental interventions for prevention and
comprehensive management of acute or chronic
obstructive pulmonary disorders, for patients who have
undergone thoracic and abdominal surgical
procedures, for patients with central nervous system
deficit, for psychological conditions or for patients who
are bedridden for extended period of time.2,3 It is known
that the regular practice of breathing exercise
(Pranayama) increases parasympathetic tone, decreases
sympathetic activity, improves cardiovascular and
respiratory functions, decreases the effect of stress on
the body and improves physical and mental health.4
Pranayama has been researched mostly for its beneficial
application in treatment of cardiovascular diseases,
Trupti Ajudia
Lecturer, Padmashree Institute Of Physiotherapy,
#23 Gurukrupa Layout, 80 Feet Ring Road,
Nagarbhavi, Bangalore - 560072, India
Ph(cell): +91-9989824237
E-mail: Trupti_Patel_511@Yahoo.co.in
51. Trupti Ajudia--264-269.pmd
264
pulmonary disease, autonomic nervous system

imbalances and psychological or stress related
disorders.5-7 Different forms of pranayama activate
different branches of the autonomic nervous system.5
Incentive Spirometry (IS), also referred as sustained
maximal inspiration (SMI), is designed to mimic natural
sighing or yawning by encouraging the patient to take
long, slow, deep breaths by using a device that provides
patients with visual or other positive feedback when
they inhale at a predetermined flow-rate or volume and
sustain the inflation for a minimum of 3 seconds.8,9
Studies have suggested that Incentive Spirometer is
effective mean as prophylaxis and as part of intensive
post-operative physiotherapy program following
cardio-thoracic and abdominal surgeries, 10-13 for
pulmonary hygiene with sickle cell disease and neuromuscular diseases, as well as a rehabilitation tool with
COPD.14-16 Some of the proposed benefits of Incentive
Spirometer are - subjects can assume responsibility for
their own treatment without any harmful side effects,
thus reducing the amount of direct patient contact time
with therapist, 10 provision of prolonged phase of
effective inspiration, more controlled flow and greater
enthusiasm to practice, suitable to children and those
with learning difficulties because it can be learnt by
demonstration.17
2/7/2013, 8:08 PM
Spirometer (Third ball as a control) and sustain it

for 3 seconds.
STATEMENT OF PURPOSE
Studies have proven that practice of pranayamic
type of breathing exercises can produce significant
effects on autonomic functions. Since, which is a SMI,
is also one type of slow breathing exercises, similar
results in terms of changes in autonomic response can
be expected with use of IS-training. Therefore, there
exists the need of the study to find out the effect of IS on
cardiac autonomic functions. Therefore, this study was
designed to assess the effect of IS on cardiac autonomic
functions in normal healthy subjects in the age group
of 18-25 years.
SUBJECTS AND METHOD
The study was conducted at Padmashree Institute
of Physiotherapy, Bangalore on 30 male and female
undergraduate physiotherapy student volunteers. The
inclusion criteria were: subject should be in the age
group of 18-25 years, should be non-smoker and free
from major health problems. Subjects who were
unwilling or unable to complete the study or had cardiorespiratory problems or were practicing any form of
regular breathing exercises were not included. Prior to
participation, a written-informed consent was taken
from all subjects and subjects were informed about study
protocol. Ethical clearance for the study was obtained
from the Institutional Ethical Committee, Padmashree
Institute of Physiotherapy, Bangalore as per the ethical
guidelines for Biomedical Research on Human subjects,
2001 ICMR, New Delhi.
PROCEDURE
The subjects were instructed not to practice any other
physical exercise or yogic technique other than the
prescribed one. Subjects were randomly assigned to
Study group (n=15) and Control group (n=15).
Autonomic function tests were performed before and 3
months after the study period for both groups.
Study group: Study group subjects were given
training to learn and perform IS. The subjects were
instructed to perform Incentive Spirometry (MediciserTM
Respiratory Exerciser) for 10 repetitions every waking
hour for 3 months.17
The IS exercise was performed as below
-
The subject was asked to sit relaxed on a chair.
Incentive Spirometer was held with one hand; other

hand supporting the tube with mouth-piece which
was inserted inside mouth.
The subject was asked to inhale inside the mouthpiece till he/she can raise two balls in the Incentive
265
Same procedure was repeated for 10 times per

session.
Control group: Control group subjects were not

allowed to perform IS.
The autonomic function test recordings were
performed in the afternoon (between 2 and 5 pm) at the
Padmashree Diagnostic Centre, Bangalore. The subjects
were instructed not to take tea, coffee or any drinks 1
hour before and any food 2 hours before the recordings
in order to exclude the effects of food and water intake
on the recordings. Before performing the test, subjects
were given enough rest of 15-20 minutes. Altogether, 30
subjects completed the study and there was no dropout.
The following cardiac autonomic function tests were
performed following the procedures described by
Banister and Mathias.4,18
Heart-rate response to Standing
The subjects were allowed to lie down for 5 min in

supine position and ECG leads (GE Medical system
MAC1200 ST) were connected. The basal heart rate was
noted from the heart-rate counter in the polygraph. The
subject was then asked to stand up immediately and
changes in the heart-rate (HR) were recorded from the
polygraph. The manoeuver was repeated 3 times at an
interval of 5 min between each and the mean of three
was taken for recording.
Heart-rate response to Deep Breathing
This was done with subjects in sitting posture with

ECG leads attached to polygraph. The subject was
asked to take a deep breath (deep inhalation followed
by deep exhalation) and HR changes during these
respiratory phases were recorded from the polygraph.
This procedure was repeated for 3 times at 5 min interval
and best of three was taken for calculation.
Statistical analysis was performed using SPSS
software (version 17). Alpha value was set at 0.05.
Descriptive statistics was used to find out mean and
standard deviation (SD) for demographic and outcome
variables. Chi-square test was used to test for gender
difference among both groups. Paired t-test was used
to measure the outcome variables before and after
training within Study and Control group. Unpaired ttest was used to test the age, height and weight
differences among both groups and also to measure
outcome variables between Study and Control group.
2/7/2013, 8:08 PM
RESULTS
Baseline characteristics of 30 male and female
volunteers of Study and Control groups are shown in
Table 1. Control group didnt show significant change
for both autonomic function tests.
data of Control group. Time for achieving the Steady

State HR was significantly less following 3 months of
IS-training compare to pre-score value in Study group
as well as post-score Steady State HR (time in sec) in
Control group.
Test 1: HR response to Standing (Refer Table 2)
Test 2: HR response to Deep Breathing (Refer

Table 3)
In Study group, the post-score Basal HR was

significantly more compared to pre-score value.
Immediately on standing, Max HR attained in the Study
group was significantly more in comparison to their
pre-score values. Post-score Steady state HR of Study
group was significantly more compare to post-score
Post-score Min HR of Study group was significantly

more in comparison to their pre-score data as well as to
post-score Min HR in Control group. Post-score DBD
was significantly less in Study group compare to postscore DBD in Control group.
TABLES
Table 1: Baseline data for demographic variables
Variable/Group
Study Group
(n=15)
Control Group
(n=15)
19.860.91
20.460.83
7/8
9/6
Height(cm)
166.46.5
164.88.4
Weight(kg)
53.25.7
57.17.3
Age(years)
Gender(Male/Female)
Data are mean SD; p-value < 0.05, Comparison of groups at baseline showed no significant difference.
Table 2: HR response to standing in Control Group and Study Group

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

standing position after reaching a steady state (the time in
seconds at which this was achieved)
Table 3: HR response to deep breathing in Control Group and Study Group

Control Group
Study Group
Pre-score
Post-score
Pre-score
Basal HR
80.335.2
79.265.0
79.666.8
Post-score
838.96
Max HR
100.0611.0
98.810.3
9812.31
101.67.9
Min HR
74.87.0
74.16.5
75.5312.63
83.3310.36*
DBD
25.28.5
24.667.8
22.467.91
18.267.54
Data are mean SD
*Statistically significant at p < 0.05, comparison made between Pre-score and Post-score data of Study group
Statistically significant at p < 0.05, comparison made between Post-score data of Control and Study groups
266
2/7/2013, 8:08 PM
Basal HR: Mean HR in sitting posture after 5 min of rest;

Max HR: Mean maximum HR recorded during deep
inspiration; Min HR: Mean minimum HR recorded during
deep expiration; DBD: Difference in HR between the
maximum during inspiration and the minimum during the
expiration
DISCUSSION
The baseline data of the demographic and outcome
variables did not show any statistically significant
difference between the subjects in the Study and Control
groups.
Test 1: HR response to Standing
In normal resting subject, Basal HR is the function
of parasympathetic system.4 In this study, significant
increase in post-score Basal HR in Study group
indicates that the practice of IS may be improving
sympathetic activity.
On immediate standing, HR increases and
continues to rise for next several seconds.19,20 Following
this, HR falls to minimum and then rises again to
stabilize at Steady State HR.4 HR response to Standing
assesses the integrity of parasympathetic cardiovagal
function.19 In this study, post-score Imm Max HR was
significantly more in Study group. However, it may be
argued that the maximum increase in HR was more in
Study group because their post-score Basal HR
following 3 months of IS-training was more.
Following standing from supine position,
subsequent HR changes are baroreceptor mediated
which enhance sympathetic tone. 19 Therefore,
significant increase in Steady State HR in Study group
indicates that there may be improvement in sympathetic
activity.
In this study, the stabilization of heart rate following
the standing occurred in less time compare to its prestudy counterpart which indicates that there may be
improvement in parasympathetic activity. Study done
by G. K. Pal (2004) showed that Steady state HR (Time
in sec) was reduced by more than 100 seconds to
consider it as increased parasympathetic activity.4
However, in this study, reduction in Steady State HR
(Time in sec) within Study group and in between Study
and Control groups were 1.36 sec and 2.84 sec
respectively, which were negligible changes. Therefore,
30:15 ratio could be considered as more appropriate
measure of parasympathetic function.21
267
Test 2: HR-response to Deep Breathing

Following HR-response to Deep Breathing, postscore Min HR was significantly more in Study group
compare to post-score Min HR in control group. The
variation of HR with respiration is known as Sinus
Arrhythmia, which is generated by autonomic reflexes.
Inspiration increases HR and expiration deceases HR
i.e. during inspiration, vagal activity decreases and
sympathetic activity increases. Opposite mechanism
occurs during expiration.4,19 Thus, increase in Min HR
during expiration in present study indicates that there
may be predominance of sympathetic activity.
Significant decrease in DBD following 3 months of
IS-training in Study group indicates that there may be
increase in sympathetic activity.
Previous studies have suggested that wellperformed slow, yogic breathing decreases sympathetic
activity. 4,21-24 However, in this study, most of the
variables of cardiac autonomic function tests were
indicating marked increase in sympathetic reactivity.
Possible reasons for obtaining this result may be as
following:
In this study, IS, which is considered as slow and
sustained maximal inspiration, is performed for 10
repetitions per session without focusing on expiration.
Previous study has shown that stimulation of carotid
chemo- or baroreceptors can evoke reflex bradycardia,
but such reflex effects are wholly or partly blocked
during inspiratory phase of breathing by central neural
inspiratory mechanisms and by the central actions of
sensory nerves from the lungs.25
Additionally, hyperventilation resulting from slow
and sustained maximal inspiration through Incentive
Spirometer without focusing on expiration phase could
be one of the possible mechanisms for getting
sympathetic predominance response because
hyperventilation is a powerful physiological stimulus
and induces tremendous sympathetic stimulation.26
Moreover, in this study, IS was performed via mouth.
Some studies have suggested that because breathing
mechanism (nerve innervation) is situated in the nose
and not in the mouth; nose breathing becomes the
function of parasympathetic nervous system.27 Studies
done by Dr Douillard mentions that on a physiological
level, nose breathing enhances deep breathing which
contracts diaphragm and makes us breathe more
efficiently by pulling more air into lower lobes of lungs.
Chest breathing through mouth fill the middle and
2/7/2013, 8:08 PM
upper lobes but tends not to engage lower lobes, which

host many of parasympathetic nerve receptors.28
Limitations of the study were small sample size,
data collection from one place which may limit the
generalizability of the findings, not performing IStraining under closed supervision of the therapist and
autonomic function tests recording in afternoon time
which may have influence on autonomic function.
Future recommendations are - conducting the study
with larger sample size with inclusion of subjects from
various sources under closed-supervised IS-training.
There is further research scope to investigate effect of
IS-training on pulmonary autonomic functions.
Conclusion - Most of the variables of cardiac
autonomic function tests were showing marked
improvement in sympathetic activity and so 3 months
practice of IS is showing considerable increase in
sympathetic activity.
7.
8.
9.
10.
11.
12.
Acknowledgement/Source of support/Conflicts of
Interest: Nil
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2/7/2013, 8:08 PM
Concurrent Validity of Clinical Chronic Obstructive

Pulmonary Disease (COPD) Questionnaire (CCQ) in South
Indian Population
C.M. Herbert1, V.K. Nambiar2, M. Rao3, S. Ravindra4
Clanical Physiotherapist, Dubai Medical Centre, 2Associate Professor, Dept. of Physiotherapy, 3Professor & Head, Dept.
of Chest Medicine, 4Professor & Head, Dept. of Physiotherapy, .M.S.Ramaiah Medical College & Teaching Hospital,
Bangalore
ABSTRACT
Background: Chronic Obstructive Pulmonary Disease (COPD) is a progressive disease associated
with a high level of disability, the treatment of which is aimed at reducing symptoms, increasing
function and improving the quality of life of the patient with lot of emphasis been given to the
development of a Health Related Quality Of Life (HRQOL) questionnaire. St. George's Respiratory
Questionnaire (SGRQ) is a self administered validated questionnaire used in COPD. The Clinical
COPD Questionnaire (CCQ) was developed as a simple tool to help clinicians identify the clinical
status of airways in individuals with COPD. Hence there is a need to validate the CCQ to identify the
health status of those with COPD in Indian population.
Aims: To measure and compare the scores and time taken with SGRQ and CCQ respectively in COPD
subjects.
Methodology: A convenience sample of 35 COPD subjects, were asked to answer the SGRQ and CCQ.
Results: Pearson correlation and Student's t-test were used for statistical analysis and it was found
that the three individual components of CCQ correlated with those of the SGRQ (r =0.909, p<0.001).
Conclusion: CCQ can be considered at par with SGRQ to assess the HRQOL in individuals with COPD
in South Indian population.
Keywords: St. George's Respiratory Questionnaire, Clinical COPD Questionnaire, Chronic Obstructive
Pulmonary Disease.
INTRODUCTION
Chronic Obstructive Pulmonary Disease (COPD) is
the major cause of morbidity and mortality throughout
the world. It is currently the 4th major cause of death in
the world. The death rate from the disease has increased
in the recent decades in apparent association with
increase in cigarette smoking and air pollution.1
Globally, by 2020, COPD is expected to rise to the 3rd
position as a cause of death and at 5th position as the
cause of loss of Disability Adjusted Life Years (DALYs)
V.K. Nambiar
Associate Professor,
Dept. of Physiotherapy,
M.S. Ramaiah Medical Teaching Hospital,
MSR Nagar,
MSRIT Post,
Bangalore - 560 054
E-mail ID: veenakiran_nambiar@yahoo.co.in
52. veena kiran--270-273.pmd
270
according to the baseline projections made in the Global

Burden of Disease Study (GBDS).2
In India, about 5% males and 2.7% females above 30
years of age have been estimated to be suffering from
COPD. There is a significant burden of COPD as a
disease in the Indian community with overall
prevalence of 6.85% in South India; with the prevalence
of males being 7.4% and females being 4.64%.3
It is known that in addition to the primary organ
dysfunction, impaired skeletal muscle performance is
a strong predictor of low exercise capacity in subjects
with severe COPD.4 Progressive decrease in functional
activity and exercise performance in subjects with severe
COPD is found. 5 The perception of the dyspnoea
worsens with the sudden onset of high intensity
constant work rate exercise. Further such dyspnoea is
found to affect the activities of daily living (ADL).6
According to GOLD (Global Obstructive Lung Diseases)
guidelines, the goals of clinical control in patients with
COPD include Health Related Quality of Life (improved
2/7/2013, 8:08 PM
exercise and emotional function) and clinical goals

(prevention of disease progression and minimization
of symptoms).7 In recent years, a great deal of attention
has been paid to developing and validating quality of
life questionnaires for individuals with COPD, in order
to identify and treat the functional as well as the
emotional problems that are most important to those
suffering from the disease.7Health Related Quality Of
Life (HRQOL) has been defined as the functional effect
of an illness and its consequent therapy, upon a patient,
as perceived by the patient. HRQOL questionnaires
allow the clinicians to measure directly the impact of
the disease on an individuals Activities of Daily Life.8
St George Respiratory Questionnaire (SGRQ) is a
supervised, self administered, reproducible, valid and
responsive instrument chosen as the gold standard to
assess the HRQOL in Indian individuals with COPD.
Clinical COPD Questionnaire (CCQ) is a self
administered questionnaire specially developed as a
simple tool to help clinicians identify the clinical status
of airways in the individuals with COPD. Since the
CCQ, which is a shorter and easier questionnaire, has
not been validated for the Indian environment, the aim
of the present study is to validate the CCQ and establish
its effectiveness in comparison to the SGRQ, in South
Indian population
An ethical clearance was issued from the institution
prior to the study. A convenience sampling was done. It
was a cross sectional study with 35 subjects inclusive
of both males and females between 35 and 60 years of
age, diagnosed with COPD(all stages according to
GOLD standard) and having good English
comprehension. Subjects with any neurological or
orthopedic dysfunction, recent surgeries and other
cardiopulmonary dysfunction were excluded from the
study. The source of data collection was from M. S.
Ramaiah Teaching Hospitals. On the day of the first
session, the subject was handed out the SGRQ and asked
to fill it up in the presence of the examiner. After two
days, subjects were given the CCQ and asked to do the
same. The scores of the individual components as well
as the overall total were separately calculated for each
of the questionnaires. Time taken by each patient for
each of the questionnaires was also recorded using a
stop watch.
STATISTICS
Data was analyzed by using SPSS 15.0, Stata 8.0,
MedCalc 9.0.1 and Systat 11.0. Microsoft word and Excel
were used to generate tables, graphs, etc. Statistical
Method: Descriptive statistical analysis has been carried
out in the present study. Results on continuous
measurements are presented on Mean SD (Min-Max)
and results on categorical measurements are presented
271
in Number (%).Significance is assessed at 5 % level of

significance. Statistical Tests: Pearson correlation was
performed to assess the correlation between the
component scores and the total scores of CCQ and
SGRQ. Students t-test has been used to find the
significance of the correlation between the component
scores and the total scores of CCQ and SGRQ.
RESULTS
Out of the 35 subjects, there were 29 males and 6
females. The scores of SGRQ Symptoms component
was a mean of 55.59 24.93; Activity component was
66.32 15.94; Impact component was 49.93 18.39
and total scores were a mean of 53.69 16.29(Table 1).
The scores of CCQ Symptoms domain was a mean of
3.11 1.40; Functional state domain was 3.75 1.08;
Mental state domain was 2.91 1.18 and total scores
were a mean of 3.32 0.99 (Table 2). The symptom
component of CCQ had a good correlation with the
symptom component of SGRQ (r=0.955, p<0.001); the
functional state component of CCQ correlated well with
activity component of SGRQ (r=0.821, p<0.001); the
mental state component of CCQ correlated well with
the impact component of SGRQ (r=0.886, p<0.001). The
overall total score of 50 questions of SGRQ and the 10
questions of CCQ showed a very high correlation
(r=0.909, p<0.001) (Table 3) and (Figure 3) .It takes a
comparatively less duration of time to complete the CCQ
as compared to SGRQ ( Table 4).
Table 1. Descriptive statistics of St. George respiratory
Questionnaire (SGRQ).
SGRQ
Min-Max
Mean SD
*SG-Symptoms
6.25-93.75
55.5924.93
25.88-88.88
66.3215.94
SG-Activity
SG-Impact
9.09-78.78
49.9318.39
SG-Total
11.68-79.50
53.6916.29
The table shows the mean scoring of each

component of SGRQ i.e. symptoms, activity and impact;
and the mean of the total scoring of SGRQ. *SGrepresents SGRQ.
Table 2: Descriptive statistics of Clinical COPD
questionnaire (CCQ).
CCQ
Min-Max
Mean SD
*C-Symptoms
0.50-12.00
3.111.40
C-Functional
1.25-5.75
3.751.08
C-Mental
0.50-8.00
2.911.18
C-Total
0.80-5.40
3.320.99
The table shows the mean scoring of each component

of CCQ i.e. symptoms, functional state and mental
state; and the mean of the total scoring of CCQ. *Crepresents CCQ
2/7/2013, 8:08 PM
Table 3: Pearson Correlation of CCQ with SGRQ
Pearson correlation
r value
P value
SG-Symptoms vs C-Symptoms
0.955
<0.001**
SG-Activity vs C-Functional
0.821
<0.001**
SG-Impact vs C-Mental
0.886
<0.001**
SG-Total vs C-total
0.909
<0.001**
Each of the components and the total of CCQ are

significantly correlated with those of SGRQ .CCQ can
predict the SG by 82.8% accuracy.
Figure 3 : Correlation scatter plot between the total
scoring of SGRQ and total scoring of CCQ;
SGRQ total
CCQ - total
The total score of SGRQ (Y-axis) is showing a high
correlation with the total score of CCQ (X-axis).
Table 4: Time taken to administer the SGRQ and CCQ
Questionnaire
Min-Max
(minutes)
Mean SD
(minutes)
SGRQ
11.05-16.25
13.500.96
CCQ
2.00-4.40
2.990.71
It takes a comparatively less duration of time to

complete the CCQ.
and the 10 questions of CCQ showed a very high

correlation (r=0.909, p<0.001) (table 3 and figure 3).The
individual components of CCQ significantly correlated
with each of the components of SGRQ (table 3). Thus
the CCQ can be considered at par with the SGRQ. Any
increase in any of the components or the total of SGRQ
would mean an increase in the corresponding
component or total of CCQ. Both questionnaires have
three components each. SGRQ, which has a total of 50
questions, is divided into symptoms component (8
questions), activity component (9 questions) and impact
component (33 questions). It includes all possible
questions that are asked in order to assess the overall
status of the patient and the impact COPD has on
people suffering from the disease. On the other hand
CCQ has a total of 10 questions and is divided into
three similar components symptoms (4 questions),
functional state (4 questions) and mental state (2
questions). CCQ has been developed by selection of
potential questions that assess the quality of life of
people suffering from COPD by experts in the field.
Hence the 10 questions of CCQ include the important
and relevant questions to be answered in order to assess
the HRQOL in individuals suffering from COPD.8 From
the present study, CCQ has shown a very high
correlation with SGRQ. Hence it is apparent that CCQ
can be used to assess the HRQOL in Indians who have
COPD. Since this study has been done on a population
of South Indians, it can be concluded that CCQ has a
concurrent validity in South Indian population when
compared to SGRQ. The CCQ takes a appreciably
shorter duration of time to administer as there are only
10 questions to be answered as compared to the 50
questions of SGRQ. Thus CCQ has the added advantage
of being easier and quicker to administer, thus can be
used as a quick tool to assess the HRQOL of South
Indians who have COPD.
FUTURE STUDIES
DISCUSSION
The (CCQ) has been deemed as a valid and reliable
tool to measure the Health Related Quality Of Life
(HRQOL) in individuals with COPD and has been
considered to be at par with the (SGRQ) in Netherlands,
Italy and Sweden.7,8,9 The validation of a questionnaire
is linked to the place and population where it is
administered. SGRQ has been validated in the Indian
population, but the CCQ has not been validated. SGRQ
has been chosen as the gold standard as it is well
validated, frequently used in COPD trials, it is available
in Hindi and it was used in the original validation of
CCQ.10 The overall total score of 50 questions of SGRQ
272
Validation of the CCQ could be done for a greater

population covering larger geographical area in India.
CONCLUSION
There was a strong correlation between the St
George Respiratory Questionnaire (SGRQ) and the
Clinical COPD Questionnaire (CCQ); hence CCQ can
be considered at par with the SGRQ in South Indian
population. The CCQ is easy to score and allows data
to be quickly collected. It is thus suitable for use in
everyday practice for clinical trials or quality of care
monitoring, of individuals with COPD, in South India.
2/7/2013, 8:08 PM
ACKNOWLEDGEMENT
The authors wish to thank Dr. S. Kumar, President
of Medical Education at M.S. Ramaiah Medical College,
Dr. Eva Wikstrom Jonsson, author, Karolinska
University Hospital Solna, Stockholm, Sweden and
referring Doctors and Physiotherapists, who provided
the subjects for the study.
REFERENCES
1.
2.
3.
4.
G. Viegi, F. Pistelli et al. Definition, epidemiology

and natural history of COPD. Eur Respir J; 2007;
30: 9931013.
Jindal, Surinder K et al. Emergence of chronic
obstructive pulmonary disease as an epidemic in
India. Indian Journal of Medical Research; Dec
2006.
K.J.R. Murthy, J.G. Sastry et al. Economic burden
of chronic obstructive pulmonary disease.
NCMH Background Papers Burden of Disease in
India, 2005.
Harry R Gosker et al. Skeletal muscle dysfunction
in chronic obstructive pulmonary disease and
heart failure: underlying mechanisms and therapy
perspectives. American Journal of Clinical
Nutrition; 2000; 71(5); 1033-1047.
273
5.
Francois Maltais et al. Oxidative enzyme

activities of the vastus lateralis muscle and the
functional status in patients with COPD. Thorax;
2000; 55; 848 853.
6.
Luis Puente Maestu et al. Dyspnea, Ventilatory
Pattern, and Changes in the Dynamic
Hyperinflation Related to the Intensity of Constant
Work Rate Exercise in COPD. CHEST; 2005; 128;
651 656.
7.
Salvatore Damato, Chiara Bonatti et al. Validation
of the Clinical COPD questionnaire in Italian
language. Health and Quality of Life Outcomes,
2005; 3:9.
8.
Thys van der Molen et al. Development, validity
and responsiveness of the Clinical COPD
Questionnaire. Health and Quality of Life
Outcomes, 2003; 1:13.
9.
Bjorn Stallberg et al. Validation of clinical COPD
questionnaire (CCQ) in primary care. Health and
Quality of Life Outcomes, 2009; 7:26.
10. Ashutosh N. et al. Validation of Hindi Translation
of St. Georges Respiratory Questionnaire in Indian
Disease. Indian J Chest Dis Allied Sci; 2007; 49:
87-92.
2/7/2013, 8:08 PM
To Study the effect of Mental Practice on one Leg Standing

Balance in Elderly Population
Vidya V Acharya1, Saraswati Iyer2
M.P.Th., Professor, Seth G.S.Medical College & K.E.M. Hospital, Parel, Mumbai
ABSTRACT
Purpose of study is: to compare "effect of only physical practice" with " effect of physical practice and
mental practice" in subjects, for activity of one leg standing.
Materials used: table, chair, cassette and record player, stop-watch, newspaper.
Methodology: 80 independently ambulatory subjects (age group 50-70yrs) were randomly selected
and divided into 2 intervention groups of 40 each. Task was to stand on the preferred leg with arms by
side and one legged balance time was measured. Two sessions (1st & 2nd) of the task, of 5 days each,
were given to subjects at a periodic gap of 30 days. Baseline and final measurements of one legged
balanced time were compared after a three days practice intervention period.
Group I (n=40, 20 male s and 20 females) performed only physical practice in both sessions (1st & 2nd)
and Group II, (n=40, 20 males and 20 females) performed only physical practice in 1st session and in
2nd session performed physical practice interspersed with mental practice. Mental Practice involved
use of idealized visual and kinesthetic mental images provided to subjects through recorded tape.
Results: Percentage improvement in balance time in both sessions was compared and statistical analysis
was done by paired 't' test and 'z' test. All groups showed improvement, but Group II showed the most
improvement in 2nd session, of 33.01% in males and 31% in female's resp. ('p' < 0.001). Comparison of
percent improvement between Group I and II, showed an increment of 10% in balance time of group II
in its 2nd session('p' < 0.001,HS).Thus showing that balance time increased significantly with physical
practice interspersed with mental practice.
Conclusion: Our study concludes that Mental Practice along with Physical Practice may hence be an
important therapeutic tool to encourage rapid acquisition of a motor skill.
Keywords: Mental Practice, Physical Practice, One Leg standing Balance
INTRODUCTION
Major concern of physical therapist is movement
its acquisition, quality and retention. Primary aim of
physical therapist is to maximize patients movement
potential. So focus is on physical techniques, for
teaching new motor skills to patients.1 However it is
not always possible to carry out task under guidance of
therapist.
Hence Mental practice, which is cognitive rehearsal
of a physical skill in absence of any gross muscular
movement, can be an utilized as a clinical tool in
assisting patients, to rapidly learn a motor task. 1
A major concern of physical therapists with all
patients, but especially with elderly, is balance. The
increased postural sway seen with age is correlated
53. Vidya Acharya--274-279.pmd
274
with loss of balance and increased incidence of falls in

elderly2.Therefore, balance is selected as physical task
to test the effect of mental practice on.
MATERIAL AND METHOD
Materials
Table, chair, cassette and record player, stop-watch,
newspaper.
ii. Method
a. Inclusion Criteria
Age group: 50 to 70 years.
All subjects are independently ambulatory without
assistive device.
2/7/2013, 8:08 PM
b. Exclusion Criteria
3. understood satisfactorily
Subjects with orthopaedic, neurological,

uncontrolled diabetes, uncontrolled blood pressure
problem, significant hearing and vision loss and
psychological problems were excluded.
4. understood properly
c.
Selection of Subjects
Group
Subjects
Sex
Number
Age
(yrs)
Mean Age
(yrs)
PP and ONLY PP
FM
2020
50-70
59.22
II
PP and PP + MP
2020
2020
50-70
59.12
5. understood properly and completely.

Group II subjects Likerts scale response was 4,5
after tape session.
So on day 2, 3, 4 group II subjects took
PHYSICAL
PRACTICE
Tape
Session
PHYSICAL
PRACTICE
Tape
Session
PHYSICAL
PRACTICE
FINDINGS
PP=PHYSICAL PRACTICE
MP=MENTAL PRACTICE
Results And Observations
d. Study Procedure
A short verbal health care history was taken.
SESSION I
Group I (Males)
Each subject from group I and group II stood on

preferred leg and lifted other foot. Arms were held by
side and time was measured using a stopwatch until
lifted foot contacted ground.
An average of three readings of measured time was
taken to have a baseline value on day 1. Group I & II
subjects carried out physical practice of activity for next
three days. Final value of balance time was taken from
an average of three readings on day 5. On day 2,3,4:
reading task was given, which distracted attention from
original activity. So on day 2,3,4 group I & II subjects
took:
PHYSICAL
PRACTICE
Reading
Session
PHYSICAL
PRACTICE
Reading
Session
PHYSICAL
PRACTICE
SESSION II
After a month Group I subjects took only physical
practice same as they took in previous month.
Group II took physical practice and mental practice
of the activity.
Baseline and final measurements of balance time of
both groups were taken again on day 1 and day 5
respectively.
Group II subjects listened to recorded speech
through record player. Speech consisted of details
regarding balance activity & relaxation. The capability
of subjects to concentrate and perceive recorded speech
was measured on Likerts scale.
Likerts Scale
1. did not understand
Percent improvement in balance time in both

sessions was compared and statistical analysis was
done by pairedt test and z test.
Day 1
Day 5
P. P1
session
54 36.57
62.15 37.13
17.45 10.37
7.52
< 0.001
P. P 2nd
session
55.95 36.78
67.60 38.56
21.88 10.97
8.89
< 0.001
st
During 1st session,% improvement in response for

balance time is 17.45.This increase is statistically highly
significant at p<0.001,which indicates response on day
5 is likely to be much more as compared to day 1 due to
physical practice.
During 2nd session,% improvement in response for
balance time is 21.88.This increase is statistically highly
5 is likely to be much more as compared to day 1 due to
physical practice.
Group I (Females)
Day 1
Day 5
P. P1st
session
59.85 44.70
70.65 46.54
19.25 10.62
7.52
< 0.001
P. P 2nd
session
62.30 45.96
78.20 49.48
23.99 12.30
8.89
< 0.001
275
% improvement t- value p- value

balance time is 19.25%.This increase is statistically
highly significant at p<0.001,which indicates response
on day 5 is likely to be much more as compared to the
day 1 due to physical practice.
the balance time is 23.99%.This increase is statistically
on day 5 is likely to be much more as compared to day
1 due to physical practice.
2. understood little
2/7/2013, 8:08 PM
Group II (Males)
Day 1
st
Group II (Females)
Day 5

st
Day 1
Day 5
P. P1
session
50.30 29.30
61.65 34.97
19.48 9.98
8.27
< 0.001
P. P1
session
52.60 39.51
61.85 41.38
19.00 10.001
8.48
< 0.001
P. P +
M.P2 nd
session
52.7529.89
77.20 40.57
33.01 11.86
12.44
< 0.001
P. P +
M. P2nd
session
55.60 38.46
77.30 42.73
31.79 12.86
11.04
< 0.001

1 due to physical practice.

balance time is 19%.This increase is statistically highly
5 is likely to be much more as compared to the day 1
due to physical practice.
During the 2nd session,% improvement in response

for balance time is 33.01%.This increase is statistically
1 due to physical practice and mental practice.

on day 5 is likely to be much more as compared to the
day 1 due to physical practice and the mental practice.
Comparison of Average % Improvement Between 1st and 2nd Session in Males and Females.
Group I
Group II
Subjects
%
Improvement I
%
Improvement II
% Difference
improvement
t- value
p- value
Males PP
17.45
21.88
4.33
8.18
P < 0.001
FemalesPP
19.25
23.99
4.74
6.74
P < 0.001
MalesMP + PP
19.48
33.01
13.53
11.67
P < 0.001
FemalesMP + PP
19.00
31.79
12.79
11.91
P < 0.001
From above table maximum improvement is seen with Group II carrying out physical practice and mental practice
in second session.
Comparison of Overall Average % Improvement Between Group I and Group II in the 1st and 2nd Session.
Group-I
(M+F)
Group-II
(M+F)
z- value
p- value
% Improvement1st Session
18.35 + 10.49P.P
19.24 + 9.999P.P
0.3
NS
% Improvement2nd Session
22.93 + 11.69P.P
32.4 + 12.37P.P
3.53
P < 0.001(HS)
From above table we can infer that

Comparison between Group I and II is statistically
not significant in first session, which indicates that
overall improvement between both groups is the same.
Difference between them is 0.89%, which is not up to
the level of significance.
Irrespective of sex of the subjects, physical practice
is not enough to increase response in 2nd session for
subjects in group I.But with supplement of mental
practice response in 2nd session for subjects in group II
increased by 10%.This increase is statistically highly
significant p<0.001, which indicates that physical
practice and mental practice is likely to yield much more
276
response in 2nd session as compared to only physical

practice.
Mental Practice interspersed with Physical practice
significantly improved balance time in the study.
The difference between comparative groups showed
highly significant results:
Within groups
All groups showed improvement, but the Group II

showed the most improvement in
2nd session of 33.01% in males and 31% in females
respectively.
2/7/2013, 8:08 PM
Between both groups
The comparison of percent improvement in Group I

and II, showed an increment of 10% in balance time of
group II in its 2nd session. Thus showing that the
balance time increased with physical practice and
mental practice of the activity.
not be performing in pattern of the one leg standing

activity. This helps into minimizing leg muscle work &
facilitating muscle work with appropriate force and
direction5, thus developing a more efficient balance &
co-ordination.
Strengthening of Engram Formation
So Mental Practice substitutes Physical Practice in

process of engram formation. This image would then
create a perception of motor act, that would activate
automatic monitoring center and facilitate
consolidation of engram formation.
The plausibility that improvement in performance

is a direct function of mental practice is related to engram
formation. Program of engram formation3 includes i)
Perception ii) Precision iii) Perceptual practice.
With engram development, volitional excitation4

takes place, which is strengthened during Physical
Practice of the activity and this adds for improvement
in performance in Group II.
Following could be the reasons for significant

increase in balance time for Group II subjects.
PERCEPTION
While carrying out, the act of standing on one leg,
perception of sensory inputs are mainly from:
proprioception, vision and auditory stimulus from tape
session, which provides information about
performance to cerebellum and automatic monitoring
centre.
Mental imaging during tape session and physical
practice facilitate process of engram formation, thus
enhancing motor learning. This is evident from
response of Group II in 2nd session. For Group 1 subjects,
it can be inferred that, engram process is not
strengthened as those subjects carried out an activity,
not related to one leg standing, during reading session.
Imaging studies by Shadmer and Holcomb have
shown cerebellum to be active during consolidation of
a learned internal model of a task4. It acts as adaptive
feed forward control system, which programs voluntary
movement skills, based on memory of previous sensory
inputs and motor outputs.
PRECISION
Precision of one leg activity is enhanced by mental
practice, which entails picturing of standing on one
leg, while imagining kinesthetic feel of act and trying to
balance on one leg and at the same time correcting
imagined mistakes. This occurs in addition to actual
physical performance of activity.
Effect of Auditory Stimulus
Mental Practice given in form of auditory cue helped

in facilitation of mental picture, by guiding activity
of balancing on one leg.
Use of background music induces relaxation

response.
Commands used during tape session affect tone

regulation, attention, arousal. This in turn enhances
performance by increasing focus to be achieved4.
EFFECT OF PRACTICE
During Physical Practice

Subjects carry out Procedural learning6 i.e. repeated
exposure of activity-hence strategies applicable to
changing stimulus configuration, within task must be
acquired through practice.
Procedural Learning is supported by circuits
involving Prefronto-caudate-striosmal topographic
projections6 . Saint and Taylor propose that straitums
role involved with mobilizing new procedures to select
among known procedures by acting as procedural
memory buffer7 .
i.
During Mental Practice

Subjects carry out Perceptual learning & Declarative
learning. Declarative learning results in ability to
store and consciously recall tape session during
actual practice session.
Perceptual practice
Results into excitation of desired neuronal linkages
and inhibition of those motor neurons, which should
277
Temporal-cortico-caudate projections are involved

(neo striatum)6.
2/7/2013, 8:08 PM
iii. Acquisition of procedural knowledge through

repeated practice may eventually result into
development of declarative knowledge of task.
iv. Conversely development of declarative knowledge
of task may hasten acquisition of procedural
knowledge8.
v.
With repetitive information through mental and

physical input, Group II showed significant
improvement in average balance time during second
session.
CONCLUSION
In elderly population, Mental Practice coupled with

Physical Practice has shown to improve one leg
balance time more significantly than Physical
Practice alone.
This improvement in balance, which is fundamental

component of human movement, suggests that
Mental Practice has promising usefulness in health
care.
Because efficacy of mental practice increases with

increasing task familiarity, it could be useful
modality for rehabilitation.
Therapeutic exercise could be supplemented with

mental imaging during rest period.
Patients confined to bed can use visualization

techniques to prepare for future retraining in gait
and activities of daily living.
It could easily be incorporated into patients home

program.
Mental rehearsal encourages patients to assume

responsibility for their recovery.
Thus, Mental Practice may be an important

therapeutic tool to encourage rapid acquisition of a
motor skill.
This improvement in the task can be supported by

the research:
Neuro-imaging Studies
In mental simulation of motor act, cerebral blood

flow studies suggest that prefrontal cortex,
supplementary motor area, basal ganglia,
cerebellum, structures required for performance of
actual movement, are active5.
PET studies have shown changes in local cerebral
blood flow associated with state of information
processing i.e. activation when hearing words.
(Stephan H Koslow, George V. Coelho)9
Effect on Memory Function
Hippocampus 10 provides drive that causes

translation of short term memory to long term i.e. it
transmits signals which seems to make mind
rehearse over & over new information.
Consolidation of long term memory of verbal type
takes place within hippocampi.
Effect of Motivation
My heartfelt thanks to the Dean of Institute, Head of

Physical Therapy Department, Bio-statistician, all my
subjects, departmental staff and colleagues.
Conflict of Interest - Nil.
Motivation hypothesis postulates that Mental

Practice increases the subjects motivation to
improve1.
REFERENCES
1.
Claudia, L.Fansler, Cathy L. Poff, Katherine F

Shepard: Effects of mental practice on balance in
elderly women. Physical Therapy, September
1985, Vol.65, No.9.
2.
Antonio Nardone, Rosella Siliotto: Influence of

aging on keg muscle reflex response to stance
perturbation. Arch Phys Med Rehabilitation,
February 1995, Vol 76.
Frederic J Kottke, Daniel Halpern: The training of
co-ordination.Arch phys Med Rehabil, December
1978, Vol.59.
Following structures are involved in motivation:

prefrontal cortex, limbic structures, hypothalamus,
thalamus, brainstem, motor cortex (structures are
also active during mental practice)11.
Effect of Neurotransmitter Activity
ACKNOWLEDGEMENT
Noradrenergic, dopamine, serotonin systems

influence operations of neural systems for decision
making12.
These systems have cognitive appraisals often
without conscious awareness.
278
3.
2/7/2013, 8:08 PM
4.
5.
6.
7.
8.
Darcy A Umphred: Interventions for Neurological

Disability, Neurological Rehabilitation 4 th Ed.
Janet Carr, Roberta Shepherd: Training motor
control, increasing strength and fitness and
promoting skill acquisition, Neurological
Rehabilitation. Optimising Motor Performance.
J.A.SaintCyr, Ann.E.Taylor, A.E.Lang: Procedural
Learning and Neo-straital Dysfunctions in man,
Brain 1988, 111,941-959.
P.Soliveri, R.G.Brown, M.Jahanshahi: Learning
manual pursuit tracking skills in patients with
Parkinsonss Disease. Brain 1997, 120, 1325-1337.
Pascual Leone, J Grafman, K.Clark,
M.Stewart:Procedural learning in Parkinsons
Disease and Cerebellar Degeneration.Annals of
Neurology,July-Dec 1993,Vol.34,1-6.
279
9.
Stephan H.Koslow, George V.Coelho: Functional

Mapping of the Human Brain.Decade of the Brain.
10. Guyton and Hall: Behavioral and Motivational
Mechanisms of the Brain. Textbook of Medical
physiology.9th Ed.
11. Paul D Cheney: Role of cerebral cortex in voluntary
movements.A Review. Physical Therapy, May
1985, Vol65, No5.
12. R E OCaroll, B P Papps: Decision making in
Humans: The Effects of manipulating the central
noradrenergic systems.J Neurology Neurosurgery
Psychiatry 2003:74:376-378.
2/7/2013, 8:08 PM
Effect of Midprone Decubitus on Pulmonary Function

Test Values in Young Adults with Undesirable Body Mass
Indices (BMI)
Junaid Ahmed Fazili1, Ajith S2, A.M.Mirajkar3, Mohamed Faisal C K4, Ivor Peter D'Sa5
Physical Therapist, Dept. of Physiotherapy, 2Asst. Professor, Dept. of Physiotherapy, 3Professor and HOD, Dept. of
Physiology, 4Professor and HOD, Dept. of Physiotherapy, 5Professor Dept of Medicine, NITTE University, Mangalore
1
ABSTRACT
Background and purpose: Body positioning is prescribed by Physical Therapists to directly enhance
oxygen transport and oxygenation, to minimize the risk of aspiration, and to drain pulmonary secretion
in most of the intensive care units. The aim of this study is to assess pulmonary function in sitting, right
mid-prone, left mid prone position in healthy young adult subjects and to compare the effect of Body
Mass Index (BMI) on pulmonary function in sitting, right and left mid prone position.
Materials and Methods: We recruited 60 healthy male volunteers by using convenience sampling with
the mean age 20.5 ranges from 18-30 years. The subjects were divided into two groups based on their
BMI (Group A BMI 18.5-24.9kg/m2and Group B BMI>25kg/m2 ). The spirometric test was done to
measure Forced Vital Capacity (FVC), Forced expiratory volume in 1 second (FEV1), Slow Vital Capacity
(SVC), Maximum Voluntary Ventilation (MVV) in sitting, right side lying and left side lying position,
the values of three different positions were compared with in the groups and between the groups.
Results: FVC and FEV1 values show significant changes in three different positions in normal and
obese subjects. The MVV of normal and obese groups in sitting, right side lying and left side lying was
significantly varied. There was no significant difference in other values.
Conclusion: With right side and left side lying position the FVC and FEV1 values decreased significantly
in compare to the sitting position, and there is no difference in lung volumes between normal and obese
except MVV. MVV is significantly reduced in right and left side lying position. Upright sitting position
will increase the lung volumes and capacities compared to the other positions.
Keywords: Midprone Decubitus, Pulmonary Function Test, Body Mass Indices (BMI).
INTRODUCTION
Body Mass Index (BMI) is a widely accepted and
used index to measure obesity in both adults as well as
in adolescents. Obesity can cause various deleterious
effects to respiratory function, such as alterations in
respiratory mechanics, decrease in respiratory muscle
strength and endurance, decrease in pulmonary gas
exchange, lower control of breathing, and limitations
in pulmonary function tests and exercise capacity. These
changes in lung function are caused by extra adipose
tissue in the chest wall and abdominal cavity,
compressing the thoracic cage, diaphragm, and lungs15.
Many studies have stated that there is a direct
relationship between lung function and body mass
54. ajith sonam-280-284.pmd
280
index .Weight and body mass index as measures of

overall abdominal adiposity are used as predictors of
pulmonary function in many epidemiological studies.
These measures are widely accepted as determinants
of pulmonary function in many epidemiological
studies6, 7. Abdominal adiposity may restrict the descent
of diaphragm and limit lung expansion compared to
overall adiposity, which may compress the overall chest
wall.2Several previous studies have stated that increase
in body weight decrease lung volume, but many studies
have been small; they included subjects with coexisting
morbidities8-10.
Therefore, it is important to understand the
relationship between body mass index (BMI) and lung
2/7/2013, 8:08 PM
function to properly interpret Pulmonary Function Tests

(PFTs).
Different side lying body positioning is prescribed
by Physical Therapists to directly enhance oxygen
transport and oxygenation, to minimize the risk of
aspiration, and to drain pulmonary secretion in most
of the intensive care units.11Compared with the upright
position, recumbent positions have well documented
deleterious effects on lung volume of the dependent
airways, reduced flow rates ,and reduced arterial
saturation .These effects are accentuated with age
,smoking history, obesity, breathing at low lung
volumes, sedation and direct effects of anaesthesia12.
Although side lying (mid prone) positions are
commonly used clinically, the differential effects of right
and left side mid prone position on lung function
compared with a reference position such as upright
sitting have not been studied in detail. There have been
a few reports of improved arterial oxygenation in left
versus right side-lying in patients with unilateral lung
disease and bilateral lung disease and in patients
following coronary artery bypass surgery.13
In recumbent positions gas exchange is improved
with the healthy lung down in patients with unilateral
lung disease and in right side lying in patients with
bilateral lung disease. In patients with unilateral lung
disease, the role of the inferior lung as gas exchanger
and diffusion capacity is enhanced because of the
cephalad displacement of the hemi diaphragm placing
it in greater mechanical advantage.14The Effect of mid
prone position on pulmonary function test among
young adults of altered BMI has not been studied with
the importance it deserves. This study aims to
understand the relationship between the side-lying
position and BMI on lung function.
METHOD
Subjects
This study was approved by the Central Ethical
Committee of Nitte University; 60 healthy male
volunteers were selected by using convenience
sampling. We included healthy male volunteers of age
range 18-30 years, and excluded the subjects with a
history of cardio respiratory disease, BMI< 18.5, yoga
and exercise practitioners, subjects with history of
281
smoking, subjects taking medication, which has effect

on respiratory system.
STUDY PROTOCOL
The study was conducted at the Nitte Institute of
Physiotherapy; the subjects were briefed about the
protocol and the informed consent was obtained from
them prior to the commencement of study. A detailed
history regarding their habits, physical activity and
history suggestive of any cardio respiratory or any
systemic illness was elicited. The percentage of body
fat was calculated by Quetelets Index15
BMI=weight (kg)/height2 (m2))
Body fat composition was measured was measured
by the skin fold thickness method in the following
manner, the skin fold thickness was measured at four
different sites on the dominant side of the body by using
skin fold callipers. Extremity skin folds were measured
at the triceps, biceps, trunk, supra-iliac and sub scapular
areas16, 17. The skin fold was picked up between the
thumb and forefinger and the readings were taken 5
seconds after the calliper was applied. Three consecutive
readings were taken and recorded at each site. The
average of three readings at each site was calculated
and sum of these values was entered into the table given
by Durnin and Womersley18.to find out the body fat
percentage. Body fat percentage and BMI of the subjects
were compared to add weight age to the classification;
high body fat percentage was seen to be associated with
high BMI. The subjects were divided into 2 groups based
on the BMI
Group I 30 subjects with BMI 18.5-24.9kg/m2
Group II 30 subjects with BMI>25kg/m2
The lung function parameters which were assessed
by computerized spirometers were Forced Vital
Capacity (FVC), Forced expiratory volume in 1second
(FEV1), Slow Vital Capacity (SVC), and Maximum
Voluntary Ventilation (MVV)
The sessions were conducted in ventilated room;
the instrument used to measure respiratory parameters
is SPIROMETER HELIOS 401.
Session I - Sitting position (recordings taken after
15 minutes in sitting)
2/7/2013, 8:08 PM
Session II- Right mid prone position (recordings

taken after 15 minutes in side lying to the right).
Session III - Left mid prone Position (recordings
taken after 15 minutes in side lying to the left).
A gap of 15 minutes was maintained in between the
sessions to avoid bronchospasm or exhaustion, the
sessions lasted for an hour and the study was divided
into three sessions based upon the position
For recording FVC and Fev1, the subject was
instructed to keep the disposable mouth piece attached
to the transducer halfway in the mouth above the tongue,
the nose clip was applied and the subject was asked to
look away from the monitor, after that he was asked to
take a deep inspiration and then blow hard in the
transducer up to 6secoonds followed by a deep
inspiration19
For recording SVC the subjects with his nose clip
was asked to breathe normally, after a minimum of 3
quiet breaths he was asked to take a deep inspiration
followed by expiration and then breathe normally and
to record MVV, the subject was instructed to breathe in
and out rapidly through the transducer for at least 15
seconds.
In right side lying positionFev1/fvc and MVV shows

significant difference (Table 4&figure3) In left side lying
position the MVV values of obese group is at a lower
level when compared to the normal group and this
difference is very highly significant.( Table 5 &figure 4).
Table 1. (Normal subjects)
Normal
Sitting
Rt
Left
Sidelying
Sidelying
P-value
FVC
3.95 0.65
3.583.61
3.484.83
.p<.05(s)
FEV1
3.32.55
3.0 .55
2.9173.77
p<.05(s)
FEV1/FVC
83.339.7
84.1308.7
82.5810.7
.829
SVC
3.807.66
3.756.68
15.92068.39
.393
MVV
119.6727.240
116.0733.909 119.4323.471
.861
Table 2. (obese subjects)

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

positions
For each manoeuvre the subject performed thrice and

the best of the 3 readings were selected. In each session
the rest period was 15 minutes to accommodate the
effects of position change on the pulmonary circulation,
notably the pulmonary capillaries, which is time
dependent.
RESULTS
64subjects were selected for the study; the data
collection of four subjects could not be completed.
Statistical analysis was performed with SPSS software
package. The mean age of the subjects who participated
in the study was 20.5; range (18-30) .T-test compared
the various positions in the two groups. Annova was
used to compare the variables within the groups.
FVC and FEV1 values showed significant changes
in all three positions in normal and obese subjects (Table
1 & 2), (figure 1). But when we compared the values in
between normal and obese groups in sitting position
there was significant difference in MVV and no
significant difference in other values (Table 3, figure 2).
282
Table 3. Comparison of Pft Variable with Obese and

Normal In Sitting
Group-1
Group-2
p-value
(N=30)
(N=30)
Fvc
3.9503.648
4.0227.547
p>0.05(ns)
Fev1
3.321.55
3.32.50
p>0.05(ns)
Sitting
Fev1/fvc
83.3189.79
82.236.26
p>0.05(ns)
Svc
3.905.65
3.759.71
p>0.05(ns)
Mvv
119.6727.24
104.7022.78
2/7/2013, 8:08 PM
p<.05(s)
Fig. 2
(1999)19 concluded that FVC and FEV1 were decreased

equally in left and right side lying positions in older
individuals without cardiopulmonary disorders.
Table 4. Comparison Of Pft Variables With Obese And

Normal In Right Sidelying
Group-1
Group-2
(N=30)
(N=30)
p-value
3.5827.61
3.6600.66
p>0.05(ns)
3.0400.55
2.9227.58
p>0.05(ns)
Right sidelying
Fvc
Fev1
Fev1/fvc
84.1238.7145 79.7887.8893
p<.05(s)
Svc
3.7563.68422 3.8123.72779
p>0.05(ns)
Fig. 2
DISCUSSION
Body position exerts a strong effect on pulmonary
position, but its effect on the side lying position with
undesirable Body Mass Indices (BMI) is still to be
understood. This study investigated the interrelationships of PFT values in side lying positions
between two different BMI groups. Studies previously
done on this subject have shown marked improvement
in patients who lay with the diseased or operated lung
uppermost compared with the dependent position and
many studies have concluded that obesity has a direct
effect on pulmonary function. Fiona Manning et al
283
Therefore the present study aims to assess the PFT

values in sitting and side lying positions in young
healthy population of different BMIs. We studied 60
healthy young adults in two different groups with three
different positions. Our study findings confirm that FVC
and FEV1 value was decreased in right side lying and
left side lying when compared to the sitting position.
The results of our study conform to the result of the
previous study done by Fiona Manning et al19 and
Behrakis et al 20. The decrease in FVC in recumbency
may reflect both increased thoracic blood volume due
to the increased venous return and cephalad
displacement of the diaphragm caused by abdominal
encroachment. Other factors which may have caused
this decrease include increased airway resistance and
decreased lung compliance secondary to anatomical
difference between the left and right lungs and shifting
of mediastinal structures. When the value between
normal and obese subjects was compared, there is
significant reduction in MVV in obese population. MVV
is a measurement of respiratory muscle endurance, is
reduced by 20% in healthy obese individuals and by
45% in obese individuals with obesity hypoventilation
syndrome (OHS) 21. This may result from diaphragm
dysfunction due to increased abdominal and visceral
adipose tissue deposition. While other studies
conducted by earlier authors have shown reduction in
the lung volumes especially FRC and ERV, many
researches proved that obesity (BMI>30) has a direct
restrictive effect on pulmonary function. Wafaa R. AlBader et al22 proved that BMI>30 is associated with a
restrictive effect on pulmonary ventilation. We selected
subjects with BMI> 25, and the number of subjects with
BMI>30 was very much limited; this may be the reason
the other values are not significant in both the groups.
The major limitations of our study is we recruited
normal subjects and we could have increased the
number of subjects that would have given more
statistical weightage, if we selected a diseased
population that would have given more clinical validity
of our study. The other components of pulmonary
function tests could also have been done to further
validate the study.
The clinical importance of our study is that since
optimal lung function is seen in upright position, it can
be beneficial if ventilator dependent patients are nursed
in the upright position as opposed to the traditionally
2/7/2013, 8:08 PM
used supine position, the need of early mobilization

after the major surgical procedure is also considered.
Since Obesity will increase the demand for ventilation,
elevated work of breathing, respiratory muscle
inefficiency and diminished respiratory compliance,
the result of our study will benefit the patients of
cardiopulmonary disorders with high BMI. The
physical therapist should know the physiological
effects of positioning while administering chest physical
therapy.
CONCLUSION
Authors concluded that with right side and left side
lying position the FVC and FEV1 values decreased
significantly in compare to the sitting position, and
there is no difference in lung volumes between normal
and obese except MVV. MVV is significantly reduced in
right and left side lying position, authors also
concluded that upright sitting position will increase
the lung volumes capacities.
ACKNOWLEDGEMENT
Authors would like to thank the Nitte University,
Dep. of Physiology K S Hegde Medical Academy and
Dep. of Physiotherapy for their complete support to fulfil
this study.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Authors agree that there was no source of conflict of
interest
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2/7/2013, 8:08 PM
Comparison of Quality of Life in off-pump Versus

on-pump Coronary Artery bypass Graft (CABG) Patients
before and after Phase II Cardiac Rehabilitation
Nikhil Vishwanath1, Ajith S2, Ivor Peter D'Sa3, M.Gopalakrishnan4, Mohamed Faisal C K5
Physical therapist, Dep. of Physiotherapy, 2Asst. Professor, Dep. of Physiotherapy, 3Professor, Dep. of Medicine, 4HOD,
Dep. of Cardio Thoracic Surgery, 5Professor and HOD, Dep. Of Physiotherapy, NITTE University, Mangalore
ABSTRACT
Background and purpose: Coronary artery Bypass Graft (CABG) is the commonly performed
revascularization procedure after a major vessel block. Many studies have indicated that there is a
reduction in Quality of Life after CABG. The aim of our study was to compare the Quality of Life (QOL)
in off pump and on pump CABG patients before and after phaseII Cardiac rehabilitation and to find out
the effectiveness of cardiac rehabilitation to improve the QOL.
Materials and Methods: The QOL of 50 patients consisting of two groups were studied on two different
occasions before phase II cardiac rehabilitation and after Phase II cardiac rehabilitation respectively by
using SF-36v2 questionnaire.
Results: 50 patients with the mean age 47.9 years, (range 40-58) completed the study. Following the
cardiac rehabilitation there was a marked improvement in the QOL of both the groups, and the physical
and mental components scores in the SF-36v2 questionnaire were increased. The difference between
the scores of off pump and on pump CABG was significant before phase II cardiac rehabilitation. After
phaseII cardiac rehabilitation, there were no significant changes between the scores except for those of
general health (p=.005), emotional role functioning (p<.001) and mental component score (p=.01)
Conclusion: The QOL was seen to increase significantly after 3 months of structured cardiac
rehabilitation program(comprising of Phase I and Phase II cardiac rehabilitation) in both on pump and
off pump CABG patients .There were significant changes in the all the 8 domains in the SF-36v2
questionnaire in both groups before and after Phase II cardiac rehabilitation, but there was no significant
difference in QOL between on pump and off pump CABG subjects after Phase II cardiac rehabilitation
program.
Keywords: Quality of Life (QOL), off Pump CABG (OPCAB), on Pump CABG, Phase II Cardiac Rehabilitation.
INTRODUCTION
Coronary artery bypass grafting (CABG) is the major
coronary artery revascularization procedure after any
major vessel block. It is one of the landmark
operations in the history of cardiac surgery that saved
the lives of millions of people afflicted with coronary
artery disease.1, 2 Coronary Artery Bypass Graft is a
commonly performed surgery worldwide. In India
around 500,000 CABGs are performed annually. CABG
is the most accepted coronary revascularization
procedure performed after a major vessel block3-5.
There are 2 different methods of doing CABG: the
traditional way, which is called the on-pump CABG,
and the newer way, which is called the off-pump CABG
(OPCAB). The pulmonary function after CABG is
severely reduced; the reasons for the restrictive
55. ajith sonam-285--292.pmd
285
impairment and atelectasis are multiple and include,

besides the effects of anesthesia, intra-operative events
such as internal mammary artery harvesting, changes
caused by mechanical alteration of the thoracic cavity,
immobilization and pain6. Roentgenologial signs of
atelectasis are common and various studies have
documented reduced lung volumes and oxygenation
in the post-operative period7. Many studies show that
the pulmonary complications are more in patients with
on pump coronary artery bypass graft8
The World Health Organization (WHO) classifies
Cardiac Rehabilitation as The sum of activities required
to influence favorably the underlying cause of the
disease, as well as to ensure the patient the best possible
physical, mental and social conditions, so that they
may, by their own efforts, preserve or resume when lost,
2/7/2013, 8:08 PM
as normal a place as possible in the life of the

community9, 10
Cardiac rehabilitation is divided into four phases,
progressing from the acute hospital admission stage to
long-term maintenance of lifestyle changes. According
to American College of Sports Medicine (ACSM) 11, the
rehabilitation phase can be divided into
Phase I in-patient period, duration 5- 7 days.
Phase II early post-discharge, duration up to 3

months.
Phase III supervised out-patient program

including structured exercise.
Phase IV long-term maintenance of exercise and

other lifestyle changes.
Even reports on health economic aspects show that

cardiac rehabilitation is a justifiable use of the healthrelated budget. However, access to cardiac rehabilitation
is often limited12, 13, 14
Cardiac rehabilitation ensures improvement in
quality of life and makes it easier for patients to work,
participate in social activities and exercise.
Quality Metrics SF-36V2 Health Survey asks 36
questions to measure functional health and well-being
from the patients point of view. Its called a generic
health survey because it can be used across age (18 and
older), disease, and treatment groups, as opposed to a
disease-specific health surveys which focus on a
particular condition or disease. The survey is
meaningful to patients, clinicians, researchers, and
administrators across the health care spectrum, and
has various applications15.
METHOD
Subjects
This study was approved by the Central Ethical
Committee of Nitte University. The patients posted for
Coronary Artery Bypass Graft (CABG) were randomly
selected from the cardiothoracic unit of K S Hegde
Medical College with the permission of the
cardiothoracic surgeon. We included subjects with
isolated CABG, aged between 40-65 years and with
Ejection fraction > 35% and we excluded the subjects
with other than isolated CABG ,Age > 65 years,
Myocardial infarction after CABG, Ejection fraction
<35% , Renal failure and high risk subjects .
286
STUDY PROTOCOL
All the patients underwent pre-operative chest
physiotherapy to clear secretions and to improve the
lung function. After surgery, the patients were divided
in to two groups based on the type of surgery.
Group 1 On pump CABG patients (n= 25).
Group 2 Off pump CABG patients (n= 25).
No mortality was recorded in both the groups after
extubation and all patients underwent phase I cardiac
rehabilitation. The phase I cardiac rehabilitation
included the physiotherapy techniques like incentive
spirometry, coughing, huffing, chest manipulation,
segmental expansion, thoracic mobilization and
ambulation. Post operatively the exercises were started
approximately 1 hr after extubation, and the patients
were encouraged to perform all the exercises twice daily
for the first 7 postoperative days.
After the phase I program the SF36-v2 questionnaire
was administered. It consists of 36 short questions
mirroring health and Quality of Life (QOL) in eight
different aspects: bodily pain (BP, 2 items); mental health
(MH, 5); vitality (VT, 4); social functioning (SF, 2); general
health (GH, 5); physical functioning (PF, 10); and role
functioning, both emotional (RE, 3) and physical (RP,
4). Role functioning reflects the impact of emotional and
physical disability on work and regular activity. All
the patients were explained about the questionnaire
and asked to fill according to the questions.
Phase II cardiac rehabilitation was a home-based
individualized tailored program of aerobic exercises;
preferably brisk walking17, 18. The exercises were taught
to the patient in the department under physiotherapist
supervision, and then the program protocol was given
to the patient to be done at home for 3months. Patients
were also trained in palpating the pulse and calculating
the heart rate, and to rate the Rating of Perceived
Exertion (RPE) of 11 to 14.The exercise program
consisted of warm up which included breathing
exercise, stretching exercise and gentle active exercise
to upper limb, lower limb and trunk muscles for a
period of 10 minutes, followed by graded aerobic
training and cool down. Aerobic training was brisk
walking for 3-5 times a week with intensity of 40-70%
of Heart Rate Reserve (HRR) achieved in exercise test
by using Karvonen formula, and RPE of 11-14 for
duration of 20 to 40 minutes (ACSM guidelines 2005)19.
Patients were contacted by phone every two weeks to
ensure their interest in the program and to monitor the
2/7/2013, 8:08 PM
progress. The exercise log was reviewed every 15 days

.Subjects were also advised to contact the
physiotherapist if any advice or help was needed. We
provided a detailed booklet in the patients mother
tongue
which contained dos and donts after cardiac
surgery and termination criteria while doing exercise.
The progression of the exercise intensity was done every
two weeks .As the RPE falls with improving fitness the
intensity of exercise was increased by 5 to 10 percent of
the maximum heart rate, and the RPE was maintained
11 to 14 throughout the 3 months duration. Subjects
started to do the exercise for 15 to 20 minutes and by the
end of 3rd month they gradually progressed to 30 to 40
minutes20.
After the end of the phase II cardiac rehabilitation
SF36V2 questionnaire was again administered to the
patients and asked to fill accordingly. Later the

questionnaire scores were compared with the pre-phase
II cardiac rehabilitation scores and scores were
compared between on pump and off pump CABG.
RESULT
58 subjects were selected for the study out of which
the questionnaire was not completed for eight subjects.
Statistical analysis was performed with SPSS software
package. The mean age of the subjects who participated
in the study was 47.9 years, range (40-58). 33 males
and 17 females completed the study. In comparison with
the pre and post values from the SF36 v2 administered
to the patients of both the group of on-pump and off
pump. There was significant difference when the scores
of the questionnaire were compared after one week of
surgery (before phase II) of both the groups. (Table- 1)
Table 1. Before phase II cardiac rehabilitation
PF
RP
BP
GH
GROUP
Mean
Std. Deviation
Group I
25
30.2360
2.70086
2.25000
GroupII
25
33.7080
4.20150
p=0.005 hs
Group I
25
31.1360
3.81744
2.83400
GroupII
25
33.7680
3.50721
p=0.04sig
Group I
25
49.5280
5.68718
4.92600
GroupII
25
54.9640
2.16578
P<.001 vhs
Group I
25
51.8080
2.75550
2.53600
GroupII
25
54.8160
4.25182
p=0.005 hs
VT
Group I
25
59.7200
5.09220
2.44700
GroupII
25
62.8640
2.70545
p=0.01 hs
SF
Group I
25
46.7960
6.65014
2.48400
GroupII
25
49.2120
3.41219
p=0.005 hs
RE
Group I
25
40.0960
3.10145
2.20700
GroupII
25
43.6120
3.34692
p=0.04sig
MH
PCS
MCS
Group I
25
59.3120
5.15871
2.55900
GroupII
25
63.9320
2.65601
p=0.01 hs
Group I
25
50.1800
3.49327
2.84700
GroupII
25
53.6880
2.76059
p=0.04 sig
Group I
25
49.2160
4.95468
2.35700
GroupII
25
53.0880
3.24807
p=0.005 hs
PCS - physical component summary score, PCS = PF+RP+BP+GH

MCS mental component summary score, MCS = VT+SF+RE+MH
There were no significant changes in the score after

Phase 2 cardiac rehabilitation in both the groups. There
were changes in the PF (physical functioning) GH
287
(general health) RE (emotional role functioning) MCS

(mental component summary score). (Table-2).
2/7/2013, 8:08 PM
Table 2. After Phase II Cardiac Rehabilitation
GROUP
Mean
Std. Deviation
Group I
25
40.8720
3.96227
2.10900
GroupII
25
41.9720
3.01407
p=0.307 ns
Group I
25
32.8120
5.25808
.45700
GroupII
25
35.2120
6.31667
P=.654 ns
Group I
25
54.9400
5.55788
.56600
GroupII
25
55.7080
3.89657
p=0.574 ns
GH
Group I
25
61.5120
2.17855
2.93000
GroupII
25
64.5280
4.66329
P=0.005 hs
VT
Group I
25
62.5880
5.26223
.10700
GroupII
25
63.4520
5.61503
P=0.916ns
SF
Group I
25
51.8160
3.48589
.45700
GroupII
25
52.2600
3.38674
p=0.656 ns
RE
Group I
25
49.0360
5.43207
4.92600
GroupII
25
54.9640
2.58697
p<.001 vhs
PF
RP
BP
MH
PCS
MCS
Group I
25
62.1400
3.30568
1.35300
GroupII
25
63.1680
1.87143
p=0.182 ns
Group I
25
52.2720
3.63198
.58400
GroupII
25
53.5440
5.07092
P=0.562 ns
Group I
25
59.7160
5.04824
2.67900
GroupII
25
62.7120
2.40387
P=.01 hs
Paired sample test was done to compare pre and

post values of both the groups, and there were
significant difference between pre phase II and post
phase II of cardiac rehabilitation scores between on

pump and off pump cardiac surgery.(Table-3 and 4)
Table 3. Paired Samples Test, Group-1

GROUP
Group I
Paired Differences
Mean
Std. Deviation
-9.6360
10.08319
RP-PRE RP-POST
-.6760
16.14273
-.209
.836
BP-PRE BP-POST
-9.4120
11.40677
-4.126
<.001 vhs
GH-PRE GH-POST
-3.7040
6.47447
-2.860
0.009 hs
VT-PRE VT-POST
-9.8680
12.44946
-3.963
<.001 vhs
SF-PRE SF-POST
-5.0200
9.54799
-2.629
0.015 sig
RE-PRE RE-POST
-16.9400
15.05631
-5.626
<.001 vhs
MH-PREMH-POST
-9.8280
10.38775
-4.731
<.001 vhs
PF- PRE PF-POST
-4.778
<.001 vhs
PCS-PRE PCS-POST
-3.0920
8.27682
-1.868
.074
MCS-PRE MCS-POST
12.5000
12.61266
-4.955
<.001 vhs
288
2/7/2013, 8:08 PM
Table 4. Paired Samples Test, Group II
GROUP
Paired Differences
Mean
GroupII
PF-PRE PF-POST
Std. Deviation
-12.2640
7.03526
-8.716
<.001 vhs
RP-PRE RP-POST
-3.4440
19.16059
-.899
.378
BP-PRE BP-POST
-12.7440
10.20139
-6.246
<.001 vhs
GH-PRE GH-POST
-7.7120
8.90048
-4.332
<.001 vhs
VT-PRE VT-POST
-13.5880
9.04366
-7.512
<.001 vhs
SF-PRE SF-POST
-10.0480
14.03852
-3.579
0.002 hs
RE-PRE RE-POST
-18.3520
13.76787
-6.665
<.001 vhs
MH-PREMH-POST
-15.2360
11.24333
-6.776
<.001 vhs
PCS-PRE PCS-POST
-5.8560
8.24768
-3.550
0.002 hs
MCS-PRE MCS-POST
-16.6240
12.54184
-6.627
<.001 vhs
DISCUSSION
CONCLUSION
Overall QOL after surgical myocardial

revascularization was fairly well preserved in both
groups and comparable with that of a standard
population in most aspects. General and mental health,
vitality, physical and social functioning, and bodily
pain were not negatively affected by surgery irrespective
of the procedure chosen. The quality of life before the
phase II cardiac rehabilitation in off pump and on pump
patients was significantly changed; the QOL rating was
more in off pump patients than on pump group. This
may be due to CABG performed with cardiopulmonary
bypass (CPB), also known as on- pump CABG, which
has been associated with significant pulmonary
complication and functional changes. Many of these
abnormalities are thought to be caused by CPB. Duration
of hospital stay and extubation period was lesser in
off-pump group compared with on-pump group. The
incidence of atelectasis and pleural effusion and
ventilator support was significantly higher in on pump
group. Four of the on pump patients were re- intubated
during the phase I cardiac rehabilitation period. Many
studies suggest that quality of life is better in OPCAB
patients in the initial 2 weeks after surgery; our study
revealed that quality of life can improve in both types of
surgery after structured cardiac rehabilitation.
The authors concluded that 3 months of structured

cardiac rehabilitation programs significantly improved
QOL in on pump and off pump CABG patients; there
were significant changes in the all the 8 domains in the
SF36 questionnaire before and after Phase II cardiac
rehabilitation. But there were no significant difference
in QOL between on pump and off pump CABG subjects
after a cardiac rehabilitation program.
One limitation of the study may be the sample size,

since the less number will not give more statistical
weightage. The phase II cardiac rehabilitation program
was an individually tailored exercise program, in
which the exercise frequency, intensity and mode were
prescribed and the patient was encouraged to perform
the exercise at home. The disadvantage of this type of
exercise program is that it is non- monitored and thus
compliance with the program cannot be ensured.
289
Conflict of Interest -nil

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Volume 7

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4th Floor, Statesman House Building, Barakhamba Road,

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Indian Journal of Physiotherapy and

January - March 2013

Effectiveness of Transcutaneous Electrical Nerve Stimulator (TENS) in Reducing ........................................................ 11

Evaluation of effects of Nebulization and Breathing Control in Asthmatic Patients .......................................................... 14

Effect of Neuromuscular Electrical Stimulation Combined with Cryotherapy on ............................................................. 21

Prediction of Relationship of Visual Attention Deficits to Balance and Functional ............................................................ 31

The effects of Therapeutic Application of Heat or Cold Followed by .................................................................................. 37

3 Weeks Continuous Passive Motion Vs Joint

1. Anil Kumar 2nd april-1-5.pmd

Below the age of 55 years of all fractures showed a

following various types of reconstructive joint surgery

day 01 and on day 21 in the study groups. Once all

Both male and female participants with knee joint

Post fracture stiffness of knee joint

Ligament injuries of grade 1 and 2

Age group between 18-50 years.

The patient was asked to rest supine on the

Total Knee Replacement.

Osteoarthritis of knee joint.

Knee joint effusion.

Bone tumours around knee joint

Knee joint malignancy

Any local or systemic infection.

Once the patient was included in the study, the

1. Anil Kumar 2nd april-1-5.pmd

Moist heat therapy was given as conventional

The physiotherapist performed an anterior

physiotherapist grasps the dorsal aspect of the

Mean Height Mean Weight

Table 2. Intra group mean difference

Table 3. Inter group comparison using Multiple Scheff test

1. Anil Kumar 2nd april-1-5.pmd

that there was recovery of all the above parameters in

have altered the results of the study and were well

1. Anil Kumar 2nd april-1-5.pmd

investigator-blinded RCT compared three rehabilitation

The findings of the present study show that

Intermediate readings of the outcome measures was

There was no control group in the present study

Thieme Atlas of anatomy; Anatomy and

1. Anil Kumar 2nd april-1-5.pmd

connective tissue; J Orthop Sports Physical

Comparison of Blood Pressure and Heart Rate between

Ankita Samuel1, Manish Rajput1, Chhavi Gupta1, Sumit Kalra2

2. Ankita 5th april --6-10.pmd

clinicians have continued to use single-leg stance

rate, cardiac contractility, resistance, and

As it always seen that men have more muscle power

Assumption of the upright posture requires prompt

RESEARCH DESIGN- Co-relational

The response of blood pressure to change in body

4. Any pain in upper limb, lower limb or spine

2. Ankita 5th april --6-10.pmd

SAMPLE SIZE- 200 (male-100, female-100)

5. Use of any limb prosthesis

1. The Omron M6 (HEM-7001-E) digital blood

Table 1. Resting and Dominant