Effectiveness of Physiotherapy For The Handwriting Problem of School Going Children PDF

See
discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/258942208
Effectiveness of Physiotherapy for the

Handwriting Problem of School Going Children.
Article July 2012
CITATIONS READS
0 304
3 authors, including:
Chandan Kumar Poonam Mehta

School of Allied Health Sciences, Greater Noi University of Otago
15 PUBLICATIONS 17 CITATIONS 14 PUBLICATIONS 17 CITATIONS
SEE PROFILE SEE PROFILE
Some of the authors of this publication are also working on these related projects:
Effectiveness of Manual Perturbation Exercises in Improving Balance, Function and Mobility in Stroke
Patients: A Randomized Controlled Trial View project
Ageing and Pain View project
All content following this page was uploaded by Poonam Mehta on 03 March 2016.
The user has requested enhancement of the downloaded file.

I
Indian Journal of Physiotherapy and

Occupational Therapy
www.ijpot.com
Contents
Volume 06 Number 03 July - September 2012
1. A Study of Correlation Between Depression, Fatigue and Intelligence in Parkinsons Patients ..................................... 01
Phansalkar Archana A, Iyer Saraswati
2. Role of Aerobic and Resistive Exercises in Postmenopausal Women .................................................................................. 07

Abha Sharma, Heena Sahi
3. Quality of Life, Disablement, Comorbidity and Socio-Demographics of Stroke ............................................................... 13

Survivors in South-Western Nigeria
Aderonke O. Akinpelu, Caleb A. Gbiri, Fatai A. Maruf
4. Efficacy of Mesh Glove Sensory Stimulation on Spasticity Control in Hemiplegic C.P. .................................................. 19
Ahmed M. Azzam
5. Rehabilitation of a Patient with Post Traumatic Triple Nerve Palsy of the Upper Limb .................................................. 24
Anil Mathew
6. The Effectiveness of Iontophoresis Over Conventional Therapy in Relieving Pain, ......................................................... 28

Improving Rom and Functional Skills in Adhesive Capsulitis
Anila Paul, Nizar, Thresiamma VT
7. Comparison of Dynamic Balance Between Flat Feet and Normal Individuals .................................................................. 33
Using Star Excursion Balance Test
Ajit Dabholkar, Ankita Shah, Sujata Yardi
8. Evaluation of 6 Minute Walk test Parameters in Normal Indian Pediatrics age Group between 6-11yrs ..................... 38
Jinal Chitroda, Anuprita Thakur, Sujata Yardi
9. Effect of Posterior Tibial Nerve Stimulation and Trospium Hydrochloride in .................................................................. 42

Treatment of Overactive Bladder Syndrome: A Randomized Controlled Study
Anwar Abdelgayed Ebid, Shamekh Mohamed El-Shamy, Ali Abd El Monsif Thabet
10. Pulse Rate Response to Footwear in Rehabilitation Phase of Coronary Artery Bypass .................................................... 48
Graft Surgery (CABG) Patients A Clinical Trial Study
Shaily Razdan, Aparna Sarkar
11. Effect of Passive Pelvic Fixation on Non-Specific lumbopelvic Pain: A Case Report ........................................................ 53
Apeksha A, Khatri SM
12. A Prospective Experimental Study of Effects of Cognitive Tasks on Balance In Stroke Individuals .............................. 57
Ami Timbadia, Archana Gore, Saraswati Iyer, Laxmiprabha Rangarajan, Amita Mehta
13. A Cross-Sectional Study on the Significance of Side Step Length for Dynamic ................................................................. 62
Balance Assessment in Ambulatory Stroke Subjects
ARJU B, Joshua A.M., Ganesan S.
Content Final.pmd 1 10/16/2012, 2:42 PM

II
14. Effectiveness of Sensory Re-education after Nerve Repair (Median or Ulnar Nerve) at the Wrist Level ...................... 68
B. Anandha Priya
15. A Comparative Study Between High Side Lying and Side Lying Position on ................................................................... 75
Oxygen Saturation in Preterm Infants
Bhanu Thapar, C. Janarthanan, Jagmohan Singh, Aarti Sareen
16. Efficacy of Knee Osteo-arthritis Outcome Score (KOOS) in Measuring .............................................................................. 79

Functional Status of Knee Osteo-arthritis Patients in the Indian Population
Bindya Sharma
17. Reliability and Concurrent Validity of Dynamic Rotator Stability Test A Cross Sectional Study .............................. 82
Binoy Mathew K V, Charu Eapen, P.Senthil Kumar
18. A Randomised Controlled Trial of Stimulation of Triceps as an Adjunct to ...................................................................... 88

Motor Training of Paretic Arm in Stroke Patients
Uma Prabhu, Archana Gore, Saraswati Iyer, Amita Mehta, RajashreeNaik
19. The Effect of Task Oriented Training on Hand Functions in Stroke .................................................................................... 93
Patients- A Randomized Control Trial
Chandan Kumar, Ruchika Goyal
20. Effects of Three Weeks Plyometrics on Sprint Velocity ......................................................................................................... 98

Jagdeep Kaur Dhamija, Jaspreet Singh Vij, Rajesh Gautam
21. Perception about Stroke amongst Rural Population in Maharashtra ................................................................................ 101
Swati Limaye, Deepak Anap, Dhiraj Shete
22. To Study and Compare the Effect of Laptop Computers with Desktop ........................................................................... 106
Computers on Working Posture and Self-Reported Musculoskeletal Symptoms
Aditi Biswas, Dheeraj Lamba
23. An Analysis of Memory Retrieval and Performance of Physiotherapy ............................................................................ 111

Exercises in Younger and Older Patients
Dhiraj R. Shete
24. Effectiveness of Physiotherapy for the Handwriting Problem of School Going Children ............................................. 117
Chandan Kumar, Poonam Mehta, Sobika Rao
25. Effect of Kinesio Tape in the Treatment of Antenatal Carpal Tunnel Syndrome ............................................................ 122
Soheir M. El Kosery, Fayiz F. Elshamy, Hamid A. Atta Allah
26. Effect of Antenatal Exercises on Umbilical Blood Flow and Neonate ............................................................................... 127
Wellbeing in Diabetic Pregnant Women
Hanan Sayed E-Mekawy, Adly Ali Sabbour, Mohamed Mostafa Radwan
27. Efficacy of Active Release Technique in Tennis Elbow A Randomized Control Trial ................................................. 132
Harneet K M, Khatri SM
28. Study of Cognitive Impairment in Parkinson's Patients and its Correlation with Freezing of ...................................... 136
Gait Episodes and Bradykinesia
Hutoxi, Poorva Kulkarni
29. Study of Trunk Movement Deficits in Golfers with Low Back Pain .................................................................................. 141
Navneet Kalra, Jagmohan Sing, Masilamani Neethi
30. A Longitudinal Study to Analyse & Quantify Functional Capacity Post- Coronary Artery Bypass Grafting ............ 145
Ruchi Katyal, Jamal Ali Moiz, J. Jayaprakash

III
31. A Comparative Study Between Muscle Energy Technique and Myofascial Release ...................................................... 150
Therapy on Myofascial Trigger Points in Upper Fibres of Trapezius
Jay Sata
32. Quantifying Emg Activity of Trapezius Muscle During Empty Can & Full Can Tests .................................................. 155
Kanupriya, Sumit Kalra
33. Socio-Economic Barriers to Maternal Health Care in Rural Bangladesh ........................................................................... 162
Lori Walton, Bassima Schbley
34. Effect of Sensory-Specific Balance Training in Elderly ......................................................................................................... 168

Manjiri Puranik, Saraswati Iyer, Archana Gore, Lakshmi Prabha, Poonam Khachane, Amita Mehta
35. A Comparitive Study of Early Intervention Programme vs Home .................................................................................... 173

Intervention Programme in Preterm Infants
Manpreet Mann, C Janarthanan, Kusum Mahajan, Jagmohan Singh
36. A Study to Compare the Effectiveness of Conventional Treatment Versus ..................................................................... 178
Temporomandibular Joint Mobilization in Patients with Temporomandibular Joint Disorders
Jay Sata
37. Effect of Home Based Low Intensity Walking Programme on Quality of Life and Functional ..................................... 185
Capacity in Left Ventricular Failure Patients A Randomized Control Trial
Mariya Jiandani, Rajeshwari Reddy, Amita Mehta, Ashish Nabar
38. Effect of Exercise on Postural Kyphosis in Female after Puberty ....................................................................................... 190
Hala M. Hanfy, Mohamed A. Awad, Abdel Hamid A. Atta Allah
39. Effect of Nerve Mobilization on Vibration Perception Threshold in Diabetic Peripheral Neuropathy ........................ 195
Pankaj Preet Singh, Supreet Bindra, Sandeep Singh, Rohit Aggarwal, Jagmohan Singh
40. A Study of Immediate Effects of Taping in Patients with Knee Osteo-arthritis ............................................................... 202
Pooja Arora, Shilpa Arya, Sujata Yardi
41. The Effects of Upper Limb Exercises on Hand Writing Speed ........................................................................................... 208
Nilukshika KVK, Nanayakkarawasam PP, Wickramasinghe VP
42. To Study the Effect of Gluteus Maximus Activation in Sub Acute Mechanical Low Back Pain .................................... 214
Rajiv Sharma, Subhash Mahajan, Jagmohan Singh
43. Epidemiology of Cerebral Palsy in Jalandhar ........................................................................................................................ 219

Raju Sharma, A.K.Purohit, E. RajinderaKumar, S. Perssona, A.G.K.Sinha, S.K. Tripathy
44. Modified Quadriceps Strengthening Maneuver for Patients Undergoing Acl ................................................................. 223
Reconstruction-surface Electromyogrphic Analysis
JAY SATA
45. A Comparison Between Land-based and Water-based Balance Training Exercise ......................................................... 227
Program in Improvement of Balance in Community Dwelling Elderly Population
Ramandeep Walia, Shefali
46. Effect of Aerofic Exercise on Functional Capacity in Asymptomatic Coronary Artery Disease ................................... 234
Risk Factors Subjects
Ravinder Narwal, Gurpreet Chawla
47. Clinical Outcome in Adult Ventilated Patients Using Multimodality Chest Physiotherapy ......................................... 240
as Treatment Approach: A Single Blinded Randomized Clinical Trial
Renu B Pattanshetty, Gajanan.S Gaude

IV
48. Efficacy of Low-Intensity Pulsed Ultrasound on Bone Mineral Density in ...................................................................... 244
Osteoporotic Postmenopausal Women
Ali A. Thabet, Omar F. Helal, Shamekh M. El-Shamy
49. Cardiovascular Co-morbidity and role of exercise in Rheumatoid Arthritis: A Review ................................................ 249
Anwer Shahnawaz, Equebal Ameed
50. Physiotherapy-supervised Mobilization and Exercise Following ...................................................................................... 254

Total Knee Arthroplasty Surgery: a Questionnaire Survey
B.Sankarmani, V.Seetharaman
51. The Effect of a Single Session of Static and Ballistic Stretching on Lower Limb .............................................................. 259
Power in Sedentary Individuals
Sharmella Roopchand-Martin, Domonique Freckleton
52. Autonomic Adaptation and Functional Capacity Outcomes after Hospital-Based ......................................................... 263
Cardiac Rehabilitation Post Coronary Artery by Pass Graft
Sherin Hassan Mohammed Mehani
53. Analysis of the Influence of Fear of Fall on the Score of Berg Balance Scale among the Elderly Population .............. 268
R. Sivakumar, C.M. Radika
54. Impairment of Spinal Proprioception Following Stroke ...................................................................................................... 272

Shruti S, Alagumoorthi G, Suresh Kumar
55. A Cost-effective Patient Designed Hand Splint for Rehabilitation after ........................................................................... 277
Two-stage Flexor Tendon Reconstruction
Muhammad Adil Abbas Khan, Mark Gorman, Arvind Mohan, Zain A. Sobani, Alastair Platt
56. Comparative Study Between Auditory, Visual and Combined EMG Biofeedback in .................................................... 280
Management of Patients with Tension type Headache
Veena Bembalgi, Karkal Ravishankar Naik
57. Effect of Manual Therapy Techniques on Knee Proprioception in Patients with Osteo-arthritis of Knee ................... 285
Singh Yuvraj Lalit, Mhatre Bhavana Suhas, Mehta Amita

A Study of Correlation Between Depression, Fatigue
and Intelligence in Parkinsons Patients
Phansalkar Archana A1, Iyer Saraswati2

1 2
Neurology, Prof and Guide, Department of Physiotherapy, G.S. Medical College, Parel, Mumbai
ABSTRACT
Purpose of the Study: To evaluate depression, fatigue, intelligence in Parkinson patients and find if
correlation exists between them and the disease severity.
Material and Methods: 30 patients with idiopathic Parkinsons disease (PD) on conservative treatment
and who could answer various questionnaire by themselves were selected. Patients with any other
neurological disorder or complications were excluded. Patients were assessed on the UPDRS, Hoen
and Yahr scale and Schawb and England scale and then were asked questions from the Beck Depression
Inventory (BDI) which gave a total score of depression. The patients were assessed for intelligence
by the MMSE. The patients were then asked questions from the Fatigue Severity Scale.
Results: Data were analysed by the statistical test of Correlation coefficient and results were obtained
as follows:
Positive correlation between depression and disease severity.
Negative correlation between intelligence and disease severity, between depression and
intelligence and fatigue and activities of daily living.
63.3% patients severely affected on BDE.
40% mild to moderately affected on MMSE.
Conclusion: There is a definite non motor / Psychological affection in idiopathic Parkinsons disease
INTRODUCTION have a significant impact on the lives of the patient.
The clinical diagnosis of PD is based on the obvious They reduce the interest of the patient in
impairments of movement that are the motor rehabilitation which further increases the bodily
symptoms of tremor bradykinesia, rigidity and (motor) symptoms thus reducing the Quality of Life.
postural imbalance1. Apart from motor impairments
there are some nonmotor / psychological affection It is a very unfortunate situation when the
which may be complicating the disease process. psychological aspects of the disease are de-
emphasized, not gaining attention in the treatment as
Most common of the akinetic rigid syndromes PD the motor symptoms in PD.
affects 1% of adults over 50 years of age with increasing
frequency in older age groups affecting both sexes Aim:
equally2. To evaluate depression, fatigue and intelligence
Along with the inhibition of movement and other and PD patients and to find if a correlation exists
motor symptoms, the nonmotor symptoms of PD fall between them and the disease severity.
into: Depression
Affective disorders (depressive symptoms) It is described as sadness of mood, loss of interest
Cognitive decline and pleasure in almost all activities. Depression in
PD is usually characterized by dysphoria pessimism,
Changes in personality and personality triats somatic symptoms and mild intellectual impairment
and is classified as
These symptoms of depression, reduced
intelligence and fatigue are markedly seen in PD and Endogenous and Reactive depression
1. aarchna phansalkar 6th aug 11 (1-6).pmd 1 10/16/2012, 2:40 PM

2 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3
Endogenous depression is due to various The connections between the striatum and the
neuropathological processes occurring in the disease. prefrontal cortex also described as Dorsolateral
prefrontal circuit., Lateral orbitofrontal circuit.,
Reactive depression is a mental reaction to motor Anterior cingulate circuit. (Alexander et al 1986)
disability occurring in the disease.
A biological basis explained is:
MONOAMINE HYPOTHESIS24
The first major theory about biological etiology of

depression hypothesized that it was due to a
monoamine neurotransmitter deficiency notably
Norepinephrine (NE) and serotonin (5HT). 5HT
production is analogus to NE and DA except for a
requirement of a different amino acid
tryphtophan.Thus, these neurotransmitters are very
important and their formation if stopped at any stage
- Depression.
NEUROTRANSMITTER RECEPTOR
HYPOTHESIS:
Fig. 1.
According to this, an abnormality in the functioning
of the receptors leads to depression.
Fatigue:
INTELLIGENCE Fatigue is described as a lack of energy, sense of

tiredness and feeling of exhaustion which can be due
The prefrontal cortex is the locus is higher intellect to peripheral mechanism and central mechanism.
in human beings,
Fatigue occurs in any physical or mental illness.
Ablation of the frontal lobes would lead to Inactivity due to any reason would lead to stress
1. Inability to solve complex problems,sequencing and increased fatigability.
tasks
Akinesia often feels likes fatigue in PD. Muscles
2. loss of ambition,
fatigue is also due to stiffness, cramps and tremors.
3. inability of do several parallel tasks at one time. Loss of muscle strength reduces stamina and
endurance leading to fatigue.
The above problems are also seen in our patients.
The explanation for this pattern of impairment has
Integrated scheme of potential mechanism
been sought by the close anatomical associations
between physical illness and fatigue
between the striatum and the frontal cortex.Delong et
al (1984) described two neuronal loops connecting
Physical illness
the striatum and frontal cortex via the discrete regions
of thalamus:
Pain Depression Direct Physical Treatment
1. Motor loop linking the putamen with the Mechanism
supplementary motor cortex. Sleep Disturbance
2. A complex loop linking the caudate with Fatigue
prefrontal cortex.
Behavioral and deconditioning
The intimate functional as well as anatomical
association between prefrontal cortex and head of the
caudate has been shown causing equivalent MATERIAL AND METHODS
impairments following lesions to either region.Also
lesions to the nuclei involved in the caudato prefrontal 1. Unified Parkinsons disease rating scale(UPDRS)
loop had a significant effect on cognitive function, 2. Beck depression inventory (BDI)
unlike those lesions placed in the thalamic nuclei, 3. Fatigue severity scale (FSS0
involved in the motor loop. (Fig. 1)

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 3
4. Mini mental status(MMSE) The above table shows negative correlation

5. Schwab &England activites of daily living. between UPDRS and MMSE suggesting, intelligence
reduces with increase in disease severity .
Inclusion Criteria:
1. Patients with idiopathic PD on conservative Rx. Table 4. Hoen & yahr and MMSE
2. Patients who are able to answer the various Samples Mean SD r t P
size
questionnaire by themselves.
HOEN&YAHR 30 2.28 +0.79 -0.74 5.84 <0.001
3. Patients who understand at least one of the 3
MMSE 30 23.73+ 5.14 H.S
languages English, Marathi, Hindi.
Exclusion Criteria: A negative correlation between HOEN&YAHR and

MMSE indicates severity increases as intelligence
1. Patients with any other neurological disorder than decreases.
idiopathic PD.
2. Patients with a history of any surgical intervention Table 5. BDE and MMSE
for the Rx of Pd. Samples Mean SD r t P
3. Patients having PD secondary to any other cause size
eg;Parkinsons plus syndrome. BDE 30 25.37+ 9.02 -0.56 3.56 <0.01

MMSE 30 23.73+ 5.14 H.S
Methodology:
A significant negative correlation between BDE and
Patients were first assessed for the severity of the MMSE is seen indicating depression increases as
disease using the UPDRS and intelligence by the intelligence reduces
MMSE. .Then they were asked questions from the BDI
where the scale was explained before. Lastly, they were Table 6. SCHWAB and England and FSS
asked questions from the Fatigue Severity Scale for Samples Mean SD R t P
PD. size
SCHWAB& 30 58.33 +27.18 -0.75 6.011 <0.01
ENGLAND
RESULTS
FSS. 30 143.46 +34.47
All the subjects could answer the questions on all 3

scales.The data was analysed by statistical test of The corelation between scale for activities of daily
correlation- coeffiecient as follows; living with the FSS is negative indicating Fatigue level
increases as ADLs reduce
Table 1
Table 7. Percentage Afection for Depression
Hoen and UPDRS Schwab BDE MMSE FSS
Yahr and England Mild Moderate Severe
ADLs
Scoring 10-17 18-24 25-30
Mean 2.82 57.9 58.33 25.37+ 25.73 143.46
+SD +0.79 +19.28 +27.28 9.02 +5.14 +34.47 % affected 20.1% 16.6% 63.3%
Correlation was obtained and t-test were observed Table 8. Percentage Afection for Intelligence.
for correlation -coefficient Normal Mild Moderate Severe
Scoring 24-30 20-23 10-19 0-9
Table 2. UPDRS and BDE % affected 60.71% 26.16% 13.13%
Samples Mean SD r t P
size Hence we see that 40% of our patients were mld to
UPDRS 30 57.9+ 19.28 0.39 2.24 <0.05 moderately affected on the mini mental status
BDE 30 25.37+ 9.02 examination.
A direct correlation of Disease severity(UPDRS) and Table 9. Percentage Afection For Fatigue
depression(BDE) is seen. Question 6,7,9,14, 3 4,30 10,11,27 8,26 1,2,5, 19,25 12.13, 24
nos from 15,16,17,28 (B) (C) 29,21 (E) 18 (G) 23 (I)
Table 3. UPDRS and MMSE % 83.3% 80% 73.3% 70% 66.6% 63.3% 50% 36.6% 20%
Samples Mean SD r t P Each question of the FSS was evaluated to find

size
percentage affection.
UPDRS 30 57.9+ 19.28 -0.592 3.91 <0.001
MMSE 30 23.73+ 5.14 H.S

DISCUSSION The dysfunction of reward -oriented systems

contribute to the dysphoric experience constituting the
From the above results, significant depression
Clinical syndrome of depression.
(63.3%) is seen in our patients.
A significant co-relation is also seen between
A significant correlation is also seen between
depression and intelligence (P< 0.01) and there were
severity of disease (UPDRS) and depression (P<0.05)
as well as scores of intelligence and depression (P< about 40% of patients who were scored as mild to
0.01). moderately affected on the mental status examination.
The explanation for the severity of depression can Charcot Vulpian in 1861 first drew attention to the
be given as occurrence of mental changes in PD. Ball & Walshe31
also opined that PD is accompanied more often than
The Serotonin Hypothesis29 thought by intellectual difficulties
Depression has been related to the altered nor Mjones32 stated that certain parallelism between
epinephrine (NE) and serotonin (5HT) metabolism the motor and intellectual deficits exists and as the
which occurs in pathogenesis of PD. Serotonin severity of motor deficits increase the degree of mental
hypothesis proposed by Van Praag suggests a major symptoms also increase which is very well seen in our
role of 5HT in mood regulation based on: study with a significant correlation.
1) Reduced content of 5HT in postmortem cases of A close anatomic association between striatum
depressed patients. and the prefrontal cortex is described by
2) Reduced CSF concentration of 5HIAA a principal Delong27suggesting 2 possible mechanisms whereby
metabolite of 5HT. Horny kiewicz attributed the cognitive loss in PD can be explained:
reduction in 5HT in PD to Down Regulation First is via one or both the lateral orbito frontal and
compensating for the loss of dopamine from dorsolateral prefrontal circuits where dopamine
nigrostriatal neurons. depletion would disrupt the caudate functions to
impair the basal ganglia input to the cortex.
The Monoamine Hypothesis
Second mechanism is the direct depletion of
Another explanation given is on the basis of
dopamine in the areas of frontal cortex which are
monoamine hypothesis7. A neuropathological co-
innervated by ventral tegmental area.(Brozoski et al
relation of depression through the involvement of the (1979)
ventral tegmental area, hippocampus and the
entorhinal cortex is discussed. Ventral tegmental area Herve Simon33 stated that the prefrontal cortex and
being the source of dopaminergic projections again anterior striatum so called the prefrontal system are
suggest a role of dopamine loss in depression. (Torrack functionally and anatomically related.
and Morris)
From the results derived for the severity of fatigue
Neuronal Loss And Lewy Body Formation6 we realize that 83.3% patients are fatigued due to
depression, long periods of inactivity and heat (FSS) ;
Neuronal loss and Lewy body formation was found 80% patients are less motivated when fatigued ,
in Hypothalamus, particularly in the nondopaminergic whereas 70% patients experience prolonged fatigue
pathway of the tuberomamillary posterior and lateral after work / exercise.About 63.3% patients complained
nuclei in depressed patients with PD as compared to of easy fatiguability loosing their patience and feeling
the non-depressed PD patients. The location of the drowsy, 50% agreed that fatigue was amongst their 3
metabolic changes differed from that observed in most disabling symptoms but only 20% said that it
idiopathic depression. was the most disabling symptom of all .
The Reward Stress Mechanism30 Fatigue in our patients are due to the effect of
mental factors like depression12.
Febiger described the reward stress mechanism .
Easy fatigability is also attributed to the increased
Dopaminergic neurons of the ventral tegmental area
efforts required by the patients to move and constant
are referred site for self-stimulation in animal
attention required to perform any voluntary task which
experiment suggesting a role of dopamine system in
is done subconsciously by a normal person.
reward and reinforcement. Abnormalities in these
systems, diminish the effectiveness and contribute to One interesting explanation given is the
the loss of motivation and apathy. mitochondrial dysfunction 35 observed in PD.

Mitochondria are intracellular powerhouses and Psy 1974; (37); 27-31).

produce most of the energy used by the mainly by 2 5. Depression, intellectual impairment and
process: Parkinsons disease Richard Mayeux; MD;
q Citric Acid or the Krebs cycle. Yaakov Stean; BA; Jeffrey Rosen PhD and jean
q Oxidative phosphorylation (OXPHOS). Leventhal, MD Neurology (Ny) 1981; 31; 645-
650.
The OXPHOS mechanism produces about 10 times 6. Depression in patients with Parkinsonism
more energy than Krebs cycle & more than 90% of ATP Ashley H. Robins Par. J Psychiatry (1976); 128;
synthesis takes place in the respiratory chain by 141-145.
OXPHOS36. 7. Range of Neuropsychiatric disturbances
Even a slightest reduction in the mitochondrial inpatients with Parkinsons disease Jr. of Neuro,
output leads to weakness and fatigue. NSX; Psy. 1999 (67) (4) 429.
8. Psychiatric Symptoms in Parkinsons disease
Reports suggest a linkage between PD pathogenesis Jr. M. N sx 1970.
and mitochondrial dysfunction where defects in 9. Depressive symptoms in Parkinson patients
OXPHOS is seen. referred for thalamotomy J. W. Warburton; J.
Neurol; MSX, Psy; 1967 (30:368).
CONCLUSION 10. Fatigue in Parkinson disease J. freidman, MD,
and H. Friedman, BA; Neurol 1993 (43: 2016).
A definite non motor/psychological affection in 11. Parkinsons Disease, dementia and Alzheimers
idiopathic Parkinsons disease is seen. disease clinicopathological correlation: Ann
A direct correlation between severity of the disease, Neurol (1980:7; 329-335). Francois Boller MD;
depression and reduction in intelligence is Tomchiko Mizutani MD, Uros Roessman MD;
observed. A negative correlation between the two Prerlurgi gametti MD.
shows that as depression increases intelligence 12. Dementia in Parkinsons disease A
reduces. neuropathological study anhoine M Hakim,
gordon Matheison; Neurol (1979 :29; 1209).
63.35% of our patients are severely depressed,
13. Dementia in Parkinson Disease F. Tison; J. F
indicating Depression as a major factor in clinical
Dartigues, S. Auricomle; L. Leberneur; F Boller;
findings of PD.
Neurol 1995; 945; 705.
60%patients were mild to moderately affected on 14. Relationship of motor symptoms to intellectual
MMSE and a strong negative correlation between deficits in Parkinson disease james Mortimen,
disease severity and intelligence proved it to be an Francis Pirozzolo Neurol, (1982:32;133).
important factor while evaluation of disease 15. Cognitive impairments and depression in
process. Parkinsons disease a follow up study Sergio E
Fatigue was evaluated using the FSS for PD .Every Stakstein, Paula L Bolduc, Helen S Mayberg,
question on the scale was evaluated and %age Thomas J Presiosi, Robrt G Robinson: Jr. N. Msx:
affection for each revealed that the questions Psy (1990 :53:597-602).
relating to heat, inactivity, exercise increases fatigue 16. The association of incident dementia with
by 83.3% mortality in Parkinson disease G. Levy MD; B
Fatigue reduces patients motivation and increases Alfaro MA; H Mejia MA; Ystern PhD, Marder,
other motor symptoms, hampering their physical MD; MPH Neurol (2002 :59: 1708-1713).
activities . 17. Cognitive impairments in advanced PD without
dementia J Geren PhD; W. M. Mcdonald; J. L.
vitek; M Evatt; a freeman; M. R. Delong
BIBLIOGRAPHY
Neurology (2002:59:1302-1324).
1. Clinics in Physical therapy: Physical therapy 18. Fatigue in PD A. Zenzola, G Masi, Mde Mari; G
Management of Parkinsons disease; - George G. Defazio P. Livera; P Lamberti Neurol Sci (2003:24;
Turnbull; 6: 69. 225-226).
2. Analysis of the motor disorder in Parkinsons 19. Exacerbated physical fatigue and mental fatigue
disease Andreas Hartmann and Wolfgang H in PD Jou J; Kerns G; Oken B; Sexton G; Mut J
Oerlet; From Parkinsons: Disease Name of Look Movement Disorder (2001 :16: 90-196).
not there? 20. Fatigue in patients with Pd Karlsen k; larsen JP;
3. Depression and Physical illness. Editect by: M.M Tandberg e; Joorgenson k Movt Disorder 1999 :
Robertson and C.L.B Katona. 16:318. 2: 237).
4. The psychological effects of Parkinsons disease 21. The influence of fatigue on health related quality
( J. Neuro, Den 1993; 43 : 6:41-46) J. Neurosurgery of life in patients which PD Herbofsor K; Larson

JP Acta Neurol Scand (2003 Jan 107 :1). 29. Cortical dysfunction in non-demented
22. Frontal Cognitive function in patients with PD Parkinsons Patients Brain (2000:2:123:340-352).
A. M. Gotham, R. G. Brown and C. D. Marsden 30. Enhanced fatigue during motor performance in
Brain (1988 :111; 299 -321). patients with Parkinsons disease I. Ziv,
23. Chronic fatigue and its syndromes Simon mavraham et al Neurology (1998:51: 1583-1586).
Wessely, Mathew Hotopf; Michael sharpe: Oxford 31. Mitochondria oxidative Phosphorlation Defects
University Pres 1998. in Parkinson disease john M Shoffnen, Ray L.
24. Altered Serotonin metabolism in depressed Waltts Ann Neurol (1991:30: 332).
patients with PD Richard Mauur, Yackov Stern, 32. Abnormalities of the electron transport chain in
Lucein Cole, Janet B. W. Williams: Neurol Teliopathic Parkinson Disease and Williams
(Develand) (1984: 34: 642). Davis Parker Jr, Sally J Boyson Ann neurol
25. Depression and Parkinsons disease: A Review (1989:26:719-723).
Jeffrey L. Cummings MD. The Am Jr of Psychiatry 33. Generalized mitochondrial dysfunction in
Special Articles (1992 :149: 443-454). Parkinsons disease detected by magnetic reasons
26. Cognitive deficits in Early stages PD AJ Lees; spectroscopy of muscle a. M. W. Penn Neurology
Eilern Smith Brain 1983 (106) 257. (1995:45: 2097-2099).
27. Brain Neurotransmitter changes in PD Olen 34. Reduced glucose metabolism in the frontal cortex
Horny Kiewicz Movement Disorder I and III. and basal ganglia of multiple sclerosis patients
28. Dopaminergic A,O neurons are involved in with fatigue A18 F Flurodeoxyglucose positron
cognitive function Herve Simon; Bernard Sectton; emission tomography study: U. Ruelcke; L
Michal Lemoal. (1980: 286; 150). Kappos: Neurology (1997:48:1566-1571).

Role of Aerobic and Resistive Exercises in Postmenopausal

Women
Abha Sharma1, Heena Sahi2

1 2
Asst. Professor, Student, Physiotherapy, Banarsidas Chandiwala Institute of Physiotherapy, Chandiwala Estate, Maa
Anand Mai Marg, Kalkaji, New Delhi
ABSTRACT
Objective of the Study: Menopausal symptom can affect womans health and well being. The role of
exercise is important in post menopausal women and in the present study we compare the effects of
resistive versus aerobic exercises in improving the quality of life and decreasing the menopausal
symptoms.
Study Design: Experimental
Methodology: 20 women who had menopause naturally selected, randomly divided into 2 groups,
Group A(N=10) aerobic exercises(cycling or walking) & Group R(N=10) resistive exercises(with
theraband) for 4 days/week for 6 weeks. Pre-test measures at start and Post-test measures at
commencement of 6 weeks were done by Menopause Rating Scale, weight and BMI.
Results: statistically significant improvement in scores of MRS (p<.05), weight reduction (p<.05) and
improvement in BMI (p<.05) in both the groups by exercises.
Conclusion: Exercises play an important role in reducing the symptoms of menopause on the MRS.
Key Words: Menopause Rating Scale, Aerobic Exercises, Resistive Exercises.
INTRODUCTION previously it was thought to provide and because large

number of women are now choosing not to take HRT.
Menopause is an adaptation process during which In mean time, despite the potential difficulties of
women go through a new biological state. This process getting middle aged symptomatic women to exercise
is accompanied by many biological and psychosocial regularly as there are no apparent long term adverse
changes. During menopause, loss of skin flexibility, a effects of exercise in this population and there is good
decrease in libido, sexual dysfunction, and an increase evidence that exercise can benefit other menopausal
in the risk of cardiovascular diseases, urinary tract related symptom as well as a non-pharmacological
infections, incontinence, bone loss, and somatic and approach in preventing or treatment of complaints of
vasomotor symptoms may appear. Depressed mood, post menopausal women.3 Lotta Lindh-strand et al
sleep disorders, and other psychological problems study concluded that apart from many other health
reduce the quality of life in postmenopausal women.1 benefits regular physical exercise may decrease
Hormonal therapy has shown to be first line therapy vasomotor symptoms and increase quality of life in
for many of these symptoms. Although hormone postmenopausal women.4 Healthy postmenopausal
replacement therapy(HRT) remains the most effective women gain significant psychological benefit from
treatment for menopause symptoms, acceptance and moderate-intensity exercise. However, exercise
long duration continuation of HRT use is low. HRT participation must continue to maintain improvements
may be linked to an increased risk of particular diseases in psychological well-being and quality of life. 5
including certain cancers. It is important to therefore Comparably to HRT, exercise affects a multitude of
investigate alternative interventions to alleviate these systems and, therefore, may be an alternative option
symptoms such as exercise.2 This is particularly for early menopausal women.6
relevant today, HRT may not provide post menopausal
women, with all the protective health benefits that The role of exercise is important in post menopausal
2. Abha sharma 19th may 11 (7-12).pmd 7 10/16/2012, 2:40 PM

women and in the present study we compare the TREATMENT PROTOCOL

effects of resistive versus aerobic exercises for
The exercise program designed for 4 days/week
improving the quality of life and decreasing the
for 6 weeks.
menopausal symptoms.
In Group A (Aerobic ) Prior to the exercise training,
Aerobic exercise training is an augmentation of the
a submaximal test on an ergonomic bike was done on
energy capacity of the muscle by means of an exercise
the subject in order to determine the instructional
training program.7 Resistive exercise is any form of workload.
active exercise in which a dynamic or static muscle
contraction is resisted by an outside force. The external Exercises used in this group were Cycling &
force maybe applied manually or mechanically.8 Walking(depending on comfort level of individual).
Following warm up exercises, 5 subjects trained on
The total score of MRS (Menopause Rating Scale) ergonomic bike (once a day) and other 5 subjects
ranges between 0(asymptomatic) and 44(highest instructed to walk (twice a day) for 4 days/week for 6
degree of complaints). The scores vary between three weeks duration.
dimensions depending on the number of complaints
allocated to respective dimension of symptoms, The progression in exercise protocol was done after
Somato-vegetative-0 to 20, Psychological0 to 16, every 2 weeks interval of exercise training.
Urogenital-0 to 8.The composite score is sum of Week Ergonomic bike Group- Walking group-walking
dimension scores.9 cycling duration duration in each session
(once day)10 (2sessions a day)11,16
SAMPLE 20 subjects(n=20) included in the study. Week 1 and 2 20minutes 15minutes

Week 3 and 4 25minutes 20minutes
Subjects were randomly assigned in two groups i.e.
Week 5 and 6 30minutes 25 minutes
Group A (n=10, Aerobic Exs.), Group R (n=10,
Resistance Exs.). In Group R (Resistance)
Inclusion Criteria- Women 45-60 years age, Prior to resistance training Borgs Percieved
experienced menopause naturally. Exertion Scale was used to determine elastic resistance
regime of individual subject. Each individual subject
Exclusion criteria- Severe metabolic and endocrine
made to perform exercises on therabands of moderate
disease; have undergone menopause surgically;
and maximum strength of resistance to decide for
receiving hormone replacement therapy; selective
grade of resistance training as per comfort and capacity
estrogen receptor agonists (raloxifene, evista);
of each subject. Therabands of moderate grade was
receiving chemotherapy or radiotherapy; history of
found to be appropriately used for all subjects.
antidepressants or antipsychotics; subjects not able to
exercise; history of subjects exercising regularly for The following 10 exercises performed with help of
past six months. therabands once a day.
Design: Experimental design. Dependent variable is Standing chest press
Postmenopausal symptoms in women; Independent Attach theraband to secure object at shoulder.
variable is Aerobic and Resistance Exercises. Hold theraband in hands, arms out from side,
elbows bent.
Procedure: Twenty women fulfilling the inclusion
Push forward, straightening elbows.
criteria were informed as to the purpose, method,
content, usefulness, duration of the study and were Strengthening muscles of back
included after a written consent. Randomly divided
Attach theraband to secure object at shoulder
into two groups, Group A, Aerobic Exercise( n = 10)
level while sitting on a stool.
and Group R, Resistance Exercise(n = 10). Details of
Grasp theraband in hands and hold close to chest.
subjects were recorded: name, age, height, weight, Pull backward, straightening the trunk.
profession, personal history, age when they went
through menopause,their most serious health Strengthening of trapezius muscle, both sides by
complaint and medications they were using regularly. shoulder shrug
The Body Mass Index recorded as per formula = Stand with arm at sides.
weight(kg)/[height(m)]2. Before and after the study of Stand on theraband, holding band in hand.
both the groups, menopausal symptoms evaluation Raise shoulder upwards towards ears and roll
was carried out with the help of MRS, as a face to face backwards.
answer to the questionnaire. Keep elbows straight.

Strengthening forward flexion both shoulders Strengthening of ankle dorsiflexors both sides.
Stand on theraband. Sit on a couch with leg in front.
Begin with arm at side, elbow straight, thumb Attach theraband to secure object in front of
up. foot.
Grasp the band. Attach other end of theraband to forefoot.
Raise arm in front over head (elbow straight) Pull foot backward towards shin.
Strengthening abduction both shoulders In each exercise slowly return to starting position
Stand on theraband. and repeat.1
Begin with arm at side, elbow straight, holding
band, palm forward. Progression in exercise protocol after every 2 weeks
Raise arm upward, out to side,overhead. interval of exercise training.12,13
Strengthening of elbow flexion both sides. Week Set/exercise Repetitions/ exercise

Week 1 and 2 1 8reps
Stand on theraband. Week 3 and 4 1 10reps
Grasp the theraband in hand, palm up, arm
Week 5 and 6 1 12reps
straight.
Pull up, bending at elbow.
RESULTS
Strengthening of elbow extension both sides.
SPSS-8 used for data analysis. The mean pre-test
Attach theraband to secure object at waist level. scores for MRS, weight & BMI were nearly same for
Grasp theraband, thumb up, elbow bent.
both groups indicating both groups same at starting
Straighten elbow, keeping elbow at side.
point. Details of subjects depicted in Table 1.1,
Strengthening of knee flexors both sides. Mean(SD) of MRS, BMI and weight depicted in
Attach theraband to secure object. Table1.2 and Mean(SD) of MRS scores in three
Sit in chair, attach theraband to ankle of leg to subgroups at baseline and post intervention in Table
be exercised. 1.3 & graphs 2.1, 2.2 & 2.3.
Pull heel under chair through full range.
Paired T-Test), Table 1.5 applied within group to
Strengthening of knee extensors both sides. compare pretest (Base line scorei.e0 sessions) and post
Secure theraband behind the chair. test (after completion of treatment. Unpaired T-Test,
Attach theraband to ankle of the leg to be Table-1.4 applied between groups. Level of significance
exercised. p-value<0.05. Within group statistically significant
Sit with legs bent to 90 degrees. improvement seen.
Straighten the knee.
Table 1.1 Details of Subjects

Total Subjects in Subjects in Age(yrs) Age(yrs) Menopause Menopause
Number Group A Group R Mean (S.D) Mean (S.D) Age(yrs) Age(yrs)
Group A Group R Mean (S.D) Mean (S.D)
Group A Group R
20 10 10 50.3(2.9) 50.7(2.0) 47.6 (1.27) 47.4 (1.51)
Table 1.2 Mean (SD) of MRS, BMI, Weight

Group Pre Exercise Post Exercise Pre Exercise Post Exercise Pre Exercise Post Exercise
Name MRS Score MRS Score Weight Score Weight Score BMI Score BMI Score
Mean S.D Mean S.D Mean S.D Mean S.D Mean S.D Mean S.D
GROUP A 22.3 2.49 10.3 1.64 64.50 7.52 62.80 7.44 25.85 3.57 25.14 3.38
GROUP R 21.9 2.77 13.3 4.16 68.90 5.49 65.65 5.54 26.37 2.67 24.55 2.46
Table 1.3 Mean And SD of Mrs Score at Baseline and Post Intervention
Group Name Somatic Symptoms of Psychological Symptoms of Urogenital Symptoms of
Postmenopause Postmenopause Postmenopause
Mean(S.D) Mean(S.D) Mean(S.D) Mean(S.D) Mean(S.D) Mean(S.D)
Pre test Post test Pre test Post test Pre test Post test
GROUP A 7.2(1.40) 3.9(0.88) 11.7(1.57) 4.8(1.14) 3.4(1.089 1.6(0.70)
GROUP R 7(1.05) 4.6(0.97) 11.2(1.87) 6.8(1.81) 3.6(1.35) 2.9(0.88)

Table 1.4 Independent Samples Test (Between Groups)

T- VALUE SIG.
WT (Pre) 1.495 >.05
WT (Post) 0.972 >.05
MRS (Pre) .339 >.05
MRS (Post) 2.12 <.05
BMI (Pre) .368 >.05
BMI (Post) .451 >.05
Table 1.5 Paired T- Test

T-VALUE SIG. T- VALUE SIG.
Group A Group R
WEIGHT 7.965 <.05 19.03 <.05
MRS 18.974 <.05 10.012 <.05 Fig. 2.3 Pre- and Post-Test Mean (SD) Urogenital Symptoms of
BMI 6.536 <.05 4.053 <.05 Postmenopause
postmenopausal women using MRS (except for sexual

symptoms as no subject reported complaints of sexual
symptoms). Women in resistance exercise group had
Borgs Rating of Perceived Exertion scale reading
between 11 to 14, while in aerobic training showed the
3 minute step-test response of average, above average
and good on heart rate. These readings helped design
a comfortable exercise protocol for postmenopausal
subjects in study.
Our study shows that both exercise regimes

1-aerobic group,2-resistance improve the menopausal symptoms. Various authors
Fig. 2.1 Pre- and Post- Test Mean (SD) - Somatic Symptoms of
have also reported the positive effect of exercises in
Postmenopause post menopausal women. Physically active lifestyle
can reduce the perceived intensity of menopausal
symptoms and increase the state of being
psychologically fine.1 Study by Grant S etal states
exercise sessions of 40-min of aerobic and strength
exercises, improved Life Satisfaction Index score in
overweight postmenopausal women. 14 American
college of sports medicine(1998) states that adults
should exercise 3-5days/week at 40/50-80% of their
maximum oxygen reserve continuously for 20-60 min
or accumulate the same amount of exercise in several
daily bouts for a minimum of 10 minutes. Regular brisk
walking can produce training effects in
1-aerobic group,2-resistance postmenopausal women if the total amount of exercise
Fig. 2.2 Pre- and Post-Test Mean (SD) Psychological Symptoms
is sufficient. Exercises can be divided into two daily
of Postmenopause bouts without compromising the training effects16 as
done in our study too. Moriyama CK et al study also
DISCUSSION shows that physical exercises can reduce menopausal
symptoms and enhance HRQOL, independent of
Until recently, HRT was a popular treatment for whether hormone therapy is taken or not17 as seen in
menopausal symptoms especially hot flushes and our study.
night sweats but the evidence reporting adverse effects
of HRT and negative media reports have raised In our study somatic complaints such as hot flush,
important questions about its use.3 cardiac problems, sleep disorders and muscle-joint
problems decreased in both groups as supported by
In light of this, our study uses exercises and findings of Ayegl Al et al. Resistance training
compares effects of aerobic and resistance training on exercise programs also have secondary general health

benefits including reversal of functional decline due Resistance Exercises in terms of intensity and
to age, prevention of osteoporosis and relief from volume of muscle contractions.
arthritis.15 2. Role of yoga and breathing exercises in Menopausal
symptoms.
A comparison of exercisers and nonexercisers,
showed that exercisers moods were significantly more Conflict of Interest: Authors reports no conflict of
positive than sedentary womens moods, regardless interest.
of menopausal state.18 Women who were depressed
had more menopausal symptoms than women who REFERENCES
were not depressed, and women who exercised
regularly were less depressed and less symptomatic 1. Ayegl Al et al, Clinical Study Short-Term
than women who did not exercise.19 Resistance training Exercise Approaches on Menopausal Symptoms,
Psychological Health, and Quality of Life in
exercises has psychological advantages such as
Postmenopausal Women Obstetrics and
alleviation of feelings of depression, loneliness and
Gynecology International, Volume 2010, Article
isolation and improvement in cognitive function.15 In
ID 274261, 7 pages.
our study too psychological symptoms on MRS like 2. Daley et al; Exercise participation, Body mass
depressive mood, irritability, anxiety, mental and index and Health related quality of life in women
physical exhaustion, sexual problems showed of menopausal age; Br J Gen. Prac 2007, Feb1,
improvement in both groups. 57(535) 130-135(6).
3. Amanda J Daley et al, Feeling hot, hot, hot: is
In addition to menopausal symptoms other benefits
there a role for exercise in the management of
are observed. In study by Brown et al, weight-bearing vasomotor and other menopausal? J Fam Plann
exercise designed to stimulate aerobic metabolism and Reprod Health Care 2007:33(3): 143-145.
bone mass increased fat-free mass and muscle strength 4. Lotta Lindh-strand et al, Vasomotor symptoms
in 6072year-old women. However, HRT with exercise and quality of life in previously sedentary
did not produce additive effects on muscle strength.20 postmenopausal women randomized to physical
Regular weight bearing exercises have great benefits activity or estrogen therapy; Vol48, Issue 2, Pages
on bone mineral density. Walking, which is an easy 97-105.
and safe form of weight bearing exercise that does not 5. Asbury, Elizabeth A, The importance of
require any special equipment, also improves muscle continued exercise participation in quality of life
strength, balance, coordination, proprioception and and psychological well being in previously
reaction time; and eventually improving postural inactive postmenopausal women: A pilot study,
balance; exercise might contribute to reduce incidence Menopause, 2006, vol 13, no.4, pp561-567.
of falls.21 Exercise training is strongly recommended 6. Wolfgang Kemmler et al; Long-Term Four-Year
in postmenopausal women to reduce coronary artery Exercise Has A Positive Effect On Menopausal
Risk Factors: The Erlangen Fitness Osteoporosis
disease risk,22,23 to counter the effects of osteoporosis
Prevention Study; Journal of Strength and
and to improve body composition and overall health.
Conditioning Research, 2007, 21(1), 232-239.
In addition, regular aerobic exercise is linked to
7. Kisner/Colby, Therapeutic exercise foundations
enhanced vascular function, including decreased and techniques, 3rd edition, Jaypee brothers, pg
arterial stiffness and improved endothelial function22, 113.
reduces risk of development of cardiovascular 8. Kisner/Colby, Therapeutic exercise foundations
problems and hypertension occurring frequently in and techniques, 3rd edition, Jaypee brothers, pg
menopausal period.23 57.
9. Syeda Batool Mazhar and Sabeena Rasheed;
CONCLUSION Menopause Rating Scale (MRS), A simple tool for
assessment of climacteric symptoms in Pakistani
Aerobic and Resistance exercises have positive women; Ann. Pak. Inst. Med. Sci. 2009, 5(3):
effects on reducing postmenopausal symptoms and 158-161.
improving quality of life. 10. Kisner/Colby; Therapeutic exercise foundations
and techniques, 3rd edition, Jaypee brothers, pg 125.
11. Riva L. Rahl; Physical Activity and Health
FUTURE RESEARCH Guidelines: Recommendations for Various Ages;
1. Variations in Aerobic Exercises like swimming, pg18, 2007, Location: Med. & Science in sports &
jogging, brisk walking and varied progression in exercise, 39(8): 1423-1434.

12. Kisner/Colby, Therapeutic exercise foundations Between Menopausal Status, Hormone

and techniques, 3rd edition, Jaypee brothers, pg Replacement Therapy and Exercise Participation,
85. Health Psychology, May 1997, Vol 16(3), 203-208.
13. Pollock, Michael L et al; ACSM Position Stand: 19. Youngwhee Lee, Hwasoon Kim; Relationships
The recommended quantity of exercise for between menopausal symptoms, depression and
developing & maintaining cardiorespiratory and exercise in middle-aged women: A cross-sectional
muscular fitness, & flexibility in healthy adults. survey; Int. Journal of Nursing Studies, Vol45,
Medicine and science in Sports and exercise June Iss12; 1816-1822.
1998, 30(6): 975-991. 20. Sarianna SIPILA$ et al; Effects of hormone
14. Grant S et al, The effects of a 12-week group replacement therapy and high-impact physical
exercise programme on physiological and exercise on skeletal muscle in post-menopausal
psychological variables and function in women: a randomized placebo-controlled study;
overweight women; D.Public Health. 2004; 118(1): Clinical Science (2001) 101, 147-157.
31-42. 21. Zafer Gunendi et al, The effect of 4-week aerobic
15. K J Elliot et al; Effects of Resistance training and exercise program on postural balance in
detraining on muscle strength and blood lipid postmenopausal women with osteoporosis,
profile in post menopausal women; British Rheumatol Int DOI 10.1007/s00296-008-0651-3.
Journal of Sports Medicine 2002:36: (340-345). 22. Emma ODonnell et al, Aerobic exercise training
16. TM Asikainen; Walking Trials in Post Menopausal in healthy postmenopausal women: effects of
Women:Effects of One vs Two Daily Bouts of hormone therapy, Menopause: The Journal of the
Aerobic Fitness; Scand. J of Med & Sci Sports; North American Menopause Society Vol. 16, No.
2002:12: 99-105. 4, pp.000/000 2009.
17. Moriyama CK et al, A randomized, placebo- 23. Rossouw JE et al, Risks and benefits of estrogen
controlled trial of the effects of physical exercises plus progestin in healthy postmenopausal
and estrogen therapy on health-related quality women: principal results from the womens
of life in postmenopausal women; Menopause health initiative randomized controlled trial;
2008 Jul-Aug; 15(4 Pt 1): 613-618. Journal of the American Medical Association 2002;
18. Slaven et al; Mood And Symptom Reporting 288(3): 321-333.
Among Middle-Aged Women: The Relationship

Quality of Life, Disablement, Comorbidity and Socio-
Demographics of Stroke Survivors in South-Western
Nigeria
Aderonke O. Akinpelu1, Caleb A. Gbiri2, Fatai A. Maruf3

1
Senior lecturer, Department of Physiotherapy, College of Medicine, University of Ibadan, Nigeria, 2Lecturer,
Department of Physiotherapy, College of Medicine, University of Lagos, Nigeria, 3Lecturer, Department of
Physiotherapy, Faculty of Health Sciences, Nnamdi Azikiwe University, Nnewi, Nigeria.
ABSTRACT
Objectives: The aim of this study was to determine the QOL of SSV in South-western Nigeria and
identify factors influencing it.
Methods: Seventy five SSV attending physiotherapy out-patient clinics of all tertiary health institutions
in South-western Nigeria between April and July 2004 were recruited consecutively into this survey.
Socio-demographic data, duration of stroke, side affected, and co-morbidity were obtained. QOL
and motor performance were measured using the WHOQOL-BREF and Modified Motor Assessment
Scale respectively. Data were analysed using Mann-Whitney U and Kruskal-Wallis tests at 0.05.
Results: The SSV (45 males and 30 females) were aged 58.811.9 years and 14 of them had co-
morbidities. Their mean QOL scores varied between 45% and 53% in all domains except the
environment domain where it was 28%. Male SSV with co-morbidity scored significantly lower than
those without co-morbidity in the physical health and psychological health domains of QOL. Socio-
demographic variables, duration of stroke, motor performance and sides affected had no significant
effect on any of the domains of QOL.
Conclusion: Our data suggest that co-morbidity reduces QOL in physical health and psychological
health domains of male SSV in South-Western Nigeria.
INTRODUCTION efficacy of medical care3. It is also used to inform

economic analyses and resource allocation as well as
Quality of life is an individuals perception of their to influence health-care policy3,4 .
position in life in the context of culture and value
system in which they live and in relation to goals, Many studies have reported significantly lower
expectations, standards, and concerns1. At patients quality of life in stroke survivors than in apparently
level, quality of life is the result of a complex process healthy controls5-7. Others have reported a strong
of interaction between personal traits, medical association between physical disability, dependency
outcome, coping behaviour, social support and the in activities of daily living and quality of life2,8,9,10.
quality of received health care2. Data derived from Dependency in activities of daily living has been
quality of life measures are useful in gaining better reported to be negatively associated with physical
understanding of patients reaction to illness, for functioning and general health domains of quality of
developing therapeutic processes and monitoring the life 10,11 , but not with the psychological and
socioeconomic aspects11. A study however, concluded
Correspondence Address that quality of life depends on much more than ones
C.A. Gbiri level of physical function 12. Many authors have
Department of Physiotherapy, reported that quality of life is independent of gender2,7.
College of Medicine, Anderson et al10 however, showed that women had
University of Lagos, Nigeria. better stroke outcome in terms of social functioning
calebgbiri@yahoo.com and mental health than men.
+2348185434054
3. Adenoke nigeria 7 th jne 11 (13-18).pmd 13 10/16/2012, 2:40 PM

Studies on quality of life of stroke survivors from had more than one episode of stroke and those with
developed countries are readily available for aphasia or cognitive impairments were excluded.
referencing. Some of the studies compared quality of
life of stroke survivors with that of non-stroke Information on duration of onset of stroke, limb
individuals5,13. Others reported quality of life of stroke side affected and co-morbid conditions were obtained
survivors as outcome measure of rehabilitation from the hospital files of participants and through
programme2,7,14. However, published data on quality interview. Quality of life was measured using the
of life of stroke survivors in Nigeria are not common. World Health Organization Quality of life measure
The aim of the present study was to determine the short-form (WHOQOL-BREF) through interview. A
influence of socio-demographic variables, functional validated Yoruba version15 was used for participant
disability and co-morbidity on the quality of life of who did not understand English. Participants level
stroke survivors in south-western Nigeria. We of motor disability was rated by one the authors, using
hypothesized that each of socio-demographics (age, Modified Motor Assessment Scale16. Occupations were
gender, occupational class, and educational grouped using the GROS 17 classification of
attainment), side affectation, duration of stroke, motor occupational status and their highest educational
disability and co-morbidity would have significant attainment, using the International Standard
influence on quality of life of participants. Classification of Education18. Data were analysed using
Spearman rank order correlation, Kruskal-Wallis and
Mann Whitney U-test.
MATERIAL AND METHODS
Seventy-five stroke survivors (40 males and 35 FINDINGS

females), recruited over a four month period from
Participants (40 male and 35 females) were aged
physiotherapy outpatient clinics of all tertiary health
58.8 11.89 years (33-90 years) (Table 1). Twelve (16%)
institutions in South-Western Nigeria participated in
participants had no formal education, 10 (13%) had
the study. Participants have had stroke for minimum
primary education, while 31 (41%) had secondary
of 3 months and had been discharged home for at least
(high school) education as their educational attainment
one month from hospital admission. Patients who have
(Table 1). Almost half of the stroke survivors were
Table 1. Frequency Distribution of Socio-demographics and Clinical Characteristics of Participants.
Variables Frequency Percentage (%)

Gender: Male 45 60
Female 30 40
Age at Onset of Stroke: <50 years 22 29
50-59 years 19 26
>60 years 34 45
Age at the Time of Study: <50 years 16 21
50-59 years 21 28
>60 years 38 51
Educational Attainment: No formal/ primary 22 29
Secondary 31 42
Tertiary 22 29
Class of Occupation: Unskilled 35 47
Skilled 26 34
Professional 14 19
Duration of Stroke: <60 months 61 81
> 60 months 14 19
Limb Side Affected: Dominant 46 61
Non-dominant 29 39
Degree of Disability: Mild 34 45
Moderate 21 28
Severe 20 27
Co-morbidity: Headache 2 14
Shoulder Pain 1 7
Diabetes 6 44
Osteoarthritis 2 14
Low-back Pain 1 7
Delayed Union of fracture 1 7
Vision Problem 1 7

unskilled workers (47%). Skilled workers and severe disability (Table 1). Fourteen had co-
professionals accounted for 34% and 19% of the stroke morbidities. The most frequent co-condition was
survivors respectively (Table 1). Sixty-one (81%) had diabetes, followed by osteoarthritis and headaches in
stroke for less than 5 years while the remaining 14 had equal proportion. The mean overall quality of life and
had stroke for 5 years and above (Table1). overall health items were 3.710.98 and 2.611.24
respectively while their mean scores in physical health,
Forty-six had deficit on the dominant side while psychological health, social relationship and
29 (39%) of them had deficit on the non-dominant side environment domains were 44.720.1, 49.117.5,
(Table 1). Almost half (45%) of the stroke survivors had 53.326.8 and 27.815.1 respectively (Table 2).
mild disability while 21 (28%) had moderate and
Table 2. Gender, Post-Stroke Duration and Limb Side of Affectation Comparison of Quality of life of Participants.
Variable PH PSH SR EV
X SD X SD X SD X SD
Gender.
All(n=75) 44.7 20.1 49.1 17.5 53.3 6.8 27.8 15.1
Male(n=45) 48.8 21.3 43.6 14.2 55.6 27.9 59.0 17.1
Female(n=30) 38.5 16.8 43.6 14.2 49.8 25.0 57.3 11.7
Test Statistics
U-Value -2.4 -2.5 -0.8 -0.3
p-Value 0.02 0.01 0.40 0.78
Post-Stroke of Stroke (Months).

<60 (n=22) 44.8 20.6 49.6 17.3 52.9 27.5 58.4 15.3
>60 (n=31) 44.2 18.9 46.6 19.2 54.9 24.03 55.0 4.1
Test Statistics
U-Value -0.08 -1.00 -0.19 -0.74
p-Value 0.94 0.32 0.85 0.46
Limb Affected.
Domt(n=46) 40.1 13.7 46.9 14.4 51.9 24.6 55.0 13.1
NDomt(n=29) 51.9 26.1 52.5 21.4 55.5 30.2 62.1 17.0
Test Statistics
U-Value -1.57 -0.80 -0.35 -1.62
p-Value 0.12 0.43 0.73 0.11
p<0.05
Key: PH = Physical Health Domain Scores, PSH = Psychological Health Domain Scores, SR = Social Relationship Domain
Scores, EV = Environmental Domain Scores, Domt = Dominant Limb, NDomt = Non-Dominant Limb
Generally, participants in all educational categories motor disability levels. Those without co-morbidity
scored lower in the physical and psychological health had higher quality of life than those with co-morbidity
domains than in social relationship and environment in social relationship and environment domains
domains (Table 3). There was no significant difference (Table 4).
in quality of life scores across educational categories
in all domains (Table 3). There was no significant DISCUSSION OF FINDINGS
difference in quality of life across different occupations
in all domains (Table 3). Those with less than 60 months The finding that males had significantly higher
duration of stroke had non-significantly higher quality quality of life on physical and psychological health,
of life than those with more than 60 duration of stroke than their female counterpart may indicate that male
(Table 3). Those with non-dominant limb side affected stroke survivors are less disturbed about their physical
had non-significantly higher quality of life scores, in capability relative to the female. The possibility of
all the domains than those with dominant limb affected stroke survivors in this study being more affected in
(Table 2). Participants with moderate level of motor their upper limbs than their lower limbs might put
disability had the highest quality of life scores in all females, who may have to carry domestic chores, at
the domains (Table 4). However, there was no disadvantage compared to males who, once able to
significant difference in the quality of life across the move around, may feel less worried about their

Table 3. Age Group, Highest Educational Attainment, and Occupational Comparison of Quality of Life of Stroke
Survivors.
X SD X SD X SD X SD
Age
<50 (n=16) 48.6 23.2 54.9 19.1 59.8 17.8 60.3 13.1
50 59 (n=21) 45.3 23.0 46.1 16.3 52.0 27.4 57.1 17.1
>60 (n=38) 42.7 17.1 47.9 17.4 51.4 29.6 57.1 11.7
Test Statistics
Kw-Value 0.5 2.3 0.9 1.3
p-Value 0.76 0.31 0.63 0.52
Educational Attainment.
NF/P (n=22) 41.9 22.8 46.1 22.4 50.3 30.3 60.5 15.8
Secondary(n=31) 42.5 16.1 50.1 15.1 52.3 24.5 53.9 12.4
Tertiary (n=22) 50.6 22.1 50.7 15.6 57.8 25.9 60.4 17.1
Test Statistics
Kw-Value 3.7 1.9 0.37 2.5
p-Value 0.16 0.38 0.83 0.29
Classes of Occupation
Unskilled (n=35) 40.7 20.1 48.3 18.5 50.4 26.9 57.5 14.9
Skilled (n=26) 51.5 21.2 50.1 17.2 54.6 27.4 60.0 15.4
Profess (n=14) 42.1 14.0 49.1 16.9 58.2 26.3 54.2 15.1
Test Statistics
Kw-Value 4.9 0.37 0.61 0.31
p-Value 0.08 0.83 0.73 0.86
p<0.05
Key:
PH = Physical Health Domain Scores, PSH = Psychological Health Domain Scores, SR = Social Relationship
Domain Scores, EV = Environmental Domain Scores, NF/P = Non formal/ primary education, Profess =
Professional.
Table 4. Comparison of Quality of Life Scores of Stroke Survivors across Levels of Motor Disability and Co-morbidity.
X SD X SD X SD X SD
Disability Level.
Mild (n=34) 45.5 21.8 48.9 19.4 52.4 26.5 54.7 s15.1
Moderate (n=21) 48.0 20.0 52.1 18.1 60.5 26.1 63.9 18.1
Severe (n=20) 39.8 17.1 46.2 13.5 47.35 27.6 56.5 9.1
Test Statistic
p-value 0.392 0.536 0.220 0.138
Co-Morbidity.
Presence (n=14) 29.8 12.1 37.2 8.3 45.4 22.7 52.6 12.0
Absence (n= 61) 48.4 20.1 52.1 18.0 55.3 27.51 59.0 15.6
Test Statistic
p-value 0.00 0.00 0.21 0.13
p< 0.05.
condition. Furthermore, the quality of life score of Although, there was no significant difference in
males, although higher than that of females in the social quality of life across different age groups in all the
relationship and environment domains, was not domains, lower age groups tend to have a higher
significantly different. This means that the quality of quality of life. This means that age of stroke survivors
life scores of male and female stroke survivors in does not influence their quality of life. However,
relation to social relationship and environment are quality of life has been shown to decline with
similar. increasing age 7 , but some authors showed no

differences between younger and older patients2. Age problems with consequent multiplying effects on the
distribution of SSv varied across the studies and, also, physical health psychological health domains of
many of the studies had more than two groups as quality of life.
opposed to this study. Educational attainment, against
expectations, did not have significant influence on Furthermore, there was no significant difference
quality of life of stroke survivors in all quality of life between the score of stroke survivors with co-
domains. However, those with higher educational morbidity and those without co-morbidity in the social
attainments tend to have a higher quality of life. The relationship and environment domains. However,
quality of life of stroke survivors across various those without co-morbidity had higher quality of life
occupations showed no significant difference in all the in the two domains. The analysis of difference in this
domains. This implies that job placement, earning study was among different groups of patients as
capacity, and social status do not determine quality of opposed to the same group of patients employed in
life of stroke survivors. The fact that there was no the previous study. Also, gender and co-morbidity had
significant difference in quality of life of those with significant effect only on the physical and
less than 60 months and those with more than 60 psychological health of quality of life of the stroke
months duration of stroke suggests that quality of life survivors. It is, hereby, recommended that questions
fails to change with time even when there is on co-morbid health problems be asked when planning
improvement in functional ability 19. Despite the for stroke patients rehabilitation.
finding that side of limb affectation does not influence
quality of life of stroke survivors, stroke survivors with CONCLUSION
non-dominant limb side affected consistently had
Quality of life of Nigeria stroke survivors is low.
higher quality of life in all the domains. This agrees
Co-morbidity reduces quality of life in physical health
with that of Ryerson20 who opined that stroke survivors
and psychological health domains of stroke survivors
with right hemiplegia are cautious and disorganized
in South-Western Nigeria.
in solving given task while those with left hemiplegia
tend to be fast and impulsive. This difference in
INTEREST OF CONFLICT
attitude towards functional activities may hence be
There is no conflict of interest.
expected to bring about significant difference observed
in the quality of life.
REFERENCES
There was no significant difference in quality of life
across levels of motor disability. However, there was a 1. World Health Organization. World Health
unique trend in the finding with the moderate group Organization task force on stroke and other
having the highest quality of life in all the domains cerebrosvascular disorders. Recommendation on
stroke prevention, diagnosis and therapy. Stroke
followed by the mild group except in the environment
1990; 20 (10): 1407-1431.
domain. This finding is in contradiction to a study
2. Kwa VIH, Limburg M and de Haan RJ. The role
which indicated a significant difference in the quality
of cognitive impairment in the quality of life after
of life of dependent and independent stroke survivors
ischemic stroke. Journal of Neurology 1996; 243:
in respect to activity of daily living, as well as for with
599-604.
or without hemiparesis, in the physical activity and
3. Claussen (2004): Using quality of life measures
social relationship domains of quality of life8. The for program evaluation: A review of literature.
finding in the present study might be due to the fact Rehabilitation on Review 15(1).
that the majority of stroke survivors were independent 4. Fallowfield L. Quality of quality-of-life data.
in functional activities. It may also be due to the fact Lancet 1996; 348: 421-422.
that quality of life usually fails to improve with time 5. Duncan PW, Samsa GP, Weinberger M, Goldstein
as activity of daily living does. The quality of life of LB, Bonito A, Witter DM, Enarson C and Matchar
stroke survivors with and those without co-morbidity D. Health status of individuals with mild stroke.
showed a significant difference in the physical and Stroke 1997; 28: 740-745.
psychological health domains. This contradicts that of 6. Jonkman EJ, de Weerd AW and Vrijens NLH.
Niemi et al8 that the quality of life of stroke in the Quality of life after first ischemic stroke. Long-
physical health domain is independent of the presence term developments and correlations with
of co-morbidity. This result can be explained in the light changes in neurological deficits, mood and
of the fact that some co-morbid conditions can cognitive impairment. Acta Neurology Scandavia
compound physical disability and psychological 1998; 98: 169-175.

7. Wyller TB, Holmen J, Laake P and Laake K. 14. Sacco RL. Risk factors, outcomes, and stroke
Correlates of subjective well-being in Patient with subtypes for ischemic stroke. Neurology 1997; 9(4):
a strokes. Stroke 1998; 29: 363-367. 39-44.
8. Niemi ML, Laaksonen R, Kotila M and Waltimo 15. Akinpelu AO, Maruf FA and Adegoke BOA.
O. Quality of life 4 years after stroke. Stroke 1988; Validation of a Yoruba Translation of the World
19: 1101-1107. Health Organizations Quality of Life Scale
9. strm M, Asplund K and strm T. Short Form among Stroke Survivors in South
Psychosocial function and life satisfaction after West Nigeria. African Journal of Medicine and
stroke. Stroke 1992; 23: 527-531. Medical Sciences 2006; 35: 418 - 424.
10. Anderson C, Laubscher S and Burns R. Validation 16. Loewen SC. Reliability of the modified motor
of the short form 36 (SF-36) health survey assessment scale and the bathel Index. Physical
questionnaire among stroke patients. Stroke 1996; Therapy 1988; 68(7): 1077-1081.
27: 1812-1816. 17. GROS annual report, 1996.
11. King RB. Quality of life after stroke. Stroke 1996; www.gro.scotland.gov.uk/grosweb/nsf/pages/
27: 1467-1472. 96_app2. Accessed 10/12/2004, 1422hr.
12. Samsa GP and Matchar DB How strong is the 18. International Standard Classification of
relationship between functional status and Education, 1990. www.prie.cl/ingles/eccion/
quality of life among persons with stroke? Journal documento/annex_3. Accessed 10/12/
of Rehabilitation Research and Development 2004; 2004,1232hr.
41(3a): 279- 282. 19. Bethoux F, Calmels P, Gautheron V. Changes in
13. Viitanen M, Fugl-Meyer KS, Bernspang B, Fugl- quality of life of hemiplegic stroke patient with
Meyer AR. Life satisfaction in long-term time: a preliminary report. American Journal of
survivors after stroke. Scandavian Journal Physical Medicine and Rehabilitation 1999; 78(1):
Rehabilitation Medicine 1988; 20: 17-24. 19-23. Ryerson

Efficacy of Mesh Glove Sensory Stimulation on Spasticity
Control in Hemiplegic C.P.
Ahmed M. Azzam
1
Department of Physiotherapy for Developmental Disturbance and Pediatric Surgery, Faculty of Physical Therapy,
Cairo University , Giza, Egypt.
ABSTRACT
Objectives: The aim of this work was to show the effect of mesh glove sensory stimulation on spasticity
control in hemiplegic C.P children.
Method: Thirty children were enrolled in this study and randomly assigned into two groups; group
A(mesh glove sensory stimulation plus traditional physiotherapy program) and group B(traditional
physiotherapy program only). Modified ash worth scale was used to detect and follow spasticity
control. This measurement was taken before initial treatment and after 12 weeks post treatment. The
children parents in( group A) were instructed to complete 3 hours of home routine program.
Results : Data analysis were available on 30 spastic hemiplegic C.P children and the mean values of
the modified ash worth scale grading pre and post treatment in both groups were non statistical
significant difference (p >0.05). Mean values of the modified ash worth scale grading in study group
pre and post treatment were highly statistical significant differences p<.0001 while the mean values
of the modified ashworth scale grading in the control group pre and post treatment were statistical
significant differenc p<.05 .The improvement of the spasticity control according to modified ash
worth scale in the study group more pronounced than the improvement of the control group.
Conclusion: The combined effect of physiotherapy training plus mesh glove sensory stimulation are
recommended to overcome the lack of hand sensory feedback and lack of its representation in
brain.
Key words: mesh glove sensory stimulation, hemiplegic C.P.
INTRODUCTION suffer from a wide range of motor disturbance.6
Cerebral palsy (C.P) is a non progressive motor An acute cerebro-vascular accident (CVA) lead to
disorder caused by pre-natal , peri-natal and post-natal an initial loss of motor functions followed by
central nervous system(CNS) damage. This disorder abnormally active proprioceptive responses that are
is characterized by impaired voluntary movement , clinically recognized as exaggerated tendon reflexes
possibly perceptual, intellectual and language deficits and increased resistance to passive stretch. Recovery
and convulsive seizures. Children with cerebral palsy of voluntary movements occurs gradually,
accompanied by an improvment in motor control and
Correspondence Address a progressive decrease of spasticity. Movements of
Ahmed M. Azzam distal limb joints and independent finger movements
College of Applid Medical Science, King Saudi University. are the last to be recovered. Motor recovery is a
Phone number:+96614693796 progressive process that may cease at any time and
Mobile number:+9660548940510-+9660597901498 patients can be categorized in different functional
E-mail:1- aazzam@ksu.edu.sa performance groups according to the level of motor
2-Ahmedazam93@yahoo .com improvement.2,3
Mail address: King Abdullah Street, Dariya
Rehabilitation Science Department Major recovery in arm motor functions occurs
Building no.24 within the first 3 months slowly reaching a plateau
P.BOX:10219 Riyad 11433 during the sixth month after the onset of hemiplegia.
4. Ahmad Azam egypt 12th april 12 (19-23).pmd19 10/16/2012, 2:40 PM

However, specific training procedures can result in the therapeutic procedure of traditional physiotherapy
further improvement of sensory and motor functions program. The effect of mesh gloves electrical
by whole hand electrical afferent stimulation mesh- stimulation on hand motor control was compared
glove. The application of mesh-glove stimulation to between study and control group. Skin sensation
the affected hand after stroke resulted in the reduction assessment was carried out on the extensor and flexor
of muscle tone and facilitation of volitional finger compartments of the forearm, intrinsic muscles of the
movements.4 hand of all subjects to ensure that none of them had
defective skin sensation. The Ashworth scale is one of
Beneficial effects of mesh-glove stimulation are the most widely used methods of measuring spasticity,
suppression of muscle hypertonia, augmentation of due to its simplicity and reproducible method.
residual volitional movement, increased awareness of
the affected hand, and decrease of spatial hemi-neglect. The assessment of spasticity using modified ash
The most relevant effects have been suppression of worth scale for wrist flexors were carried out prior to
muscle hypertonia, augmentation of residual volitional the commencement of the treatment sessions (pre-
movement, increased awareness of the affected hand, treatment). These assessments were also carried out
and decrease of spatial hemi-neglect. This form of at the end of the 12th week (post-treatment) on all the
whole-hand electrical stimulation is feasible for the subjects. The child Keep the elbow as straight as
restoration of arm and hand functions which impaired possible. Passively Extend and flex the wrist to the
by upper motor neuron dysfunction.8 point of catching or resistance. Record a score for
muscle hypertonia in this position according to the
Patients with incomplete recovery of arm and hand modified ash worth scale grading description.
function have a wide variety of sensory or motor
deficits that manifest clinically as altered muscle tone, Intervention
exaggerated tendon jerks, and absent or impaired
ability to perform volitional movements. Impaired For all children, the programs were conducted three
control of parallel and sequential components of times weekly, for 12 weeks. Each session lasted
previously highly integrated planning, setting, and 45minutes manual and 40 minutes electrical in
executing mechanisms of motor control results in the addition to 3 hours of home program, day after day
clinical observation of gross pattern movement, three times a week during the treatment period.
incomplete skillful movement, and sometimes only Both groups (A and B) received a traditional
traces of movement of the arm and hand.1 physiotherapy program, as the following:
1. Hot packs to improve circulation and relax muscle
tension applied on the wrist flexors for 10 minutes
Subject: 30 hemiplegic C.P with age ranged between 2. Facilitation of anti-spastic muscles(wrist extensors):
4-7 years at the time of recruitment. The degree of tapping followed by movement, quick stretch,
spasticity was evaluated according to modified ash triggering mass flexion, biofeedback, weight
worth scale. Patients were excluded from the study if bearing, clenching to toes, compression on bony
they had any dermatological problems, seizures and prominence, rapping the muscle, approximation,
patients on muscle relaxing medication, no botulinum vibration, irradiation to weak muscles by strong
toxin treatment for six months previously. muscles, ice application for brief time
The thirty subjects that met the study criteria were 3. Prolonged stretch to wrist flexors to gain relaxation
randomly assigned into two groups: via (positioning, night splint, reflex inhibiting
pattern, Bo bath technique)for 10 minutes.
Group A: Consists of 15 patients (6 females and 9
males) and were treated by traditional physiotherapy 4. Passive stretching was performed to tight muscles
program plus mesh gloves stimulation at sensory level. (wrist flexors) to destruct adhesions in muscles and
sheath. For 10 minutes
Group B: Consisted of 15 patients (10 female and 5
male) and were treated by traditional physiotherapy 5. Graduated active exercises were performed for
program only. upper limb muscles.
Outcome measurements: 6. Gait training using aids in closed environment

using obstacles, side walking then by pass walking
Modified ash worth scale: The study was a to stimulate protective reaction for the hand
comparative experimental design with a baseline

7. Balance training program which include static and Changes in modified ash worth scale grading:
dynamic training
Mean test scores and standard deviations for both
The experimental group (group A) received groups are shown in the Table 2. The mean value of
specialized mesh glove stimulation at sensory level spasticity in both groups at baseline measurement (pre-
as following; treatment) was insignificant (p>.05). Both groups had
a significant improvement in spasticity post-treatment.
The subjects received mesh glove whole hand The average improvement of spasticity tend to being
electrical afferent stimulation with two rubber highly significant in the study group (2.530.99 versus
electrodes placed over the dorsal and ventral aspects 1.800.94, P=0.0003) than in the control group
of the forearm in two channel stimulator. The electrical (2.530.99versus2.21.15, P=0.01). The percentage of
stimulation consists of a dual-channel devise with
improvement of spasticity was (28.85 %) in the study
pulse set between 30-40 HZ to produce tickling
group compared to the control group (15%).
sensation without visible nor palpable contraction at
threshold sensory stimulation but in some children it Table 2. The average test of modified ash worth scale
was necessary to start with 20 HZ. The intensity grading in both groups.
required to achieve sensory awareness varied from 2 Average test of Study group Control group p-value
to 10mA. Pulse duration was fixed at 300 micro-second. modified ash worth Mean SD Mean SD (Between
scale grading group)
The electrical stimulation was applied for duration of Pre-treatment 2.530.99 2.530.99 1.00
40 minutes day after day stimulation for a period of Post-treatment 1.800.94 2.21.15 0.305
12 uninterrupted weeks. % improvement 28.85% 15% 0.5124
p-values 0.0003 0.01
The subject was enrolled in a day after day mesh- (Within group)
glove stimulation program which consisted of 20 min

continuous synchronous two-channel stimulation just DISCUSSION
below the sensory threshold then 20 min continuous There are two types of sensory stimulation produced
synchronous two-channel stimulation at the sensory by NMES distal sensory stimulation(mesh glove
threshold. The first 20 minutes of sub-threshold stimulation) activate sensory cortex and proximal
sensory stimulation would be used throughout the sensory stimulation at infra-spinatus and common
treatment in attempt to further enhance motor extensor wrist which may improve motor skills.3
functions, 2nd 20 minutes of stimulation at sensory level
added cutaneous and kinesthetic input. There is not only a lack of movement but also a
loss of sensory input from muscle, joint, and skin
receptors. It therefore appears that all these factors are
RESULT likely to play an important part in the construction of
Patients Characteristics motor plans in both C.P and other conditions. The
favorable effect of our combination of stimulation at
Table 1 shows the demographic and clinical sensory level can be explained by signal increase took
characteristics of all patients. There were 14 patients place in the primary and secondary motor and somato-
(46.7%) are boys and 16 patients (53.3%) as girls. Right sensory areas.1,7
hand dominance reported in 18patients (60%), while
12 patients (40%) were left hand dominance. There was The primary goal of our intervention was to
no significant difference between both groups in terms improve awareness and thereby function, and in this
of age (p=0.4317), sex 0.1534), hand dominance 0.4734). respect it differs from most other studies of electro-
stimulation in children with C.P, as their main goal
has been to improve muscle contraction. As the
Table 1. Patients characteristics therapeutic goal in most of these studies of electro-
variables Control group Study group p-value stimulation in children with C.P has been improved
n=15 n=15
muscle contraction, the underlying assumption has
age 5.671.05 5.331.23 0.4317
been that the sequential function of the muscles of the
Sex N(%)
Boys 5(33.3%) 9(60%) 0.1534
child can be improved by firing the agonist muscles of
girls 10(66.6%) 6(40%) the fingers by means of electro-stimulation. Firing of
Hand dominance N% the agonist poly-synaptically inhibits the antagonist
Right 8(53.3%) 10(66.6%) 0.4734 or spastic muscle in the refiex arc, thereby reducing
left 7(46.7|%) 5(33.3%)
the abnormal co-contraction.6,7

NMES at sensory level improved sensory fiexion. To overcome this difficulty, we wanted a
awareness of the impaired upper limb, coordination surface stimulation approach that would elicit
and the spontaneous use of the limb. Sensory independent finger extension without wrist extension.
stimulation aims to provide feedback to the brain about The objective was to stimulate the whole hand, and
the muscles that are activated during therapy. we found that this could be achieved with a mesh glove
Stimulation at sensory level helps the child to localize made of conductive wires .This form of whole-hand
the muscle he/she is trying to use. The feedback electrical stimulation is feasible for the restoration of
information from the childs own movements arm and hand functions impaired by upper motor
facilitates motor learning. Electrical stimulation neuron dysfunction.8,10
applied transcutaneously at an intensity sufficient to
evoke a perception analogous to a tapping or tickling Diminished afferent input to the brain from the
feeling is presumed to activate sensory nerve fibers. affected hand is a common deficit after stroke. Patients
The stimulation is applied so that the child is able to become less aware of their affected upper extremity
detect a sensation, but a muscle contraction is neither because of sensory loss and partial paralysis. As a
visible nor palpable. It is hypothesized that this kind consequence, they use that extremity less and less,
of sensory stimulation increases the awareness of the learning to use the unaffected arm in its place. Over
involved extremity, thereby improving function. Distal time, disuse weakens muscles and most likely reduces
sensory stimulation (glove electro-stimulation) below the representation area of the affected part in the cortex.
the level needed to feel the stimulus (sub-sensor level) Stimulation with the mesh glove at levels below
caused sensory evoked potentials. This was interpreted sensory perception can diminish the extent of deficit
as an activation of the sensory cortex. So sensory from deafferentiation of the hand.3,4
stimulation in children with C.P in conjunction with Mesh glove sensory stimulation used to restore arm
physiotherapy may improve motor skill.9,10 and hand motor functions after stroke. After 40
The arm and hand are subject to more complex minutes of whole-hand stimulation below and at the
neuronal control. Before initiating a purposeful motor threshold for sensation, the results are (1) suppression
act such as grasping an object, the nervous system of muscle hypertonia and (2) a decrease in the extent
needs information. Vision describes the shape of the of neglect of the affected side of the body. Prolonged
object, its location, and its distance from the body. and repetitive mesh glove stimulation below and at
Proprioceptive input defines the condition of the inner the sensory threshold for 40 minutes a day over a
world and the position of the limbs and trunk. The period of 12 weeks induces (3) enhanced residual
brain searches for stored memories of similar volitional activity of the hand and arm. The responses
situations. Once the object is touched, cutaneous indicate that, under these stimulating conditions, we
proprioceptive sensation updates the recorded can selectively depolarize large diameter muscle
memories of weight, surface, and shape. afferent fibers and externally increase kinesthetic input
to the posterior column nuclei, thalamus, and sensory
The neurophysiological characteristics of the hand and motor cortex. Suppression of hypertonia, probably
include: by inhibitory mechanisms related to muscle afferent
1. Had greater number of muscle spindle and GTO volleys, is not restricted to the hand but also affects
which provide hand with great control the muscles of the forearm and shoulder. We believe
2. Great representation in sensory area via great the effect is mediated through an extended spinal-brain
number of tactile receptors mechanism rather than being restricted to segmental
3. Broad tips of finger to increase exposed area for refiex mechanisms.. Therefore we anticipate that it is
distinguishing between materials the result of synaptic reorganization, changes in
4. Presence of the web space between thumb and connectivity, and probably an increase in the
index provide freely movement of thumb to occupy contribution of the unaffected motor structures to the
50% hand function restoration of volitional activity.
5. Purely supplied by 15-20% of directly pyramidal
tracts on alpha , gamma motor neuron. The purpose of mesh-glove stimulation is to
simultaneously depolarize large diameter afferent
one of the major obstacles to the restoration of fibers of the entire volar and dorsal aspects of the hand.
extensor movement of the fingers by neuromuscular At a stimulation level below and at the threshold for
electrical stimulation of the extensor muscles of the sensory perception, awareness it is likely that primary
forearm has been that successful wrist extension is activation occurs in musculotendinous and joint
often accomplished while the fingers remain in partial afferents that are known to mediate kinesthetic

sensation. In general, afferent stimulation was a REFERENCES

common feature in all subjects regardless of the actual
1. Carey L.M. : Somato-sensory loss after stroke.
current intensity. Considering supraspinal and
Critical Reviews in Physical Medicine and
peripheral afferent convergence onto spinal inter-
Rehabilitation Medicine 1995; 7: 51-91.
neurons, depolarization of large diameter afferent
2. George H. K, Sally S. F and Margaret C. H:
fibers (primarily activated by electrical stimulation) Techniques to improve arm and hand function
has been found effective in modifying the segmental in chronic hemiplegia. Archives of Physical
and supra-segmental excitability levels and might be Medicine and Rehabilitation March 1992; 73:
responsible for increased pre-synaptic inhibition, if pre- 220-227.
synaptic inhibition is indeed diminished after stroke. 3. Goldman H. improvement of double
Plasticity of the CNS has been recognized as a part of simultaneous stimulation perception in
the structural and physiological substrate for recovery hemiplegic patients .Arch Phys Med Rehab 1996;
of function after brain injury. 47: 681-687.
4. Humphrey D. R. and Freund H.J. Motor Control
Neuro-physiological evidence that cortical Concepts and Issues. New York , John Wiley &
reorganization may ensue as a consequence of Sons, 1991.
prolonged sensory input as consequence motor 5. kraft GH , Fitts SS and Hammond MC.
representation areas for evoking a wrist extension Techniques to improve function of the arm and
movement receive cutaneous input from wide hand in hemiplegia. Arch Phys Med Rehab 2002;
receptive fields located over the volar aspect of the 73: 220-227.
fingers. The evidence for cortical plasticity, in the 6. Lagasse PP , Roy MA. Functional electrical
presence of such functional organization, may provide stimulation and the reduction of co-contraction
some insight into the neurophysiological basis for in spastic biceps brachii. Clinic Rehabilitation
improved hand motor control following a daily 1999; 3: 111-116.
program of mesh-glove stimulation.6,7 7. Lieber RL and Friden JH. Spasticity causes a
fundamental rearrangement of muscle-joint
interaction. Developmental Medicine and Child
CONCLUSION
Neurology. 2005; 25(2): 265-270.
The combined effect of physiotherapy training plus 8. Meta M.D.: {Mesh glove method.] Scandinavian
mesh glove sensory stimulation are recommended to Journal of Rehabilitation Medicine December
1994; 26: 183-186.
overcome the lack of hand sensory feedback and lack
9. Mindy F. L and Christina W.Y.: [Electrical
of its representation so improve motor control of upper
stimulation relieves spasticity and improves
extremity in hemiplegic C.P children after 12 weeks
motor functions.] Electroencephalography and
follow up. Mesh gloves stimulation at sensory level Clinical Neurophysiology April 1992; 85: 131-142.
can be used as an adjunct to physiotherapy and\or 10. Porter R.H and Lemon R.G: Cortico-spinal
occupational therapy in children with spastic Function and Voluntary Movement . New York,
hemiplegia Oxford University Press, 1995; 16(6): 34-40.

Rehabilitation of a Patient with Post Traumatic Triple

Nerve Palsy of the Upper Limb
Anil Mathew
Associate Professor, Dept. of Orthopaedics & Hand Surgery
ABSTRACT
Post traumatic triple nerve palsy in the upper limb is rare and usually follows the unregulated use of
a tourniquet, severe proximal limb injuries and near total amputations. This paper describes a peculiar
case of triple nerve palsy following a road traffic accident in which the patient developed a radial
nerve palsy complicating a closed humeral fracture and a low median and ulnar nerve palsy in the
same limb due to a mid forearm level glass-cut injury. The challenges in rehabilitation included: lack
of extensors and intrinsic muscle function initially that made flexor tendon rehabilitation difficult; a
wrist drop and finger drop deformity that became more apparent after the flexor tendon rehabilitation;
gradual onset of intrinsic minus deformity as the radial nerve spontaneously recovered. The orthotist
had to make special splints and the rehabilitation team had to tailor the therapy at every stage of
nerve recovery to provide optimal function without the development of contractures.
Key words: Triple Nerve palsy, Cock up Splint, Opponensplasty
INTRODUCTION closed fracture of the right humerus with a radial nerve

palsy and multiple flexor tendon injuries and median
Multiple nerve palsies usually follow neuropathic and ulnar nerve injury at the mid forearm level of the
conditions. The term triple nerve palsy was used in same limb.
the past with regard to multiple nerve palsies involving
the radial, median and ulnar nerves; encountered in Surgical compression plating of the humerus was
Hansen's disease1. Following trauma however the done the same day during which the radial nerve was
incidence of dual nerve injury is common, especially inspected and found to be continuous. The mid
involving ulnar and median nerves in wrist or forearm forearm laceration was debrided and the injured flexor
level trauma. Published literature on a combination tendons, median, ulnar nerves and the ulnar artery
of radial, ulnar and median nerves are very few. This were repaired. The tendons were repaired using a four
report endeavours to describe the management and strand 3-0 braided, polyester core sutures (described
rehabilitation of a peculiar case of trauma that present by Mc Larney et al2 and 6-0 nylon running epitenon
with paralysis of all these three nerves. sutures. Both nerves and the ulnar artery were repaired
under a microscope with interrupted 9-0 nylon micro
MATERIAL AND METHODS sutures3. The wound was primarily closed and the
forearm and hand was supported by dorsal and volar
The patient in this study is a 24 year old male who slabs allowing early wound inspection.
had sustained a closed trauma to the right arm and a
penetrating injury at the mid forearm level by broken
FINDINGS
glass pieces of the rear view mirror following a road
traffic accident. Clinical evaluation revealed an isolated The presence of a radial , median and ulnar nerve
palsy in the early stages of rehabilitation meant no
Correspondence Address active extension of the interpahalangeal (IP) joints were
Anil Mathew possible. This prevented the use of the active -passive
MOSC Medical College & Hospital modified Klienert's protocol of flexor tendon
Kolenchery, Ernakulam dist rehabilitation.
Kerala 6823111
mathewanil@hotmail.com
In the first stage of the flexor rehabilitation an all
phone 09995409989 passive regimen of flexion and extension of the IP joints
5. anil mathew 21st sept 11 (24-27).pmd 24 10/16/2012, 2:40 PM

was started. The forearm and hand were supported indicating a late recovering neuropraxic injury of the
by an extension block splint. The therapist took radial nerve. The volar splint which is usually
particular care to avoid flexion contractures at the IP discarded at the tenth week in the standard flexor
joints. At the end of four weeks and the tendon rehabilitation, was in this case was used till
commencement of the second stage, the patient was the finger and wrist extensors began to show grade
allowed supervised active flexion, while the fingers three power.
were passively extended by the therapist. A broad
padded Velcro strap kept the fingers extended at the As the finger extensors regained power beyond
IP joints and supported on to the dorsal extension block grade four, (around four months after surgery) the
when they were not mobilized. The patient was fingers began to demonstrate a clawing tendency and
allowed passive flexion and extension of the IP joints the patient was then given a knuckle bender and
at home. The dorsal extension block was gradually thumb abduction splint (fig. 2). He was allowed to use
extended at the MCP joint level from the fifth week to the hand for limited activities with care since the hand
allow gradual extension at the MCP joint level. was anaesthetic.
By the end of the sixth week and the

commencement of the third stage of flexor tendon
rehabilitation the MCP joints could be brought to
neutral by passive extension. Since the patient had an
associated radial nerve injury at the level of the arm,
following removal of the plaster, the patient
demonstrated a finger drop deformity at the MCP joint
level. The lack of functioning intrinsics prevented
active extension at the IP joints. A modified dynamic
cock up splint (orthosis) was provided (figure: 1). An
additional volar resting splint keeping the wrist in
neutral, MCP in 60 deg of flexion and IP joints extended
was given for use at night.
Fig. 2 A simple thermoplastic knuckle bender and thumb

abduction splint to correct the claw hand deformity and to
prevent adduction contracture of the flail thumb.
By the seventh month of surgery the patient began to

show demonstrable hypothenar muscle function and
over the next five months progressive intrinsic muscle
recovery indicative of recovering ulnar palsy
Fig. 1 A modified dynamic cockup splint was given at the end of
the 2nd stage of flexor tendon rehabilitation. The fingers could
be brought passively to neutral at the MCP & IP joints by rubber
bands from a distal outrigger, connected to hooks glued onto
the nails. An additional outrigger with a padded loop maintained
the abducted posture of the thumb.
At the end of the tenth week the flexor tendon

rehabilitation was stopped the traction outrigger of
the orthosis was removed and the remaining volar
splint was used as a cock up splint to prevent a wrist
drop. The patient was asked to passively extend the
MCP and IP joints regularly to keep the joints supple.
Fig. 3 Recovery of the ulnar nerve palsy demonstrated by the
The patient began to show wrist extension and
ability to flex the MCP joints while keeping the IP joints straight
finger extension between the 12th and the 14th week (the intrinsic plus position)

(fig. 3). He was started on resistive exercises to increase

intrinsic muscle strength. The knuckle bender splint
was discarded at the 12th month after surgery.
Perceptible finger tip sensation was first seen

around the 11 month after surgery which gradually
improved to a protective sensation level by the 15th
month demonstrated by Semmes-Weinstein
monofilaments testing. The 18th month postoperative
evaluation showed grade four power of the intrinsics
Fig. 5 Good functional outcome after opponensplasty showing:
(interossei) and grade four power of the hypothenar
(a) full finger closure, (b) intrinsic plus posture indicative of
muscles. This recovery was confirmed by a good ulnar nerve motor recovery, (c) Palmar abduction of the thumb
interference pattern seen by EMG4 evaluation of the using the transferred FDS tendon of the ring finger.
intrinsic and hypothenar muscles. The wrist and long
extensors demonstrated grade four power. The thenar CONCLUSION
muscles supplied by the median nerve however had
not shown any recovery with no motor unit action Kouyoumdjian6, identifies the incidence of multiple
potentials demonstrable on EMG. The sensory nerve injuries involving three nerves at 3% (13 cases
recovery in the median nerve innervated area, however out of 437). The peculiarities of this case include a radial
was adequate. nerve palsy associated with a low median and ulnar
nerve palsy preventing extension of all IP and MCP
At the 18th month an opponensplasty using a FDS joints in early flexor tendon rehabilitation. To prevent
(flexor digitorum superficialis) tendon of the ring adhesions from developing a total passive regimen was
finger was done using the Campbell Thompson 5 initially instituted without the use of traction devices.
technique (fig. 4). The humeral implant was removed In stage two of the same therapy where supervised
in the same sitting as the humerus fracture had healed active flexion is initiated, the same passive protocol
well. was continued to bring the patient's fingers back into
extension. An extensor traction device was given in
the third stage of rehabilitation to keep the fingers
extended at the MCP & IP joints while allowing all the
above joints to actively flex to 90 deg. A standard dorsal
orthotic device7 for finger drop with padded loops
around the proximal segments of the fingers was not
given since the patient had an additional intrinsic palsy,
preventing extension of the IP joints. The radial nerve
injury demonstrated combined neuropraxic and
axonotomic components with most of the wrist
extensors and finger extensors recovering
simultaneously although a little late for neuropraxic
recovery. The recovery of the ulnar nerve innervated
intrinsics was significant in decreasing the morbidity
Fig. 4 FDS opponensplasty tendon transfer using the ring finger
superficialis tendon. The two slips of the tendon can been seen and disability following the injury, since the claw hand
at the radial side of the thumb, prior to insertion into the abductor deformity gradually corrected and pinch improved
apparatus. with time. Median and Ulnar nerve sensory recovery
that occurred would go a long way in preventing
Rehabilitation for the tendon transfer was started trophic changes. The only component of triple nerve
after three weeks of surgery. The patient showed rapid injury that did not recover was the motor component
improvement and was able to regain palmar abduction of the median nerve which was subsequent addressed
and demonstrable opposition by the sixth week of by the FDS-opponensplasty. Tailoring of the
surgery (fig. 5). rehabilitation at every stage of nerve recovery with
appropriate orthotic devices and modified therapy
allowed this patient with a rare triple nerve palsy to
achieve a good functional outcome.

ACKNOWLEDGEMENT REFERENCES
I am extremely grateful to: 1. Sundararaj GD, Mani K. Surgical reconstruction

1. Smt. Sreedevi P, senior hand therapist, for her of the hand with triple nerve palsy. Bone Joint
meticulous follow up and dedication through all Surg Br 1984; 66: 260-264.
the stages of hand therapy towards all patients and 2. McLarney E, Hoffman H, Wolfe SW.
this one in particular. Biomechanical Analysis of the cruciate four-
2. Smt. Liya P Mathew,hand therpaist, for her strand flexor tendon repair. J Hand Surg Am.
motivation and proffesionalism in this case and all 1999; 24: 295-301.
3. Isaacs J. Treatment of acute peripheral nerve
other hand therapy cases coming to our hand
injuries: current concepts. J Hand Surg Am. 2010;
centre.
35: 491-497
3. Sri. Shaju Cherian , orthotist whose skills are
4. Robinson LR. Traumatic injury to peripheral
unsurpassed in making perfect and quick orthosis nerves. Muscle Nerve 2000; 23: 863-873,
for the numerous patients undergoing hand 5. Thompson TC. A modified operation for
therapy. opponens paralysis. J Bone Joint Surg Am. 1942;
24: 632-640.
6. Kouyoumdjian JA. Peripheral nerve injuries: a
CONFLICT OF INTEREST retrospective survey of 456 cases. Muscle Nerve
2006; 34: 785-788
NIL 7. Duncan RM. Basic principles of splinting the
hand. Phys Ther. 1989; 69: 1104-1116.

The Effectiveness of Iontophoresis Over Conventional

Therapy in Relieving Pain, Improving Rom and Functional
Skills in Adhesive Capsulitis
Anila Paul1, Nizar2, Thresiamma VT3

1
Associate Professor, M.G.M. School of Physiotherapy, Sector30, Vashi, NaviMumbai, Maharashtra, 2Associate
Professor, School of Medical Education, Mahatma Gandhi University, Kottayam, Kerala, 3HOD, Department of
Physiotherapy, Karithas Hospital, Thellakam (P.O.), Kottayam, Kerala.
ABSTRACT
Background: Adhesive capsulitis is a common problem affecting the middle aged people. In the
second stage of Adhesive capsulitis, the pain and limitation of the ROM will restrict the patients in
their functional activities. Iontophoresis with Lidocaine is rarely used as an effective treatment for
adhesive capsulitis in our country.
Objective: To study the effectiveness of iontophoresis with lidocaine as an adjunct to the conventional
treatment for relieving pain and improving ROM and functional skills in phase II adhesive capsulitis.
Design: An experimental approach was used and study design is pre test post test group design.
Method: Population included 30 patients with phase II adhesive capsulitis.15 patients each were
taken in the experimental and control group. The control group has given the conventional treatment
and the experimental group has iontophoresis in addition. Outcome measures taken for the study
were shoulder pain using Visual Analogue Scale (VAS), abduction and external rotation Range of
Motion (ROM) using Goniometry and shoulder function score using Shoulder Pain and Disability
Index (SPADI). Analyzed statistically with studentst test.
Results: It was found that iontophoresis with lidocaine along with the conventional treatment causes
significant reduction of pain, improvement of abduction and external rotation Range of Motion (ROM)
and improvement of shoulder function.
Implications: A follow up study could ensure the long term effectiveness of treatment given. Study
can be done using other ionic medications.
Conclusions: Results of this study provide evidence that iontophoresis with lidocaine provide better
results when used as an adjunct to ultrasound therapy, passive joint mobilization, exercises and
home programme. There was significant reduction of pain which is one of the chief complaints in
patients with phase II Adhesive capsulitis and hence should be a part of the treatment regimen for
the same.
Key words: ROM Range of Motion, SPADI Shoulder Pain and Disability index, VAS Visual Analogue
Scale, Iontophoresis.
INTRODUCTION of shoulder pain accompanied by progressive

limitation of both active and passive gleno humeral
Adhesive capsulitis is a common clinical entity, movements. In the early stages, the capsule becomes
which mainly affects the middle aged people between contracted with loss of the inferior capsular fold. In
40-60 years. It is characterized by spontaneous onset the later phases, increased capsular fibrosis occurs.
Correspondence Address Abduction and external rotation are the gross
Anila Paul (PT) movements that would be restricted mostly (A I Binder
4 A, 1306-07, DREAMS, LBS Marg, et al, 1984)1.
Bhandup (west), Mumbai,
Maharashtra - 400078. During the phase II of Adhesive capsulitis, pain will
6. Anila Paul 19th april 11 (28-32).pmd 28 10/16/2012, 2:40 PM

limit the glenohumeral motion and later lead to the circle goniometer, Visual Analogue Scale (VAS),
complication of joint and soft tissue contractures. The Shoulder Pain And Disability Index (SPADI), recording
painful limitation of ROM will cause functional sheets, consent form, data collection sheets etc.
limitations and disabilities.
Consent was taken from the patients prior to the
Iontophoresis is the introduction of topically study. Assessment was taken on the first day and
applied, physiologically active ions into the epidermis treatment was given for five days. Assessment was
and mucous membranes of the body by the use of again done using an assessment form after five days
continuous direct current. Even today, Iontophoresis on completion of treatment. For the patients in the
is not considered as a first choice of treatment in control group, conventional treatment methods were
Adhesive capsulitis. But there has been a recent given and for the experimental group, iontophoresis
resurgence in its use and literature review suggests was given in addition to the conventional methods.
Iontophoresis offers the promise of therapeutic efficacy
and cost effectiveness (Liliana L Jorge, 2011)2. The patients in control group were treated with
therapeutic ultrasound in continuous mode with an
Even today, iontophoresis is not considered as a intensity 1.5 Watts/ cm2 for six minutes, passive joint
first choice of treatment for pain relief in adhesive mobilization which included anterior and inferior
capsulitis. Different studies had been conducted to glides, active assisted gleno humeral exercises which
evaluate the effects of iontophoresis in the included codmans exercises, overhead pulleys, finger
management of pain (Kezban Yigister et al, 2002)3. Such ladder and wand exercises and instructions on home
studies did not give significance to the improvement programme.
on functional capacities of the patients.
The patients in the experimental group were treated
This study was conducted to detect the with conventional treatment and in addition
effectiveness of Iontophoresis with lidocaine over iontophoresis with 2% lidocaine solution. For
conventional treatment of Adhesive capsulitis for pain iontophoresis, continuous direct current was used with
relief, improving ROM and functional abilities of the an intensity 2 mA for 20 minutes. The patient was in
patients. sitting position with the shoulder abducted to 90
degrees and positioned conveniently. The active
MATERIAL AND METHODS electrode (anode) was placed over the gleno humeral
joint and the dispersive electrode (cathode) at distal
This study used experimental research approach. end of arm. The cathode size was twice that of the
The study was conducted in the Physiotherapy anode. The medication of 2 % lidocaine was taken in
department of Chazhikkattu Hospital, Thodupuzha. the wet gauze and used under the anode. The
Thirty patients referred to the Physiotherapy stimulator was turned on and slowly advanced the
department with a diagnosis of shoulder pain were control unit until 2 mA is reached on the milliammeter
selected for the study after the evaluation based on and the patient feel a slight tingling sensation. The
inclusion criteria. They were divided into two groups treatment was continued for 20 minutes duration.
by convenient sampling method, where 15 patients
each were taken in control and experimental groups. The outcome measurements used were Goniometer
for measuring abduction and external rotation ROMs
The inclusion criteria was, patients diagnosed with (Hayes et al, 2001) 4, Visual Analogue Scale for
primary adhesive capsulitis referred by Orthopedician, measuring shoulder pain (Michelle H Cameron,1999)5
4-8 months of symptomatic duration, age between 50 and Shoulder Pain and Disability Index for assessing
& 60, patients with 50% reduction of total ROM in shoulder function (Bicer et al, 2010)6.
external rotation and 25% reduction of total ROM in
abduction. Any other pathologies of the shoulder joint, Control and experimental groups responses to the
patient with history of recent trauma were excluded treatment were analyzed using pairedt test. For
from the study. comparing experimental group response over control
group towards treatment, unpairedt test was used.
The materials used in the study were,
A diagnostic and therapeutic muscle stimulator RESULTS

with visual / audio indicators, 2% lidocaine, a The experimental and control groups had 15
therapeutic ultrasound machine with electronic timer patients each. Before the treatment session an
with digital display and audio alarm, a plastic half

evaluation of all patients were taken and documented. On analysis of active ROM in experimental group,
the t values of abduction and external rotation were
Study sample characteristics of control and 14.63, 19.78 respectively.They were found greater than
experimental groups were as follows. table value for t at 0.05 level of significance (t=1.7).
Table 1. Sample characteristics on age, sex and This implicates that there was significant difference
dominant side. between the pre and post treatment values of
Groups Age in years Sex Dominant side abduction and external rotation in experimental
50-55 55-60 Male Female Involved Non group.
Rt involved Lt
Experimental 8 7 7 8 9 6 On analysis of active ROM in control group, thet
Control 9 6 5 10 7 8 values of abduction and external rotation were 9.13
Table 2. Sample characteristics on duration of disease in
and 18.5 respectively and they were found greater than
weeks. table value for t at 0.05 level of significance (t=1.7).
Groups Duration of disease in weeks This implicates that there was significant difference
16-20 wks 20-24 wks 24-28 wks 28-32 wks between the pre and post treatment values of
Experimental 2 2 5 6 abduction and external rotation in control group.
Control 3 4 3 5
Analysis of active ROM after the treatment for
Analysis of active ROMS of external rotation and 5 days between the experimental and control
abduction of experimental and control groups were groups showed t value for abduction and external
done as follows. rotation were 4.33 and 6.02 respectively. As these
Table 3. Pre and post treatment mean ROM values of
values were greater than the table value for t at
experimental and control groups. 0.05 level of significance, it can be concluded that
Movement Mean Active ROM Mean Active ROM there were significant difference between two
experimental group control group groups after treatment and hence the null
Pre t/t Post t/t Pre t/t Post t/t hypothesis is rejected.
Abduction 149.2 168.13 147.53 157
External rotation 56.13 71.87 54.53 61.87 Analysis of shoulder pain of experimental and
control groups were done as follows.
Table 6. Mean values of pre and post treatment VAS

Group Mean pre Mean post Gain in % reduction of
treatment VAS treatment VAS VAS score VAS score
Experiental 8.066 3.13 4.936 49.36
Control 7.866 4.933 2.933 29.33
Fig. 1. Percentage gain in abduction and external rotation ROM

in experimental and control group
Table 4. Results of statistical testing of gain in active

abduction ROM
Group Pre test Independentt Post test Independentt Dependentt
initial test value after 5 days test value test value
Experiental 149.2 0.64 at 0.05 168.13 4.33 at 0.05 14.63
Control 147.2 level of 157 level of 9.13
significance significance Fig. 2. Percentage reduction of VAS score
Table 5. Results of statistical testing of gain in active
external rotation ROM. Table 7. Results of stastical testing of VAS values
Group Pre test Independentt Post test Independentt Dependentt Group Pre test Independentt Post test Independentt Dependentt
initial test value after 5 days test value test value initial test value after 5 days test value test value
Experiental 56.13 0.83 at 0.05 71.87 6.02 at 0.05 19.78 Experiental 8.066 0.817 at 0.05 3.13 6.02 at 0.05 23.26
Control 54.53 level of 61.87 level of 18.5 Control 7.866 level of 4.933 level of 13.82
significance significance significance significance

On analysis of VAS score of experimental group, DISCUSSION

thet value (23.26) found to be greater than table value,
which implicates that there was significant difference This study was conducted with the aim of
between pre and post treatment values of VAS score identifying the effect of lidocaine iontophoresis in
in experimental group. On analysis of VAS score of pain relief, improvement in ROM and shoulder
control group, the t value (13.82) was found greater function. The tools used in the study to measure the
than table value, which showed sinificance difference outcome measures were, Visual Analogue Scale,
between pre and post treatment values of VAS score Goniometry and Shoulder Pain and Disability Index.
in control group. These tools are widely used, easy to administer and
yield measurements that have known reliability and
On analysis of VAS score between experimental and validity.
control groups post treatment, the calculated value oft
was found to be 6.02 at 0.05 level of significance. It can On statistical analysis using paired t test, both
be concluded that there was significant difference groups showed significant difference in pre and post
between two groups after treatment, rejecting the null treatment scores. The analysis within the groups
hypothesis. showed that both groups had significant gain in
abduction and external rotation ROMs, reduction of
Analysis of shoulder function score of experimental pain and gain in shoulder function.
and control groups were done as follows.
On statistical analysis using unpairedt test, the
Mean values of pre and post treatment shoulder calculated t value of VAS score (6.02), active abduction
function score. ROM (4.33), active external rotation ROM (6.02) and
SPADI score (4.22) were found to be greater than the
Table 8. Percentage gain in shoulder function score
table value, rejecting the null hypothesis.
Group Mean pre Mean post Gain in % increase in
treatment treatment score shoulder shoulder
score function score function score Lidocaine iontophoresis is primarily used for an
Experiental 8.04 3.19 4.85 48.5 analgesic effect. Lidocaine, which is a positive ionic
Control 7.73 4.44 3.29 32.9 solution, is applied at the positive electrode, so that
the ions will pass through the skin by electro repulsion
(S D N Guptha, 2005)7.
The possible causes for the gain after the

conventional treatment may be, the thermal effects of
ultra sound which increase the temperature of deep
tissue with a high collagen content, and thus increase
the tissue extensibility and / or control pain (M Dyson,
1982)8. The increase in the extensibility will help to
decrease the joint stiffness.
The passive joint mobilization may have an

inhibitory effect on perception of painful stimuli by
Fig. 3. Percentage gain in shoulder function score
repetitively stimulating mechanoreceptors and used
to stretch the joint structures and thus increase joint
Table 9. Results of statistical testing of shoulder play (Carolyn Kisner, 1996)9.
function score
Group Pre test Independentt Post test Independentt Dependentt Active assisted exercises like finger ladder, wand
initial test value after 5 days test value test value
Experiental 8.04 1.105 at 0.05 3.19 4.22 at 0.05 27.59
exercises etc can provide the patient with objective
Control 7.73 level of 4.44 level of 17.49 reinforcement and therefore motivate for performing
significance significance
shoulder range of motion exercises. Home exercises
are advised to maintain the mobility gained during
On analysis, there were significant difference
the treatment sessions (Dickon P Crawshaw et al,
between pre and post treatment scores in both control
2010)10.
and experimental groups. On analysis of
independentt value post treatment between the The patients from experimental group, who
experimental and control groups showed significant received lidocaine iontophoresis, showed significant
changes in the scores, rejecting the null hypothesis. relief of pain compared to control group. Lidocaine is

a standard local anesthetic drug. Iontophoresis with 4. Kimberley Hayes, Judie R Walton, Zoltan L
lidocaine can provide deeper levels of analgesia with Szomor and George A C Murrel, Reliability of five
a much shorter time span (Louis P Gangarosa et methods for assessing shoulder range of motion.
al,1981)11. Australian Journal of Physiotherapy, 2001, 47,
289-294.
A current of 2 mA for 20 minutes duration has been 5. Michelle H Cameron, Physical agents in
given so that the dosage of entire treatment would be rehabilitation from research to practice. W B
40 mA minutes. This enabled the penetration of ions Saunders company, Philadelphia, 1999, 402-405,
through the stratum corneum which is the most 52-53.
resistant layer of the skin (Kalbitz J et al, 1996)12. 6. Bicer A, Ankarali H. Shoulder Pain and Disability
Index: a validation study in Turkish women.
Iontophorecally driven lidocaine can be transferred Singapore Med J. 2010, 51(11), 865-870.
into all tissue layers underlying the active electrode 7. S D N Guptha, Sangolli M Prabhakar, S
including tendons and cartilages (Massimiliano Nino Sacchidanand. Iontophoretic delivery of
et al, 2010)13. More than that, the duration and depth lignocaine and epinephrine. Indian J Dermatol
of anesthesia produced by lidocaine iontophoresis is Venereol Leprol, Sept- Oct 2005, 71(5), 362-363.
significantly high (Charles T Costello et al, 1995)14. 8. M Dyson, Non thermal cellular effects of
Ultrasound. Br J Cancer, 1982, 45 suppl vol:65,
The better reductions in pain after lidocaine 165-171.
iontophoresis motivated patients to co operate with the 9. Carolyn Kisner et al, Therapeutic exercise-
further treatment sessions. This enabled them to relax foundations and techniques, third edition, Jaypee
and actively participate in the exercise program. The brothers, New Delhi. 1996, 191-206, 45-49.
following sessions of passive joint mobilization and 10. Dickon P Crawshaw, Philip S Helliwell, Elizabeth
active assisted exercises further added the improvement M A Hensor, Elaine M Hay, Simon J Aldous and
in shoulder ROMs (Gert J D Bergman et al, 2010)15. The Philip G Conaghan. Exercise therapy after
corticosteroid injection for moderate to severe
better reduction of pain and improvement in ROMs
shoulder pain: large pragmatic randomized trial.
gained by lidocaine iontophoresis enhanced shoulder
BMJ 2010, 340, c3037.
function considerably.
11. Louis P Gangarosa, SR. Newer local Anesthetics
From this discussion, it can be concluded that and techniques for administration. J Dental Res,
lidocaine iontophoresis can be added with the 1981, 60; 1471.
12. Kalbitz J et al, Modulation of drug penetration in
conventional treatment of adhesive capsulitis for better
the skin. Pharmazie, Sept 1996, 51(9), 619-637.
improvement in reduction of pain, ROMs and shoulder
13. Massimiliano Nino, Gabriella Calabro, Pietro
functions.
Santoianni, Topical delivery of active principles:
The field of dermatological research.
REFERENCES
Dermatology Online Journal, Jan 2010, 16 (1): 4
1. A I Binder, D Y Bulgen, B L Hazleman, J Tudor 14. Charles T Costello, Arthur H Jeske, Iontophoresis:
and P Wraight. Frozen shoulder: an arthrographic Applications in transdermal medications
and radio nuclear scan assessment. Annals of the delivery. Physical Therapy, June 1995, Vol 75, No
Rheumatic Diseases, 1984, 43, 365-369. 6, 554-563.
2. Liliana L Jorge, Caroline C Feres and Vitor E P 15. Gert J D Bergman, Jan C Winter, Maurits W van
Teles. Topical preparations for pain relief: efficacy Tulder, Betty Meyboom-de Jong, Klass Postema
and patient adherence. J Pain Res. 2011; 4: 11-24. and Greet JMG van der Heijden. Manipulative
3. Kezban Yigister et al. A comparison of the effect therapy in addition to usual medical care
of two different iontophoresis applications on accelerates recovery of shoulder complaints at
pain in patients with adhesive capsulitis of the higher costs: economic outcomes of a randomized
shoulder, The pain clinic, 2002, 14(1), 49-53. trial. BMC Musculoskelet Discord, 2010, 11: 200.

Comparison of Dynamic Balance Between Flat Feet and
Normal Individuals Using Star Excursion Balance Test
Ajit Dabholkar1, Ankita Shah2, Sujata Yardi3

1
Associate Professor, 2BPTh, 3Professor & Director, Pad. Dr. D.Y. Patil College of
Physiotherapy Nerul, Navi Mumbai.
ABSTRACT
Objectives: 1) To compare dynamic balance between flat feet and normal individuals using Star
Excursion Balance Test (SEBT). 2) To determine the most affected excursion distance.
Research Design: Cross sectional study.
Method: 30 subjects with bilateral flexible flat feet as assessed by sit to stand navicular drop test and
30 subjects with normal feet both in the age group 18-25 years were chosen for the study.
The sample size therefore was 120 feet (60 flat feet and 60 normal arched feet).The outcome assessed
were sit to stand navicular drop test, calcaneum angle, width of the foot, great toe extension range of
motion and SEBT.
Data analysis: Unpaired't' test using Graph Pad Instat software system was used.
Results: Extremely significant mean differences in sit to stand navicular drop test, calcaneum angle,
width of the foot, great toe extension range of motion and SEBT was found in individuals with flat
feet. Also the lateral excursion distance was least in these individuals (p<0.0001
Conclusion: Dynamic balance is affected in flat feet individuals
Key words: Flat Feet, SEBT, Pronation, Navicular Drop.
INTRODUCTION using star excursion balance test which is designed to

measure dynamic postural.
The foot is the most distal segment in the lower
extremity chain and represents a relatively small base Methodology
of support on which the body maintains balance
(particularly in single-leg stance).1 It is likely that Research design: Cross sectional
deficits in foot posture, flexibility, strength, or sensation Sample size: 120 Flat Feet
impair the support function of the foot and predispose
to loss of balance. Group1 (Experimental group) - 60 flat feet.
Although it seems reasonable that even minor Group2 (Control group) - 60 normal arched feet.
biomechanical alterations in the support surface may
influence postural-control strategies.1 When the arch Material:
starts collapsing, balance is broken at the feet, &
1) Half Goniometer
therefore the balance throughout the entire body is also
2) Ruler
broken.
3) Marker
Taking into consideration effect of flat feet on body 4) Measuring tapes
alignment, the implication of flat feet on balance have 5) Weighing Machine
received little attention to date. Hence this study was 6) Graph Pad Instat software
done to find if subjects of flat feet have balance problem
7 ankita shah 28th sept 11 (33-37).pmd 33 10/16/2012, 2:40 PM

Outcome measures- a) To diagnose flat feet by SIT TO STAND

NAVICULAR DROP TEST (SSNDT)
1) Sit to stand navicular drop test (SSNDT)
2) Calcaneum angle The SSNDT test is performed by calculating the
3) Width of the foot difference between the height of the navicular from
4) Great toe extension range of motion the floor when the subtalar joint is positioned in
5) Star Excursion Balance Test (SEBT) neutral and the height of the navicular from the floor
when in relaxed stance in a full weight bearing
Inclusion criteria- position (Brody 1982). 34
1) Flexible flat foot b) To measure CALCANEUM ANGLE (CA)
2) Girls in the age group of 18- 24 years
Calcaneum Angle is defined as the number of
Subjects Exclusion criteria - degrees the posterior midline of the calcaneum
1) Symptomatic and stiff flat feet. deviates from being perpendicular to the level floor.
2) Flexible flat foot with neuromuscular involvement. To obtain the posterior mid line of the calcaneum, the
3) Any past history of injury or treatment of the subject was positioned prone with bear foot over the
affected lower limb. edge of bed. Opposite limb was flexed, abducted,
4) Any other associated congenital abnormality. externally rotated with knee flexed, this will internally
5) Limb length discrepancy. rotate the limb to be measured placing the calcaneum
6) Pregnancy in horizontal orientation. With skin marker, a line
7) Body Mass Index (BMI) > 30 bisecting the idle 1/3 of posterior surface of calcaneum
was drawn and subsequently measured with a
Exclusion criteria for performing SEBT- goniometer with the patient in standing position.
Individuals were excluded if they reported any c) To measure GREAT TOE EXTENSION
1) Somatosensory condition that could impair The subject is in standing position. The great toe
balance. is extended actively and assisted passively without
2) Previous head injury resulting in a loss of dorsiflexing the 1st ray. The range of motion is
consciousness. measured with the goniometer.
3) Lower extremity injury or feelings of giving way
that resulted in any time loss of physical activity d) To measure the WIDTH OF THE FOOT
from practice or competition within the past year. A piece of blank paper is placed on a hard floor.
4) Feelings of either ankle giving way at the time of The subject sits with the foot firmly on the paper. The
the study and unrelated to previous injury. outline of the foot is traced and the distance between
5) Flu-like or cold-like symptoms within the past the two widest points on the tracing is measured. This
weeks, which could impair balance. number will help determine the foot width.
6) Lastly, volunteers were excluded if they were
unable to perform the SEBT during the practice e) To measure the LIMB LENGTH: The subject is in
session. supine position. A tape measure was used to
quantify the distance from the anterior superior
Procedure iliac spine to the centre of the ipsilateral medial
All the participants with normal arched feet and malleolus.
flat feet diagnosed on basis of SSNDT were screened f) HEIGHT was measured with a standard height
and selected as per the inclusion and exclusion criteria. chart.
They were briefed about the nature of the study and
their informed written consent was taken. The STAR EXCURSION BALANCE TEST
demographic data like age, gender, height, weight and
limb length were noted. The SEBT was performed with the participants
standing in the middle of a grid formed by eight
Following this the foot was assessed for sit to stand measure tapes extending out at 45 from each other.
navicular drop test, measurement of calcaneum angle, The participant was asked to reach as far as possible
width of the foot, great toe extension in resting along each of the eight measure tapes, make a light
standing foot posture.33 touch on the tape, and return the reaching leg back to

the center, while maintaining a single-leg stance with Table 1. Comparison of Normal Arched Feet and Flat
the other leg in the center of the grid. When reaching Feet for following parameters
in the lateral and posterolateral directions, participants Conrol Experimental P Infe-
Group Group value rence
must reach behind the stance leg to complete the task. Mean SD Mean SD
Age 21.4 1.33 21.36 1.43 0.925 NS*
They began with the anterior direction and
Ht 159.76 5.98 159.33 6.10 0.075 NS*
progressed clockwise around the grid. All participants LimbLength 88.21 3.19 87.93 3.24 0.734 NS*
began with a right stance leg in the center of the grid. SSNDT 0.51 0.09 1.03 0.05 <0.0001 S**
After completion of the three trials in the eight Calcaneumangle 5.28 2.53 9.68 4.19 <0.0001 S**
directions and another 5-min rest period, the test Widthof foot 8.22 0.38 8.48 0.59 0.0045 S**
continued with a left stance leg. The investigator Great toe ROM 59.33 7.18 52.21 7.54 <0.0001 S**
recorded each reach distance with a mark on the tape NS* = Not significant
as the distance from the center of the grid to point of SS** = Significant
maximum excursion by the reach leg.2 Table 2. Comparison of Normal Arched Feet and Flat
Feet for Excursion Distance
Conrol Group ExperimentalGroup Pvalue
Mean SD Mean SD
Anterior 57.9 5.262 54.66 5.055 <0.0008*
AntLateral 55.22 5.043 51.05 4.942 <0.0001*
Lateral 47.02 8.444 41.8 6.854 <0.0003*
Post Lateral 52.85 8.555 46.63 5.923 <0.0001*
Poste-rior 53.63 7.307 47.15 4.772 <0.0001*
Post Medial 55.3 7.174 50.06 4.825 <0.0001*
Data analysis:
Medial 55.95 6.995 50.18 4.942 <0.0001*
Unpaired t test using Graph Pad Instat software Ant Medial 58.02 4.914 53.52 4.616 <0.0001*
system was used for comparison of dynamic balance * P value is extremely significant.
between flat feet and normal individuals using SEBT.
On analysis, there was an extremely significant mean DISCUSSION
difference in sit to stand navicular drop test, calcaneum
angle, width of the foot, great toe extension range of The results of the present study showed that
motion and SEBT found in individuals with flat feet. balance is affected in flat feet individuals.
Also the lateral excursion distance was least in these
In flat feet individuals, the angle is increased
individuals (p<0.0001)
indicating that the foot is pronated. Since in flat feet,
the medial longitudinal arch of the foot appears
RESULTS
flattened, this causes the foot to roll inwards in order
Various statistical measures such as mean, standard to gain contact with the floor and support the weight
deviation and test of significance such as unpairedt of the body and is the main clinical feature of
test were utilized for this purpose. Unpairedt test was pronation.31 Thus calcaneus lies in valgus and external
utilized to compare the height, limb length, SSNDT, rotation relative to tibia and talus faces medially and
calcaneum angle, width of the foot, great toe extension downwards. There may also be associated midfoot sag
range of motion and excursion distance using due to dorsal subluxation of navicular on talus.29,30
SEBT.(Table 1)
Also width of the foot is comparatively greater in
A total of 120 feet were evaluated in the study of flat feet. The possible reason being splaying of the
which 60 were flat (experimental group) and 60 were forefoot, a condition where the intermetatarsal
normal arched (control group). The age range was ligament is soft and loose, allowing the foot to spread.
between 18- 25 years in both the group with all female As the foot pronates and the longitudinal arch
participants. The mean age of the subjects in control collapses, the transverse arch of the foot also will
group was 21.4 1.33 and mean age of experimental collapse. Once this happens, the metatarsal heads are
was 21.361.43. aligned and this causes them to spread to make room.32

The decrease in the great toe extension range of established that excursion is most affected in lateral
motion in flat feet is supported by the ineffective direction.1 Further, researchers should investigate the
windlass mechanism10 resulting from the IFM during effect of foot type on muscle activity patterns and joint
static standing and during gait (Gray et al 1968)6 to forces during these balance tasks to better understand
compensate for lax ligaments and general foot potential neuromuscular and biomechanical
hypermobility. compensations for altered structural stability.
Although investigators found static and dynamic

CONCLUSION
balance to be adversely affected by changes in
peripheral input secondary to joint injury21-24 and From the study it is concluded that balance is
changes in the stability of the surface on which one is affected in individuals with flat feet.
standing,25,26 far less attention has been focused on
whether more subtle alterations in the surface, stability, Therefore correction of flat feet is necessary to
or peripheral input of the support foot may also affect improve balance in these individuals to prevent
balance in those with different foot types. Other than further musculoskeletal injuries in terms of ankle
the work by Hertel et al.18,20 we are not aware of any sprains, plantar fasciitis etc and also to prevent
other studies that have examined balance as a function compensatory adjustments in the proximal segments
of foot type. Understanding this relationship is of the lower limb.
important since these measures can be used to assess
Conflict of Interest: None.
potential deficits related to injury mechanism e.g. ankle
injury.
BIBLIOGRAPHY
In our study dynamic balance was assessed since
1 Karen P Cote, Michael E Brunet, II, Bruce M
most activities an individual participates in are Gansneder, and Sandra J Shultz. Effects of
functional or dynamic as opposed to static. The SEBT Pronated and Supinated Foot Postures on Static
is a relatively new assessment tool, described as a and Dynamic Postural Stability. J Athl Train.
functional test that emphasizes dynamic postural 2005 Jan-Mar; 40(1): 41-46.
control,21 which has been defined as the extent to which 2 Phillip A. Gribble and Jay Hertel: Considerations
a person can reach or lean without moving the foot and for Normalizing Measures of the Star Excursion
still maintain upright posture.27 Hence, this test requires Balance Test. Measurement in Physical
a combination of foot, ankle, knee, and hip motion and Education and Exercise Science, 7(2), 89-100.
imposes greater demands on strength and joint range 3 A. K. L. Leung , A. F. T. Mak ,J. H. Evans:
of motion, in addition to proprioception and Biomechanical gait evaluation of the immediate
neuromuscular control within the stance leg to maintain effect of orthotic treatment for flexible flat foot.
balance while reaching with the opposite leg.9 Prosthetics and Orthotics International 1998, Vol.
22, No. 1, Pages 25-34.
Since significant correlations were revealed between 4 Guskiewicz KM, Perrin DH. Research and
height and excursion distance and leg length and clinical applications of assessing balance. J Sport
excursion distance with leg length having the stronger Rehabil. 1996;5: 45-63.
correlation, control participants who were matched to 5 Franco AH.: Pes cavus and pes planus: Analyses
experimental participants according to leg length were and Treatment. Phys Ther.1987;67:688694.
taken. 6 Gray EG, Basmajian JV. 1968 Electromyography
and cinematography of leg and foot (normal
Our study revealed that the reach distance on the and flat) during walking. Anat Rec 161: 1-16.
SEBT was significantly less in individuals with flat feet 7 Kwong PK, Kay D, Voner PT, White MW. Plantar
than in normal feet ad these results were found across fasciitis: mechanics and pathomechanics of
all reach directions and were not direction dependent. treatment. Clin Sports Med. 1988; 7: 119126.
8 Whiting WC, Zernicke RF. Biomechanics of
Lateral direction was most affected. Excessive Musculoskeletal Injury. Champaign, IL: Human
pronators tend to collapse toward the medial aspect of Kinetics; 1998. Lower-extremity injuries; pp.
the foot and have a reduced ability to maintain a rigid 172-173.
support in full weight bearing. This medial deviation 9. Hicks JH. The mechanics of the foot II: the plantar
plus greater foot mobility may account for pronators aponeurosis and the arch. J Anat. 1954; 88:
reduced dynamic reach in the lateral direction.1Thus 25-30.
our study supports the work of Karen P Cote, who 10. Lori A. Bolgla and Terry R. Malone : Plantar
Fasciitis and the Windlass Mechanism: A

Biomechanical Link to Clinical Practice.J Athl Sports Med. 1996; 24: 370-374.
Train. 2004 JanMar; 39(1): 77-82.11) Thordarson 23. Leanderson J, Wykman A, Eriksson E. Ankle
DB, Schmotzer H, Chon J, Peters J. Dynamic sprain and postural sway in basketball players.
support of the human longitudinal arch: a Knee Surg Sports Traumatol Arthrosc. 1993; 1:
biomechanical evaluation. Clin Orthop. 1995; 316: 203-205.
165-172. 24. Cornwall MW, Murrell P. Postural sway
12. Kappel-Bargas A, Woolf RD, Cornwall MW, following inversion sprain of the ankle. J Am
McPoil TG. The windlass mechanism during Podiatr Med Assoc. 1991; 81: 243-247.
normal walking and passive first metatarsal- 25. Hertel JN, Guskiewicz KM, Kahler DM, Perrin
phalangeal joint extension. Clin Biomech (Bristol, DH. Effect of lateral ankle joint anesthesia on
Avon). 1998; 13: 190-194. center of balance, postural sway, and joint
13. Aquino A, Payne C. Function of the plantar fascia. position sense. J Sport Rehabil. 1996; 5: 11-119.
Foot. 1999; 9: 73-78. 26. Riemann BL, Caggiano NA, Lephart SM.
14. Karr SD. Subcalcaneal heel pain. Orthop Clin Examination of a clinical method of assessing
North Am. 1994; 25: 161-175. postural control during a functional performance
15. Nashner LM, Black FO, Wall C., III. Adaptation task. J Sport Rehabil. 1999; 8: 171-183.
to altered support and visual conditions during 27. Goldie PA, Bach TM, Evans OM. Force platform
stance: patients with vestibular deficits. J measures for evaluating postural control:
Neurosci. 1982; 2: 536-544. reliability and validity. Arch Phys Med Rehabil.
16. Shumway-Cook A, Horak FB. Assessing the 1989; 70: 510-517.
influence of sensory interaction of balance. Phys 28. Overuse Knee Injurie- American Academy of
Ther. 1986; 66: 1548-1550. Podiatric Sports Medicine www.aapsm.org/
17. Riemann BL, Myers JB, Lephart SM. Sensorimotor ct1100.htm
system measurement techniques. J Athl Train. 29. David J. Magee: orthopedic Physical Assessment
2002; 37: 85-98. 4th edition Pg 783
18. Hertel J, Gay MR, Denegar CR. Differences in 30. Wheeless Textbook Of Orthopedics- http:
postural control during single-leg stance among www.wheelessonline.com/ortho pes_ planus_
healthy individuals with different foot types. J flat_foot.
Athl Train. 2002; 37: 129-132. 31. http://www.feet1stshoes.com/Flat_Feet.html
19. Robbins S, Waked E, Allard P, McClaran J, 32. Forefoot Splaying by Paul, www.footankle.ca/
Krouglicof N. Foot position awareness in younger 2009/08/17/forefoot-splaying/comment-page-1/
and older men: the influence of footwear sole 33. Mattacola CG, Dwyer MK, Miller AK, Uhl TL,
properties. J Am Geriatr Soc. 1997; 45: 61-66. McCrory JL, Malone TR. Effect of orthoses on
20. Olmsted LC, Hertel JN. Influence of foot type and postural stability in asymptomatic subjects with
orthotics on static and dynamic postural control. rearfoot malalignment during a 6-week
J Sport Rehabil. 2004; 13: 54-66. acclimation period. Arch Phys Med Rehabil. 2007
21. Olmsted LC, Carcia CR, Hertel J, Shultz SJ. May; 88(5): 653-60.
Efficacy of the Star Excursion Balance Tests in 34. Juli Deng, Rita Joseph, Christopher Kevin Wong.
determining reach deficits in subjects with Reliability and validity of the sit-to-stand
chronic ankle instability. J Athl Train. 2003; 37: navicular drop test: Do static measures of
22. Leanderson J, Eriksson E, Nilsson C, Wykman navicular height relate to the dynamic navicular
A. Proprioception in classical ballet dancers: a motion during gait? Journal of Student Physical
prospective study of the influence of an ankle Therapy Research 2010; 2(1): 21-28.
sprain on proprioception in the ankle joint. Am J

Evaluation of 6 Minute Walk test Parameters in Normal

Indian Pediatrics age Group between 6-11yrs
Jinal Chitroda1, Anuprita Thakur2, Sujata Yardi3

1
Dept. of Physiotherapy, MPT, 2Assoc. Prof, 3Prof & Director
ABSTRACT
The 6 minute walk test is a practical simple test that is very commonly used to assess the submaximal
functional capacity of patients with pulmonary dysfunctions. This test measures the distance that a
patient can quickly walk on a flat, hard surface in a period of 6 minutes ie the 6 minute walk distance
(6MWD). It is widely administered in adults as well as paediatrics groups. Though there are reference
values of the 6MWD available for adult group, no such values are available for Indian paediatric
groups. This study aims to find the reference values for 6 minute walk test for Indian paediatric
group.
Methodology: The 6 minute walk test was administered on 300 school children of both sexes. The
distance covered and the pre and post test basal parameters were assessed or each subject.
Conclusion: The distance covered by the subjects was found to be 599.4781 mtrs with little difference
between the two sexes.
Key words: 6 Minute walk test, Children
INTRODUCTION The self-paced 6MWT is a practical simple test to

assess the submaximal level of functional capacity and
Assessment of functional capacity has traditionally requires a 100-ft hallway but no exercise equipment
been done by merely asking patients the following: or advanced training. Walking is an activity performed
"How many flights of stairs can you climb or how daily by all but the most severely impaired patients.
many blocks can you walk?" However, patients vary This test measures the distance that a patient can
in their recollection and may report overestimations quickly walk on a flat, hard surface in a period of 6
or underestimations of their true functional capacity. minutes (the 6MWD). Because most activities of daily
Objective measurements are usually better than self- living are performed at submaximal levels of exertion,
reports. the 6MWD may better reflect the functional exercise
In the early 1960s, Balke developed a simple test to level for daily physical activities.4
evaluate the functional capacity by measuring the 6 min walk test is widely used in adult as well as
distance walked during a defined period of time.1 A paediatric age groups. Reference values for adult
12-minute field performance test was then developed groups are available in literature.5 However despite
to evaluate the level of physical fitness of healthy its frequent use, there are no normal values available
individuals.2 for children under 11 years of age in Indian population.
In an attempt to accommodate patients with Thus this study aims to provide reference values for
respiratory disease for whom walking 12 minutes was 6 minute walk test in children between 6 to 11 years of
too exhausting, a 6-minute walk was found to perform age group.
as well as the 12-minute walk.3
MATERIAL & METHODOLOGY
Correspondence Address
The study design was prospective cross sectional
Jinal Chitroda
study. A sample size of 300 normal, healthy children
Pad Dr D.Y. Patil University,
including equal number of males and females in the
6th floor, Pad DR D. Y. Patil Medical College Bldg.,
age group 6 to11 yrs were selected. BMIs in all age
Sector 5, Nerul, Navi Mumbai
groups were, on average, within the normal range as
8. Anuprita 16th july 11 (38-41).pmd 38 10/16/2012, 2:40 PM

outlined by the Center of Disease Control Growth The grading of the test was based on the distance
charts for Children.6 covered in 6min.. At the end of 6minutes, the basal
parameters and RPE by Borg scale were measured and
Subjects with history of any cardio-respiratory, the recovery was taken after 3 and 6 minutes.
musculoskeletal or neurological disorders in the last 6
months were excluded from the study. During the study, none of the subjects needed to
prematurely terminate the test and none of them
The study was approved by the ethics committee required rest.
and school as well as parental consent was obtained.
Procedure RESULTS
Comfortable clothing and appropriate shoes were Graph 1. Mean distance covered by the subjects
worn by the participants.
The test was carried out as per American Thoracic

Society guidelines.4
A 30mts flat, straight, hard surface corridor was

used. The turnaround points were marked with a cone.
The subject was made to sit and rest in a chair,

located near the starting position, for at least
10 minutes before the test starts. During this time, basal
parameters i.e. pulse rate, blood pressure and
respiratory rate were measured. The mean distance covered by the subjects was 599.4781 mtrs
Subjects were instructed- the object of this test is Graph 2. Mean distance covered by males and females
to walk as far as possible for 6minutes. You will walk
back and forth in this hallway. 6 minutes is long time
to walk, so you will be exerting yourself. You are
permitted to slow down, to stop, and to rest as
necessary, but resume walking as soon as you are able.
Remember that the object is to walk as far as possible
for 6 minutes, but dont run or jog.
Instructions were given in the language that they

could easily understand. The verbal instructions were
encouraging and standardized statements- Youre
doing well or Keep up the good work, but no other
phrases were used. The mean distance covered by males was 605.273.382 mtrs and
by females was 593.7387.941mtrs. The difference in the distance
st
After the 1 minute of the test instructions like You covered by both sexes was found to be statistically insignificant.
are doing well. You have 5 minutes to go. were given
Graph 3. Interpretation of pre and post walk Pulse Rate
between Males and Females
At the end of 2 minutes instructions like: Keep up
the good work. You have 4 minutes to go. were given
At the end of 3 minutes instructions like: You are

doing well. You are halfway done. were given
At the end of 4 minutes instructions like: Keep up

the good work. You have only 2 minutes left. were
given
When only 1 minute was remaining instructions

like: You are doing well. You have only 1 minute to
go. were given
The change between pre and post Pulse Rates were within
normal limits in both the sexes.

Graph 4. Interpretation of pre and post Blood Pressure Graph 7. Age wise distribution of mean distance covered
between Males and Females in meters.
The changes in pre and post systolic and diastolic blood It was observed that the mean distance covered increased
pressures were seen to be within normal limits in both the sexes. with an increase in age.
Graph 5. Interpretation of pre and post Respiratory rate

DISCUSSION
Males and Females
The 6MWT, which is easy to perform and cost-
effective, has been proposed as the best indicator of
functional capacity among all submaximal exercise
tests.6
The 6-min walk test has been validated by high

correlation with workloads, heart rate, and SaO2, the
dyspnea responses when compared with standard
bicycle ergometry and treadmill exercise tests.4
The distance achieved within 6 minutes allows an

estimation of individual response to incremental
The change between pre and post Respiratory Rates were within maximal exercise and has been found to accurately
normal limits in both the sexes.
reflect physical capacity of patients with pulmonary
disease.5
Graph 6. Interpretation of Average Rate of Perceived
Exertion amongst Males and Females As no reference values for 6MWT distance have
been available in younger children, quantification of
exercise intolerance in this population is largely based
on data extrapolated from older individuals and is
prone to error.
The current study thus attempted to establish the

normal values for 6WMT distance in children between
6 and 11 years of age in Indian population. It was found
that the mean distance covered by children between 6
and 11 years was 599.4781 mtrs.
It was also seen in this study that the basal

parameters like Blood pressure, heart rate and
The average reported Rate of Perceived Exertion on BORGs respiratory rate and rate of perceived exertion were
Scale was found to be same in males and females i.e. 2- Slight.
within normal limits before and after the test and were
not significantly different in males and females.
Also the distance covered increased as the age

increased. This can be attributed to increase in mean
height with age. A taller height is associated with a

longer stride, which makes walking more efficient, REFERENCES

probably resulting in a longer distance walked with
1. Balke B. A simple field test for the assessment of
elder age group students.
physical fitness. CARI Report 1963; 63: 18.
2. Cooper KH. A means of assessing maximal
CONCLUSION oxygen intake: correlation between field and
The mean distance covered by children in the age treadmill testing. JAMA1968; 203: 201-204.
3. Butland RJA, Pang J, Gross ER, Woodcock AA,
group between 6-11 years is about 599.4781 mtrs with
Geddes DM. Two-, six-, and 12-minute walking
an average of 605.273.382 in males and 593.7387.941
tests in respiratory disease. BMJ 1982; 284:
in females.
1607-1608.
Also the basal parameters were within normal 4. ATS Statement Guidelines for the Six-Minute
limits of exercise and recovered on an average within Walk Test American Journal of Respiratory and
Critical Care Medicine Vol 166. pp. 111-117, (2002).
3 minutes after stopping of the test.
5. Solway S, Brooks D, Lacasse Y, Thomas S. A
Conflict of Interest: None. qualitative systematic overview of the
measurement properties of functional walk tests
used in the cardiorespiratory domain. Chest 2001;
FUTURE RESEARCH
119: 256-270.
The study can be extended to compare for the 6. Kuczmarski RRJ, Ogden CCL, Grummer-Strawn
distances covered by children with different socio- LLM, et al. CDC growth charts: United States.
economic status, children from urban and rural areas, Advance data from Vital & health statistics of the
etc. National Center for Health Statistics. 2000:1-27.
Declaration
This study is an original study and has been done

by the above mentioned authors. Also it has not been
sent to any other journal for publication

Effect of Posterior Tibial Nerve Stimulation and Trospium

Hydrochloride in Treatment of Overactive Bladder
Syndrome: A Randomized Controlled Study
Anwar Abdelgayed Ebid1*, Shamekh Mohamed El-Shamy2, Ali Abd El Monsif Thabet3
1,2,3
Assistant Professor Physical Therapy, Faculty of Applied Medical Science, Umm Al-Qura University,
Kingdom of Saudi Arabia
*Member of Rehabilitation Research Chair (RRC)-Faculty of Applied Medical Science (CAMS)-Umm Al-Qura
University
ABSTRACT
Objective: To compare the effects of long term posterior tibial nerve electrical stimulation and trospium
hydrochloride on urodynamic parameters, bladder diary and severity of urgency in patients with
overactive bladder syndrome.
Design: Randomized controlled trial.
Subjects: Thirty-seven patients were divided into either posterior tibial nerve electrical stimulation
(Group 1) or trospium hydrochloride (Group 2).
Main outcome measures: All patients were assessed at the beginning of the treatment, at week 12
(end of treatment), 18 and 24 according to urodynamic parameters, voiding diary parameters and
severity of urgency (visual analogue scale VAS).
Results: Statistically significant improvements were observed in both groups according to some
urodynamic parameters, voiding diary parameters, VAS urgency severity at the end of the treatment.
During the 24-week follow-up period, deteriorations were observed in many parameters in both
groups although improvements in the volume at first desire to void, frequency of urgency and VAS
urgency severity in group 1 persisted. Significant differences were not detected between groups at
the end of the treatment or during the post treatment follow-up controls.
Conclusion: No difference was detected in long term of posterior tibial nerve electrical stimulation
and trospium hydrochloride in the treatment of patients with overactive bladder syndrome.
Discontinuation of both treatments caused deterioration in most of the symptoms of overactive bladder
syndrome.
Key words: Posterior Tibial Nerve Stimulation, Trospium Hydrochloride, Overactive Bladder
INTRODUCTION on quality of life, impairing several areas, including

emotional well-being, productivity at home and at
Overactive bladder syndrome is defined as work, social relationships, sexual intimacy and
urgency, with or without urgency incontinence, physical functioning2.
usually with frequency and nocturia. Overactive
bladder syndrome affects individuals adversely, both Pharmacological treatment comprises the main
physically and psychosocially, and worsens their therapeutic modality in overactive bladder syndrome.
quality of life. It also causes infection, sleep disorders However, the adverse effects of antimuscarinic therapy
and depression and places a significant burden on can influence a patients quality of life and result in
health economics1. suboptimal dosing, poor patient compliance and even
drug discontinuation.Trospium chloride, which was
Overactive bladder syndrome is a common approved for overactive bladder syndrome recently
disorder, which can have a significant negative impact and is gaining popularity, improves urodynamic
9. Answar (42-47).pmd 42 10/16/2012, 2:40 PM

parameters and symptoms markedly with fewer side- (The second author) using a table of random
effects (anticholinergic and central nervous system numbers. The randomization results were kept in
side-effects) than other anticholinergics3. sealed envelopes, one for each patient. There was no
complete blindness in the study, since stimulation was
The most commonly used non-drug treatment applied by a separate researcher, while examination
modalities include bladder training, pelvic floor and data collection were carried out by a different
muscle training and electrical stimulation. Electrical researcher.
stimulation has been suggested to permit an effective
inhibition of detrusor activity and reported as safe and Thirty-seven patients were randomized to the
effective for urinary incontinence4. posterior tibial nerve electrical stimulation group
(Group 1, n=19) and medical treatment (trospium
Posterior tibial nerve stimulation is a minimally hydrochloride) group (Group 2, n=18) by sealed
invasive neuromodulation system designed to deliver envelope. Three patients in group 1 and one patient in
retrograde electrical stimulation to the sacral nerve group 2 could not complete the study. Sixteen patients
plexus through percutaneous electrical stimulation of in group 1 and seventeen patients in group 2
the posterior tibial nerve5. completed the study (Figure 1).
So the present study was carried out to compare Detailed histories related to incontinence (type of
long term posterior tibial nerve electrical stimulation incontinence and duration of incontinence) of patients
and trospium hydrochloride on urodynamic before treatment and patient demographics (age
parameters, bladder diary and VAS urgency severity ,gender and body mass index) were gathered by face-
in patients with overactive bladder syndrome. to-face interviews. Urological and neurological
examinations, urinalysis and urine culture were
MATERIAL AND METHODS performed. The patients in group 1 did not take
Subjects placebo tablets, and the patients in group 2 did not
have sham PTNS. Accordingly, the treatment was
The study was conducted on 37 patients (male and planned to cover twelve weeks period. All patients
female) who presented to Almataryia National were evaluated using the following methods at
Institute of Urology with urge incontinence and had baseline, week 12 (end-of-treatment), 18 and 24.
overactive bladder or mixed type urinary incontinence
with predominantly overactive bladder symptoms. Urodynamic examination
Exclusion criteria were history of pelvic surgery, post- Urodynamic examination was performed with the
voiding residual volume 4100 mL, neurological deficit Dantec Duet system (Dantec, Denmark).Urodynamic
or peripheral neuropathy that may cause neurogenic examination was performed after appropriate
bladder, presence of a medical condition that may antimicrobial treatment when infection was diagnosed
preclude anticholinergic drug use, pregnancy or by urine culture. A double-lumen cystometry catheter
suspicion of pregnancy, cardiac pacemaker, was used to fill the bladder with 0.9% saline solution
genitourinary infection or haemorrhage, and at a rate of 20 mL/min. Volume at first desire to void
deterioration in cognitive or intellectual functions. and maximal detrusor pressure during filling phase.
None of the patients were on anticholinergics or
tricyclic antidepressants, and none had been treated Voiding diary
by pelvic floor exercise, bladder training or pelvic
Before each assessment, patients were asked to fill
surgery before entry into the study. All subjects gave
in a three-day voiding diary that included daily
written informed consent to participate in the study.
voiding frequency (n/day) and frequency of urgency
Fifty patients were selected initially for this study. before voiding (n/day)
Eight patients did not fulfil the criteria and were
Visual analogue scale (VAS)
therefore excluded from the study. Five patients refuse
to participate in the study. The patients who consented In addition to voiding diary parameters, patients
to participate were initially assessed by the third were asked to show the severity of urgency. A 10-cm
author. Then the researcher randomized each patient visual analogue scale (VAS) was used to assess the
into one of the two groups by opening sealed severity of urgency in the patients. The VAS used a
envelopes. The randomization list was generated by a 10 cm line oriented vertically with no urgency
blinded researcher corresponding to the bottom of the line and worst
9. Answar (42-47).pmd 43 10/16/2012, 2:40 PM

imaginable urgency to the top of the line. Patients were weeks at a dose of 45 mg/day, 30 mg in the mornings
instructed to place a mark on the 10 cm vertical line and 15 mg in the evenings. Compliance was calculated
that corresponded to their severity of urgency. at weeks 12, 18 and 24 by subtracting the number of
Moreover, before treatment, all patients were given an medication capsules returned by each subject from the
instructional leaflet showing behavioral modifications number originally dispensed.
to get incontinence and urgency attacks under control.
STATISTICAL ANALYSIS
Treatment procedure
Data were analyzed using SPSS for Windows
Patients in group 1 underwent posterior tibial nerve
version 10.0 statistical package (SPSS Inc., Chicago, IL,
electrical stimulation for twelve weeks, three times a
USA). MannWhitney U-test was used to compare
week, for 30 minutes each. PTNS was applied
the urodynamic parameters, voiding diary and VAS
unilaterally with 26-gauge stainless steel needles
measurements between groups. Comparisons between
(disposable concentric needle Medtronic,
pre- and post-treatment within groups were tested by
Minneapolis,Minn) inserted 5-cm cephalad from the
the Wilcoxon test; a level of 0.05 was accepted as
medial malleolus and posterior to the edge of the tibia,
significant.
placing the ground electrode on the ipsilateral
extremity. Electrical stimulation (Medtronic Key Point
RESULTS
Net, Medtronic) was applied unilaterally by using
charge-compensated 200 microsecond pulses with a Prior to the training period, there is no statistically
pulse rate of 20 Hz. Intensity level was then chosen as significant differences were found in the demographic
the intensity immediately under the threshold characteristics when the two groups were compared
determining motor contraction. Before the start of for any variables as in (Table 1). Similarly, both groups
urodynamic recording electrical stimulation was were comparable with respect to urodynamic
triggered with a push button to determine the parameters (volume at first desire to void, maximal
appropriate stimulation amplitude and to confirm detrusor pressure during filling phase), voiding diary
correct needle placement. The stimulation amplitude parameters (daily voiding frequency (n/day) and the
was set at the maximum tolerable level according to frequency of urgency before voiding (n/day), VAS
the subject under investigation, which was usually 1.5 (severity of urgency).
times the threshold for evoking plantar flexion of the
toes and/or toe fanning (range: 1 to 5 mA). Results of Urodynamic Parameters
Patients in group 2 were given trospium There are significant increases in volume at first
hydrochloride (Spasmex 30-mg tablet) for twelve desire to void at the end of the treatment (week 12) in
both groups (Table 2). Even though there was a
decrease in maximal detrusor pressure in both groups
at the end of treatment (week 12), only that in group 1
was statistically significant (Table 2).
Table 1. Subject Characteristics (Mean SD) for both
groups.
Group 1 (Posterior tibial Group 2 (Trospium
nerve stimulation + Pelvic hydrochloride+Pelvic floor
floor exercise) (n=16) exercise) (n=17)
Age (year) 51.686.60 50.626.83
Body mass index, kg/m2 30.076.27 31.415.42
Duration of incontinence 4.251.91 4.821.94
(years)
Type of incontinence 11/5 13/4
Urge/Mixed
Gender (Male/Female) 6/10 7/10
During the follow-up visits following treatment

(week 12). In both groups, the volume at first desire to
void tended to decrease at week 18, reaching a level at
week 24 that was statistically significantly different
from baseline (P<0.05, Table 2). Increase in maximal
Fig. 1. Flow diagram of the study detrusor pressure was observed after treatment in both
9. Answar (42-47).pmd 44 10/16/2012, 2:40 PM

Table 2. Comparison of posterior tibial nerve electrical stimulation (Group 1) and trospium hydrochloride (Group
2) with respect to the urodynamic parameters, voiding diary, severity of urgency (VAS)
Pre -T Post T (week 12) Post-T (week 18) Post-T (week 24)
Group1 Group2 Group1 Group2 Group1 Group2 Group1 Group2
Urodynamics
Volume at first desire 126.5 120.0 205.0* 210.0* 205.5* 157.0* A 151.0* 149.5* B,C
A
Maximal detrusorpressure 27 29 23* 13 31.0 28 18 27
VAS (severityof urgency) 57.5 58.0 32.0* 24.5* 27.0* 31.5* 16.0* 36.5*
Voiding diary
Frequency of urgency 4.5 5.5 1.8* 2.8* 1.4* 3.6* 3.0* 4.4* B
A
Voiding frequency 8.5 10.40 7.0* 6.0* 6.1* 8.0* 6.5 8.3 B
Pre-T, before treatment; Post-T, after treatment; VAS, visual analogue scale.
*Pre-treatment comparison: P < 0.05.
A
Comparison of Post-T (week 18) and Post-T (week 12): P< 0.05.
B
Comparison of Post-T (week 24) and Post-T (week 12): P<0.05.
C
Comparison of Post-T (week 24) and Post-T (week 18): P<0.05.
groups, but the difference between the baseline and (week 12) and was significantly lower than the baseline
week 24 was not significant (P<0.05). There were no at week 18 (P<0.05, Table 2). Comparisons of the
significant differences between groups during all groups after treatment did not reveal any significant
controls after treatment in terms of urodynamic differences in terms of urgency severity (P<0.05).
parameters (P<0.05).
DISCUSSION
Voiding diary
This study conducted to examine the effect of
With regard to the voiding diary parameters, posterior tibial nerve electrical stimulation and
frequency of urgency voiding improved at the end of trospium hydrochloride on urodynamic parameters,
treatment (week 12) in both groups (P<0.05, Table 2). voiding diary and severity of urgency in patients with
During the follow-up evaluations after treatment overactive bladder syndrome. The results of our study
(week 12), the frequency of urgency in Group 1 revealed improvements in urodynamic parameters,
increased from the end of treatment (week 12) until voiding diary parameters and severity of urgency with
week 24 and the frequency of urgency at week 24 were treatment in both groups. Even though there were
significantly lower than the baseline (P<0.05, Table 2). deteriorations in many of these parameters with the
In group 2, on the other frequency of urgency cessation of treatment, improvements in the volume
decreased at week 18 and frequency of urgency were at first desire to void, frequency of urgency and VAS
lower at week 24 compared to the baseline (P<0.05, urgency severity continued in the electrical stimulation
Table 2). Improvement in the voiding frequency group
continued at a significant level until week 18 in both
groups, but at week 24, the difference compared to Application of various forms of electrical
baseline was not significant (P<0.05, Table 2). stimulation is considered as therapeutic option to
Comparisons between groups after the treatment did manage different types of lower urinary tract
not reveal any significant differences in terms of dysfunction 5. Detrouser muscule overacitvity was
voiding diary parameters (P<0.05). suppressed by electrical stimulation without reducing
its contractile force , also there was increased beta
VAS urgency severity adrenergic activity in the detrusor muscle after pelvic
floor electrical stimulation, whereas cholinergic
VAS urgency severity decreased significantly in receptor activity was reduced6.
both groups after treatment (week 12) (P<0.05, Table
2). During the follow-up assessments, even though the The main treatment goal of overactive bladder
VAS urgency severity gradually increased after syndrome is to inhibit detrusor overactivity and thus
treatment (week 12) until week 24 in group 1, the VAS to increase functional bladder capacity 1. Previous
urgency severity was still significantly lower than the studies showed that in overactive bladder syndrome,
baseline (P<0.05, Table 2). In group 2, on the other trospium hydrochloride leads to improvement in
hand, the decrease persisted after the end of treatment urodynamic parameters compared to placebo7 . Few
9. Answar (42-47).pmd 45 10/16/2012, 2:40 PM

studies have explored the effects of electrical stimulation and anticholinergic treatment is similar to
stimulation on urodynamic parameters, and these those in the literature3,7.
studies presented evidence that it causes
improvements8. Voiding diary is an objective tool to assess
urodynamic parameters in patients with overactive
Posterior tibial nerve electrical stimulation was bladder. In our study, significant improvements were
chosen as the physiotherapeutic method because it is observed in the voiding diary and urgency severity
an interesting alternative for the treatment of in both treatment groups. Improvements in voiding
overactive bladder, which is effective and without side habits as a result of treatment observed in the
effects, despite the fact that pharmacological treatment electrical stimulation8 and trospium hydrochloride
is currently the first option for the treatment of patients groups are in agreement with the literature12. A study
with clinical symptoms of overactive bladder, that investigated the effects of electrical stimulation
adherence to treatment is low, especially due to side and anticholinergic treatment on the voiding diary
effects which lead to discontinuation in 60% of cases. argued that electrical stimulation was more effective
Posterior tibial nerve electrical stimulation is than anticholinergic treatment13 though studies have
considered to be a simpler, less invasive and easy to also shown that the two treatments were equally
apply form of peripheral sacral stimulation that is well effective14,15.
tolerated by patients and more affordable9.
In the week 20 follow-up period, although there
Pelvic floor muscle exercises increase muscle was no difference between the treatment groups in
volume and strength, so it is recommended as a terms of the examined variables, we observed declines
treatment for men with urinary frequency, terminal in voiding parameters and urgency severity following
dribbling, and urinary incontinence, pelvic floor the termination of treatment in the trospium
exercises seem to help in reducing symptoms and ydrochloride group whereas improvements in voiding
provides better psychological and social quality10 . parameters and urgency severity continued in the
electrical stimulation group. Because of this favourable
The psychological well-being of patients with effect of electrical stimulation, we are of the opinion
overactive bladder syndrome is important for the that studies with longer follow-up periods are needed.
quality of life; no studies have investigated the
effects of anticholinergic and electrical stimulation Finally, both posterior tibial nerve stimulation and
treatments on the psychology of patients. Our result trospium hydrochloride were similarly effective in
indicates that both anticholinergic treatment and patients with overactive bladder syndrome, and thus
electrical stimulation markedly improved the the continuation of these two treatments is important
depressive symptoms. This was attributed to the because the discontinuation of these treatments would
decrease in symptoms and consequent psychological cause a relapse of most of the symptoms of overactive
well-being. Moreover, this effect continued even bladder syndrome. However, further studies are
after the termination of the electrical stimulation needed to compare the effects as well as the treatments
treatment. superiority over one another in long-term use.
Our result is consistent with previous studies which

CONCLUSION
stated that PTNS produce improvement in bladder
instability.voiding frequency and bladder capacity by Posterior tibial nerve stimulation and trospium
urodynamics evidence, also effect of PTNS on patients hydrochloride have an equivalent effect in the
with over active bladder symptoms (urgency, treatment of patients with overactive bladder
frequency) had a good results and urodynamics syndrome and discontinuation of both treatments
parameters were improved after treatment and causes deterioration in most of the objective and
statistically significant decrease in leakage episodes, subjective symptoms of overactive bladder syndrome
frequency and nocturea11. and the two line of treatment can be used safely in
clinical applications.
In this study, we found that patients were satisfied
with both treatments. This indicates that both
ACKNOWLEDGEMENT
treatments can be used in clinical practice. However,
when side-effects are considered, electrical stimulation I would like sincerely to thank all staff working in
caused fewer side-effects than anticholinergic Almataryia National Institute for Urology for their
treatment. The side-effects observed with electrical technical assistance and effort, also many grateful to
9. Answar (42-47).pmd 46 10/16/2012, 2:40 PM

Urologist staff for their generous assistance in sample due to detrusor overactivity. Urology 2000; 55:
collection. 353-357.
9. Patricia O. Bellette, Paulo C. Rodrigues-Palma,
REFERENCES Viviane Hermann, Cssio Riccetto, Miguel
Bigozzi, JuanM.Olivares. Posterior tibial nerve
1. Alhasso AA, McKinlay J, Patrick K, Stewart stimulation in the management ofoveractive
L.Anticholinergic drugs versus non-drug active bladder: A prospective and controlled study.
therapies for overactive bladder syndrome in Actas Urolgicas Espaolas 2009; 33(1): 58-63.
adults. Cochrane Database Syst Rev 2006; 4: 10. Marion McGovern, RN. Evaluating the Pelvic
CD003193. Floor Muscle.The Journal for Nurse Practitioners
2. Khullar V, Chapple C, Gabriel Z, Dooley JA.The 2009; 5. 302-303.
effects of antimuscarinics on health-related 11. Vandoninck M.R. van Balken E.F. Agr J.P.F.A.
quality of life in overactive bladder: a systematic Heesakkers F.M.J. Debruyne L.A.L.M. Kiemeney
review and meta-analysis. Urology 2006; 68: & B.L.H. Bemelmans: Posterior tibial nerve
38-48. stimulation in the treatmentof voiding
3. Staskin DR. Trospium chloride: Distinct among dysfunction: urodynamic data. Neurourol
other anticholinergic agents available for the Urodyn 2004; 23: 246-251.
treatment of overactive bladder. Urol Clin North 12. Zinner N, Gittelman M, Harris R, Susset
Am 2006; 33: 465-473. J,Kanelos A, Auerbach S. Trospium Study
4. Fall M. Does electrostimulation cure urinary Group.Trospium chloride improves overactive
incontinence? J Urol 1984; 131: 664-667. bladder symptoms: a multicenter phase III trial.
5. Van Rey J.P.F.A.and Heesakkers : Applications of J Urol 2004; 171: 2311-2315.
neurostimulation on Urinary Storage and Voiding 13. Wang AC, Chih SY, Chen MC. Comparison of
for Dysfunction in Neurological Patients Urol electric stimulation and oxybutynin chloride in
Int2008; 81: 373-378. management of overactive bladder with special
6. Mariotti, G Alessandro Sciarra, Alessandro reference to urinary urgency: a randomized
Gentilucci, Stefano Salciccia, Andrea Alfarone, placebo controlled trial. Urology 2006; 68: 999-
Giovanni Di Pierro, &Vincenzo Gentile : Early 1004.
recovery of urinary continence after radical 14. Soomro NA, Khadra MH, Robson W, Neal DE.A
prostatectomy using early pelvic floor electrical crossover randomized trial of transcutaneous
stimulation and biofeedback associated electrical nerve stimulation and oxybutynin in
treatment Journal of Urology 2009; 181(4) 1788- patients with detrusor instability. J Urol 2001; 166:
1793. 146-149.
7. Halaska M, Ralph G, Wiedemann A et al. 15. Arruda RM, Castro RA, Sousa GC, Sartori
Controlled, double-blind, multicentre clinical trial MG,Baracat EC, Girao MJ. Prospective
to investigate long-term tolerability and efficacy randomized comparison of oxybutynin,
of trospium chloride in patients with detrusor functional electrostimulation, and pelvic floor
instability. World J Urol 2003; 20: 392-399. training for treatment of detrusor overactivity in
8. Yamanishi T, Yasuda K, Sakakibara R,Hattori T, women. Int Urogynecol J Pelvic Floor Dysfunct
Suda S. Randomized, double-blind study of 2008; 19: 1055-1061.
electrical stimulation for urinary incontinence
9. Answar (42-47).pmd 47 10/16/2012, 2:40 PM

Pulse Rate Response to Footwear in Rehabilitation Phase

of Coronary Artery Bypass Graft Surgery (CABG) Patients
A Clinical Trial Study
Shaily Razdan1, Aparna Sarkar2

1
Research Scholar Department of Research, Singhania University, Jjunjhunu, Rajasthan,
2
Asst. Proffessor, AIPT K-Block, Amity University, Uttar Pradesh
ABSTRACT
Introduction: Cardiac rehabilitation is a well-established treatment in patients with coronary artery

disease. However, no research has intervened the implementation of the footwear immediately after
CABG surgery or the during the rehabilitation phase.
Aims & Objectives: To find the effect of walking with running shoes and without running (with
slippers ) shoes on pulse rate of rehabilitating CABG subjects and to compare the effects produced
after walking with running shoes and without running shoes.
Methodology: On fifth postoperative day CABG, subjects were asked to cover a distance of 100meters
with slippers and with running sports, shoes with a rest time of one hour between the two sessions.
Pulse rate was measured after covering the 100-meter distance with both types of footwears.
Results and Analysis: Students t- test & f -test were applied to find out the relevance among the
attained values of pulse rate after walking 100 meter distance without running shoes (with slippers)
and with running shoes to that of the resting pulse rate .
Conclusion: The study concluded that incorporation of footwear that is comfortable running shoes
is physiologically important to include in the rehabilitation protocol of Coronary artery by pass graft
subjects, as it will not risk the patients with abrupt increment in the pulse rate that may be a risk
factors for them.
Key words: CABG, Rehabilitation, Pulse Rate, Resting Pulse Rate, Running Shoes(WS), Slippers (WOS).
INTRODUCTION most favorable to promote long-term health in

runners.6 It is recognized that the typical cushioned
Cardiac rehabilitation is a well-established in running shoes may alleviate actual joint contact
patients with coronary artery disease. 1,2 Regular forces, the authors hypothesize that certain attributes
physical activity is required to maintain these training of running shoe design increase the relative
effects.3 Only exercise and fitness protocols have been distribution of these forces7-10. Until date, these studies
studied till date4. Indeed, although it is recognized have only focused on walking and shown that
that the typical cushioned running shoes may altering the AP rocker of the shoe produces the
alleviate actual joint contact forces, the authors greatest adaptations at the ankle joint 11,13 . The
hypothesize that certain attributes of running shoe footwear industry has recognized this importance
design increase the relative distribution of these and has been developing shoes which try to attend
forces.5 The design of modern running footwear is the demands of each single activity/sport for example
Correspondence Address running shoes, soccer shoes, trying to consider the
Shaily Razdan specific aspects of each activity in order to improve
Research Scholar Department of Research, Singhania the performance of the athletes. Besides athletic
University, Jjunjhunu, Rajasthan, India. performance, footwear can be also developed as a
srazdan@amity.edu. 91.98.18.77.02.99 therapeutic strategy against diseases known to cause
10. Aparna Sarkar 15th june 12 (48-52).pmd 48 10/16/2012, 2:40 PM

motor impairments, like Diabetes Mellitus and RESULTS

Parkinsons disease, focusing on the comfort
properties of the shoes but no footwear has been Table 1. Test for Pulse Rate
incorporated in Cardiac rehabilitation. 11-14 It is Parameters Mean SD SE T-value Level of
Difference Significance
unfortunate that individualized studies on footwear (P)
mechanics without or with respect to orthopedic R / WOS 12.0 10.62 .868 13.831 0.001
studies have taken place since so many decades while R / WS 24.47 13.581 1.109 22.064 0.001
the effect of footwear on rehabilitation of cardiac WS /WOS 12.47 9.913 14.07 15.402 0.001
patients or CABG patients is not even touched. The R : resting WOS : without shoe WS : with shoe
Nike Zoom Vomero + 5 with enhanced fit, smoother

ride and lighter weight benefits best for under Table 2. f Test for Pulse Rate between the groups
Parameters Type III Sum DF F Level of
pronators to neutral-gait runners free snug, secure, Squares significance
seam-free fit, elastic mesh panels for lockdown and PR 3795196.169 1 5807.950 <.001
an adaptable fit lightweight, responsive cushioning
(five layered ) weight 329 grams make it a
physiologically low cost foot wear. Stretch mesh DISCUSSION AND CONCLUSION
panels work with other parts of the shoe to keep the
middle of your foot locked down while stretching and Student t test was applied to find out the relevance
flexing with it for comfort and support. In addition, among the attained values after walking 100 meters
an external heel counter wraps the heel for a snug, distance without running shoes (with slippers) and
secure fit, boost the comfort factor is an inner-sleeve, with running shoes to that of the resting pulse rate
or bootie, for a plush fit and feel.15, 16 Lee et al gave (Table 1&2). The percentage of increase in the pulse
positive results of walking for Hypertensive rate after running without shoes (with slippers) is 15%
patients.17 Friedrick et al put forward that cushioning while after walking with running shoes is 30.71%. It is
effect in running shoes maximizes performance18. physiologically related to afferent input from the feet
Helen Braithwaite did a correlation study on foot provided by mechanoreceptors located in the skin,
comfort and heart rate. 19 Blackstone et al proved which are able to perceive different forms of
positive effect of Cardiac rehab on heart rate of CABG mechanical stimulation, e.g. vibration and touch21-27.
subjects.20 Skin temperature and blood flow are reciprocal
influence factors 28,-31. Therefore, changes in foot
temperature are likely to evoke changes in the blood
flow at the foot area30 -33. The relation between skin
The design of the study was quasi-experimental. temperature and foot sensitivity have shown non-
One fifty CABG rehabilitating subjects participated conclusive and often controversial results34, 35. While
in the study were recruited through non-probability this indirect relation between foot sensitivity and
convenient sampling method. Male subjects in the age footwear is becoming an important tool in the
group of 50-70 years both smoker and non smoker evaluations of different kinds of footwear the direct
under cardiac Rehabilitation Protocol were included influence of footwear on foot sensitivity is yet little
in the study while the subjects with unstable angina, investigated36- 40. The perception of mechanical stimuli
exercise induced asthma, acute illness with fever, is possible through the activation of cutaneous
resting blood pressure > 160mmHg (systolic) and mechanoreceptors located in the skin, both hairy and
resting blood pressure > 100mmHg (diastolic) were glabrous41, 42. On the other hand, the rapid adapting
excluded from the study. Equipments utilized in the receptors respond to either the velocity
study were a chair that can be easily moved along the (meissnercorpuscles) or the acceleration of the
walking course, 10 meter of walking pathway in the deformation caused by mechanical stimulation (vater-
hospital, a stopwatch, and work sheet, a measuring pacini corpuscles). While the meissner corpuscles fire
tape. A pair of running shoes, a pair of hospital slippers, as long as the deformation velocity of the skin remains
two small cones to mark the turn around points. On constant, the vater-pacini corpuscles react to the
fifth postoperative day CABG subjects were asked to changes in this velocity, firing intensively at the onset
cover a distance of 100 meters with slippers and with and offset of the stimulus43. The distribution of the
running sports shoe with a rest time of one hour mechanoreceptors in foot sole divides a skin layer cut
between the two sessions. Pulse rate was measured in thirty nine zones found a much higher number of
thereafter. Subjects usual medical regimen was mechanoreceptors in the human foot sole. These
continued. mechanoreceptors get stimulated through cushioned

layered shoe sole hence enhance a better circulation mechanics by wearing five different types
leading to sufficient venous return. At the same time ofrunning shoes on tartan compared to barefoot
walking with slippers is equivalent to high intensity running on grassfocusing on the gearing at the
exercise therefore the pulse rate should increase ankle and knee joints. J Biomech. 2010 Aug 10; 43
proportionately but this is not happening in the CABG (11): 2120-2125.
subjects in the present study, which indicates that the 7. Boyer KA, Andriacchi TP. Changes in running
demand is not being fulfilled by the working heart. kinematics and kinetics in response to a rockered
shoe intervention. 2009 Dec; 24(10): 872-876.
However, when the subjects are walking with running
8. Potthast W, Lersch C, Segesser B, Koebke J,
shoes the circulatory system of their body is proving
Brggemann GP. Intraarticular pressure
to be sufficient 45-47 . The footwear industry has
distribution in the talocrural joint is related to
recognized this importance and has been developing lower leg muscle forces. Clin Biomech (Bristol,
shoes, which try to attend the demands of each single Avon). 2008n; 23(5): 632-9. Epub 2007 Dec 20.
activity/sport, e.g. running shoes, soccer shoes, trying 50-54.
to consider the specific aspects of each activity in order 9. George Giannopoulos, Alexandra Tripolitsioti,
to improve the performance of the athletes48-52. Till date Christina Christoforou & Antreas papadopoulos.
the footwear implementation in the rehabilitation The difference in the energy cost of walking and
protocols is applied to greater percentage of ankle foot running with taped ankles vs. untapped ankles,
deformities, muscle weaknesses in lower extremities, Journal of biology of exercise. JBE-VOL. 6.2, 2010.
osteoarthritis conditions etc. However, this study 782-789.
strongly recommends the implementation of running 10. Zadpoor AA, Nikooyan AA. Modeling muscle
shoes in postoperative phase of Coronary artery by activity to study the effects of footwear on the
pass graft subjects specifically when they walk on impact forces and vibrations of the human body
hard terrain like hospital corridors. Hence, the running during running. Medicine & Science in Sports &
shoes should be included therapeutically in the Exercise: September 2002 - Volume 34 - Issue 9 -
pp 1529-1532.
rehabilitation protocol of CABG subjects.
11. Bourgit D, Millet GY, Fuchslocher J. Influence of
shoes increasing dorsiflexion and decreasing
ACKNOWLEDGEMENTS metatarsus flexion on lower limbmuscular
I am highly thankful to my statistician Dr. V.K activity during fitness exercises, walking, and
running.Science & Sports Volume 25, Issue 2,
Tiwari for his valuable guidance and professional
April 2010, Pages 81-87.
inputs.
12. Von Tscharner V, Goepfert B, Nigg BM. . Changes
REFERENCES
in EMG signals for the muscle tibialis anterior
1. Haller JD, Olearchyk AS (2002) , Cardiologys while running barefoot orwith shoes resolved by
10 greatest discoveries. Tex Heart Inst J 29 (4): non-linearly scaled wavelets. Journal of
342-344. Biomechanics Volume 36, Issue 8, Pages 1169-
2. Nirav J. Mehta, MD and Ijaz A. Khan, MD 1176, August 2003.59. Running related injury
Houston Division of Cardiology, Cardiologys prevention Med. Sci. Sports Exerc, Vol. 21, No. 2,
10 Greatest Discoveries of the 20th Century Texas 1989 pp. 130-139.
Heart Institute Journal, 29(3):164-171. 13. Nigg BM, Anton M .Energy aspects for elastic and
3. Jolliffe JA, Rees K, Taylor RS, Thompson D, viscous shoe soles and playing surfaces. Medicine
Oldridge N, Ebrahim S. Exercise based & Science in Sports & Exercise.January 1995-
rehabilitation for coronary heart disease Volume 27 - Issue 161. 569-575.
(Cochrane Review). 2001; 1 -11 14. Quoc Hung Ly, Silvano Erlicher Laurent Baly
4. Abbas Soleimani, MD, Mojtaba Salarifar, MD, Influence of shoemidsole properties and ground
Seyed E Kasaian, MD, Saeed Sadeghian, MD, stiffness on the impact force duringrunning was
Mostafa Nejatian, MD, Ali Abbasi, MD. Effect of studied by. Journal of Biomechanics (2010): 43,
Completion of Cardiac Rehabilitation on Heart Issue: 2, 310-317.
RateRecovery. Asian Cardiovasc Thorac Ann 15. Nigg, Benno M. Impact forces in running Impact
2008; 16: 202-207. forces have been associated with he development
5. Kerrigan DC, Franz J R, Keenan GS, Dicharry J, of musculoskeletal injuries.Current Opinion in
Della Croce U, Wilder RP. The effect of running Orthopedics., December 1997, 8(6): 43-47.
shoes on lower extremity joint torques. PM R. 16. http://dorunning.blogspot.in/2007/01/nike-
2010 Apr; 2(4): 310-311. air-zoom-vomero.html.
6. Braunstein B, Arampatzis A, Eysel P, 17. Lee LL, Watson MC, Mulvaney CA, Tsai CC, Lo
Brggemann GP. The adjustment of running SF. The effect ofwalking intervention on blood

pressure control: a systematic review corpuscle. Journal of Physiology, Land, 1958. 145:
International journal of nursing studies, 51-52.
December 2010, 47/12 (1545- 1561). 33. Sato M, Ozeki M .Response of the non-myelinated
18. E.C. Frederick. Physiological and ergonomics nerve terminal in Paciniancorpuscles to
factors in running shoe design .Appl Ergon. 1984 mechanical and antidromic stimulation and the
dec; 15(4): 281-287. effect of procaine, choline and cooling. The
19. Helen Braithwaite .The Role of Footwear in Japanese Journal of Physiology, 1963. 13: 564-582.
Rehabilitation:. The Internet Journal of 34. Halonen P. Quantitative vibration perception
Rehabilitation 2010: Volume 1 Number 1; 128-135. thresholds in healthy subjects of working age. Eur
20. Christopher R. Cole, M.D., Eugene H. Blackstone, J Appl Physiol 1986; 54: 647-655.
M.D., Fredric J. Pashkow, M.D., Claire E. Snader, 35. Thyagarajan D, Dyck PJ. Influence of local tissue
M.A., and Michael S. Lauer, M.D. Heart-Rate temperature on vibration detectionthreshold. J
Recovery Immediately after Exercise as a Neurol Sci 1994; 126: 149-152.
Predictor of Mortality. N Engl J Med 1999; 36. Periyasamy R, Manivannan M, Narayanamurthy
341:1351-1357. VBR Changes in two pointdiscrimination and the
21. Vega JA, Garcia-Suarez O, Montao JA, Berta P, law of mobility in diabetes mellitus patients.
Cobo JM. The Meissner and acinian sensory Journal of Brachial Plexus and Peripheral Nerve
corpuscles revisited new data from thelast Injury 2008, 3:3 1749- 7221.
decade. Microscopy Research and Technique, 37. J. Grosskreuz, C. S.-Y. Lin, I. Mogyoros, D. Burke,
2009. 72: 299-309. Ischaemic changes in refractoriness of human
22. Peterka RJ .Sensorimotor Integration in Human cutaneous afferents under threshold clamp
Postural Control. Journal of Neurophysioly, 2002. conditions, J. Physiol. 2000 : 523.3 817-814.
88: 1097-1118. 38. Milani TL, Hennig EM, Lafortune MA Perceptual
23. Nurse MA, Nigg BM . The effect of changes in and biomechanical variables for running in
foot sensation on plantar pressure and muscle identical shoe contructions with varying midsole
activity. Clinical Biomechanics 2001; 16: 719-727. hardness. Clinical Biomechanics, 1997 : 12:
24. Perry SD, McIlroy WE, Maki BE .The role of 294-300.
plantar cutaneous mechanoreceptors in the 39. Mndermann A, Stefanyshyn DJ, Nigg BM.
control of compensatory stepping reactions Relationship between footwear comfort ofshoe
evoked by unpredictable, multi-directional inserts and anthropometric and sensory factors.
perturbation. Brain Res : 2000 : 877: 401-06. Medicine and Science in Sports andExercise; 2001:
25. Meyer PF, Oddsson LIE, De Luca CJ. Reduced 33: 1939-1945.
plantar sensitivity alters postural esponses to 40. Vallbo AB, Johansson RS Skin mechanoreceptors
lateral perturbations of balance. Experimental in the human hand: neural andpsychophysical
Brain Research, 2004 : 157: 526-536. thresholds. Sensory Functions of the Skin, 1976.
26. Aniss AM, Gandevia SC, Burke D. Reflex 185-199.
responses in active muscles elicited by 41. Sterzing T, Kunde S, Scholz F, Milani TL .Soccer
stimulation of low-threshold afferents from the shoes reduce footsensitivitycompared to barefoot
human foot. J Neurophysiol 1992; 67: 1375-1384. for external vibration stimuli. In: American
27. Eils E, Behrens S, Mers O, Thorwesten L, Vlker Congress on Biomechanics, Sept. 09, 2009.
K, Rosenbaum D. Reduced plantar sensation 42. Vallbo AB, Johansson RS. Skin mechanoreceptors
causes a cautious walking pattern. Gait Posture in the human hand:neural andpsychophysical
2004; 20: 54-60. thresholds. Sensory Functions of the Skin, 1979 :
28. http://deposit.d-nb.de/cgi 201- 219.
29. Wissler EF A quantitative assessment of skin 43. Schmidt RF, Thews G, Hrsg. Physiologie des.
blood flow. European Journal of Applied Menschen. 26. Auflage, Springer Verlag Berlin,
Physiology, 2008. 104: 145-157. Heidelberg, New York, 1995: 460-464.
30. Chester MR, Rys MJ, Konz SA Leg swelling, 44. C.M. Akbari, R. Macsata, B. M. Smith, A. N.
comfort and fatigue when sitting, standing, and Sydawi, Overview of the diabetic foot, Semin
sit/standing. International Journal of Industrial Vasc. Surg. 16 (2003) 3-11.
Ergonomics, 2002. 29: 289-296. 45. Ubbink DT, Kitsiaar PJEHM, Tordoir JHM,
31. Mc Worther JW, Wallmann H, Landers M, Reneman RS, Jacobs MJHM (1993). Skin
Altenburger B, LaPortarum L, Altenburger P.The microcirculation in diabetic and non-diabetic
effects of walking, running and shoe size on foot patients at different stages of lower limb
volumetrics. Physical Therapy in Sport, 2003. . ischaemia. European Journal of Vascular and
32. Inman DR, Peruzzi P .The effects of different Endovascular Surgery, 7: 659-666.
temperature on the responses of the Pacinian 46. Hennig EM, Milani TL (2000). Pressure

distribution patterns for evaluation of running 50. Milani TL, Hennig EM, Lafortune MA (1997).
shoe properties. Sportverletzungen Perceptual and biomechanical variables for
Sportschaden, 14: 90-97. running in identical shoe contructions with
47. Nigg BM, Bahlsen HA (1988). Influence of heel varying midsole hardness. Clinical Biomechanics,
flare and midsole construction on pronation, 12: 294-300.
supination, and impact forces for heel-toe 51. Mndermann A, Stefanyshyn DJ, Nigg BM
running. International Journal of Sports (2001). Relationship between footwear comfort
Biomechanics, 4: 205-219. of shoe inserts and anthropometric and sensory
48. Butler RJ, Hamill J, Davis I (2007). Effect of factors. Medicine and Science in Sports and
footwear on high and low arched runners Exercise, 33: 1939- 221-233.
mechanics during a prolonged run. Gait and 52. http://www.ncbi.nlm.nih.gov/pubmed/
Posture 29: 219-225. 11721574.
49. Jordan C, Bartlett R (1995). Pressure distribution
and perceived comfort in casual footwear. Gait
and Posture, 3: 215-220.

Effect of Passive Pelvic Fixation on Non-Specific
lumbopelvic Pain: A Case Report
Apeksha A1, Khatri SM2

1
Postgraduate student, College of Physiotherapy, Pravara Institute of Medical Sciences,
Loni, Maharashtra State, 2Professor & Principal
ABSTRACT
The purpose of this study was to evaluate the efficacy of passive pelvic fixation in a patient with
lumbopelvic pain. A 35 year old male patient (Mr A. T) came to the Physiotherapy Department with
the complaint of lumbopelvic pain and difficulty in forward bending since 30 days. He experienced
severe pain which was 7.1/10 on Visual Analogue Scale on active lumbar flexion. On physical
examination, paraspinal muscle spasm was present in the lumbopelvic area. Range of active lumbar
flexion was 2cm as per Schobers method. Active Straight Leg Raising (ASLR) on right side was
painful and range was 70 degrees. Hence, an attempt was made to find out an immediate effect of
passive pelvic fixation on intensity of pain and active range of lumbar flexion. Pelvis was stabilised
manually and patient performed active lumbar flexion 10 times. Patient was re-evaluated after every
set of 10 repetitions. Total three sets of the above were given. There was remarkable relief of pain by
3.2/10 and 0.5cm increase in lumbar forward flexion range as per Schobers method. ASLR on right
side increased to 85 degrees after the treatment. Hence, it was concluded that passive pelvic fixation
can be used as an adjunct to routine physiotherapy interventions for immediate relief of low back
pain and increase in spinal mobility.
Key words: Active Lumbar Movements, Lumbopelvic Pain, Passive Pelvic Fixation.
INTRODUCTION Lumbopelvic pain is the pain around lower

lumbar segment, sacrum with coccyx and posterior
Whether its a dull, nagging ache or sharp shooting aspect of pelvis. Lumbopelvic misalignment/
pain, low back pain is a condition that plagues malalignment is the leading factor for the same. These
millions of lives all over. 1 Low-back pain is a may be due to the abnormal positioning of the pelvis.4
substantial health problem. The incidence of low back Ligaments and muscles surrounding lumbar and
pain in India is quite alarming affecting 60 per cent pelvis area helps in maintaining position and stability
of the population at some time or the other in their of this area. Any dysfunction of these anatomical
lives.2 It is the most frequent cause of limitation of structures will result in lumbopelvic pain.5 So in order
activity (work, housekeeping, or school) in to maintain the stability of this area, any external
individuals younger than 45 years.3 Low back pain corrective forces other than muscles and ligaments
may manifest in the form of lumbago, low back pain may be helpful.
with buttock pain, low back pain with sciatica and
lumbopelvic pain. Lumbopelvic pain is one of the Few studies regarding the effect of scapular
major components of low back pain. repositioning in shoulder impingement syndrome
have been documented suggesting its effectiveness in
decreasing pain and increasing shoulder strength.6 The
Apeksha Agarwal evidence for the relative benefit of this concept in pelvic
College of Physiotherapy, girdle is limited & questions concerning about passive
Pravara Institute of Medical Sciences, pelvic fixation an innovative technique use frequently
Loni, Maharashtra State, India- 413 736. by the authors for treating lumbopelvic pain and to
Phone: +91-2422-271489, +919970170485 find out the need of lumbosacral corset remain
E-mail: apeksha.physio@gmail.com unanswered. Hence the present case study was an
Fax No: +91-2422-273413. attempt to find the efficacy of passive pelvic fixation
Web: www.pravara.com on lumbopelvic pain.
11. apeksha 3rd june 11 (53-56).pmd 53 10/16/2012, 2:40 PM

Case Description: The patient (Mr. A. T.) was a 35 outcome measures were reassessed.
year old computer professional. He was referred for
low back pain by an Orthopaedic surgeon. The case
was attended by physiotherapist and enrolled on daily
treatment basis.
Patient history: Mr. A.T. complained of low back

pain for 30 days that started gradually. There was no
history of trauma. Pain was dull aching, precipitated
by forward bending activity and relieved by rest in
supine lying position. The temporal variation included
increase in his lumbopelvic pain during night. He rated
his pain as 7.1 on a 0 to 10 centimetre Visual Analogue
Scale (VAS). He had no history of similar problem in
the past.
Physical examination: On physical examination,

it was found that the patient had increased lumbar
lordosis, grade one tenderness over L4, L5, S1 spinous
processes, paraspinal muscle spasm at lower lumbar
area, painful restriction of active lumbar spinal flexion.
Lumbar spine flexion range was 2cm as measured by
Schobers method. Active Straight Leg Raising (ASLR)
on right side was 70 degrees. Strength of abdominals
was 3+ and that of back extensors was 4 as per manual
muscle testing. Thomas test was positive bilaterally.
He rated the pain on active movement as 7.1/ 10 on
visual analogue scale. Lumbar spine radiograph
Fig. 1. PPF-Starting Position
revealed no bony abnormality. The quantity of pain
felt by the patient on forward bending was considered
as an asterisk sign.
Treatment methods: The patient was informed

about the study and his consent was taken. Outcome
measure in terms of quantity of pain on VAS and active
range of lumbar spine flexion by Schobers method
were used. Prior to the treatment his pain and active
lumbar flexion range was noted. Patient was then
educated about his condition and the possible
treatment to be given. Initially the patient was treated
with continuous short wave diathermy for 10 minutes
in supine position with pad electrodes placed in
coplanar arrangement at the lumbopelvic region. The
manual treatment given was in form of passive pelvic
fixation (PPF) along with active spinal flexion
movement. The starting position of the patient was
standing. The procedure was performed with the
therapist standing behind the patient. The therapist
held the pelvis in neutral position at the anterior Fig. 2. PPF-End Position
superior iliac spine level bilaterally with the thumb
and index finger (Figure 1) while the patient performed RESULTS
the offending painful spinal flexion movement (Figure
Immediately after the interventions, it was found
2). It was repeated 10 times. Patient was re-evaluated
that his pain on active lumbar flexion got decreased
after every set of 10 repetitions. Total three sets of the
from 7.1/10 to 3.9/10 (45.1%) on VAS (Figure 3) and
above were given. Immediately after the intervention,

active spinal flexion improved by 0.5cm (25%) as symptoms like pain and heaviness in subjects with
measured by Schobers method (Figure 4). It was also Pelvic Girdle Pain during an ASLR and other
found that ASLR on right side also increased from 70 aggravating movements, postures and functional
to 85 degrees (21.4%). tasks, via a number of possible mechanisms.9,10,11,12,13,14
Obvious limitation of this study included difficulty in
generalizing the results for other patients and hence
future research may be done with case series in specific
and nonspecific lumbopelvic pain.
CONCLUSION
Passive pelvic fixation can be used as an adjunct to

routine physiotherapy interventions for immediate
relief of low back pain and increase in lumbar spine
mobility.
Fig. 3. Graph showing Immediate Pain Relief After PPF REFERENCES
1. http://www.medhelp.org/tags/health_page/
223/Pain/Guide-to-Low-Back-Pain
Introduction?hp_id=190 (accessed on 27th March,
2011).
2. Suryapani R. 1996. Backache borne of modern
lifestyle. The Tribune. 6 Nov. P. 16
3. Richard A.Deyo: Conservative Therapy for Low
Back Pain-Distinguishing Useful From Useless
Therapy, JAMA, 1983; 250: 1057-1062.
4. Lahad A, Malter AD, Berg A0, Deyo RA. The
effectiveness of four interventions for the
Fig. 4. Graph showing change in Active ROM of Lumbar Flexion prevention of low back pain. J of the Amer Med
After PPF Assoc. 1994; 272(16): 1286-1291.
5. http://www.sportsinjurybulletin.com/archive/
DISCUSSION sacroiliac-joint-pain (accessed on 25th March,2011)
6. Angela R. Tate, Philip Mcclure et al: Effect of the
The results of the study suggest that passive pelvic Scapula Reposition Test on Shoulder
fixation technique may be an effective technique for Impingement Symptoms and Elevation Strength
patient with non specific lumbopelvic pain with in Overhead Athletes, Jan 2010, vol 38, no 1.
limited and painful active lumbar flexion range of 7. Darren John Beales et al: The effects of manual
motion. This might be due to the direct effect of this pelvic compression on trunk motor control
technique like neurophysiological or mechanical during an active straight leg raise in chronic
effects or increased stability that may reduce the load pelvic girdle pain subjects, Manual Therapy. 2010;
on pain sensitive structures and thereby relief of pain 15: 190-199.
and inhibited muscle function which in turn may 8. Hungerford B, Gilleard W and Hodges P
increase active range of lumbar flexion. Further, this Evidence of altered lumbopelvic muscle
recruitment in the presence of sacroiliac joint
effect could be due to effects like placebo or
pain Spine. 2003; 28:1593-1600.
psychological effect directly or indirectly by
9. Vleeming A, Buyruk HM, Stoeckart R,
minimizing protective muscle guarding. However, the
Karamursel S, Snijders CJ. An integrated therapy
cause and effect relationship was not investigated in for peripartum pelvic instability: a study of the
the present study. Since there is hardly any similar biomechanical effects of pelvic belts. American
study, the results of this study could not be interpreted Journal of Obstetrics and Gynecology 1992;
in terms of the available literature. However, it has been 166(4): 1243-1247.
reported that there may be decreased sagittal sacroiliac 10. Snijders CJ, Ribbers MT, de Bakker HV, Stoeckart
joint rotation in cadaver specimens by pelvic R, Stam HJ. EMG recordings of abdominal and
compression using a belt.9 Further, it has been seen back muscles in various standing postures:
that ilium compression has the potential to improve validation of biomechanical model on sacroiliac

joint stability. Journal of Electromyography and 13. Damen L, Spoor CW, Snijders CJ, Stam HJ. Does
Kinesiology 1998; 8(4): 205-214. a pelvic belt influence sacroiliac joint laxity?
11. Mens JM, Hoek van Dijke G, Pool-Goudzwaard Clinical Biomechanics 2002; 17(7): 495-498.
A, van der Hulst V, Stam H. Possible harmful 14. OSullivan PB, Beales DJ, Beetham JA, Cripps J,
effects of high intra-abdominal pressure on the Graf F, Lin IB, et al. Altered motor control
pelvic girdle. Journal of Biomechanics 2006b; strategies in subjects with sacroiliac joint pain
39(4): 627-635. during the active straight-leg-raise test. Spine
12. Mens JM, Vleeming A, Snijders CJ, Stam HJ, Ginai 2002; 27(1): E1-8.
AZ. The active straight leg raising test and
mobility of the pelvic joints. European Spine
Journal 1999; 8(6): 468-474.

A Prospective Experimental Study of Effects of Cognitive
Tasks on Balance In Stroke Individuals
Ami Timbadia1, Archana Gore2, Saraswati Iyer3, Laxmiprabha Rangarajan4, Amita Mehta5,
1 2
, Asst Prof, 3Professor, 4Asst Prof, 5HOD & Prof., PT School and Center, Seth GSMC & KEMH,
Parel, Mumbai-12
ABSTRACT
Background: Load of cognitive task increases the demands on postural control and balance in stroke
patients making patients more susceptible to falls. So assessing balance under dual task conditions
become important aspect of rehabilitation of stroke patients.
Aims: To see the effect of cognitive task on balance in chronic stroke patients.
Settings and design: Prospective experimental study carried out at tertiary care hospital, Mumbai.
Materials and Methods: 30 Chronic stroke patients (>6 months duration) above 50 years of age were
assessed for balance with modified Clinical Test of Sensory Integration of Balance (mCTSIB) scale
with and without cognitive task of calculation. Outcome measure was the balance score under four
different conditions of the scale with and without cognitive task.
Statistical analysis: Wilcoxson Signrank test and paired t- test were used to analyze the difference
between the balance scores with and without cognitive task.
Results: Balance decreased significantly with cognitive tasks in all four conditions of the mCTSIB
scale. Condition 1- EOFI: (20.4 +7.32 - 17.5 +9.099) (p <0.001). Condition 2-ECFI: (12.7+7.29 - 9.25+7.196)
(p <0.001); condition 3- EOFO: (11+7.87 10+9.099) (p <0.001); condition 4- ECFO: (3.4+ 4.95 2.1+
4.65) (p <0.001).
Conclusion: Balance decreases under different conditions with concurrent cognitive task in chronic
stroke patients. Hence treatment under dual task conditions in different environments should be an
integral part of balance rehabilitation in stroke patients.
Key words: Stroke, Cognition, Postural Control, Modified CTSIB.
INTRODUCTION Balance (mCTSIB) scale is a sensitive and specific

measure of balance6, 7. Hence the purpose of our study
Balance is called as family of adjustments which was to see the effect to cognitive tasks on balance in
is needed in order to maintain a posture and to move. chronic stroke patients using mCTSIB scale. The tasks
This requires a complex interaction of many systems. considered were mathematical calculation of counting
Sensory and musculoskeletal systems are most backwards while subtracting 3 and memorizing a
important along with movement strategies, postural shopping list comprising of 7 items. Both these tasks
response latencies, cognitive factors like attention, represent everyday cognitive requirements for a
motivation and intent. Cognitive impairment is a functional individual.
known predictor of falls in older adults. An additional
cognitive task increases the demands on postural
control and balance in post stroke patients making the
patient more susceptible to falls 1-5. This may be This was a prospective experimental pre-post
attributed to untrained cognitive function which has design study carried out in Physiotherapy O.P.D. of a
an effect on balance. So, thorough evaluation and tertiary care hospital. Subjects were chronic post stroke
assessment of balance with cognitive task is necessary. patients, above 50 years of age. Sample size was
Modified Clinical Test for Sensory Interaction in calculated for prevalence of 0.018 and 95% confidence
12. Archna gore 11th july 11 (57-61).pmd 57 10/16/2012, 2:40 PM

interval. The sample size is 27 but we decided to Average time of three trials was recorded as initial
include 30 hemiplegic patients in our study so our mCTSIB score. Subjects were made familiar with the
confidence interval is more than 95%. tasks A and B.
Inclusion criteria: Subjects were post-stroke since TASK A: A cognitive task of backward counting by
more than 6 months, above 50 years of age and ability subtracting 3 from 100 under all four conditions of
to independently stand on their own. mCTSIB and total score is recorded.
Exclusion criteria: Subjects with any cognitive or
perceptual problems, aphasia, vestibular disorders, TASK B: A cognitive task of memorizing a shopping
other neurological or neuromuscular disorders and list of 7 items. Then they were asked to recollect those
any musculoskeletal injury in lower limbs. Materials 7 items under all four conditions of mCTSIB and total
used were foam of medium density, i.e. dense enough score is recorded.
to avoid bottoming out and a stopwatch. In between the two tasks patients were given the
Study procedure: After the synopsis of the study rest pause.
was approved by the ethics committee, a detailed
evaluation of 48 stroke patients was done. RESULTS
The subjects comprised of 22 males and 8 females;

Table 1. Flow chart Recruitment of subjects Of these 12 were less than 55 years, 11 were between
56 and 60 years, 6 were between 61 and 64 years and
48 stroke
Patients. only one was above 65 years. 20 subjects were right
(> 6 months, brain damaged and 10 were left brain damaged. 19
Above 50
years). subjects had been diagnosed of stroke 20-49 months
earlier.
Table 2. Comparison in EOFI condition

Excluded Included Mean effect Initial Task P-value
(18) =30
Initial with 2.1 sec 20.4(7.32) 17.5(9.099) <0.001 Significant
task A
Wilcoxon
Sign Rank
test
Mean effect Initial Mean Task Mean P-value Significance
9 patients (SD) (SD)
4 patients 5 patients
Required Fulfilled Initial with 5.13 21.68 (5.42) 16.55 (6.75) <0.001 Significant
had had Cognitive
support criteria task B
Aphasia problems.
for standing
The deterioration in balance score was statistically significant after
task A & B in EOFI condition.
The purpose of the study was explained to the
subjects and consent was taken from them for their Table 3. Comparison of Inter Quartile ranges in ECFI
active participation. condition using Wilcoxon sign Rank test
Mean effect Initial Task P-value significance
Subjects were evaluated using mCTSIB
Initial with 2.46 sec 12.7(7.29) 9.25(7.196) <0.001 Significant
Task A
Starting position of patient was standing with feet Initial with 3.81 sec 12.7 (7.29) 8.95 (7.101) <0.001 Significant
together and shoulder width apart and crossed across Task B
the chest. The four conditions of the scale were as The deterioration in balance score was statistically significant after
below: task A & B in ECFI condition.
1) Standing with eyes open on a FIRM surface.
2) Standing with eyes closed on a FIRM surface. Table 4. Comparison of Inter Quartile ranges in EOFO
3) Standing with eyes open on a FOAM surface. condition using Wilcoxon sign Rank test
4) Standing with eyes closed on a FOAM surface. Mean effect Initial Task P-value significance
Initial with 1.47 sec 11 (7.87) 10 (9.099) <0.001 Significant
Protocol: 30 seconds trial time using stopwatch was Task A
recorded. Initial with 2.98 sec 11 (7.87) 8.6 (8.7) <0.001 Significant
Task B
TOTAL SCORE: _____/ 120 seconds (30 seconds The deterioration in balance score was statistically significant after
for each of the four conditions). task A & B in EOFO condition.

Table 5. Comparison of Inter Quartile ranges in ECFO required to maintain stable posture are different in
condition using Wilcoxon sign Rank test different conditions. They depend on the sensory
Mean effect Initial Task P-value significance system available for balance along with performing
Initial with 1.31 secs 3.4 (4.95) 2.1 (4.65) <0.001 Significant cognitive task9-11 .
Task A
Initial with 1.99 secs 3.4 (4.95) 1.6 (4.995) <0.001 Significant
No. Condition Sensory system Demands placed on
Task B available for balance during
balance task A&B
The deterioration in balance score was statistically 1. Eyes open firm surface Somatosensory, visual, Cognition only
andVestibular
significant after task A & B in ECFI condition. 2. Eyes closed firm surface Somatosensory and Vision and cognition
vestibular
3. Eyes open foam surface Vision and vestibular Somatosensory and
cognition.
DISCUSSION 4. Eyes closed foam surface Vestibular Vision, somatosensory
and cognition.
Results can be explained by conceptual model of

systems theory of postural control by (Shumway- In stroke patients these attentional demands are
Cook). It states that: further challenged by underlying sensori-motor
impairments.
Postural control is not regulated by a single system,
but emerges from the interaction of many systems. In EOFI condition:
Thus, in a systems approach, postural control results
from a complex interaction among many bodily The balance deteriorated significantly with both the
systems that work cooperatively to control both cognitive tasks A and B.
orientation and stability of the body. Here, all three sensory systems are available for
Cognition is one of the components affecting balance. So, this could be explained by affected motor
balance according to systems approach. Attention is aspect of postural control of stroke patients in quiet
one of the important components contributing to stance increasing demands of attention.
cognition. Attention is defined as the information In stroke patients, it has been studied that there is
processing capacity of an individual. An assumption impaired motor strength due to impaired recruitment
regarding this capacity is that it is limited for any of motor units secondary to brain damage resulting
individual and that performing any task requires a in inefficient generation of forces by lower limb
portion of this capacity. This suggests that if two tasks musculature 1,12. Asymmetric body alignment .i.e.
are performed together and require more than total displaced centre of mass, reduced range of motion
processing capacity the performance of either task or due to spasticity and biomechanical constraints and
both task will deteriorate9-11. impaired ability to use ankle movement strategy
When concurrent cognitive task is performed with result in impaired balance. Co-ordination,
postural task these attentional demands are shared sequencing, timing, and amplitudes of postural
between the two tasks. Thus the amount of attention muscle activity are impaired in the paretic limb. All
provided for postural control decreases causing further of these make the subjects use either hip strategy or
deterioration of postural control in stroke patients in stepping strategy which were end points while
dual tasking. It deteriorates more on foam surfaces as scoring on mCTSIB.
attentional demands are more on foam surface. Thus increased attentional demands are required
According to Kerr et al. who studied attention and to maintain postural control.
postural control using dual task paradigms in which In dual tasking when these attention demands are
postural task (primary) and secondary task are shared, it causes deterioration of postural control.ie.
performed together. Decrease in performance on either early loss of balance in stroke patients with concurrent
task suggests interference between the processes cognitive task
controlling the two tasks and therefore the amount of
attentional resources that are shared. In ECFI condition:
Normal postural control occurs automatically The balance decreased significantly with cognitive
without conscious effort. Its assumed that few tasks A and B. Loss of visual input in this condition
attentional resources are needed when controlling increases the reliance on somatosensory and
balance. But in conditions of mCTSIB demands vestibular systems in addition to cognitive tasks A &

B . The sensory aspect of postural control in stroke CONCLUSION

patients could be explained on basis of, a) loss of
sensory redundancy i.e. inability to use impaired The following conclusion can be drawn from the
somatosensory and vestibular inputs1; b) impaired above study:
sensory organization i.e. ability to integrate sensory 1) Balance decreases significantly with cognitive task
inputs and resolve inter-sensory conflict. Thus a of calculation under all four conditions of modified
subject may rely heavily on one particular sense for clinical test for sensory interaction of balance
postural control. Stroke subject may also demonstrate (mCTSIB) scale.
problems with sensory selection. They are unable to 2) Balance decreases significantly with cognitive task
maintain stability when there is incongruence among of memorizing under all four conditions of
senses. modified clinical test for sensory interaction of
balance (mCTSIB) scale.
Eyes closed condition removes the visual
information available for balance leading to selection Application: Balance should be trained considering
of vestibular and somatosensory inputs to maintain the cognitive task requirements of individuals with
balance. Inability to do so by stroke patients causes stroke.
increased instability and thus increased demands of
attention. ACKNOWLEDGEMENTS
In EOFO condition: To all the patients who contributed in the study.
There was significant decrease in balance with both Conflict of Interest: - none
cognitive tasks A and B in this condition. The probable
explanation to this could be inaccurate somatosensory REFERENCES
information received.
1. Difabio RP, Badke MB. Stance duration under
Foam surface inaccurately gives information about sensory conflicts conditions in patients with
somatosensory system required for balance. There is hemiplegia. Arch Pyhs Med Rehabilitation 1991;
increased reliance on vision and vestibular inputs. On 72: 292-295.
foam surface muscle response requirements are greater 2. Marchese R, Bove M, Abbruzzese G. Effect of
than on firm surface. This further increases the demand Cognitive and motor tasks on postural stability
for attention of postural control. in Parkinsons disease: a posturographic study.
Movt Disord 2003; 18(6): 652-658.
In ECFO condition: 3. Brauer Sg, Broome A, Stone C, Clewett S, Herzig
P. Simplest tasks have greatest dual task
There was significant decrease in balance with interference with balance in brain injured adults.
both cognitive tasks A and B in this condition. Here, Hum Move Sci 2004; 23: 489-502.
loss of visual and somatosensory inputs increased 4. Hauer K, Pfisterer M, Weber C, Wezler N, Kligel
attention demands on balance. When both visual and M, Oster P. cognitive impairment decreased
somatosensory inputs for postural control are postural control during dual tasks in geriatric
reduced, attentional demands were higher than other patients with a history of severe falls. J Am Geriatr
previous conditions leading to earlier loss of balance Soc 2003; 51: 1638-1644.
amongst all other conditions with cognitive tasks. Age 5. Petterson AF, Olsson E, Wahlund LO. Motor
related changes also contribute to increase in attention function in subjects with mild cognitive
demands. As the demand for stability increases, there impairment and early Alzheimers disease.
is a concomitant increase in attentional resources used Dement Geriatr Cogn Disord 2005; 19(5-6):
by the postural control system. 299-304.
6. Shumway-Cook A, Horak F. Assessing the
Decreasing sensory information would demand influence of sensory interaction on balance. Phys
more attention for postural control. When cognitive Ther 1986; 66: 1548-1550
task is combined, attentional demands are shared and 7. Shumway cook A, Woollacott M, Attentional
postural control deteriorates. This implies that amount demands on postural control: the effect of sensory
of attention is dependent on the degree of instability context. J Gerontology 2000; 55A: M10-M16.
inherent in the task13- 15. 8. Duncan P, Badke MB. Stroke Rehabilitation: the
recovery of motor control. Chicago:Year Book,
1987.

9. Shumway-Cook A, Woollacott M, Kerns KA, 12. Swanenburg J, de Bruin ED , Uebelhart D, Mulder

Baldwin M. The effects of two types of cognitive T. Compromising postural balance in the elderly.
tasks on postural stability in older adults with Gerontology. 2009; 55(3): 353-360.
and without a history of falls. J Gerontol A Biol 13. Wrisley DM, Whitney SL.The effect of foot
Sci Med Sci. 1997 Jul; 52(4): M232-240. position on the modified Clinical Test of Sensory
10. Shumway-Cook A, Woollacott M. Attentional Interaction and Balance. Archives of physical
demands and postural control: the effect of medicine and rehabilitation 2004 Feb; 85(2):
sensory context. J Gerontol A Biol Sci Med Sci. 335-338.
2000 Jan; 55(1): M10-16. 14. Woollacott M, Aging, postural control and
11. Sandra G. Brauer, Marjorie Woollacott, Anne movement preparation Columbia: University of
Shumway-Cook. The Interacting Effects of South Calorina 1989; 155-175.
Cognitive Demand and Recovery of Postural 15. Woollacott MH, Shumway- Cook A, Nashner
Stability in Balance-Impaired Elderly Persons. L.Aging and posture control: changes in sensory
The Journals of Gerontology: Series A 2000 June; organization and muscular co-ordination. Int J
56(8): M489-M496. Aging. Hum Dev 1986; 23: 97-114.

A Cross-Sectional Study on the Significance of Side Step

Length for Dynamic Balance Assessment in Ambulatory
Stroke Subjects
ARJU B1, Joshua A.M.2, Ganesan S.3

1
MPT, Consultant Neuro-Physiotherapist, Children first, 2Head of Department, Physiotherapy, KMC Mangalore,
Manipal University, 3Associate Professor, KMC Mangalore, Manipal University from the Department of Physical
therapy, Manipal University, Mangalore
ABSTRACT
Objective: To establish the correlation between the Side step length and Berg Balance Scale (BBS) for
dynamic balance assessment in ambulatory stroke subjects.
Design: A Cross-sectional study.
Setting: Tertiary care hospital.
Subjects: A total of thirty subjects (mean age: 56years 10.66) with supratentorial stroke were recruited
for the study by convenient sampling. All the subjects were ambulatory and were able to walk 10
meters unassisted.
Intervention(s): Not applicable.
Main Outcome measure (s): Correlational analysis was done between the BBS and Side step length
by using Spearmans rank correlation coefficient.
Results: Results showed a high linear positive correlation between the Side step length and BBS
(p<0.01).
Conclusion: Present study concluded that the Side step length of affected and unaffected side had
linear positive correlation with BBS total score. Side step length of both sides was almost equal.
Approximate score of BBS may be estimated by the side step length of affected or unaffected side.
Side step length can be used as a marker of dynamic balance in ambulatory stroke subjects.
Key words: Stroke, Berg Balance Scale, Balance.
INTRODUCTION stance asymmetry which causes a shift in the position

of centre of pressure toward the unaffected lower
The prevalence of stroke in western countries is extremity. This leads to pronounced lateral postural
400-800/100,000 whereas in India it ranges from 200- instability, so that less weight is taken through the weak
250/100,000.1 leg. They also have smaller excursions when moving
Following stroke, subjects lose functions of the their weight around the base of support, especially in
motor, sensory and higher cognitive skills to various the direction of the weaker leg.5-7
degrees which diminish their ability to balance The asymmetrical pattern is seen in all aspects of
effectively and make necessary postural adjustments2,3. balancestatic, dynamic and responses to external
Impaired balance has been implicated in the poor perturbations. This asymmetry is also seen in stroke
recovery of activities of daily living and is related to subjects who have high levels of function such as those
incidence of falls between 23% and 50%.4 who are ambulatory in the community.8
The major characteristic of impaired balance in Subjects with hemiparesis can shift only
hemiparetic subjects is increased postural sway and approximately 55% of their body weight onto paretic
13. arju 22nd sept 11 (62-67).pmd 62 10/16/2012, 2:40 PM

limb in step stance and 65% of their weight in lateral Table 1. Characteristics of Subjects (N= 30)
direction. On the contrary, healthy elderly can Age (Years) Mean 56
voluntarily shift 95% of their body weight onto single SD 10.66
limb in both forward and lateral directions.9 Sex Male 18
Female 12
The evaluation and treatment of balance disorders Type of Lesion Infarct 23
is an integral component of a comprehensive stroke Hemorrhage 07
rehabilitation program.10 A variety of laboratory and Paretic side Right 15
clinical tools are available to measure static and Left 15
Duration since stroke (months) Mean 8.7
dynamic balance in stroke population.11
SD 9.94
Analysis of movements during dynamic weight Brunnstorms recovery stage Stage V 04
shifts may provide clinicians an improved Stage VI 26
understanding of the specific problems that causes

instability and falls in subjects with hemiparesis. Such Subjects had to meet the following criteria in order
information could also provide valuable directives for to be eligible to participate: (1) Unilateral
selecting the most appropriate therapeutic strategies.12 Supratentorial stroke subjects referred by the
Physician. (2) Brunnstorms Stages of lower extremity
Berg Balance Scale,13.14 Functional Reach Test15 and recovery grade V and VI. (3) A Mini Mental State
Timed Up and Go test16 are some of the commonly Examination score e 24. (4) Able to walk 10 meters
used objective clinical tools for evaluating the balance without any walking aids.
impairment in hemiparetic subjects.
Subjects with history of any other neurological
BBS is an objective measure of static and dynamic disorders that would affect balance, diagnosed
balance abilities. Based on extensive clinical use and musculoskeletal disorders or any history of joint
frequency of comparison with other balance measures replacement in lower limbs which could affect
in both laboratory and research settings, the BBS is ambulation and visual field defects were excluded.
accepted as the clinical criterion standard to measure
balance.9 Procedure
Side Step Test developed by Fujisawa and Takeda The study was approved by the scientific committee
meets the need for a test of balance disorder in the and Institutional Ethics committee. The purpose of the
frontal plane. This test incorporates dynamic weight study was explained to the study population and
shifts, which is found to be impaired in hemiparetic written informed consent was taken. Subjects were
subjects.17 selected on the basis of inclusion and exclusion criteria.
Fujisawa and Takeda et al found the correlation BBS and Side step length were used as outcome
between Side Step Test and gait parameters. However measures to evaluate the balance of subjects with
the relationship of Side Step Test with any of the stroke. In order to minimize the influence of one test
standard test of balance was not established. In the over the other, order of the tests was randomized. The
present study we aimed to establish the correlation subjects were randomized into 2 groups (Group A &
between the Side step length and BBS. The Side step Group B) by block randomization method. Group A
length was measured with inked footprints method. was evaluated first by the BBS followed by Side step
test and group B was evaluated first by the Side step
We hypothesized that the correlation between the test followed by BBS. Rest period of 15 minutes was
Side step length affected and unaffected side with BBS given between the two tests to avoid fatigue.
total score would be significant.
The principle investigator administered the BBS
MATERIAL AND METHODS and Side step test and an independent rater measured
the Side step length with standardized measuring tape.
Participants This rater was blinded to the scoring obtained in BBS.
The 30 subjects (mean age: 56 years10.66) with
Berg Balance Scale
supratentorial stroke were selected for the study.
Participants characteristics are listed in table1. Standard procedure for evaluating balance using
the BBS was performed and scoring was done.

Side Step Test There was a highly significant correlation between

BBS total score and the ratio of side step length/ leg
Prior to commencing the Side Step Test, visual length of affected (r=0.80) and of unaffected side
demonstration of the Side Step Test was done so that (r=0.84). (Table 2)
subjects could understand the method to perform the
same. Long lasting dye was applied over the plantar Table 2. Spearmans rank-correlation coefficient and
aspect of subjects feet and subjects were made to stand Pearsons correlation coefficient between the ratio of
side step length/ leg length of affected and unaffected
along the 10 meters walkway with the feet together. side with BBS total score
This walkway was pasted with 10 meter long white
Spearmans p r Pearsons p
sheet paper to obtain a good imprint of the inked feet rank- square correlation
of each subject (Fig 1). correlation
coefficient
coefficient
(r)
(r)
Side step length/leg length 0.804 0.000** 0.64 0.764 0.000**
of affected side
Side step length/leg length 0.848 0.000** 0.71 0.776 0.000**
of unaffected side
** p<0.01
The r square for the ratio of side step length/ leg

length of affected side was found to be 0.64 and for
unaffected side r square was 0.71, which indicates that
if the ratio of side step length/ leg length of affected
Fig. 1. Inked footprint of affected and unaffected side.
side and of unaffected side contributes 64% and 71%
for BBS total score respectively.
Subjects were asked to take side step as wide as
As shown in figure 2 there is a linear positive
possible on the 10 meters walkway, without supporting
correlation between the ratio of side step length/leg
their bodies or their hands. Five repetitions of side
length of affected side as well as of unaffected side
stepping were performed on both affected and
with BBS total score. As the ratio of side step length/
unaffected sides. Precautions were taken to protect the
leg length of either side increases, the BBS score also
subjects from falling.
increases.
Side step length of both sides was measured by
distance between the successive mid point of heel of
both the extremities with measuring tape. The mean
of 5 side step lengths of affected and unaffected side
was taken for the purpose of analysis. Ratio of the side
step length to the distance between anterior superior
iliac spine and medial malleolus was taken as a
standardized value, as normative data for the side step
length was unavailable.
Data Analysis
Statistical analysis was performed by the use of

SPSS version 13.0.
Spearmans rank correlation coefficient was used

to analyze the relationship between the ratio of side
step length/ leg length of affected and unaffected side
with BBS total score as well as with the individual
components of BBS.
FINDINGS
Relationship between the ratio of side step length/

leg length of affected as well as unaffected side with Fig. 2. Scatter plot denoting the relationship between the ratio
of Side step length/leg length of affected and unaffected side
BBS total score. with BBS total score.

Relationship between the ratio of side step length/ leg length of affected and unaffected side and individual
components of BBS
Results are shown in table 3.

Table 3. Spearmans rank correlation of coefficient between the ratio of side step length of affected and unaffected
sides and individual components of BBS
Berg Balance Scale ( BBS ) Side step length/ leg length Side step length/leg
affected side length unaffected side
r value p r value p
Static Components Standing unsupported 0.244 0.194 0.315 0.090
Sitting unsupported 0.172 0.364 0.161 0.395
Standing with eyes closed 0.180 0.342 0.186 0.324
Standing with feet together 0.227 0.227 0.285 0.127
Tandem standing 0.564 .001** 0.527 .003**
Standing on one leg 0.404 .027* 0.317 .088
Dynamic Components Sit to stand 0.725 .000** 0.626 .000**
Standing to sitting 0.334 .071 0.351 0.057
Transfers 0.568 .001** 0.648 .000**
Reaching forward 0.403 .027* 0.581 .001**
Pick up object from Floor 0.491 .006** 0.535 .002**
Turning to look Behind 0.506 .004** 0.606 .000**
Turn 3600 0.638 0.000** 0.690 .000**
Stepping on stool 0.804 0.000** 0.734 .000**
* =p<0.05, **=p<0.01.
DISCUSSION with feet together and standing with eyes closed. Lack
of significant correlation of these components with the
One of the major characteristics of subjects with side step length of affected and unaffected side may
stroke is difficulty in accepting and transferring the be attributed to the fact that these components do not
weight on the involved lower extremity.18 Subjects incorporate weight shifts.23
with stroke show postural instability, particularly in
the frontal plane. Previous studies concluded that falls Incidentally two of the static components of the BBS
occur most commonly during movement related showed significant correlation with the side step length
activities in stroke population, as it requires weight that is tandem standing and standing on one leg.
bearing and weight shifts in different postures and Reduced base of support in tandem standing &
directions.19,20 standing on one leg 24increases the demand on the
paretic leg to accept almost equal weight as nonparetic
A variety of clinical tests have been described for
leg which could be the reason for significant
monitoring the changes in balance. BBS is accepted as
correlation.
the gold standard to measure the balance, which
consists of various functional tasks of activities of daily We found the significant correlation between the
living to assess static and dynamic balance in terms of side step length of affected and unaffected sides with
postural maintenance and execution of voluntary if the dynamic components of BBS except standing to
movements.21,22 sitting. Probable reason for the correlation is that all
the dynamic components of BBS such as transfers and
Strong correlation between the ratio of side step
turning 3600 consist of dynamicity which induces
length/ leg length of affected and unaffected side with
BBS could be explained since both BBS and Side step weight shifts and may be a reflection of increased
test emphasize on weight shifts. We found that subjects postural instability.
with higher side step length had a higher BBS score With regard to BBS component standing to sitting,
which may indicate a better functional mobility and no significant correlation was seen with the side step
stance symmetry. length of affected and unaffected side. Change in the
Our findings showed non- significant correlation muscle work (eccentric control of the hip extensors) in
with most of the static components of BBS that is spite of weight shifts seen in this task25 could be the
unsupported standing, unsupported sitting, standing factor responsible for non-significant correlation.

Limitations of the study weight-transfer capabilities in adult with

hemiparesis. PhysTher 1994; 7: 647-659.
In the present study only the subjects with 7. Gruendel T. Relationship between weight-
Brunnstorms recovery stage V &VI were selected and bearing characteristics in standing and
there is lack of normative data for the side step length ambulatory independence in hemiplegia.
measure. There was no control group for comparison. Physiother Can 1992; 44: 16-17.
8. Au-Yeung S, Ng J, Lo S. Does balance or motor
Future Research impairment discriminate the ambulatory status
Future studies may also include healthy elderly as of stroke survivors? Am J Phys Med Rehabil 2003;
82: 279-283.
control and there is need to establish a normative data
9. Janice J, Kelly S. Reliability and comparison of
for side step length measure.
weight bearing ability during standing tasks for
individuals with chronic stroke. Arch Phys Med
CONCLUSION Rehabil 2002; 83: 1138-1144.
10. Outi P, Pertti E, Ulla T. Relationships between
Present study concluded that the Side step length
standing balance and symmetry measurements
of affected and unaffected side had linear positive
in patients following recent strokes (<3 Weeks)
correlation with BBS total score and with most of the
or older strokes (>6 Months). Phys Ther 2004; 84:
dynamic components of BBS. Side step length of both 128-136.
sides was almost equal. Side step length can be used 11. Niam S, Cheung W, Sullivan PE, Kent PS, Gu X.
as a marker of dynamic balance in ambulatory stroke Balance and physical impairments after stroke.
subjects. Arch Phys Med Rehabil 1999; 80: 1227-1233.
12. Rogers MW, Hedmun W, Hanke TA. Alterations
Clinical Implications
in weight-transfer capabilities in adults with
Side step length can be used as an easy and quick hemiparesis. Phys Ther 1994; 74: 647-659.
measure for assessment of lateral balance in stroke 13. Berg K, Wood DS, Williams J. The Balance Scale:
patients in routine clinical settings. Clinician may use reliability assessment with elderly residents and
patients with acute stroke. Scand J Rehabil Med.
the Side step length with reasonable confidence as it
1995; 27: 2736.
provides comparable information to the BBS for initial
14. Diana LK, Stacy LF, Yi-Po C. Rating scale analysis
examination purposes.
of the Berg Balance Scale. Arch Phys Med Rehabil
2004; 85: 1128-1135.
ACKNOWLEDGEMENTS 15. Duncan P, Weiner K, Chandler J & Studenski S.
Functional Reach: A new clinical measure of
We thank the Dean of the Kasturba Medical College,
balance. J Gerontol 1990; 45: 92-197.
a constituent college of Manipal University and
16. Langhammer, Birgitta, Lindmark. The relation
Department of Physical Therapy for support and between gait velocity and static and dynamic
guidance during the study. balance in the early rehabilitation of patients with
acute stroke. Adv Physiother 2006; 8: 60-65.
REFERENCES 17. Fujisawa H, Takeda R. A new clinical test of
1. Banerjee T and Kumar S. Epidemiology of stroke dynamic standing balance in the frontal plane:
in India. Neurology Asia 2006; 11: 1-4. the side step test. Clin Rehabil 2006; 20: 340-346.
2. Holt RR, Simpson D, Jenner JRK . Ground 18. Tessem S, Hagstrom N, Fallang B. Weight
reaction force after a sideways push as a a distribution in standing and sitting positions, and
measure of balance in recovery from stroke. Clin weight transfer during reaching tasks, in seated
Rehabil 2000; 14: 88-95. stroke subjects and healthy subjects. Physiother
3. Chen C, Cheng PT, Chen CL. Effects of balance Res Int. 2007; 12: 82-94.
training on hemiplegic stroke patients. Med J 19. Lamb SE, Ferrucci L, Volapto S. Risk factors for
2002; 25: 583-590. falling in home- dwelling older women with
4. Harris JE, Eng JJ, Marigold DS. Relationship of stroke: the womens health and aging study.
balance and mobility to fall ncidence in people Stroke 2003; 34: 494 -501.
with chronic stroke. Phys ther 2005; 85: 50-158. 20. Hyndman D, Ashburn A, Stack E. Fall events
5. Eng J, Chu K. Reliability and comparison of among people with stroke living in the
weight-bearing ability during standing tasks for community: circumstances of falls and
individuals with chronic stroke. Arch Phys Med characteristics of fallers. Arch Phys Med Rehabil.
Rehabil 2002; 83: 1138- 1144. 2002; 83: 165170.
6. Pai Y, Rogers M, Hedman L, T. Alterations in 21. Zverev Y, Adelove A, Chisi J.Quantitative

analysis of gait pattern in hemiparetic patients. 23. Abu A., Qutubuddin, Phillip OP, David XC,
East Afr Med J 2002;79:420-422. Rashelle B, Shane M, William C. Validating the
22. Chern JS, Yang S, Wu CY. Whole body reaching Berg Balance Scale for patients with Parkinsons
as a measure of dynamic balance in patients with disease: A key to rehabilitation evaluation. Arch
stroke. Am J Phys Med Rehabil 2006; 85: 201-208. Phys Med Rehabil 2005; 86: 789-792.
23. Hill KD, Bernhardt J, McGann AM, Maltese D, 24. Ferrante S, Pedrocchi A, Ferrigno.
Brrkovits D. A new test of dynamic standing Electromyographic analysis of standing up and
balance for stroke patients: reliability, validity and sitting down. Italy. Proceedings of the10th Annual
comparison with healthy elderly. Physiother Can. Conference of the International FES Society 2005
1996; 48: 257-262. July; Montreal, Canada.

Effectiveness of Sensory Re-education after Nerve Repair

(Median or Ulnar Nerve) at the Wrist Level
B. Anandha Priya
M.O.Th (Hand), Occupational Therapist, ESIC Hospital, K.K. Nagar, Chennai-78,
Tamil Nadu, India
ABSTRACT
The present study was done to examine the effectiveness of sensory reeducation in patients after
median or ulnar nerve repair at the wrist level. 22 male patients with peripheral nerve injury and
repair at the wrist level were divided equally into experimental (mean age = 26.45 yrs) and control
group (mean age = 32.09 yrs). The control group received only the home program, while the
experimental group received additionally sensory reeducation therapy. The therapy was given in
6 sessions per week for 3 months. The outcome measures were checked in terms of touch-pressure,
two-point discrimination static and dynamic, level of paresthesia and the number objects identified
in Object Recognition Test. Parametric statistics was used to compute data of the above outcome
measures. The experimental group showed significant change (p < 0.05) in the five parameters than
the control group.The findings suggest that sensory reeducation when added with home program
enhances better recovery of sensation.
Key words: Sensory reeducation, Paresthesia.
INTRODUCTION by nerve response in the form of nerve degeneration

Hands without sensation are like eyes without and regeneration. The choice of interventions for
vision sensation is based on the diagnosis, prognosis, and
-Moberg evaluation findings. Bowden in discussing recovery
after nerve injuries noted in 1954, that there is an
The human hand is a delicate and complicated indication that constant usage may lead to greater
multi system organization that provides sensory manual dexterity.2
information and precise motor execution. A sensate
hand can give an instant picture of the overall shape, Glickman and Mackinnon3 identified the factors
size, weight and general texture of an object1.Without that influence digital sensibility following re-
sensation in the hand, there is greater risk of injury to plantation. These factors include age, level and
the hand and decreased ability to manipulate small mechanism of injury, digital blood flow, cold
objects .There is also a tendency not to use the hand in intolerance and postoperative sensory reeducation.
functional activities, which adds to the phenomenon Therefore, following peripheral nerve repair,
of learned nonuse, loss of function that results from not functional sensibility of the hand improves overtime,
using the hand (Carr & Shephard, 1998). with use, and with training4.
The sensory system is organized into serial chains Sensory re-education is provided for patients who
of neurons that ascend from the hand to the brain. The have some sensation and potential for better sensation
brain is a complicated neural network, which or better interpretation of sensory information 3.
continuously remodels itself as a result of changes in Sensory reeducation is the reprogramming of the brain
sensory inputs. Age, occupation, intelligence and callus in a re-learning process where items of increasing
formation affects the sensitivity of the receptors1. The difficulty are touched and experienced with the eyes
median and ulnar nerves are the most commonly open or closed1.
injured peripheral nerves leading to sensory
Rosen B., Lundborg5 stated that the recovery of
compromise in the hands.
functional sensibility after nerve transection and repair
In general, injury to the peripheral nerve is followed is often disappointing. Sensory reeducation is
14. B anandha priya 22nd 11 (68-74).pmd 68 10/16/2012, 2:40 PM

traditionally not introduced until there is reinnervation and Dynamic, Level of Paresthesia and the number
in the hand, and such a late onset of training may be objects identified in Object Recognition Test was done
one explanatory factor for the poor functional results in the autonomous zones of the repaired nerves .
after nerve repair.
Following initial evaluation, therapy in graded
Only few earlier studies have incorporated early steps was started for the experimental group as per
intervention (sensory re-education) in peripheral nerve the intervention protocol given below. Therapy was
injuries. The sensory re-education programs in earlier given 6 days (1 session/ day) in a week for 3 months
studies have included manipulation of objects which and each session lasted for 15 minutes. A detailed home
stimulates mechanoreceptors and other deep sensory program was also given to the patients. The patient
receptors along with the superficial touch receptors. was made to observe the procedure of the treatment
Thus object identification (naming objects) following step, then to close his eyes and concentrate on what
training may not be attributed to re-education of touch was being felt.
sensation alone. The current study was done on
individuals with median or ulnar nerve injury and Following it the patient had to explain in words
repair at the wrist level using a protocol specifically to about what he felt. Then the patient was made to
re-educate touch sensation through early intervention observe the stimulus again to confirm the sensory
in relatively less duration (number of therapy experiences with perception. Assessment was done
sessions). at the end of each month to check the improvement.
The control group was given detailed home program
only.
Intervention Protocol:
The sample selected for the study consisted of 22
male patients with peripheral nerve injury at wrist The method of treatment used in the study is a
level. They were divided equally (n = 11) into combination of the programs proposed by Wynn Parry
experimental (mean age = 26.45 years) and control and Dellon. The following are the steps used in the
group (mean age = 32.09 years). Among them, 11 reeducation program:
patients had median nerve injury and 11 others had
ulnar nerve injury associated with flexor tendon Step 1: Reeducation of perception of moving touch
injuries. They underwent repair of the cut tendons by and constant touch:
modified Kesslers technique and suturing of the
The eraser end of a pencil was used to stimulate
nerves by microsurgical technique. The duration
the specific area and a moving touch stimulus was
between the time of injury and repair was maximum
applied either in transverse or longitudinal manner in
24 hours. The patients were immobilized for 3 weeks
the autonomous zone of the repaired nerves. A similar
and included in the study from 4th week after nerve
procedure was employed for training constant touch
repair. They were screened to confirm the presence of
using static stimulus.
protective sensation. Those who had associated crush
injuries of the distal and middle phalanges of fingers Step 2: Differentiation of roughness of the sand
were excluded from the study. papers:
The materials used in the study consisted of the In this step, the patient was trained to identify the
tools including, pencil with eraser end attached, sand textures of sand papers that were stuck on a dowel.
papers (5 different textures), wooden blocks (6 different Both the ends of a selected dowel were lightly moved
shapes) and 12 different metal objects stuck on wooden over a zone of dysfunction while the patients eyes
board. Various measures of sensation of the hands were were closed. The patient was asked to state whether
done using instruments like Monofilaments, the two ends are the same or different. If the patient
Calibrated aesthesiometer, Object recognition test and was incorrect, the stimulation was given again with
Paresthesia level scale. opened eyes. Following this, the stimulation was
repeated with closed eyes for further reinforcement.
Procedure for Data Collection: For correct response, appropriate feedback was given.
A verbal consent was taken from all the patients Initially the contrast grade sand papers were selected.
included in the study. An initial base line evaluation As discrimination improved, the grades of sandpaper
of Touch-Pressure, Two-Point Discrimination Static chosen for practice became more similar.

TEXTURE TRAINING USING SAND PAPERS while manipulating using the fingers with and
without vision occluded.
6. Education regarding the consequences of the injury,
expected functional outcomes after nerve repair,
risk factors related to loss of sensation.
RESULTS AND DISCUSSION
Parametric statistics was used to compare data of

the following outcome measures in both the control
and experimental groups. The touch pressure,
dynamic two-point discrimination and object
recognition test were analyzed using pairedt-test.
Independentt-test was used to compare the outcome
Step 3: Identification of shapes of wooden blocks: measure between the control and experimental
groups. The significance level of the test was kept
In this step, the patient was trained to identify the
at 0.05 level. The statistical analysis was done using
various shapes of the wooden blocks. Six different
SPSS version 15.
shaped wooden blocks were used.
Two-Point Discrimination Test:
Step 4: Identification of objects:
A) Dynamic test:
In this step, the patient was trained to identify 12
different small metal objects each of which were fixed The graph 1 shows the result of effectiveness of
on wooden plates.Along with the above described intervention in both experimental and control groups
sensory reeducation techniques, the patients were in Dynamic Two-Point Discrimination test. The
taught about the home program activities similar to analysis of the data showed statistically significant
control group patients. change in the experimental group when compared to
the control group following intervention. No
OBJECT IDENTIFICATION statistically significant change was found in the
dynamic two-point discrimination test value scored
by the control group before and after intervention.
Though the home program has enhanced the cortical
sensation as seen in the graph 1 (decrease in the
height of post therapy bar), the change was not
statistically significant. Based on the analyses of the
data in experimental and control groups, it is found
that Sensory re-education is better than mere home
program in improving two-point discrimination in
patients with median / ulnar nerve injury at wrist.
Home Program:
The control group was given only the following home
program:
1. Practicing compensatory techniques for decreased
sensation.
2. Identifying different textures by using sand papers
(rough and smooth).
3. Identifying objects which are used in day to day
life by manipulating it with the fingers.
4. Encouraging the use of the affected hand during
the activities thereby providing tactile stimulus. Graph 1. Comparison of Two-Point Discrimination (Dynamic)
5. Correlating the details of the stimulus (objects) Experimental VS Control Group.

B) Static test:
Experimental group Control group
Graph 2. Comparison of Two-Point Discrimination (Static) in both the Groups.
The graph 2 shows the comparison of Static Two- control group. It might be due to the sensory re-
Point Discrimination test grades between the education they underwent in addition to the home
experimental and control groups before and after program. The effect of sensory re-education is also
intervention. 18% of the experimental group showed supported by Imai et.al6. They studied the effect of
change in the test grades of two-point discrimination. sensory reeducation in a group of 22 adult patients
Their grades have improved from protective level to who had a repair of a clean-cut Median Nerve injury
fair level. But the control group showed no change at the wrist. The results demonstrated that sensory
in the level of two-point discrimination grades. reeducation significantly diminished the severity of
postoperative paresthesia and gave better
Thus, the experimental group showed statistically improvement in Dynamic Two-Point Discrimination
significant improvement in both Static and Dynamic than in Static Two Point Discrimination.
Two-Point Discrimination when compared to the

Object Recognition Test: groups (graph 3), shows that the experimental group
has changed more than the control group following
their respective interventions.
The significant increase in the number of objects

identified in control group might be due to the
inclusion of manipulation of day to day objects in the
home program. Both the groups were instructed in
constant usage of hand and taught the methods how
to relearn a new stimulus (object) that is used in daily
activities. This might be the reason for improvement
in Object Recognition Test in the control group also.
The finding is supported by Onne (1962), who
observed that the capacity to adapt sensibility deficits
in the hand depends on the extent to which the hand
was consciously used in daily activities and the
motivation of the patient. More over, all the patients
Graph 3. Comparison of Object Recognition Test scores
Experimental VS Control Group. who participated in this study had a minimum
qualification of 8th standard and were involved in some
From the analysis of the data, it was found that sort of vocation (e.g.: Clerical work, Glass cutter,
there is statistically significant change in both the Librarian etc.) which might demand use of common
experimental group and the control group following objects. The experimental group showed more
the intervention. Though both the groups had significant change than control group. This might be
statistically significant change in the object recognition because of the sensory re-education given along with
test, observation of the difference in mean in both the the home program.
Level of Paresthesia:
Experimental group Control group
Graph 4. Comparison of Level of Paresthesia in both the Groups.

The graph 4 shows the comparison of levels of From the results obtained, it was found that the
paresthesia between the experimental and control experimental group has shown significant change in
groups before and after intervention. In the the five parameters used to measure level of sensation
experimental group, it is found that the level of than the control group.
paresthesia has changed from severe to moderate level
in 64% of the subjects and from severe to mild level in The findings of the study have important
36% of the subjects. Therefore all the subjects in the implications for occupational therapy practice. It
experimental group have undergone change in the reinforces the need of sensory re-education for patients
paresthesia level. But in the control group, only 27% with peripheral nerve injuries (especially median and
of the subjects have changed from severe to moderate ulnar) to reduce their discomfort and to gain better
level of paresthesia. Therefore the change in the level sensibility. To hasten the recovery and achieve
of paresthesia is found to be much better in the independence in ADL, the involved hand need to be
experimental group than in the control group. Thus in incorporated more in the functional use of common
the experimental group, the paresthesia reduced objects.
significantly to a point where they no longer interfere The study also has its own limitations. It was
conducted only on male subjects. Hence the results
with the Activities of Daily Living (ADL). This might
cannot be generalized to the female individuals. There
be due to the positive effect of the sensory re-education
were chances for the home program given being not
in addition to the home program. The finding is
followed by the subjects as there was no
supported by Imai et al.6 who found in his study that documentation of the home program in terms of
paresthesia was diminished in patients who received regular fill up check list of home program activities
sensory reeducation training. done by the patient on any particular day. Only verbal
enquiry was done on regular basis.
Touch Pressure Threshold:
CONCLUSION
The findings from this study suggest that sensory

reeducation when added with home program
enhances better recovery of sensation. Hence, it can
be concluded that sensory reeducation helps in
functional recovery of sensibility in men following
Median or Ulnar nerve repair. Further study can be
done to find out the influence of sex on recovery of
sensation following sensory re-education. It is found
in the review of literature that the recovery of sensation
differs with age. Therefore future research can be done
to reveal the effectiveness of sensory reeducation
across age.
Graph 5. Comparison of Touch Pressure Threshold scores
Experimental VS Control Gr. ACKNOWLEDGEMENT
The graph 5 clearly illustrates the changes in the This research would not have been possible,
touch pressure threshold score in both the without the support and encouragement of several
experimental and control group following intervention individuals. I would like to thank Dr. Indira R.
. In the experimental group, statistically significant Kenkre,Former Head of Occupational Therapy
change was found where as in the control group, the Dept., Seth G.S. Medical College, Mumbai , Dr.
mean value of the touch threshold pressure remained Ambrish Baliarsingh,Former Head of Plastic
the same following the intervention. This means that Surgery Dept., K.E.M Hospital, Mumbai and Ms.
the home program has not produced any change in Snehal Pradip Desai,Lect., OT, Seth G.S. Medical
the touch pressure threshold of the repaired hands in College,Mumbai for their encouragement and
the control group. The statistically significant change support. I extend my sincere thanks to Mr. B.S.
in the experimental group might be due to the graded Ganesh Kumar, Occuapational Therapist for his
tactile stimulation which the subjects received as part guidance and timely help. Sincere thanks to the
of the sensory re-education. patients who participated in the study.

REFERENCES 5. Rosen, B., Lundborg, G. (2004). Sensory

reeducation after nerve repair Aspect of timing.
1. Malaviya, G.N. (2003). Sensory perception in Hand Chir. Mikrochir Plastic.Chir, 36(1), 8-12.
leprosy neurophysiological correlates. 6. Imai, H., Tajima, T., & Natsumi, Y. (1991).
International Journal of Leprosy and other Successful reeducation of functional sensibility
Mycobacterial diseases, 2, 119-124. after median nerve repair at the wrist. Journal of
2. Bentzel, K. (1995). Remediating sensory Hand Therapy, 1, Vol.-16A, 60-65.
impairment. In Trombly C.A., Occupational 7. Nakada, M., Dellon, L. (1989). Relationship
Therapy for Physical Dysfunction (4th ed.) (pp. 423- between sensibility and ability to read Braille in
431). Philadelphia: Williams & Wilkins. diabetics. Microsurgery, 10, 138-141.
3. Glickman, L.T., Mackinnon, S.E. (1990). Sensory 8. Tan, A.M. (1992). Sensibility testing. In Stanley,
recovery following digital replantation. B.G., Concepts in Hand Rehabilitation (pp. 92-112).
Microsurgery, 11, 236. Philadelphia: F. A. Davis Company.
4. Bentzel, K. (2002). Assessing abilities and 9. Fess, E.E. (2002). Sensory reeducation. In Hunter-
capacities: Sensation. In Trombly C.A., Mackin-Callahan, Rehabilitation of the Hand and
Occupational Therapy for Physical Dysfunction (5th Upper Extremity (5th ed.) (pp. 635-639).
ed.) (pp. 159-175). Philadelphia: Lippincott Philadelphia: Mosby.
Williams & Wilkins. 5. Rosen, B., Lundborg, G. 10. Callahan, A.D. (2002). Methods of compensation
(2004). Sensory reeducation after nerve repair and reeducation for sensory dysfunction. In
Aspect of timing. Hand Chir. Mikrochir Plastic.Chir, Hunter-Mackin-Callahan, Rehabilitation of the
36(1), 8-12. Hand and Upper Extremity (Vol. 1) (pp. 701-714).
St.Louis: Mosby.

A Comparative Study Between High Side Lying and Side
Lying Position on Oxygen Saturation in Preterm Infants
Bhanu Thapar1, C. Janarthanan2, Jagmohan Singh3, Aarti Sareen4

1
MPT 2 Year (Pediatrics), 2Associate Professor, 3Principal and Professor, Gian Sagar College of Physiotherapy,
nd
4
Assistant Professor, Gian Sagar Medical College and Hospital, Ram Nagar, Rajpura, Dist.
ABSTRACT
Background: Premature birth, commonly used as a synonym for preterm birth, refers to the birth of
a baby before its organs mature enough to allow normal postnatal survival and growth and
development as a child. Positioning an infant appropriately is one of the easiest ways to provide
postural support that has both an immediate and lasting impact on an infants motor development.
We can prevent complications like respiratory distress syndrome, chronic lung disease, pneumonia
by proper positioning of child. No relationship between these two positions with oxygen saturation
is yet proved in preterm infants.
Methods: This was a comparative study between high side lying and side lying position that were
randomly assigned to 40 preterm infants i.e. those who were born in less than 37 weeks gestation age
and were haemodynamically stable. They were made to lie in each position in neonatal nursery
under constant supervision for 3 regular hours in same day. Saturation of peripheral oxygen in infant
was recorded by pulse oximeter every 15 minutes during these 3 hours and monitoring was continued
till it reached the baseline again. The infant was assigned in the next position once oxygen saturation
reached the baseline again. Random order of positioning was used.
Results: The influence of both positions on the saturation of peripheral oxygen (SPO2) in preterm
infants was then evaluated and results formulated using paired t-test for evaluation of data. The data
was collected with positioning using Pulse Oximeter as an outcome measure.
Conclusion: This highlighted that high side lying is better than side lying in improving saturation of
peripheral oxygen in preterm infants.
Key words: Saturation of peripheral oxygen (SPO2); Pulse oximeter; Respiratory distress syndrome; Preterm
infants; Neonatal nursery
INTRODUCTION babies typically spend the first days/weeks of their

life on a ventilator7. Worldwide prematurity accounts
Prematurity as defined by the World Health for 10% of neonatal mortality or around 500,000 deaths
Organization (WHO) is a baby born before 37 weeks per year5. Premature birth and complications cause
of gestation counting from the first day of the last about 25% of neonatal deaths. About 16000 babies
menstrual period. Premature infant is one that has develop respiratory problem each year. Very preterm
not yet reached the level of fetal development that infants are physiologically ill-prepared for extra-
generally allows life outside the womb2. In the normal uterine life4. Positioning of preterm infants is a basic
human fetus, several organ systems mature between neonatal nursing care. It includes supine, prone, side-
34 and 37 weeks. The lungs are one of the last organs lying and head up tilted position. A variety of
to develop in the womb, because of this; premature outcomes can be demonstrated that are affected by
Correspondence Address different body positioning of preterm infants 11 .
Bhanu Thapar Positioning describes use of body position as a specific
Gian Sagar College of Physiotherapy, treatment technique. Positioning for Intensive care unit
Ram Nagar, Rajpura, Dist. Patiala, patients can be used with physiological aims of
Punjab, India, Phone no. 09463425213 improving oxygen transport through its effects of
E-mail: arora035@gmail.com improving ventilation/perfusion (V/Q) matching,
15. bhanu thapar 24th june 11 (75-78).pmd 75 10/16/2012, 2:40 PM

increase lung volume, reducing work of heart and in this study. Those infants were excluded from this
enhancing mucociliary clearance8. High side lying study that was post term or full term i.e. babies born
position in adults refers to the use of five or six pillows after 37 weeks gestational age. During course of our
to raise the patients shoulders while lying on his side. study when any infant became haemodynamically
It is more comfortable if the knees are bent and the top unstable, he/she was excluded from our study. If child
leg placed in front of the one beneath. The patient who showed signs of distress when placed in assigned
is exhausted and is using the accessory muscles of position and could not tolerate it, he/she was to be
respiration can be helped by careful positioning, using excluded from the study. Infants with any chest
the support of pillows, in high side lying or in upright deformity or diaphragm paralysis were also excluded.
position, so that it is more possible to gain relaxation Random sampling method was done among preterm
of the upper chest and shoulder girdle muscles1. In babies who were admitted in Neonatal nursery of Gian
practice, it is imperative to ensure that when the patient Sagar Medical College and Hospital, Ram Nagar,
is in the supine or lateral position that a head up tilt to Rajpura during the period of this study. Independent
a maximum of 30 is obtained. This improves venous variables were high side lying and side lying position
drainage with minimal effect on arterial pressure. In whereas dependent variable was Saturation of
addition the higher the head, the greater is the effect peripheral oxygen (SPO2).
of gravity on the flow of venous blood. However, as
the head is raised, the gravitational effect on the arterial Sample size: Total 42 preterm infants participated
pressure at the brain is also increased. The best in the pre-assessment session to confirm the inclusion
compromise is the position described above of 30 criteria. 2 preterm infants were excluded from the
degrees head raise. When patients with severe head study. The two had to be excluded due to their nursing
injuries are nursed or transported it must be with a care protocol involving feeding every hourly. Due to
30 head up tilt and the blood pressure maintained10. this no position could be maintained for regular three
Side-lying Position in the preterm infants is weight hours in these infants.
bearing on one side of body, hips and knees flexed to Positioning procedure: 40 Preterm infants were
approximately 110 degrees, head slightly flexed included in the study based on inclusion/exclusion
forward, upper extremities protracted with hands in criteria after signing the informed consent form. A
the midline. The side-lying position eliminates gravity, comparative study was done in which random
encourages relaxation, visual awareness and midline sampling technique was used. 40 subjects (22 male
orientation of the upper extremities3. A pulse oximeter preterm infants and 18 female preterm infants) were
typically has a pair of small light-emitting diodes taken. Treatment was divided into two groups. Parents
(LEDs) facing a photodiode through a translucent part
of all preterm babies who were included in study
of the patients body, usually a fingertip, toe or an
signed a parental consent form. Normal nursing care
earlobe. Because of their simplicity and speed, pulse
was continued along with positioning in both the
oximeters are of critical importance in emergency
groups. The order of these 2 positions was randomly
medicine and are also very useful for patients with
assigned to all preterm infants.
respiratory or cardiac problems6. Positioning an infant
appropriately is one of the easiest ways to provide Group 1- High Side Lying positioning (figure 1.1)
postural support that has both an immediate and
lasting impact on an infants motor development. 1st group- This group included total 40 subjects. They
Positioning itself is a unobstrusive intervention were made to lie in high side lying position in Neonatal
strategy that can be used to promote infant nursery for 3 regular hours in one day. Saturation of
neurobehavioral and neuromotor stability. Therefore peripheral oxygen (SPO2) in infant was recorded by
the way the preterm infants are placed in the initial pulse oximeter every 15 minutes during these 3 hours
days, weeks and months after birth, as well as how after which infant was made to lie supine and
long that position is maintained, can affect the infants monitoring was continued till SPO 2 reached the
future safety, posture, movement and overall baseline again.
development9. Group 2- Side Lying positioning (figure 1.2)
METHODOLOGY 2nd group- This group had same 40 subjects. When the
oxygen saturation reached the baseline in supine
Haemodynamically stable preterm babies i.e. those position, they were made to lie in side lying position
who were born in less than 37 weeks of gestation age (with 30 degrees head raise) for next 3 hours. Saturation
with no post, peri and anti natal trauma were included of peripheral oxygen (SPO2) in infant was recorded by

pulse oximeter every 15 minutes during these 3 hours Table 1. Mean, Standard deviation and Standard error
after which infant was made to lie supine till SPO2 of the difference of post and pre-intervention readings
reached the base line again. of SPO2 in high side lying and side lying position
Positions Number of Mean Standard Standard
The thickness of the cotton padding used to raise subjects deviation error
the head of the infant to approximately 30 degrees was High side lying 40 8.98 2.309 0.369
4 inches. It was prepared regularly with the help of Side lying 40 6.7 2.4 0.38
the nursing staff on duty. No proper instrument was

used to raise head to 30 degrees because of practical Graph 1.1 Comparison between mean of SPO2 in pre
intervention and post intervention readings in both
difficulties. The order of these 2 positions was
high side lying and side lying position
randomly assigned to infants. It was a single blinded
study because the staff on duty taking the readings
was unaware of our research and its possible effects
on oxygen saturation in preterm infants. Any change
in SPO2 with both positions was evaluated.
Graph 1.2 Comparison between t-values when high

side lying was compared with side lying position
Figure 1.1 High Side Lying Figure 1.2 Side Lying
RESULTS
The mean of gestation age of 40 preterm infants

taken in this study was calculated as 33 weeks 4 days readings in both the positions. On comparison using
and the mean birth weight was 1 kg 727 gms. The paired t-test, the results in two groups showed
values of SPO2 of 40 preterm infants taken after every significant difference (p<0.05). Using ANOVA,
15 minutes in 3 hour period was tabulated and f-calculated (17.48) was compared with f-tabulated
statistically analyzed. All data was expressed as (3.072) at 5% level of significance at degrees of freedom
mean + standard deviation. Parametric statistical tests 2 and 117. On comparison the results showed
were used to determine the statistical difference significant difference in both groups (p<0.05).
among parameters. The post and pre-intervention
The comparison between the high side lying and
readings of both high side lying and side lying were
side lying was done after comparing mean and
compared using paired t-test. Also comparison
standard deviation in these two positions. The mean
between effect on SPO2 with high side lying and side
of high side lying was more than side lying whereas
lying was compared using unpaired t-test. One way
standard deviation of high side lying was less than
ANOVA was applied to both these values to justify
side lying. The t-tabulated value at 5% level of
the final results.
significance in right tail test at n1+n2-2 degree of
The comparison between post and pre-intervention freedom was found to be 1.645 whereas t-calculated
readings (graph 1.1) revealed that mean of post- value was calculated as 2.13. The t-calculated was
intervention readings was more than pre-intervention found to be more than t-tabulated as in graph 1.2. Thus,

null hypothesis was rejected. It revealed that high side positions. Also, same order of positioning can be taken
lying position shows significant difference in rather than random order. Same gestation age and
saturation of peripheral oxygen (SPO2) as compared baseline SPO2 can be taken in inclusion criteria.
to side lying. One-way ANOVA was done to prove
which position is better than the other two positions. CONCLUSION
The f-calculated (25.73) was compared with f-tabulated
(3.072) at 5% level of significance at degrees of freedom This highlights that both high side lying and side
2 and 117. The f-calculated was found to be more than lying produced significant increase in SPO2 when post
f-tabulated. So this justifies the result that high side and pre-intervention readings were compared among
lying has better results than side lying position. 40 preterm infants. However, high side lying was
found to be better than side lying in improving SPO2
DISCUSSION in preterm infants. Thus, we should prefer placing the
preterm infants in neonatal nursery in high side lying
The post-intervention and pre-intervention position.
readings in 40 preterm infants were compared for
saturation of peripheral oxygen (SPO2) in both the REFERENCES
positions. The difference between the two readings was
found to be clinically significant in both positions. The 1. Downie P, Innocenti D, Jackson S, editors. Cashs
t-calculated for high side lying and side lying was textbook of chest, heart and vascular disorders
for physiotherapists. 4th ed. Jaypee brothers: New
found to be more than t-tabulated in both the positions.
Delhi. 1993; p. 333, 509.
Therefore, it proves there is increase in the value of
2. Kaempf JW, Tomlinson M, Arduza C. Medical
saturation of peripheral oxygen (SPO 2 ) when
staff guidelines for periviability pregnancy
compared with the pre-intervention readings with counseling and medical treatment of extremely
positioning. There always is an increase in values (in premature infants. J Peds. 2006; 117 (1): 22-29.
%) of saturation of peripheral oxygen (SPO2) when the 3. Kelly K, Palisano RJ, Wolfson MR. Effects of a
preterm infant is placed in any of the two positions. developmental physical therapy program on
Thus, this study justifies the importance of positioning oxygen saturation and heart rate in preterm
in preterm infants. infants. Phys Ther. 1989; 69 (1): 467-474.
4. Martius JA, Steck T, Oehler M, Wulf K. Risk
Also, in comparison between two positions using factors associated with preterm and early preterm
unpaired t-test, t-calculated (2.13) was found to be birth: univariate and multivariate analysis of
more than t-tabulated (1.645). This revealed that high perinatal survey of Bavaria. Eur J Obstet Gynecol
side lying is better than side lying in improving SPO2. Reprod Biol. 1998; 80 (2): 183-189.
5. Mathew TJ, Dorman MF. Infant mortality
Both statistically and clinically, it was found that the statistics from the 2003 Period Linked Birth/
maximum significant improvement was there in high Infant Death Data Set. National Vital Statistics
side lying position as compared to in side lying position. Reports. 2006; 54 (16): 24-40.
6. Millikan GA. The oximeter: an instrument for
Limitations: Small sample size among the
measuring continuously oxygen-saturation of
preterm infants admitted in Gian Sagar Medical
arterial blood in man. Review of scientific
College and Hospital, Ram Nagar, Rajpura was Instruments. 1942; 13 (1): 434-444.
taken. Due to the limited resources, more 7. Porter TF, Fraser AM, Hunter CY, Ward RH,
sophisticated tools like bed with provision for fixed Varner WM. The risk of preterm birth across
head raise could not be used. Also, subjects taken in generations. Obs & Gyne. 1997; 90 (1): 63-67.
this study had different gestation ages. In the 8. Stiller K. Physiotherapy in intensive care towards
inclusion criteria, same baseline SPO2 and ranges of an evidence based practice. Chest. 2000; 118 (6):
all other vitals like heart rate, respiratory rate and 1801-1813.
birth weight were not considered. 9. Waitzman AK. The importance of positioning the
near-term infant for sleep, play and development.
Future studies: There is great scope of future Newborn and infant nursing reviews. 2007; 7 (2):
studies through this present study. Other 77-78.
physiotherapy interventions can be added or 10. Walters FJ. Intracranial pressure and blood flow.
compared along with positioning for evaluating effect Physiol. 1998; 8 (4): 2-4.
on SPO2 on a large sample using more sophisticated 11. Young J. Positioning premature babies, nursing
tools for measurement. Equal number of male and preterm babies in intensive care: which position
female can be compared for SPO2 in the different is best?. J Neonat Nurs. 1994; 1(2): 27-30.

Efficacy of Knee Osteo-arthritis Outcome Score (KOOS) in
Measuring Functional Status of Knee Osteo-arthritis
Patients in the Indian Population
Bindya Sharma
Assistant Lecturer, Padmashree Dr. D.Y. Patil College of Physiotherapy, Pimpri, Pune
ABSTRACT
Knee osteoarthritis is the most common disease encountered in the Physical Therapy Clinic. The
main outcomes of Physiotherapy treatment is based on symptomatic pain relief along with prevention
of deterioration of the functional capacity and improvement in ADL. But measurement tools usually
measure these aspects as separate identities. KOOS as a tool, measures all these aspects in a
comprehensive manner. This study compares KOOS and WOMAC, and establishes the reliability of
the best scale.
Objectives: To find out the efficacy of KOOS over WOMAC in assessing the functional status of the
knee OA patients in the Indian population.
Methods: 30 subjects included in the study based on inclusion and exclusion criteria. Both groups
were made to fill two questionnaires, WOMAC and KOOS.
Results: Data analysis, it was found that KOOS and WOMAC were positively correlating.
Conclusion: It was concluded that KOOS can also be used in the clinical as well as functional
assessment of Knee OA in the Indian Population.
Key words: KOOS, WOMAC, Knee Osteoarthritis, Functional Status.
INTRODUCTION conditions including congestive heart failure, Diabetes,

Heart diseases, Chronic obstructive pulmonary
Osteoarthritis, also called as Degenerative Joint diseases or Depression. Despite ethnic and cultural
Disease (DJD), Osteoarthrosis, Hypertrophic arthritis, diversities in the Asian scenario, there is a common
Post-traumatic arthritis, is the most common of all joint thread that binds millions of its inhabitants in near
diseases to affect mankind. It is considered almost an similar lifestyles, ranging from squatting and kneeling
inescapable consequence of aging if accompanied by to sitting cross-legged on the ground for prayers.
risk factors like obesity, heavy physical activity or Hence, predisposition to knee OA increases in the
inactivity. Although joint inflammation is implied by Asian, especially Indians. Primary OA of knee is almost
the suffix itis in osteoarthritis, inflammation is a disease of elderly population.
typically found only after there has been substantial
articular degeneration. According to epidemiological Knee OA is associated with considerable disability;
studies, OA of the knee is the leading cause of chronic and functional limitation is an inevitable consequence.
disability in the US. Knee OA, a problem that is much However, knee OA does not affect all types of
more prevalent in India than in the west, accounts for functional activities equally. Activities like walking,
at least as much disability as any other chronic squatting and stair climbing are the ones affected to
the most. The need for a standardized assessment tool
Correspondence Address hence becomes important. Various assessment
Bindya Sharma (PT), batteries are available; Arthritis Impact Measurement
Padmashree Dr. D.Y. Patil College of Physiotherapy, Scale (AIMS), Lequesne Index of Severity for OA of
Sant Tukaram Nagar, the knee, Lysholm knee scoring scale, WOMAC and
Pimpri, Pune KOOS, to name a few. Traditionally, process measures
Mobile No. 9823063774.
16. Bindya Sharma 18th Feb 12 (79-81).pmd 79 10/16/2012, 2:40 PM

like radiographs, laxity and other clinical findings have osteoarthritis with grade 3 of Kellgren and
been used to evaluate knee OA. Clinical trials have Lawrence grading system for osteoarthritis,
used these measures as their primary dependent 1957.
variables. Seldom have patients preferences for Patients having primary medial compartment
outcomes (i.e. functional improvement) been used to osteoarthritis with at least 3 of the clinical
evaluate treatment; they have often been perceived as symptoms according to Criteria for
important but subjective and unreliable. These classification of idiopathic Osteoarthritis of the
knee, 1986 (American college of
concerns have stimulated researchers in clinical and
Rheumatology)
rehabilitative sciences to expand the methods and
metrics used to evaluate the effects of health services. Exclusion Criteria:
It is well recognized that weak correlations and Males
frequent discordance is found when comparing Osteoarthritis secondary to any trauma like
process measures like radiographic findings and laxity ligament injury, fractures etc.
to patient relevant outcome measures such as pain, Osteoarthritis of any other compartment of the
function and activity level. Therefore, the use of patient Knee.
relevant outcome measures should be promoted and
Study Design:
should be considered the primary outcome measure
Cross-Sectional survey
in clinical trials.
Need For The Study: METHODS
There are several knee specific instruments but The study includes 30 females selected based on
only 3 are knee OA specific, namely, WOMAC (1980), the inclusion and exclusion criteria. The patients have
Lequesne index of severity (1989), and KOOS (1995). to undergo radiographic examination of the knee in
The WOMAC OA Index is the first patient- AP view standing on one leg.
administered outcome measure developed for OA. The
The stage of osteoarthritis is determined according
questionnaire is validated for use in knee and hip OA
to the Kellgren and Lawrence grading system for
and is frequently used around the world. The Lequesne
osteoarthritis, 1957.
index of severity of OA of the knee assesses Pain or
discomfort (5 questions), walking (2 questions) and According to this grading system:
ADL (4 questions).
Grade 3 moderate osteophytes and joint space
KOOS is basically a derivative of WOMAC narrowing, some sclerosis and possible deformity.
whereby the KOOS has 2 more domains, namely,
Sports and Recreation and Quality of Life. WOMAC Patients are then assessed for the clinical symptoms
is considered to be a gold standard for assessment of according to Criteria for classification of idiopathic
OA patients. The intended purpose of this study is to Osteoarthritis of the knee, American college of
check the efficacy of KOOS in comparison to WOMAC Rheumatology, 1986. The patient should have knee
in measuring severity of symptoms and functional pain and at least 3 positive symptoms out of the 6 to
status of knee OA patients in the Indian population. fulfill these criteria.
Aims And Objectives: To measure the functional status of the patients,

they are made to fill both questionnaires i.e. KOOS
To find out the efficacy of KOOS over WOMAC in and WOMAC.
assessing the functional status of the knee OA patients
in the Indian population. RESULTS
Methodology: Data analysis is done using Karl-Pearson Correlation
Coefficient. The r value was 0.92 which is considered
Materials used: KOOS, WOMAC. to be high positive correlation.
Table 1. Showing the Correlation Coefficient r=0.92
The population of the study is defined as having showing highly positive correlation
medial compartment knee OA and a sample 30 females
Mean Standard Correlation
were taken. Deviation Coefficient
KOOS 99.83 10.56 r=0.92
Inclusion Criteria: WOMAC 49.83 8.19
Female patients having medial compartment

CONCLUSION
The clinicians in the field of Orthopaedics,

Physiotherapy and Occupational therapy are using
several assessment batteries to evaluate the pain,
stiffness and other features of OA. WOMAC and
KOOS were used among various populations with
knee OA and proved that they are efficient in assessing
and quantifying the clinical presentations by different
authors at different time periods. Among these two
instruments, comparatively KOOS is having more
Fig. 1. Scatter plot graph showing strong positive linear number of items under the domains of sports and
correlation between KOOS and WOMAC. recreational activities and quality of life. Assessment
tools hold a significant place in the field of Physical
DISCUSSION Therapy. As this profession is based on Rehabilitation
i.e. bringing the individual back to his optimal
Data analysis for comparison of KOOS and
functional capacity, emphasis is on Function. Knee OA,
WOMAC is done using non-parametric statistics as
a debilitating condition, is the frequent presentation
the data obtained from both the questionnaires are
in a Physiotherapy clinic. Patients complaints range
ordinal. WOMAC is a valid, reliable and responsive
from pain to inability to carry out ADL. Numerous
measure of outcome, and has been used in diverse
scales measure these aspects, but only a few deals with
clinical and interventional environments. The
it in a comprehensive manner. WOMAC is considered
WOMAC OA Index, developed for elderly with more
to be the gold standard in assessing knee OA patients.
advanced OA, fulfilled the metric requirements. The
In this study, it was our intention to establish KOOS,
instrument is linguistically validated and is widely
which is a scale that deals with Pain, symptoms and
used in the evaluation of knee OA. Numerous
Function, sports and recreation and Quality of life, for
validation studies have addressed specific clinimetric
use in the Indian population.
issues regarding reliability, validity and
responsiveness. Results were found to be satisfactory. It has been concluded that KOOS and WOMAC are
The reliability of KOOS is also established. To ensure positively correlating indicating that KOOS can also
content validity for the older population with OA, be used for the assessment of functional status of OA
the questions from WOMAC were included in their patients in Indian population.
full and original form in the KOOS questionnaire. In
an article by Ewa M. Roos and Stefan Lohmander REFERENCES
(2003), the authors write that KOOS was developed
as an extension of the WOMAC OA index with the 1. Garratt AM, Brealey S, Gillespie WJ. Patient-
purpose of evaluating short- and long-term assessed health instruments for the knee; a
symptoms and function in young and physically structured review. 2004
active subjects with knee injury and OA. KOOS has 2 2. Angst F. WOMAC, SF-36 Measuring
more domains, namely, Sports and Recreation and improvement in OA patients. 200, Ann Rheum
Quality of Life, otherwise WOMAC as an instrument Dis; 60: 834-840.
is sufficient for older population with severe OA and 3. Ewa M Roos, L Stefan Lohmander. The Knee
injury and Osteoarthritis Outcome Score (KOOS):
still remains to be an instrument of choice to detect
from joint injury to osteoarthritis.2003 Nov,
severity of OA symptom in geriatric population.
Health and Quality of Life Outcomes, 1:64 doi:
Addition of the 2 subscales makes KOOS more
10.1186/1477-7525-1-64.
comprehensive and covers the total picture of the 4. A Users Guide to: Knee injury and Osteoarthritis
condition of the patient. The items under these Outcome Score KOOS. 2003, KOOS Users Guide.
dimensions concentrate on the questions relating to 5. Roos E, Roos H, Loohmander LS, Ekdahl C,
recreational activities which can be linked to the Beynnon B. Knee injury and Osteoarthritis
activities commonly seen in Indian population e.g. Outcome Score (KOOS) - development of a self-
kneeling can be related to prayer pattern or squatting administered outcome measure. 1998, The
could be related to gardening. Journal of Orthopaedic and Sports Physical
Therapy 78(2): 88-96, 1998.

Reliability and Concurrent Validity of Dynamic Rotator

Stability Test A Cross Sectional Study
Binoy Mathew K V1, Charu Eapen2, P.Senthil Kumar3

1
Clinical Instructor cum Lecturer, College of Physiotherapy, Medical Trust Institute of Medical Sciences, Kochi, Kerala,
2,3
Associate Professor, Kasturba Medical College Hospital, Mangalore, Karnataka
ABSTRACT
Purpose of the Study: To find intra rater and inter rater reliability of Dynamic Rotator Stability Test
(DRST) and to find concurrent validity of Dynamic Rotator Stability Test (DRST) with University of
Pennsylvania Shoulder Score (PENN) Scale
Material and Method: 40 subjects of either gender between the age group of 18-70 with painful
shoulder conditions of musculoskeletal origin was selected through convenient sampling .Tester 1
and tester 2 administered DRST and PENN scale randomly. In a subgroup of 20 subjects DRST was
administered by both the testers to find the inter rater reliability. 180 Standard Universal Goniometer
was used to take measurements.
Results: For intra-rater reliability, all the test variables were showing highly significant correlation
(p=.94 -1). For inter -rater, with tester 2, test variables like position, ROM, force, direction of abnormal
translation, pain during the test, compensatory movement during test were found to be significant
(p=.71-1).only some variables of DRST showed significant correlation with PENN scale (P=.320-.450)
Conclusion: Dynamic Rotator Stability Test has good intra rater and moderate inter rater reliability.
Concurrent validity of Dynamic Rotator Stability Test was found to be poor when compared to PENN
Shoulder Score.
Key words: Dynamic Rotator Stability Test, Shoulder, Instability, Rotator Cuff.
INTRODUCTION ligaments along with the joint capsule provide mainly

end range stability.5
Shoulder pain is estimated to be the third most
common cause of musculoskeletal consultation in The dynamic stabilizing structures include the
primary care.1 The incidence of shoulder pain is quite rotator cuff muscles and other shoulder muscles. Mid-
high.2 range stability is provided by rotator cuff muscles by
concavity compression.6
Shoulder pain often impairs the ability to sleep, and
restricted and/or painful range of motion of the Failure of function of rotator cuff muscles in their
shoulder influences performance of activities of daily stabilizing role leads to creation of an abnormal axis
living. 3 of rotation and abnormal translation of the head of
humerus.7 Excessive translation of the humeral head
Four basic mechanical abnormalities causing pain along the glenoid results in pain and functional
at the shoulder are stiffness, instability, weakness, and impairment.8
roughness. Instability is a functional complaint.
Asymmetry, reproduction of symptoms, and Commonly used tests for shoulder joint stability
apprehension are possible signs of instability.4 were mostly done at end range or mid range which
were passive and assess only integrity of the capsular
The shoulder joint instability occurs due to an and ligamentous structures.9
imbalance in the interaction of both static and
dynamic-stabilizing structures. Static stabilizers Recent research findings have shown the need to
include the bony anatomy, negative intra-articular consider dynamic joint stability and the local muscle
pressure, the glenoid labrum, and the Gleno-humeral system in the treatment of segmental spinal pain.10
17. binoy mathew 19th nov 10 (82-87).pmd 82 10/16/2012, 2:41 PM

Strong evidence is available that pain alters the timing Study design
of contraction in stabilizing muscles transversus
abdominis and multifidus in relation to the lumbar Cross sectional design for which ethical clearance
spine,vastus medialis obliquus in relation to the knee.6 granted by the institutional ethical committee
Tests to detect lumbar and cervical dynamic stability Subjects
are routinely used in clinical practice.11
40 subjects of either gender between the age group
Such tests developed to assess and treat dynamic of 18-70 with painful shoulder conditions of
stability of the shoulder is Dynamic Rotator Stability musculoskeletal origin referred to KMC Hospitals,
Test and Dynamic Relocation Test developed by Attavar and Ambedkar Circle were recruited for the
Mary Magarey and Mark Jones. 6, 11 DRST is more study.
important for assessment of humeral head
translation due to abnormal rotator cuff activity and Inclusion criteria
the test involves multiple positions which might 1. Subjects with painful shoulder of musculoskeletal
mimic function. origin
In order for any type of measurement tool to be 2. Availability of active shoulder ROM up to 120
used with confidence when making decisions 3. Subjects with pain, apprehension or click with
regarding patient care, the psychometric or active shoulder movement.
measurement properties of reliability, validity, and 4. Willingness to participate in the study
responsiveness must be established. 12 To date, 5. Capable of understanding instructions given by the
research on reliability and validity and on tester.
establishing normative values for DRST is
incomplete.6,11 But no study has been published which Exclusion criteria
confirms reliability and validity of this test.13 The 1. History of recent fracture of the shoulder complex
purpose of this study is to find reliability and 2. History of recurrent shoulder dislocation
concurrent validity of Dynamic Rotator Stability Test
3. Subjects with diagnosed neurological problems
in subjects with painful shoulder.
pertaining to trunk and upper extremity
METHODOLOGY 4. Worsening of symptoms or high irritability with
movement of shoulder complex.
Source of data
Department of physiotherapy KMC Hospitals,

Mangalore.
Fig. 1.

PROCEDURE
Dynamic Rotator Stability Test (DRST)
The subject seated on a stool. The therapist holds

around the head of the humerus as shown in the figure.
The test is done as described by Mary Magarey and

Mark Jones.11The movement is done first in Scaption
between 0-120 degrees. (Fig. 1) All the movements are
started in internal rotation direction(Figure 3); later
movement to external rotation is done. The force
initially used is isometric (30% of max.voluntary
contraction force). As progression free active (Fig. 4),
resisted concentric and eccentric force is used. If no
abnormal humeral head translation is detected in
Scaption, the test progress to flexion (sagittal) and Fig. 4. Free active internal rotation
abduction (coronal) plane. The test stops at the position
where abnormal translation is detected and
measurement is taken using Goniometer. (Figure 5)
Fig. 5. Goniometric measurement of the arm position in DRST

positive position
University Of Pennsylvania Shoulder Score (Penn)

Scale. 12
Fig. 2. Hand positioning of therapist for Humeral Head Palpation
during DRST.
Penn Scale,100-point self-report scale consisting of
3 sections: pain, satisfaction, and function. There are 3
questions regarding pain (30 points), 1 regarding
satisfaction of shoulder function (10 points), and 20
regarding function (60 points). Measurement
properties have been established for the Penn scale in
patients with various shoulder pathologies.12
Prior to starting of study, testers underwent a

habituation programme to habituate with the test
variables or parameters of assessment in dynamic
rotator stability test. Dynamic Rotator Stability Test was
done in shoulders of 4 asymptomatic subjects of age
between 20-25 years.
Penn shoulder score was also administered in a

sample population of 40 asymptomatic subjects of
Fig. 3. Therapist hand placement- manual resistance with either gender between the ages of 20-30 for cross
subjects arm in Scaption for Isometric internal rotation. cultural validation.14, 15

Subjects were selected through convenient Reliability- Results for DRST (Spearmans Correlation
sampling. Written informed consent was obtained after Co-efficient Rho):
explaining them about the objectives and methodology Intra Rater Inter Rater
(Trial 1 & 2) (1&2)
of the study. Subjects were then screened using
Position (S/F/Ab) 1.00* 1.00*
screening check-list for inclusion and exclusion criteria.
ROM .94* 0.70*
Force 1.00* .72*
Part- I Reliability of DRST:
Rotation 1.00* .12
Order of the tester for the performance of DRST Direction of Abnormal Translation 1.00* .71*
Pain during DRST 1.00* .75*
was randomized and the testers were blinded to each
Click during DRST .95* .546
others findings.
Compensatory movements during DRST 1.00* .76*
Part-II Validity-Concurrent Validity (*-denotes significant findings) (S=Scaption, F=flexion, Ab=abduction)
One tester evaluated the patient by administering For intra-rater reliability, all the test variables were
score. Other tester did Dynamic Rotator Stability Test. showing highly significant correlation. For inter -rater,
Randomization of the tester was done for selected test with tester 2, test variables like position, ROM ,force,
for each subject. Each tester was blinded to other direction of abnormal translation, pain during test,
testers finding. Only one trial of assessment was done. compensatory movement during test were found to
be significant.
Statistical analysis
Concurrent Validity- Results (Spearmans Correlation
All statistical testing was carried out using Co-efficient Rho):
Statistical Package for Social Science version 13.0 Pain Pain with Pain with Pain Satisfaction Functional
software. Differences were considered statistically at rest normal Strenuous Subscale Subscale Subscale
Position
significant at p<0.05.
ROM .107 .065 -.094 -.018 -.145 -.138
For reliability, Spearmans correlation coefficient Force .062 -.060 -.019 -.045 .318* -.100
Rotation -.228 .010 .129 .000 .329* -.196
was used for pair wise comparison regarding
Direction of
agreement with the test variables between testers. Abnormal
Translation .041 -.121 -.327* -.207 -.284 .088
For validity, Spearmans correlation coefficient was Pain during

DRST .074 .210 .048 .109 .201 .358*
used for pair wise comparison of test variables of DRST Click during
and test variables of Penn Shoulder Score. DRST .143 -.129 .077 -.011 .237 -.091
Compensatory
movements
during DRST .137 .320* .170 .280 .061 .450*
RESULTS
40 subjects between the ages 0f 18 to 70 was

For concurrent validity of Dynamic Rotator
included in the study.22 subjects were males and 18
Stability Test with Penn Shoulder Score, variables
were females. All the subjects were right hand
which showed significance are Force and satisfaction
dominant. In the subgroup of 20 for finding inter rater
subscale, Direction of rotation and satisfaction
reliability 11 were males and 9 were females.
subscale, Direction of abnormal translation and pain
The subjects demographic characteristics were as with strenuous activities, Pain during DRST and
shown functional subscale, Compensatory movements during
Intra Rater Inter- Rater DRST and pain with normal activities, Compensatory
Reliability- Reliability- movements during DRST and functional subscale
DRST(Tester 1) DRST (Tester 1&2 )
Sample Size 40 20
DISCUSSION
Age Mean SD 47.3514.94 47.3814.94
Gender- Total (M/F) 22/18 11/9 The result of intra-rater reliability shows highly
Hand Dominance(R/L) 40/0 20/0 significant correlation among all test variables. This
Side of Shoulder Pain(R/L) 23/17 14/6 can be attributed to the habituation underwent by
Duration of pain- Median (Range) 71.50(2-3650) 87.00(2-3640) tester 1. To avoid recall bias DRST was administered
(M=male, F=female,R=right, L=left) randomly on either shoulder of the subjects.

Preliminary screening was only done prior to the effect. A great variability in reliability exists even in
administration of the test. Clinical implication of the other physical tests of shoulder girdle.20
intra-rater results shows that DRST is a useful test for
detecting dynamic instability in clinical practice, For concurrent validity, some variables of DRST
especially when the tester uses the test on a one to one showed significant correlation with Penn Shoulder
basis. Score.
In inter-rater reliability, apart from clicks and Force and satisfaction correlation can be attributed
rotation during DRST, all other variables showed to the fact that satisfaction is purely subjective. The
significant agreement between the testers. patients satisfaction with the ability to use the
shoulder is an important construct to measure for both
There was mutual agreement between the testers the patient and clinician.12 Rotation and satisfaction
regarding the position where DRST were positive. For showed significant correlation .It may be due to the
all the subjects the abnormal translation of humeral fact that subjects with more external rotation range
head occurred in scaption. Scaption is defined as 30 may be more satisfied. Maximum elevation on all
degree anterior to the coronal plane.7 In the scaption planes of shoulder required external rotation of
plane, the capsular fibers of the glenohumeral joint are humerus. Loss of external rotation results in significant
relaxed.16 Hence the joint relies more on rotator cuff functional disability.16
muscles for stability. So any alteration in rotator cuff
muscle activation results in instability. Pain with DRST and function showed significance.
Greater functional loss may be associated with pain
Range of motion showed moderate correlation with DRST. Functional disability due to pain in the
between the testers. Minor variations in the position shoulder at rest or during movement or functional
of arm, force applied by the subjects and placement of disability due to restricted range of motion is
Goniometer while taking reading might have caused frequently observed in painful shoulder subjects.21
this variation.
Overall all of our subjects had a better Penn
Force used during testing and direction of abnormal Shoulder Score, near normal. DRST can be positive
translation in DRST showed correlation . In an unstable even in the absence of any symptoms. Studies in low
shoulder, or one in which dynamic control is lacking, back pain subjects showed motor control deficits
humeral head translate when the rotator cuff is loaded, persisting even after the reduction of symptoms.22
usually anteriorly during resisted lateral rotation and
posteriorly with resisted medial rotation. Studies had We do not have as on data, an established gold
shown consistent activation of rotator cuff prior to standard measure for dynamic stability of the shoulder.
more superficial delto-pectoral muscles in normal So we chose Penn Shoulder as a first line attempt.
subjects.6 Strong evidence is available that pain alters Condition-specific questionnaires of the shoulder have
timing of contraction in stabilizing muscles.11 demonstrated greater responsiveness than generic
measures in patients with shoulder disorders. 12
Pain during DRST showed good agreement Although DRST seems to have face validity, concurrent
between testers. The result can be attributed to the validity could not be found.
habituation programme and efficiency of examiners
in collecting subjective feed back during test. The study however is the first of its kind on DRST,
after the initial description given by the developers
Compensatory movements showed good which opens a new era of research and future studies.
correlation. It is demonstrated that increase of upper
trapezius activity occur during external rotation in One of the limitations of the study was small sample
shoulder pain patient group and decreased activity in size which had reduced the statistical power. The
the middle trapezius.8 important observations of the study are that DRST was
well tolerated, had produced no adverse effects and
Inter rater reliability of DRST was moderate in our no latent symptoms occurred. So the test is very safe
study. This is in agreement with Inter-rater reliability to use in clinical practice though it depends solely on
of physical tests for shoulder in other studies showing the thorough patient understanding. This could be
moderate reliability. 17-20 Differences in clinical solved by testing and explaining on the unaffected side
experience between testers would still have caused this first.

REFERENCES 12. B G. Leggin, L A. Michener, Michael A. S, Susan

K. B, Joseph P,Gerald R. Williams Jr, The Penn
1. Urwin M, Synons D, Allison T, Brammah TH, Shoulder Score: Reliability and Validity. J Orthop
Roxby M. Estimating the burden of Sports Phys Ther. 2006; 36: 138-151.
musculoskeletal disorders in the community: 13. Mark. A Jones. Personal communication through
the comparative prevalence of symptoms at e mail, Mark.Jones@unisa.edu.au to tester
different anatomical sites, and the relation to 14. Beaton, Dorcas E. B, Claire G, Francis F, Marcos
social deprivation. Ann Rheum Dis.1998; 57: B. Guidelines for the Process of Cross-Cultural
649-655. Adaptation of Self-Report Measures. Spine.2000;
2. Craig L .Self-management of shoulder disorders 25: 3186-3191.
Part 1. J Bodyw Mov Ther. 2005 ; 9: 189-197 15. Daniela G, Saul M P, Patrcia M Z, Maria L R J,
3. Green S, Buchbinder R, Hetrick S. Physiotherapy Gianfilippo M C, Isabela A P, Paul J. Cross-
interventions for shoulder pain. Cochrane cultural adaptation of the Child Perceptions
Database Syst Rev. 2003; 2. Questionnaire 11-14 (CPQ 11-14) for the Brazilian
4. B. Goldstein. Shoulder anatomy and Portuguese language. Health Qual Life
biomechanics. Phys Med Rehabil Clin N Am. Outcomes. 2008, 6: 2-8.
2004; 15: 313-349. 16. Robert A.D. Functional Anatomy and Mechanics.
5. Paul A. B, Kevin G. L, Eric L. S. Mobility and In: Physical Therapy of the Shoulder.3 rd
Stability Adaptations in the Shoulder of the ed.Churchill Livingstone.1997; Chp1:p1-15
Overhead Athlete-A Theoretical and Evidence- 17. Jettie G. N, Anton J. S, Gert J.D. Bergman, Jan C.
Based Perspective. Sports Med. 2008; 38: 17-36. W,Thomas J.B. K, Pieter U. D. Interobserver
6. M.E. Magarey, M.A. Jones. Dynamic evaluation reliability of physical examination of shoulder
and early management of altered motor control girdle. Man Ther. 2009; 14: 152-159.
around the shoulder complex. Man Ther. 2003; 18. W. Munro, R Healy. The validity and accuracy of
84: 195-206. clinical tests used to detect labral pathology of
7. Pamela T, Leanne B, B Vicenzino.The initial effects the shoulder - A systematic review. Man Ther.
of a Mulligans mobilization with movement 2009 ; 14: 119-130.
technique on range of movement and pressure 19. Hughes PC, Taylor NF, Green RA. Most clinical
pain threshold in pain-limited shoulders. Man tests cannot accurately diagnose rotator cuff
Ther. 2008; 13: 37-42. pathology: a systematic review. Aust J Physiother.
8. L P Diederichsen, J Nrregaard, Poul D-P , A 2008; 54: 159-170.
Winther, Goran T, T Bandholma, L R Rasmussen, 20. Wayne A. Dessaur, M.E. Magarey. Diagnostic
Michael K. The activity pattern of shoulder Accuracy of Clinical Tests for Superior Labral
muscles in subjects with and without subacromial Anterior Posterior Lesions: A Systematic Review
impingement. J Electromyogr Kinesiol. (2008- .Orthop Sports Phys Ther. 2008; 38: 341-352.
article in press) doi: 10.1016/j. jelekin. 2008.08.006 21. Gert J.D. Bergman, Jan C. Winters, Klaas H. G,
9. Marie A J, Zita G King. Differential Soft Tissue Jan J.M. Pool; Betty M J, Klaas P, Geert J.M.G.
Diagnosis.In:Robert A Donatelli, editor. Physical van der Heijden. Manipulative Therapy in
Therapy of the Shoulder.3 rd ed.Churchill Addition to Usual Medical Care for Patients with
Livingstone. 1997; Chp3: p-76-78. Shoulder Dysfunction and Pain. Ann Intern Med.
10. M. J. Comerford, S. L. Mottram. Movement and 2004; 141: 432-439.
Stability Dysfunction - Contemporary 22. Kyle B. K, Frank B. U, Carl G. M, Arthur J. N,
Developments. Man Ther. 2001; 6: 15-26. Terry R. M. A comparison of select trunk muscle
11. M.E. Magarey, M.A. Jones. Specific Evaluation of thickness change between subjects with low back
the Function of Force Couples Relevant for pain classified in the treatment-based
Stabilization of the Glenohumeral Joint. Man classification system and asymptomatic controls.
Ther. 2003; 84: 247-253. Orthop Sports Phys Ther. 2007; 37: 596-607.

A Randomised Controlled Trial of Stimulation of Triceps

as an Adjunct to Motor Training of Paretic Arm in
Stroke Patients
Uma Prabhu1, Archana Gore2, Saraswati Iyer3, Amita Mehta4, RajashreeNaik5

1
Physiotherapist at Lilavati Hospital, Bandra, Mumbai, 2Assistant Professor, 3Professor, 4Professor HOD, PT school
and center, Seth GSMC and KEMH, 5Professor, HOD PT LTMMC, Sion Hospital
ABSTRACT
Backrground: 30-60% of patients with stroke have no arm function.Spasticity causes hyperactivity in
those muscles that can lead to decreased activity of their antagonists. Thus biceps spasticity can
cause reduced control of triceps amounting to reduced reach function which is usually an important
therapeutic goal.
Some studies have evaluated efficacy of electrical stimulation (ES) on spasticity.
Aims: Purpose of the trial was to assess effect of stimulation of triceps on forward reach distancein
stroke patients.
Settings and Design: Prospective, analytical, experimental, randomized and open trial done in
Physiotherapy OPD of a tertiary care hospital.
Methods and Material: 50 post stroke patients, in the age group of 30 to 60year withspasticity of
shoulder, elbow, wrist and hand muscles of affected extremity up to grade 2 on Ashworth Scale and
Brunnstrom sequential recovery stage 3 or 4; were assessed for modified Tardieu Scale(MTS), active
elbow extension range at elbow(AROM) and forward reach distance(FRD). They were randomly
assigned to either of the Conventional (CG) or Experimental Group (EG). CG received motor training
only whereas the EG received motor training and ES to triceps on affected upper extremity. After 3
weeks they were evaluated again for the above outcomes.
Statistical tests were non-parametric tests as the data obtained was not normally distributed, as
analyzed using Shapiro-Wilk test for normality. Wilcoxon Sign rank test for comparing medians in
all 3 outcome measures. Mann Whitney test was also used to compare percent mean differences in
both groups for all 3 outcome measures.
Results: FRD, AROM and MTS improved after 3 weeks in CG with significance of p-value of 0.0122
each and in experimental group with significance of p-value of 0.0121 each. FRD showed insignificant
change between groups with p-value of 0.207. The mean percent difference in MTS, AROM and FRD
was 0.007, 0.007 and 0.977 respectively.
Conclusions: Electrical Stimulation when given to the triceps muscle as an adjunct to the motor
training has shown additional improvement in reducing the biceps spasticity, improving AROM but
not significantly improving the FRD.
Key words: Stroke, Motor Training, Electrical Stimulation.
INTRODUCTION the most significant impairment constraining function

in the patients with stroke. It causes decreased activity
Stroke is the leading cause of neurological disability of their antagonists through reciprocal inhibition. This
in adults. Out of the total stroke survivors, 85% of leads to shortening and alteration of the length
patients have an initial arm sensorimotor dysfunction tension relationship of antagonist muscle. In a study
with impairments persisting in 55 to 75% of cases for by Cheng-Chi Tsao it was shown that the maximum
more than 3 months and 30-60% of patients have no voluntary contraction of elbow extensors was
arm function.1Many Clinicians view spasticity to be
18. Archna gore 26th july 11.doc (88-92).pmd 88 10/16/2012, 2:41 PM

significantly lower in spastic than healthy arms and problems, any cognitive or behavioral abnormalities
inversely correlated with reflex stiffness gain of elbow and skin allergies.
flexors.2 We also have varied views on management
of spasticity and its effect on function. One such Materials used: Electrical stimulator (Electro
treatment method is the ES. It involves the contraction Medica)with 2 plate electrodes, lint pads, Velcro straps,
of innervated yet paretic muscles by electrical belt for trunk stabilization, a universal goniometer,
stimulation of corresponding intact peripheral nerve.3-5 measuring tapeanda plastic blackboard duster.
A Cochrane Database systemic review revealed Study intervention: Synopsis of the study was
insufficient robust data to inform use of ES for neuro- approved by the ethics committee at institution.
muscular re-training. 6 Synder-Macleretal have Sample size of 25 in each group was calculated
described 3 approaches of application, a) stimulation considering prevalence of stroke subjects with desired
of antagonist to the spastic muscle, b)stimulation of inclusion criterions as 0.015, error probability 0.05
spastic muscle itself and c) alternate stimulation of and power of test (1-) 95%. After evaluation the
agonist and antagonist.7 Taylor et al in 2002 had shown subjects included in the study were explained the
that by stimulating the spastic muscle itself, the purpose and written consent was taken from them for
spasticity may be stronger when it returns and hence their active participation. MTS, AROM and FRD were
this method is not preferred.5 Whereas, Santos et al measuredby UP.
2006 has proved that electrical stimulation of
antagonist muscle can reduce spasticity immediately For forward reach distance, subject was seated
following treatment.4 Hence we chose to stimulate the with trunk supported and secured to the back rest of
antagonist muscle i.e. triceps to reduce spasticity in the chair with a belt for minimizing compensatory
biceps. As therapist our goal for patients is always trunk movements. Upper extremity length was
function related. We agree with all the studies on measured from the acromion process till the tip of
electrical stimulation, regarding it as an adjunct to middle finger as per the anthropometric techniques
conventional treatment for motor training. Thus motor by H.V. Vallois. Patients affected upper extremity was
training comprised of myofascial release, weight placed in the initial position of slight abduction and
bearing through upper extremity (WU) and task flexion of shoulder and elbow flexed to 90 degrees with
specific training which included repetition of trunk forearm supported on the table. The hand was placed
restraint reach training (TRRT). FRD was considered in the plane of the shoulder and the point at ulnar
as primary, whereas MTS and AROM were considered styloid was marked as initial position.8 A target was
as secondary outcomes measures respectively.Hence placed at 100% of arms length in the forward plane of
our aim was to evaluate effect of stimulation of triceps the affected shoulder. Patient was then instructed to
on biceps spasticity as an adjunct to motor training of pick up the object (a plastic blackboard duster) kept at
paretic arm in post stroke patients. the initial starting position of the hand and reach as
far as possible towards the target. The point at the ulnar
MATERIAL AND METHODS styloid at the final position of the hand was marked
again and the distance between the two markings
This is a prospective analytical experimental study (initial starting point and the final point) was noted as
with simple randomized sampling done on 50 post the forward reach distance.9
stroke patients, both males and females in the age
group of 30 to 60 years at Physiotherapy OPD of a After pre assessment, they were then
tertiary care hospital from period June 2008- June 2010. randomlyassigned using a computer generated list for
randomization to either of the CG or EG by UP. Both
Inclusion criteria-a) Medically stable patients post groups were given conventional treatment of motor
stroke, after 6 months of diagnosis, b) complete passive training and total time of treatment for every subject
range of motion at elbow of the affected extremity; was 45 minutes for 5 days per week and this for 3
c) spasticity of affected extremity up to grade 2 on weeks.
Ashworth Scale and d) Brunnstrom sequential
recovery stage 3 or 4.3 Myofascial release over biceps muscle was given
with hold of 90-120 seconds, till soft tissue release was
Exclusion criteria for trail were previous felt. WU was given in position of slight shoulder
neurological or any other sensory and sensori-motor abduction and external rotation, elbow extension, and
impairments of affected upper extremity, epilepsy, wrist extension. They were then asked to move the
dementia, cerebellar affection or any perceptual trunk well over the supporting arm, transferring most

of the weight onto the affected hip and hand for 30 A home programme was given to all the
seconds and such 7-8 repetitions. participants in both the groups. This comprised of auto
assisted shoulder, elbow and wrist flexion- extension:
Trunk restraint reaching training was done with weight bearing on affected upper extremity and
the subject in seated position with forearm on chair. A stretching the trunk.
straight line was drawn along the forward plane of
shoulder from the initial starting point. Two other lines After three weeks, assessments of all the
were made at 45 degrees on the ipsilateral and participants were done for the 3 outcome measures.
contralateral side of the initial straight line from the The pre and post intervention measurements were
initial starting point. Targets were placed at 100% of compared and statistical analysis was done.The study
arms length along all three lines. Patient was was performed from June 2008 to June 2010.
instructed to pick up object (a plastic blackboard
duster) from the initial starting position and reach as RESULTS
far as possible along the drawn paths towards the
target at a self-paced speed. The data obtained was not normally distributed as
found by Shapiro-Wilk test for normality.
10 repetitions were given for each of the 3 directions
with a 30 sec pause after each 10 repetitions.8 Both the groups were comparable at the
commencement of the study for the factors such as
In experimental Group 25 subjects were treated age mean 51years and 50 years in CG and EG
first with electrical stimulations for 15 minutes and respectively by Mann-Whitney test, gender- 5 females;
then treated with conventional training. For 20 males and 4 females; 21 males in CG and EG
stimulations, participants were seated on a chair and respectively using Chi-Square test, dominance- left
forearm rested on an arm rest. 2 plate electrodes were sided 12% and 16%; right sided 88% and 84% in CG
strapped at either end of triceps muscle belly and and EG respectively using Chi- Square test and the
electrical stimulation was given using the following time period between stroke onset and commencing the
set of parameters: study mean 19.68 and 19.72 months in CG and EG
respectively using Mann-Whitney test; as there was
Frequency: 50 Hz, Duration: 0.3ms, On: Off time no statistical significance.
2sec: 2sec, Time: 15 minutesAmplitude: adjusted for
every subject to intensity such that minimal muscle
contraction was present.9
Table 1. Comparison between medians of outcome measures in Conventional group and Experimental group before
and after intervention. (Wilcoxon Sign Rank test)
Outcome Conventional Significance Experimental Significance
measure
Pre Post Difference Pre Post Difference
MTS 101 70 31 0.0122(S) 97 36 41 0.0121(S)
AROM 45 92 47 0.0122(S) 51 118 67 0.0121(S)
FRD 8.1 20 11.9 0.0122(S) 9.1 21.6 11.5 0.0121(S)
MTS-modified Tardieu scale; AROM active range of motion for extension; FRD-forward reach distance
All the 3 outcome measures have significantly improved post intervention in conventional therapy group
and experimental group as shown in Table 1.
Table 2. Forward Reach Distance medians between Conventional and Experimental groups
Pre intervention Post intervention Diff P-value
Conventional Experimental Conventional Experimental Conventional Experimental
8.1 9.1 20 21.6 11.6 12.5 0.207i.e. NS
Statistical analysis of pre to post intervention in the measurements of Forward reach distance between
groups showed no statistically significant difference as seen in Table 2.

Table 3. Mean difference (%) of outcome measures between Conventional and Experimental groups pre and post
intervention
Outcome measures Conventional Experimental Difference SignificanceP-value
MTS 27.7 62.1 34.5 0.007 (S)
AROM 51.6 55.7 4.1 0.007 (S)
FRD 58.5 59.4 0.9 0.977 (NS)
MTS-modified Tardieu scale; AROM active range of motion for extension; FRD-forward reach distance
Table 3 shows MTS, AROM have improved but FRD has not improved statistically.
DISCUSSION contraction.12,13 Thus, electrical stimulation of triceps

reduces biceps spasticity, also seen by improvement
Optimal functional recovery is the ultimate aim of in MTS. And this in turn decreased the inhibitory
neuro-rehabilitation after acute brain lesion. In effects on the triceps leading to increased recruitment
response to intervention, functional or adaptive of motor units. It also served to reset the balance
recovery takes place. In our study, both the between flexor and extensor tone thus allowing active
conventional and the experimental groups were given contraction of the agonist with less effort than
treatment interventions. We will discuss the study previously required in the presence of increased
under 3 domains; effects of conventional therapy, spasticity.14,15 Both of these led to improvement in the
effects of electrical stimulation and forward reach AROM (of extension).
distance as an outcome measure.
FRD as an outcome measure has improved in both
In CG and EG, all 3 outcome measures MTS, groups by 58.5% and 59.5% respectively. One
AROM and FRD have improved.Our subjects had important distinction characterizing the movement in
complete passive range at elbow. So, myofascial release stroke subjects is the non-typical use of trunk for
could have helped in altering structural alignment reaching a target placed well within the range of arms
within the muscle and to some extent, reducing reach. Use of trunk restraint as a treatment paradigm
spasticity. WB helps in normalizing tone.10 This is aimed at decreasing compensatory strategies and
because of activation of elbow joint receptors causing along with the goal directed movements it improved
inhibition of biceps spasticity; and slow stretching of the inter-joint coordination. It also led to forced use of
biceps thereby causing relaxation and decreased the affected upper extremity thus, making active use
spasticity as suggested by Brenda Brower et al. The of the affected extremity for accomplishing the
cutaneous and proprioceptive inputs can markedly reaching task. The underlying normal patterns of
increase magnitude of cortically evoked responses and movement coordination were thus uncovered to
reduction in homonymous group 2 inhibition maximize function. Also repetitive training would
associated with maintained stretch of spastic flexors.11 have caused increased recruitment of the triceps
In ES group, ES along with conventional training muscle and reaching movements using increased
caused improvement in MTS, AROM and FRD. When angular ranges obtained by this method are made in a
a muscle contracts, activity in the muscle spindles is more coordinated way.
relayed via inhibitory interneurons to the alpha motor As a study question, we analyzed the effectiveness
neurons of the antagonist muscle reducing its activity. of electrical stimulations, by comparing both groups
The essence of Sherringtons principle of reciprocal using Mann-Whitney test for their mean differences.
innervation is that, during contraction of agonist Here MTS and AROM have significantly improved,
muscles, the antagonists do not behave passively, but both with p-value of 0.007.
are actively inhibited by central nervous mechanisms.
When the agonist muscle is activated, its spindle 1a Butfor FRD p-value is 0.977 which is not significant.
afferent discharge, through action of the gamma loop Levin et.al defined articular ranges in which
may increase and feedback is send to the spinal cord hemiparetic patients could make isolated elbow flexion
to inhibit antagonist muscles, peripherally via the 1a and extension movements byusing a reciprocal muscle
inhibitory interneuron. 1a afferents and inhibitory activation pattern which mainly took place in the
neurons are of larger diameter, they require only low midrange. Movement beyond this range required more
level of stimulation to excite them, so will always be effort and is accompaniedby a pattern of excessive
excited even if stimulation produces only a small agonist/antagonist co-activation. FRD assessment in

our subjects required this mid-range to outer range stroke, Cochrane Database Systemic Rev. April,
movement. ES could not, in addition to motor training 2006; ( 2): CD003241.
improve the FRD. 7. Andrew J. Robinson, Robinson, Lynn Snyder-
Mackler Clinical Electrophysiology:
CONCLUSION Electrotherapy and Electrophysiologic Testing.
Lippincott Williams & Wilkins; 2nd edition, Jan
Electrical Stimulation when given to the triceps 1994.
muscle as an adjunct to the motor training has shown 8. Darcy S Reisman and John P.Scholz. Aspects of
additional improvement in reducing the biceps joint coordination are preserved during pointing
spasticity, improving elbow active extension range but in persons with post stroke hemiparesis. Brain
not significantly effective in improving the forward Nov 2003;126(11): 2510-2527.
reach distance. 9. Stella M. Michaelsen, DEA Mindy F. Levin, PhD.
Short-Term Effects of Practice with Trunk
Restraint on Reaching Movements in Patients
ACKNOWLEDGEMENTS with Chronic Stroke A Controlled Trial. Stroke
To all the patients who contributed in the study. 2004; 35: 1914.
10. Brenda J. Brouwer, Philip Ambury. Upper
Conflict of Interest: - none extremity weight bearing effect on corticospinal
excitability following stroke. Archives Physical
medicine and Rehabilitation 1994; 75: 861-866.
11. Sung Ho Jang, Sung H You, Sang Ho Ahn.
REFERENCES Neurorehabilitation-induced cortical
1. Wade DT, Heller A, wood VA, Sunderland A. reorganization in brain injury: A 14-month
Arm Function after Stroke: Measurement and longitudinal follow-up study. Neuro
recovery over 1st three months. Journal Neurol Rehabilitation 2007; 22(2):117-122.
Neurosurgery Psychiatry, 1987 Jan; 50(6): 714-719. 12. Amir H Bakhtiary, Does electrical stimulation
2. Cheng-Chi TsaoandMehdi M Mirbagheri Upper reduce spasticity after stroke? A Randomized
limb impairments associated with spasticity in controlled study. Clinical Rehabilitation, 22; 5:
neurological disorders. Journal of Neuro 418-425, 2008.
Engineering and Rehabilitation November 2007, 4:45 13. Scott D. Bennie,Jerrold S. Petrofsky, Jodi Nisperos,
3. de Kroon JR, IJzerman MJ, Lankhorst GJ, Zilvold Mitchell Tsurudome and Mike Laymon.Towards
G. Electrical stimulation of the upper limb in the optimal waveform for electrical stimulation
stroke: stimulation of the extensors of the hand of human muscle.European Journal of Applied
vs. alternate stimulation of flexors and extensors. PhysiologyNovember 01, 2002, Page(s) 13-19.
Am J Phys Med Rehab 2004 Aug; 83(8): 592-600. 14. Joanna Powell, MCSP; A. David Pandyan, PhD;
4. Santos M, Zahner LH, Mckiernan BJ, Malcolm Granat, PhD; Margaret Cameron, MCSP
Neuromuscular electrical stimulation improves David J. Stott, MD. Electrical Stimulation of Wrist
severe hand dysfunction for individuals with Extensors in Post stroke Hemiplegia. Stroke 1999;
chronic Stroke: A pilot Study. Journal of 30: 1384-1389.
NeurolPhys Therapy 2006; 30: 175-183. 15. John Chae, MD; Francois Bethoux, MD; Theresa
5. P Taylor, G. Mann, C. Johnson, L Malone. Upper Bohinc, OTR; LoreenDobos, PT; Tina Davis, OTR;
limb electrical stimulation exercises. SalisburyFES Amy Friedl, OTR. Neuromuscular Stimulation
Newsletter, Jan 2002. for Upper Extremity Motor and Functional
6. VM Pomeroy, L King, A Pollock, A Baily-Hallam, Recovery in Acute Hemiplegia. Stroke 1998; 29:
P Langhorne. Electrostimulation for promoting 975-979.
recovery of movement or functional ability after

The Effect of Task Oriented Training on Hand Functions in
Stroke Patients- A Randomized Control Trial
Chandan Kumar1, Ruchika Goyal2,

1
(PT) Assistant Professor M. M. Institute of Physiotherapy & Rehabilitation Mullana, Ambala,
3
M.P.T (Neurology-Student) M. M. Institute of Physiotherapy and Rehabilitation, Mullana, Ambala
ABSTRACT
Purpose: The goal of this study is to find out the effect of task oriented training on hand functions in
stroke patients.
Methodology: This was an experimental study of 30 stroke patients with unilateral involvement,
with paresis of hand. All the subjects were enrolled in identical subgroup and divided into two equal
groups (15 patient in each group) one control group (A) and another experimental group(B).
Experimental group receive task oriented training and control group receive conventional
physiotherapy training.
We assessed the hand functions (Gross and Fine manual dexterity) by Box and Block test and Nine
hole peg test respectively and tried to find out the additional effect of task oriented training on hand
functions .
Results: Result shows that, both the group improved significantly but task oriented training group
improved much better than conventional training group.
Conclusions: This study suggests that task oriented is more effective as compare to the conventional
training for the hand functions in stroke patients.
Key words: Task Oriented Training, Gross Manual Dexterity, Fine manual Dexterity.
INTRODUCTION THE COMMON NEUROLOGICAL

IMPAIRMENTS DUE TO STROKE ARE
Stroke affects 15 million people in the world each
year and approximately one-third will live with the Motor impairments are most prevalent of all deficits
sequel of this disease1.After coronary heart disease seen after stroke, usually with involvement of the face,
(CHD) and cancer of all types, stroke is the third arm and leg (hemiparesis) alone or in various
commonest cause of death worldwide. However combinations, which include involvement of cranial
unlike the Caucasians, Asians have a lower rate of nerves, muscle power and tone, reflexes, balance, gait,
CHD and a higher prevalence of stroke2. Stroke is one co ordination and apraxia.5 Most common sensory
of the 10 highest contributors of Medicare costs and losses include asterognosis, agraphia, barognosis,
among elderly, stroke and transient ischemic attacks kinesthesia, tactile extinction and two point
are leading causes of hospitalization3. discrimination6.
The definition of stroke originates with the World The stroke causes the inability to understand and
Health Organization (WHO) and dates back to 1980 express emotions. Common speech disorder that are
(1): which states that Rapidly developing clinical signs seen include aphasia, dysphasia. Dysphasia may be
of focal (at times global) disturbance of cerebral exhibited by disturbances in comprehension, naming,
function, lasting more than 24 hours or leading to death repetition, fluency, reading or writing7.
with no apparent cause other than that of vascular
origin4. Hemiparesis represent the dominant functionally
limiting symptoms in 80% of patients with acute stroke
19 chandan kumar 14th april 12 (93-97).pmd 93 10/16/2012, 2:41 PM

within 2-5 months after stroke; patients recover a immobilization and improve ADL skill at the earliest.
Variable degree of function, depending on the This helps in preventing contractures and
magnitude of the initial deficit. Arm recovery after development of abnormal postures.14 The purpose of
stroke is typically poor; with 20% to 80% of patients this study is to find out that how much task oriented
showing incomplete recovery depends on the initial training is effective as compared to the conventional
impairment. training in functional recovery of hand in stroke
rehabilitation.
Upper limb dysfunction in stroke is characterized
by paresis, loss of manual dexterity, and movement
METHODOLOGY
abnormalities that may impact considerably on the
performance of ADLs.8 Total 30 patients of stroke were selected from M.M
hospital Mullana and nearby areas. For patient
Grasping, holding, and manipulation objects are selection purposive sampling was done. The total
daily functions that remain Deficient in 55% to 75% of 30 patient were divided into two equal groups
patient 3 to 6 months poststroke.8 (15 patients in each group), one experimental and
After rehabilitation 9% of patients with severe UE another control group. Experimental group received
weakness at onset may gain good recovery of hand task oriented training and control group received
function. As many as 70% of patients showing some conventional physiotherapy training.
motor recovery in the hand by 4 weeks make a full or
good recovery8. INCLUSION CRITERIA
Grasping, holding, and manipulation objects are 1. Age group=40-70 years.

daily functions that remain Deficient in 55% to 75% of 2. Both males and females included.
patient 3 to 6 months poststroke.9 3. Duration of stroke within 30 150 days
(1-5 months), prior to start of study.
VARIOUS TREATMENT APPROACHES 4. Paresis in upper extremity and Hand
FOR HEMIPARESIS 5. First time stroke survivors.
6. Able and willing to participate in the study of 6
In physiotherapy a variety of movement therapy weeks and to sign consent form.
approaches are available for retraining motor skill in
adult patients with hemiparesis. Certain approaches EXCLUSION CRITERIA
like proprioceptive neuromuscular facilitation, Rood,
Brunnstrom, and Bobath relay on reflex and 1. Any associated medical and high risk
hierarchical theories of motor control and motor cardiovascular diseases.
learning as well as the principles of neural plasticity.11 2. Any musculoskeletal impairment of upper
extremity.
TASK ORIENTED TRAINING 3. Any neurological pain or disorder limiting the
movement.
Task oriented training is newer approach. Task- 4. MMSE less than 23.
oriented training involves practicing real-life tasks, 5. Still enrolled in any form of physiotherapy
with the intention of acquiring or reacquiring a skill treatment.
(defined by consistency, flexibility and efficiency).12
The tasks should be challenging and progressively PROCEDURE
adapted and should involve active participation (Wolf
& Winstein, 2009). Previous studies done on task Thirty patients of stroke who fulfill the inclusion
oriented training has advocated the different effects criteria were included in this study. Total numbers of
of it in stroke patients13. But currently available data patients were divided into two equal groups, one
do not definitively answer all the questions. Therefore, experimental group and another control group.
to obtain a clear characterization of effectiveness of task Each group contained 15 patients. The task oriented
oriented training a research study was required. training for upper extremities had given to the
experimental group and conventional training for
CONVENTIONAL PHYSIOTHERAPY upper extremity had given to the control group. All
TRAINING participants were evaluated by Box and Block test and
Nine Hole Peg test for gross and fine manual dexterity
These exercises prevent complications of respectively.

Box and Block test (BBT) elbow joint, wrist joint, metacarpophalangeal joints
and interphalangeal joints with the use of upper
This instrument is designed to measure the gross extremities.
manual dexterity of hand in stroke patients. It
consists of a wooden/cardboard box having two After active movements patients were made to start
compartments and some small wooden blocks in it. weight bearing, strength training reaching activities
The number of blocks displaced from one with the use of upper extremity and at last patients
compartment to another in one minute is recorded as was performed ADL activities (e.g. dressing and self
reading/score/value15. feeding activities).
Nine Hole peg test (9HPT) These exercises start with simple movements and
subsequently complex movements and actions are
This instrument is designed to measure the fine tried.
manual dexterity of hand in stroke patients. It consists
of a wooden base having nine holes in it and nine All the exercises were performed in 90 minutes.
dowels/pegs are provided separately with it. Time to There was no subdivision of time for each activity.
place nine dowels in holes and then removing them is Patients were performed exercises on the bases of their
noted in seconds and is recorded as reading/score/ motor control for 90 minutes in a day and 3 days in a
value15. week for 6 weeks.
Mini mental status scale is a reliable and valid scale Data and Statistical Analyses
to asses the mental status of subjects used in this
study.16 Comparison was performed between both the
groups first at baseline level. Then again, comparisons
At the first, the patients were informed about the were done at discharge level as well as from baseline
purpose, procedure, possible discomforts, risks and to discharge level and results were noted. Paired T test
benefits of the study prior to obtaining an informed was used for analyzed the pre to post changes within
written consent from the patient. the groups. Unpaired T test was used to analyze the
changes between the two groups. Data was analyzed
All patients were first assessed by Mini-Metal using SPSS 17.
status scale to know the mental status.
After that all patients were assessed by Box and RESULTS

block test and Nine hole peg test. The subjects were
We successfully matched 30 patients of both control
asked not to participate in any other study or
and experimental group for hand functions. First we
physiotherapy treatment for hand functions from for
compared demographic and functional data of the age
the duration of the study and to follow the designated
matched subgroup. Analysis comparison was done
protocol.
between both the groups first at base line and then at
Treatment protocol the end of intervention.
Experimental Group Baselines characteristics of both the group are

shown in table1.cheracteristic of both the groups were
All subjects in this group performed task oriented same at the base line level prior to intervention.
exercises which contain both simple and complex task
programs with attending therapist. The task oriented Table 1. Baseline Characteristics of both the Group.
training protocol was inspired by Gad Alon et al.13 was Group A B
a standardized protocol .Components of task oriented Age Mean S.D 55.93 9.08 56.67 9.05
protocol included were range of motion exercises, Values t=0.22 P=0.82
weight bearing and supporting reactions, reaching Gender M 9(60%) 8(53.3%)
holding and releasing activities and activities of daily F 6(40%) 7(46.6%)
living involving use of hand. Side
Affected L 8(53.3%) 7(46.6%)
R 7(46.6%) 8(53.3%)
Control Group
Type
of Stroke I 5(33.3%) 9(60%)
All subjects in this group performed exercises based
H 10(66.6%) 6(40%)
on conventional physiotherapy. Patients of the
conventional PT training group were made to start of M-Male, F-Female, L-Left, R-Right, I-Ischemic, H-
exercise from passive/ active movements of all the Hemorrhagic
joints of upper extremities including shoulder joint,

This table shows that before intervention there was training group improved much better than task
no significant difference of Box and block test score oriented training. The overall evaluation of data
(p=0.59) and nine hole peg test score (p=0.87) between suggests that the gross manual dexterity has been
the groups. improved more in task oriented training group
(experimental group), whereas fine manual dexterity
Table 2. Box and block test Scores of both the group
has been improved clinically but not statistically in
before and after intervention
between group comparison post intervention, but
Group Before treatment After treatment p value
within group results are statistically significant.
A 6.00 8.00 0.0001
B 5.67 10.33 0.0001
The results of the study are consistent with
Above table shows that after intervention there was the previous studies done on task oriented
significant difference in both the groups. training.11-13 & 17.
TABLE 3. Nine hole peg test score of both the group The task oriented training is based on the motor
before and after intervention programming theory of motor control and system
Group before after P theory. The former theory puts an emphasis on the
Intervention intervention value special neural circuits known as central pattern
A 73.40 72.87 0.00610. generators (CPJ). The practice play important role in
B 74.47 71.93 0001 strong engrams formation in the brain. The task
oriented training focuses on the intention of acquiring
or reacquiring a skill (defined by consistency, flexibility
Above table shows that after the intervention there and efficiency) important to a functional task rather
was significant difference between the groups ( p value than educating the specific muscles in isolation hence
- .001). it is a functional approach. In this approach, movement
TABLE 4. BBT and 9HPT scores of both the is organized around a behavioral goal; thus multiple
group after intervention systems are organized according to the inherent
Group BBT score after P value 9HPT after P value requirements of the task being performed. In this
intervention intervention approach, the patient is working on functional tasks
A 8.00 0.0007 72.87 0.89 rather than on movement patterns for movement alone
B 10.33 71.93
as compared to conventional physiotherapy.
Above table is showing the BBT and 9HPT scores The significant results in task oriented training
after treatment in both the groups. Independent t test group also may be due to more motor unit recruitment
was to analyses data in between the groups and being activated as the patient is practicing the same
dependent t test was used to analyze the data within functional task again and again. Task oriented
the groups. approach leads to acquisition of new skills as patient
gets feedback simultaneously which leads to better
The evaluated data suggest that the gross manual learning of activities of daily living. The results for fine
dexterity has been more improved in task oriented manual dexterity are clinically significant at post
group (experimental group=0.0007).whereas fine intervention level but are not statistically significant.
manual dexterity has been improved clinically but not The gain in changes was small and also may be due to
statistically in between group comparison (p=0.89) but the fact that nine whole peg test is not a very sensitive
within group results are statistically significant. measure to analyze such small changes of fine manual
dexterity in hemiparetic patients. Moreover the test
DISCUSSION used the time values that too in seconds which is
further a very specific count.
In this experimental design study, result shows the
effects of task oriented training as compare to the
conventional training on hand functions in stroke CLINICAL IMPLICATION
patients. The results support the hypothesis that task This treatment will help the patients to enhance the
oriented training is more effective for hand functions functional recovery of hand in stroke patients and
in stroke patients as compare to the conventional increased functional recovery will provide the
training. Although both the groups task oriented improvement in quality of life. So, task oriented
training and conventional training improved approach can be used clinically as it will be much easier
significantly post intervention, but task oriented to perform, safer and convenient for patients.

Limitations of a Study 8. Sherry H. Post stroke speech disorders; 2011.

9. Alexander w. Dromerisk, Catherine G. Lang,
The sample size used in this study was small so Robecca. Brikenmeirer, Michael G. Hahn.
that result is not generalized. There is no follow up Relationships between upper limb functional
period after 6 weeks, so it may be another limitation limitation and self. Reported disability 3 months
of the study. The measure of fine manual dexterity was after stroke. Journal of Rehabilitation Research
not appropriate. and development 2006; 43: 401-405.
10. Gad Alan, Alon F. Leritt, Patricia A. Mc Corthy.
Future Scope of Study Functional electric stimulation enhancement of
upper extremity functional recovery during
Follow-ups can be done to see the long term effects
stroke Rehabilitation: A pilot study. Neurorehabil
of training. The initial degree of level of deficit can be Neural Repair 2007; 21 (3): 1-9.
taken. More sensitive measure can be used to 11. Dickstein R: Contemporary exercise therapy
determine fine manual dexterity. Study can be approaches in stroke Rehabilitation ritical
replicated by molding the treatment protocol and large Reviews in Physical and Rehabilitation Medicine
sample size can be taken. 1989; 1:161 181.
12. NorineFoley , Robert Teasell , Jeffrey Jutai ,
CONCLUSION SanjitBhogal , Elizabeth Kruger , Cauraugh and
Kim(2003). Upper Extremity Interventions
This study suggests that task oriented training is TheEvidence-BasedReview of Stroke
more effective as compare to the conventional training Rehabilitation reviews current practices in stroke
for the functional recovery of hand in stroke patients. rehabilitation.2011;24-28
13. Winstein CJ, Rose DK, Tan SM, Lewthwaite R,
REFERENCES Chui HC, Azen SP. (2004). A randomized
controlled comparison of upper-extremity
1. World Health Organization. The WHO stroke rehabilitation strategies in acute stroke: A pilot
surveillance... 2004. World study of immediate and long-term outcomes.
2. Health Organization. 29-7-2004. Arch Phys Med Rehabil, 85(4), 620-628.
3. Shyamal K. Das, Tapes K. Banrejee. 14. Gad Alon, F. Levitt et al. Functional electrical
Epidemiology of stroke in India. Neurology Asia stimulation enhancement of upper extremity
2006; 11:1-4. during stroke rehabilitation A Pilot study.
4. Judith h. Lichtman, EricaC.Leifheit-Limson, Sara Neuro Rehabilitation and Neural Repair 2007;
B, ones Michael, S. Phipps, L.B. Goldstein. 21:207.
Predictors of hospital readmissions after stroke 15. Dickstein R. Hocherman S. Pillar T el at: Stroke
2010; 41: 2525-2533. rehabilitation. Three exercise Therapy
5. Aho K, Harmsen P, Hatano S, et al. approaches. Phys Therapy: 1986; 66: 1233 1238.
Cerebrovascular disease in the community: 16. Mathiowetz et al. Box and block test information
results of a WHO collaborative study. Bull WHO and nine hole peg test information 1985.
1980; 58: 113 130. 17. Folstein MF, Folstein SE, McHugh PR (1975).
6. C. Collin and D. Wade. Asessory Motor Mini-mental state. A practical method for
impairment after stroke Journal of Neural, grading the cognitive state of patients for the
Neurosurgery and psychiatry. 1990; 53 (7): 576- clinician. Journal of psychiatric research 12 (3):
579. 189198.
7. Lee Anne M. Carey et al. Frequency of 18. Higgins J, Salbach NM, Wood-Dauphinee S,
Discriminative sensory loss in the hand after Richards CL, Cote R, Mayo NE. (2006). The effect
stroke in a rehabilitation setting. J Rehab Med 2010; of a task-oriented intervention on arm function
43:82-88. in people with stroke: a randomized controlled
trial. Clin Rehabil, 20(4), 296-310.

Effects of Three Weeks Plyometrics on Sprint Velocity
Jagdeep Kaur Dhamija1, Jaspreet Singh Vij2, Rajesh Gautam3

1
Asst. Prof., Department of Physiotherapy, Lyallpur Khalsa College, Jalandhar (Punjab) India
2
Professor and Coordinator, Department of Physiotherapy, LPU, Phagwara (Punjab)
3
Asst. Prof., Department of Physiotherapy, Lyallpur Khalsa College, Jalandhar (Punjab) India
ABSTRACT
In Plyometrics the muscles store energy during the landing (stretching phase) which is released in
the immediate rebound. The stretching during the lowering stimulates the nervous tissue within the
muscles. This result in a greater number of muscle fibers called into action and stimulates closely the
situations like sprinting. The study analyzed the effect of plyometrics on sprint velocity in male
sprinters of 20-25 years with minimum of one year athletic background. Out of 30 male subjects aged
between 20-25 years, 15 were selected conveniently for experimental group (GROUP B) and 15
randomly for control group (GROUP A). For both the groups 3 week research was done. The training
session was held once a week. On each training day both the control group and experimental group
started their warm up exercises for 40 minutes. After the warm up the experimental group were
subjected to Plyometrics. The assessment of running time through 60 meter was assessed after every
week. On comparing the both groups it was found that both groups show statistically insignificant
improvement after week 1 but experimental group show statistically significant improvement after
week 2 and week 3 as compared to control group
Key words: Plyometrics, Sprint, Sprinters, Sprint velocity
INTRODUCTION the 4 x 400 meter relay. Although the sprints are events
in themselves, the ability to sprint is an important
Plyometrics are training techniques used by weapon in an athletes any sports. Sprint training or
athletes in all types of sports to increase strength and speed training is the ability to perform at high
explosiveness1. Plyometrics consists of a rapid stretch frequency. Maximum Plyometric program efficiency
shortening cycle 2 .It involves eccentric loading and injury prevention depends on the logical
immediately followed by a concentric contraction. progression of exercise intensity7.
Plyometrics is a method of developing explosive
power by shortening the amortization phase3. Thats Methodology
why it is an important component of most athletic
performances. It is a combination of exercises The research design is experimental.
incorporating skipping, hopping, jumping and The data was collected from the athletic population
throwing exercises etc. Plyometrics training is from lovely college of physical education .In the
commonly adapted in sprint running and many other present study Random sampling through chit system
sports to develop leg extensor strength and power4. was used.
These exercises have been credited with inducing
neuromuscular adaptations to the stretch reflex, Inclusion criteria: No previous Plyometrics
elasticity of muscle, and Golgi tendon organs. The training.
stretching of the muscle prior to subsequent Males aged 20-30 years with professional
contraction enhances utilization of muscle properties background in sprint run.
and has positive effect in the velocity at a certain
concentric level 5. Researchers have shown that Being involved in athletics for minimum of 3 years
Plyometric training can improve the strength and Exclusion criteria: Athletic background of less than
explosiveness of performance in as little as 6 weeks 6. three years
The sprints cover the following track events: 100 Subjects with any systemic disease like visceral
meters, 200 meters, 400 meters, 4 x 100 meter relay and pathology.
20 Jagdeep Dhamija 24th sept (98-100).pmd 98 10/16/2012, 2:41 PM

Subjects with traumatic injury of bones, muscles, Two sets of double leg bound on and off 6 to 8 (30
ligaments, tendons -80cm height) box with 3 min rest between the sets.
Subjects with any kind of muscular, bony, visceral Findings
pain
Statistics were performed by using SPSS 11. Results
Subjects involved in any other specific and major were calculated at 0.05 level of significance.
conditioning or training program like circuit training
program, weight lifting program, endurance Table 1. Mean and standard deviation for the variable
development program, progressive resisted exercise at different sessions (0, 1, 2 and 3 weeks) for Group A
training. Variable Mean SD
0 week 9.15 1.24
Demographic profile and detailed medical history 1 week 9.44 1.12
was taken through individual interview and past 2 week 9.18 0.93
medical history. After one week of conditioning 3 week 9.20 0.74
session, all subjects underwent pre training sprint
velocity assessment through 60 meter distance at their Table 2. Mean and standard deviation for the variable
maximum speeds. The time taken by each subject to at different sessions (0, 1, 2 and 3 weeks) for Group B
cover 60 meter track was recorded with the help of Variable Mean SD
electronic stop watch. Out of 30 male subjects aged 0 week 8.82 0.69
between 20-25 years, 15 were selected conveniently for 1 week 8.60 0.56
experimental group and 15 randomly for control 2 week 8.33 0.87
group. The following plyometrics regimen was 3 week 8.27 0.86
implemented and the assessment of running time
through 60 m was assessed after every week 8. Table 3. Comparison of mean values at different
session for the variable within Group A
Easy Variable t-value p-value
0 week Vs 1 week -1.382 p>0.05
Hop on both feet over a line for 30 sec followed by
0 week Vs 2 week -0.146 p>0.05
rest for 3 min and repeat again.
0 week Vs 3 week -0.207 p>0.05
Hop on one foot over a line for 30 sec followed by 1 week Vs 2 week 1.669 p>0.05
rest for 3 min and repeat again with other leg. 1 week Vs 3 week 1.250 p>0.05
2 week Vs 3 week -0.110 p>0.05
Hop for distance and height with legs, 10
repetitions, and rest for one minute. It can be seen in table 3 that in group A(control
group)shows insignificant results therefore showing
Hop for distance and height on right leg, 10 no improvement whereas in table 4 group
repetitions, and rest for one minute. B(experimental group)shows significant results at
Hop for distance and height on left leg, 10 week 2 and week 3 as compared to 0 week.
repetitions, and rest for 60 sec Table 4. Comparison of mean values at different
session for the variable within Group B
Moderate
Variable t-value p-value
Two sets of 10 depth jumps of (30-80cm height) with 0 week Vs 1 week 1.906 p>0.05
rest of 2 minutes between the sets. 0 week Vs 2 week 2.433 p<0.05
0 week Vs 3 week 2.814 p<0.05
Three sets of tuck jumps for 30 sec with 3 minutes 1 week Vs 2 week 1.329 p>0.05
rest between the sets 1 week Vs 3 week 1.632 p>0.05
2 week Vs 3 week 0.953 p>0.05
Three sets of double leg hurdle hopping (6 hurdles)
of height (12-36 inches) with 90sec rest between the P < 0.05 Significant
sets P > 0.05 Not Significant
Difficult Table 5. Mean diff. (3 week - 0 week) and SD for the

variables of Group A and Group B
Two sets of single leg bounds on each leg on and Variable Group A Group B
off (30-80 cm height) box with 3 minutes rest between Mean diff. SD Mean diff. SD
the sets. 3 week - 0 week 0.04 0.92 - 0.54 0.74

Table 6. Comparison of mean values at different sessions training of moderate and difficult intensity specifically
for the variable between Group A and Group B improves running economy. So it can be interpreted
Variable Mean SD that moderate and difficult level of plyometrics
0 week 0.893 P > 0.05 training helps to improve the sprint velocity in
1 week 2.602 P < 0.05 sprinters receiving plyometrics instead of sprinters not
2 week 2.578 P < 0.05 subjected to plyometrics. Hence plyometrics decreases
3 week 3.118 P < 0.05 the time taken to cover the distance of 60meters and
Mean diff. (3-0) weeks 1.927 P > 0.05
the performance is not noticeable immediately but it
improves with time. Thus plyometrics should be
P < 0.05 Significant included as an important part of training in athletes.
P > 0.05 Not Significant
In the present study the effect of plyometrics ACKNOWLEDGEMENTS

training on sprinters was studied by measuring the Authors wish to express Acknowledgements to
sprint time as pre test (0 week) and post test (1,2,3 Physical education department, its staff and students
week).The two groups were taken as group A(control for permitting to conduct the research and providing
group)and group B(experimental). The result shows various instrumentations for carrying out the research.
that there was statistically significant improvement in
sprint velocity in sprinters of experimental Group and Conflict of Interest: - Nil
statistically insignificant results in sprinters of control
group. On the very 1st week(0 week-week 1) of
REFERENCES
treatment there was statistically insignificant
improvement of sprint velocity in experimental group, 1. Donald A.Chu. Jumping into Plyometrics.
but the results show statistically significant Human Kinetics United graphics; 1998
improvement of sprint velocity after the treatment of 2. Thomas R. Baechle, Roger W. Earle. Essentials of
2 weeks(0 week -2 week) and 3 weeks(0 weel-3 week) strength training and conditioning. Human
from the initial readings of 0 week .On comparing the kinetics;2008
both groups it was found that both groups show 3. Donald A.Chu. Jumping into Plyometric.
statistically insignificant improvement after week 1 but Human Kinetics. United graphics; 1998
experimental group show statistically significant 4. Ademola O Abass. Correlational effect of
improvement after week 2 and week 3 as compared to Plyometric training on leg muscle strength,
control group. endurance and power of characteristics of
Nigerian university undergraduates.
CONCLUSION International journal of African and African
American studies.2005 Jan; 4(1): 42-52.
From the present study it is concluded that 5. Bober T, E Jasklski, and Z. Nowacki. Study on
Plyometrics has statistically significant effect in eccentric-concentric contraction of the upper
increasing the sprint velocity in sprinters. In addition, extremity muscles. Journal of biomechanics.1980
the results support that there was statistically Feb; 13(2): 135-138.
significant improvement in sprint velocity in as little 6. Michael G.Miller, Jeremy J. Herniman, Mark D.
as 3 weeks of plyometrics training. The effect of Richard, Christopher C. Cheatham, Trimothy J.
plyometrics is only significant after 2nd and 3rd week Michael.The effect of 6 weeks Plyometric
and not in 1st week. It is also seen that sprint program on Agility. Journal of Sports Science and
performance did not improved with easy level of Medicine. 2006 June; 5: 459-465.
plyometrics but with progression to moderate, difficult 7. Ralph White and Fletcher Brooks. Plyometric
level the performance was improved. This study Routine. Coaching management. 2005; 13(8):
implementing one Plyometric session in 1 week of 30-31.
Plyometric training improves running economy of 8. William P Ebben. Practical guidelines for
regular but not highly trained distance runners. After Plyometric intensity. NSCA'S performance
searching the literature, it is believe that this is the first training journal.2007 Oct; 6(5): 12-14.
study to demonstrate that a regimen of Plyometric

Perception about Stroke amongst Rural Population in
Maharashtra
Swati Limaye1, Deepak Anap2, Dhiraj Shete3

3
BPT College of Physiotherapy, Pravara Institute of Medical Sciences, Loni (Maharashtra),
1
MPT Associate Professor, 2MPT (CBR) Lecturer, Asst. Professor
ABSTRACT
Background: Prevalence of stroke in India varies in different regions of country and ranges from 40
to 270 per 1,00,000 population. Only one study in India evaluated the perception of warning signs of
stroke and its risk factors. Amount of evidence available with this respect is very low and there is a
need for extensive research.
Method: In this prospective study 600 subjects from Loni, Maharashtra were handed over a multiple
choice questionnaire in the local language that addressed questions regarding warning signs and
risk factors of stroke and sources of information regarding stroke.
Results: Awareness for stroke was considerably low with only 51% subjects being able to recognize
brain as the organ responsible for stroke. Knowledge of risk factors was moderate with 66%
participants being able to establish at least 1 risk factor. Weakness of one side of the body was the
most established warning sign, other warning signs were however less known. Awareness of warning
signs was in direct proportion with educational qualification.
Conclusion: The study revealed that the knowledge regarding the organ involved, warning signs
and some risk factors is lacking in the population. It is important to bring about awareness amongst
the population so as to minimize the long term debilities associated with stroke. Different means of
mass communication should be effectively used in this regard to reach out to the rural Indian
population.
Key words: Stroke, Risk Factors, Warning signs, Awareness
INTRODUCTION 48 hours of onset prevents death or dependency of 13%

patients at 3 month post stroke. However due to lack
Stroke is the third leading cause of the death and of awareness about warning signs of stroke, the acute
the most common cause of disability among adults. stroke therapy proves inefficient.
About 22 percent of men and 25 percent of women
with a stroke will die within 1 year of onset. Of Even in developed countries, like the united state,
survivors an estimated one third one third will be Australia, South Korea and Canada there is recognized
functionally dependent after one year experiencing lack of knowledge in the community about established
difficulty with activities of daily living, ambulation and stroke risk factors and warning signs.
speech. Stroke survivors represent the largest group
admitted to inpatient centers. For stroke, one of the leading causes of death and
disability worldwide, studies about knowledge of
The inability of the patients and the bystanders to warning signs and risk factors have been conducted
recognize stroke signs and symptoms happens to be in several countries involving different populations,
the greatest barrier in providing emergency medical but little is known about factors that contribute to the
care to the stroke patients. perception of stroke risk.
Thrombolytics administered within 3 hours of onset The aim of this study was to examine the influence
prevents death or dependency of 6 % of patients at of existing risk factors on an individuals perception
3 months post stroke. Aspirin administered within of stroke risk.
21 Deepak anap 18th jan 12 (101-105).pmd 101 10/16/2012, 2:41 PM

METHOD Table 1. shows knowledge about the organ

involved. 52% identified brain as the organ responsible
The study participants were randomly approached
for stroke, followed by heart (19%). 2%, 2% and 1%
individuals which included shopkeepers, farmers and
opined lungs, kidney and stomach respectively while
housewives. They were approached door to door and
24% did not know about the organ involved. In a
requested to fill up the questionnaire. The inclusion
multivariate analysis the knowledge of organ
criteria were personal willingness to participate, Oral
involvement was highest among those educated up
consent was obtained. Exclusion criteria was inability
to primary level (72%) and graduates (73%), while the
to read as the questionnaire had to be completed by
values were low amongst 12std standard (41%) and
the participant himself. The survey questionnaire was
secondary (43%) groups. Heart (38%) was a typical
adapted from previous studies (1) with modifications
incorrect answer given by the 12th std group.
by the authors to suit the sociocultural practices. The
questionnaire was translated in the local language Table 1. Knowledge of organ involved.
(Marathi) for easy understanding of the subjects. The Organ Response
questionnaire comprised of two sections. The first Brain 51%
section asked about personal information including Heart 19%
name, age, sex and education. The second section was Kidney 2%
about stroke awareness. The subjects were asked to Lungs 2%
identify the warning signs of stroke and rate the risk Stomach 1%
factors. Lastly they were asked about the media Don't know 24%
through which they got information about stroke. 66% of the participants could identify at least 1 risk
Respondents knowledge of important warning factor The best known risk factors were High blood
signs of stroke was assessed with signs established by pressure(48%), Cigarette smoking(38%), History of
American Stroke Association, which list the following heart disease(31%) and High blood cholesterol (30%)
as important warning signs of stroke in their and the less known were Diabetes(23%) and Previous
educational materials: history of stroke(13%). 51% population rated Mental
stress as an important risk factor while Lack of
(1) sudden numbness or weakness of the face, arm, exercise(47%), Excessive alcohol consumption(42%),
or leg, especially on one side of the body; (2) sudden Old age(40%), Excess caffeine consumption(27%) were
confusion or trouble speaking or understanding the other perceived important risk factors. When asked
speech; (3) sudden trouble seeing in one or both eyes; to identify at least one risk factor, the awareness was
(4) sudden trouble walking, dizziness, or loss of found highest amongst Graduates (86.9%) followed by
balance or coordination; and (5) sudden severe 12std group 86%, secondary(64.7%), Primary(63.6%)
headache with no known cause. and informally educated(40%).
Knowledge of risk factors was assessed using the With respect to the warning signs listed, 81% of
following established risk factors: hypertension, the population could identify at least 1 warning sign.
history of heart disease, previous stroke, excessive The most commonly recognized sign was sudden
alcohol consumption, smoking, psychological stress, numbness or weakness of hand, leg face or half of the
lack of exercise, old age, high blood cholesterol levels, body(82%), followed by sudden difficulty to
diabetes, and excessive caffeine intake. speak(57%), sudden trouble walking, dizziness or loss
of balance(52%). Table 2 gives a bivariate analysis
STATISTICAL ANALYSIS
between educational qualification and ability to
A summary variable Stroke awareness was recognize at least one warning sign.
derived by calculating the percentage of correct
Table 2. Bivariate analysis between educational
answers to the presented risk factors , Stroke warning qualification and ability to recognize at least one
signs and source of information about stroke, for each warning sign
participant.
Education Response
RESULTS Informal 90%
Primary school 72.7%
Of the total 600 individuals contacted 376 Secondary school 76.4%
completed the questionnaire yielding to a response rate 12th standard 76.6%
of 62.6%. 76.4 % males 23.6 %females. 30% were Graduate 86.9%
educated up to 12th standard. Post Graduate 88.8%

DISCUSSION Study16, a cross-sectional study among middle-aged

persons, in which low levels of HDL cholesterol were
Majority of the population correctly identified brain associated with echolucent carotid artery plaques, a
as the organ causing stroke, as opposed to a previous major risk factor for stroke. A study demonstrated that
study1 which reported lack of awareness about the low HDL cholesterol level was associated with a 2.0-
same. fold higher risk of fatal cardiovascular disease (95%
In an observational analysis a considerable confidence interval [CI], 1.2-3.2). Another study
misconception was found between a heart attack and observed inverse relationship between HDL
stroke. The term stroke was found to be commonly cholesterol levels and ischemic stroke in middle-aged
used for emergency conditions related to cardiac Israeli men17.In our study18 the participants knowledge
involvement. On the other hand Paralysis was the demonstrated a direct relation between stroke and
term commonly used with relation to stroke. cholesterol levels, which is coherent with the findings
for HDL cholesterol levels as above. This in turn
Psychological stress was reported as a highest estimates the knowledge of inverse relation between
known risk factor for stroke. This has previously LDL cholesterol level and stroke seems to be lacking.
been reported by only one study till now5. Several However the knowledge about levels of the two types
studies1-4 stated hypertension as an important risk of lipoproteins was not assessed separately in our
factor for Stroke. Similar results were found in our study, owing to the limitations of the language.
study.
The presence of signs or symptoms of coexistent
Lack of exercise was reported amongst the cardiovascular disease have been shown to increase
most important risk factors in our study. Previous stroke risk in many studies19, 22, 21, 22-23. Similar results
studies6-9 have shown an inverse relation between were found in our study. Atrial fibrillation (AF) is a
exercise and risk of stroke. Heart Disease and Stroke powerful risk factor for stroke, independently
Statistics 2011 Update: A Report from the American increasing risk 5-fold throughout all ages.
Heart Association 24 demonstrated a consistent
relationship between higher levels of physical activity The risk of ischemic stroke associated with cigarette
associated with lower stroke risk. smoking has been shown to be approximately double
that of nonsmokers after adjustment for other risk
In our study excess alcohol consumption was also factors (FHS, CHS, Honolulu Heart Program [HHP]24
reported as an important risk factor. In previous A good awareness with this respect was found in our
studies10-13 light and moderate alcohol consumption study. The result could be attributed to the mandatory
was associated with a reduced relative risk of ischemic warning signs on cigarette packets. Smokers living in
stroke whereas heavy alcohol consumption was countries with government mandated warnings
associated with increased relative risk of hemorrhagic reported greater health knowledge. Smokers who
stroke. A meta-regression analysis revealed a noticed the warnings were significantly more likely
significant nonlinear relationship between alcohol to endorse health risks, including lung cancer and heart
consumption and total and ischemic stroke and a linear disease25.
relationship between alcohol consumption and
hemorrhagic stroke. In our study excess coffee consumption was
perceived to be a risk factor for stroke, a possible reason
A previous study14 demonstrated that dementia being increase in systolic blood pressure with
in old age may be an early manifestation of increased coffee consumption, as reported by a
cerebrovascular disease (CVD), that eventually previous study26. However another study suggested
becomes clinically evident as an acute cerebrovascular that habitual coffee consumption of >3 cups/day was
accident, another term for stroke. On The Short not associated with an increased risk of hypertension
Portable Mental Status Questionnaire (SPMSQ) 15 compared with <1 cup/day 27 . Another study
Stroke incidence was lowest in those with normal suggested that decaffeinated coffee consumption may
SPMSQ score, intermediate in those with moderate modestly reduce risk of stroke28.
impairment, and highest in those with severe
impairment. Our study demonstrated a considerable However the knowledge for two major risk factors
awareness regarding the relationship between old age for stroke, Diabetes and History of previous stroke
and stroke. (listed by American Heart Association) was lacking,
the finding being consistent with two other
Confirmatory data were presented in the Troms studies2, 29. This emphasizes the need to generate

specific awareness regarding these two risk factors. 10. Herman B, Schmitz PIM, Leyton ACM, van Luijk
JH, Frenken CWGM, Op de Coul AAW, Schulte
The awareness of warning signs was directly BPM. Multivariate logistic analysis of risk factors
proportional to the educational qualification. (Those for stroke in Tilburg, the Netherlands. Am J
with Informal education were an exception to this Epidemiol. 1983; 118: 514-525.
pattern with 90% being able to identify at least 1 11. Kristi Reynolds, MPH; L. Brian Lewis, MPH; John
warning sign.) Knowledge about sudden numbness David L. Nolen, MD, PhD, MSPH; Gregory L.
or weakness of hand, leg, face or half of the body as Kinney, MPH; Bhavani Sathya, MPH; Jiang
warning signs as given by the American Heart He,MD, PhD Alcohol Consumption and Stroke-
Association was good , however that about sudden A Meta Analysis
difficulty to speak, sudden trouble walking, dizziness 12. Ralph L. Sacco, MD, MS; Mitchell Elkind, MD;
or loss of balance was comparatively low. A limitation Bernadette Boden-Albala, MPH; I-Feng Lin,
of this study was that deviation of mouth to one side MS;Douglas E. Kargman, MD, MS; W. Allen
Hauser, MD; Steven Shea, MD, MS; Myunghee
was not taken into. The authors considered it under
C. Paik, PhD. The Protective effect of Moderate
weakness of one side of face as mentioned above. The
alcohol consumption on Ischemic Stroke.
terms were adopted from the warning signs of stroke
13. Meir J. Stampfer, M.D., Graham A. Colditz, M.B.,
listed by American Heart Association. B.S., Walter C. Willett, M.D., Frank E. Speizer,
M.D., and Charles H. Hennekens, M.D.A
REFERENCES Prospective study of Moderate Alcohol
Consumption and Risk of Coronary and Stroke
1. Public Awareness of Warning Symptoms, Risk
in WomenN Engl J Med 1988; 319: 267-273
Factors, and Treatment of Stroke in Northwest
August 4, 1988
India Jeyaraj D. Pandian, DM; Ashish Jaison,
14. Ferrucci L, Guralnik JM, Salive ME, Pahor M,
MBBS; Sukhbinder S. Deepak, MBBS; Guneet
Corti MC, Baroni A, Havlik RJ. Cognitive
Kalra, MBBS; Shivali Shamsher, MBBS; Douglas
impairment and risk of stroke in the older
J. Lincoln, MBiostat; George Abraham, MD
population. J.American Geriatrics Society. [1996,
2. Pancioli AM, Broderick J, Kothari R, Brott J,
44 (11): 1410-1]
Tuchfarber A, Miller R,Khoury J, Jauch E. Public
15. Pfeiffer A short portable mental status
perception of stroke warning signs
questionnaire for the assessment of organic brain
andknowledge of potential risk factors. JAMA.
deficit in elderly patients. J.American Geriatrics
1998; 279: 1288 -1292.
Society. [1975, 23 (10): 433-41]
3. Sug Yoon S, Heller RF, Levi C, Wiggers J,
16. Mathiesen EB, Bonaa KH, Joakimsen O. Low
Fitzgerald PE. Knowledge of stroke risk factors,
levels of high-density lipoprotein cholesterol are
warning symptoms and treatment among an
associated with echolucent carotid artery
Australian urban population. Stroke. 2001; 32:
plaques: the Troms study. Stroke. 2001; 32:
1926 -1930.
1960-1965.
4. Reeves MJ, Hogan JG, Rafferty AP. Knowledge
17. Tanne D, Yaari S, Goldbourt U. High-density
of stroke risk factors and warning signs among
lipoprotein cholesterol and risk of ischemic stroke
Michigan adults. Neurology. 2002; 59: 1547-1552.
mortality: a 21-year follow-up of 8586 men from
5. I-Min Lee, MBBS, ScD; Charles H. Hennekens,
the Israeli Ischemic Heart Disease Study. Stroke.
MD, DrPH; Klaus Berger, MD; Julie E. Buring,
1997; 28: 83-87.
ScD; JoAnn E. Manson, MD, DrPH Exercise and
18. Annelies W. E. Weverling-Rijnsburger, MD; Iris
Risk of Stroke in Male Physicians.
J. A. M. Jonkers, MD; Eric van Exel, MD; Jacobijn
6. Paffenbarger RS Jr, Williams JL. Chronic disease
Gussekloo, MD, PhD; Rudi G. J. Westendorp,
in former college students: early precursors of
MD, PhD High-Density vs. Low-Density
fatal stroke. Am J Pub Health. 1967; 57: 1290-1299.
Lipoprotein Cholesterol as the Risk Factor for
7. Paffenbarger RS Jr, Hyde RT, Wing AL, Steinmetz
Coronary Artery Disease and Stroke in Old Age
CH. A natural history of athleticism and
19. Boysen G, Nyboe J, Appleyard M, Sorensen PS,
cardiovascular health. JAMA. 1984; 252: 491- 495.
Boas J,Somnier F, Jensen G, Schnohr P: Stroke
8. Kiely DK, Wolf PA, Cupples LA, Beiser AS,
incidence and risk factors for stroke in
Kannel WB. Physical activity and stroke risk: the
Copenhagen, Denmark. Stroke 1988; 19:1345-1353
Framingham Study. Am J Epidemiol. 1994; 140:
20. Kannel WB, Wolf PA, Verter J: Manifestations of
608-620.
coronary disease predisposing to stroke. The
9. Salonen JT, Puska P, Tuomilehto J. Physical
Framingham Study. JAMA 1983;250:2942-2946
activity and risk of myocardial infarction, cerebral
21. Sacco RL, Wolf PA, Bharucha NE, Meeks SL,
stroke and death. Am J Epidemiol. 1982;115:
Kannel WB, Charette LJ, McNamara PM, Palmer
526-537.

EP, D'Agostino R: Subarachnoid and Tobacco Control (ITC) Four Country Survey.
intracerebral hemorrhage: Natural history, 26. Sun Ha Jee; Jiang He; Paul K. Whelton; Il Suh;
prognosis, and precursive factors in the Michael J. KlagThe Effect of Chronic Coffee
Framingham Study. Neurology 1984; 34: 847-854 Drinking on Blood Pressure A Meta-Analysis of
22. Davis PH, Dambrosia JM, Schoenberg BS, Controlled Clinical Trials (Hypertension. 1999; 33:
Schoenberg DG, Pritchard DA, Lilienfelt AM, 647-652.)
Whisnant JP: Risk factors for ischemic stroke: A 27. Zhenzhen Zhang, Gang Hu, Benjamin Caballero,
prospective study in Rochester, Minnesota. Ann Lawrence Appel, and Liwie Chen. Habitual
Neurol 1987;22:319-327 coffee consumption and risk of hypertension: a
23. Iso H, Jacobs DR Jr, Wentworth D, Neaton JD, systematic review and meta-analysis of
Cohen JD: Serum cholesterol levels and six-year prospective observational studies. Am J Clin Nutr
mortality from stroke in 350,977 men screened June 2011 vol. 93 no. 6 1212-1219.
for the Multiple Risk Factor Intervention Trial. N 28. Esther Lopez-Garcia, PhD; Fernando Rodriguez-
Engl J Med 1989;320:904-910 Artalejo, MD, PhD; Kathryn M. Rexrode, MD,
24. Vronique L. Roger, Alan S. Go, Donald M. MPH; Giancarlo Logroscino, MD, PhD; Frank B.
Lloyd-Jones, Robert J. Adams, Jarett D. Berry. Hu, MD, PhD; Rob M. van Dam, PhD Coffee
Heart Disease and Stroke Statistics?? 2011 Consumption and Risk of Stroke in Women
Update: A Report from the American Heart Circulation. 2009; 119: 1116-1123.
Association. 29. Klaus Kraywinkel, Jan Heidrich, Peter U
25. D Hammond, G T Fong, A McNeill, R Borland, Heuschmann, Markus Wagner, Klaus Berger
K M Cummings. Effectiveness of cigarette Stroke risk perception among participants of a
warning labels in informing smokers about the stroke awareness Campaign BMC Public Health
risks of smoking: findings from the International 2007, 7: 39 doi: 10.1186/1471-2458-7-39.

To Study and Compare the Effect of Laptop Computers

with Desktop Computers on Working Posture and
Self-Reported Musculoskeletal Symptoms
Aditi Biswas1, Dheeraj Lamba2

1,2
Incharge, Physiotherapy IAHSET, Government Medical College, Haldwani
ABSTRACT
Purpose: Comparing the effect of the laptops with desktops on the working posture and self reported
musculoskeletal system.
Objective: To determine the extent to which health problems associated with laptops, and the risk
factors involved. How do these risk factors compare with those using full sized desktop.
Methodology: The study was done on randomly selected sample from different age group of people.
Sample size was 135 respondents from 3 different places (Haldwani, Pantnagar and Delhi). Data was
analyzed by descriptive statistics.
Results: It has been observed that Length of working hours have strong association with
suffering.(.729) It has also been observed that age of the computer users is having a considerable
effect on the upper back pain (.381). Out of 47 laptop users 37 have reported that they are suffering
with some pain, fatigue or numbness. i.e. 78 per cent of laptop users are suffering from some kind of
pain in comparison to 28 per cent of desktop users.
Conclusion: The study showed the ill effect of laptop on posture is more when compared with desktop.
The musculoskeletal problems are more reported by the laptop users as compared to desktop users.
The future
Key words: Cumulative Trauma Disorders, Work-Related Musculoskeletal Disorders, Computer Vision
Syndrome, Desktop, Personal Computers, Repetitive Stress Injury, Musculoskeletal Problems.
INTRODUCTION discomfort.2,4 In a study by Saito et al (1997) the neck

muscle load (EMG value) was significantly greater
Since computer were introduced in the 1980s, using the laptop PCs than with the desktop PC.
personals computers have become powerful and Furthermore, there was greater forward head
extremely versatile tools that have revolutionized how inclination, less head movement and shorter viewing
people work, learn, communicate and find distance increasing the visual and musculoskeletal
environment.1 Laptop computers have become widely workload at the laptop PC as compared to the desktop
used in many workplaces and schools and are PC.5
currently the largest growth area within the PC
market.2. There was a sell of 2.5 million laptops in India In a recent follow up study on newly hired
that is a growth of 63% over previous year.3 employees with computer use for more than 15 hours
a week and follow up period of 3 years, incident neck-
In laptop the issues of comfort, adjustability and shoulder and hand-arm symptoms were frequent.8,9
ergonomics are important to prevent foreseeable
ergonomic and occupational health problems. Laptops Villanueva net al 1996 found that screen height
are designed with the screen attached to the keyboard, strongly influenced neck flexion, with lower screens
resulting in constrained body postures and resulting in greater neck flexion.6 prior research has
movements. suggested that increased neck and shoulder flexion
increases the biomechanical load an surrounding
Given this ergonomic disadvantage of the structures, leading to discomfort and possibly the
conventional laptop several studies have shown an development of musculoskeletal disorders.
increase in neck flexion, torque and physical
22 Dheeraj lamba 29th july 11 (106-110).pmd 106 10/16/2012, 2:41 PM

PURPOSE AND OBJECTIVES OF THE STUDY RESULTS
The purpose of this study was to evaluate and to Observations on the following variables was
compare the effect of the laptops with desktops on the collected.
working posture and the risk associated with the long
term use of laptops and desktops on the Name, Occupation, Age, Left / right handed, User
musculoskeletal system. Specifically the objective of type (Laptop / Desktop), Length of use, Work related
the study is to determine the extent to which health suffering (Neck problem, Right shoulder, Left
problems associated with laptops, and the risk factors shoulder, Right arm, Left arm, Right forearm, Left
involved. How do these risk factors compare with forearm, Right palm, Left palm, Upper back, Lower
those using full sized desktop. back).
Table 1: Correlation Coefficients
METHODOLOGY
Age User Length Rt.arm Rt. Forearm
To fulfill the objective of the study, it was decided Type (in years) pain pain
that data from randomly selected 135 individual from User Type 0.152 1.000 -0.010 -0.045 -0.035
GB Pant University, Pantnagar and Amrapali Institute Length (in years) 0.440** -0.010 1.000 0.132 -0.023
of Applied Sciences, Haldwani and respondent, who suffering (overall) 0.128 -0.066 0.729** 0.082 0.119
are working in some BPOs will be collected. The mean Neck pain 0.038 -0.081 0.311 0.029 -0.089
age of the subjects will be taken as 34 years (range 20- Rt.Shoulder pain 0.057 -0.173 0.111 0.263* 0.118
45), whose work/studies involve minimum 3 hours Rt.arm pain 0.127 -0.045 0.132 1.000 0.392
of regular PC use. The subject had 3 years of mean PC Rt. Forearm -0.036 -0.035 -0.023 0.391** 1.000
experience (range 1-4 years) and 2 years of laptop PC Rt. Palm 0.262** 0.074 0.259** 0.291** 0.122
work experiences (range 2-4). Lt. shoulder -0.069 -0.151 0.088 0.101 0.047
Lt. arm pain -0.079 -0.104 0.041 0.348** 0.115
Lt. Forearm pain -0.100 -0.096 -0.068 0.111 0.884**
Inclusive Criteria
Lt. Palm pain 0.019 -0.010 0.159 0.021 0.047
1. The subject should be minimum 2 years of laptop Upper back pain 0.381** 0.076 0.114 -0.056 -0.081
and 3 years of desktop work experiences Lower back pain 0.105 0.096 0.400** -0.089 -0.067
2. Work should involve minimum 3 hours of regular Table value of r at 120 d.f. at 5% level 0.195 and at 1% level 0.254
PC use. *significant at 5% level, ** significant at 1% level
3. Subject aged between 20-45 years.
Tabular analysis and Graphic representation :
Exclusive Criteria
The calculated results were placed in the following
The volunteer were excluded if they had previously tables and graphs. The results are based on counting
diagnosed torticollis, forward head, rounded and calculation of frequencies and percentage of
shoulders, excessive thoracic kyphosis and lumbar effected persons in comparison to total users.
lordosis and asymmetrical shoulder height or if they
had a medical history of idiopathic scoliosis or recent
back or neck injuries or had experienced symptoms of
musculoskeletal injuries or discomfort in previous to
the use of laptops with or without attached keyboards
which resulted in medical treatment or time off work.
DATA ANALYSIS
SPSS 10.1 was used to calculate counts and

frequency tables on various variables.
Cross tabulation between User type verses different

variables was calculated to know the behaviour of
particular variable in comparison to Laptop or desktop Fig. 1. It can be seen in the picture, how two type of computer
users. Simple correlation coefficient was also calculated users, (1) Laptop and (2) Desktop, are suffering from various type
from the collected data to know the association of body pains. As many as 75 % people are suffering due to
between different variables. working with computer for a prolonged period.

Fig. 2. Shows complains of neck problem between two type of Fig. 5. Also shows affect of computer use on forearm. It can be
users of computer. It can be observed that out of 37 laptop users seen from the observation that both forearm area of the users are
19 have reported having problem at their neck, whereas out of 88 not very affected due to use of computer as only smaller percentage
desktop users 28 have reported problem in neck. of users are affected. Here also it can be observed that laptops are
more harmful.
Fig. 3. Shows how people are suffering with shoulder pain in both
Fig.6. Shows the affect of laptop and desktop use on palm. It has
side due to use of computers. It is observed that laptop users are
been observed that around 20 percent laptop users are suffering
suffering more that desktop users.
from palm pain, where as 10-12 percent desktop users have
reported for the same.
Fig. 4. Shows how use of computers are affecting the users on

their arm. It seems arm areas of the users are not that affected due Fig. 7. Shows how people are suffering with back pain working
to use of computer, as only 4 percent of laptop users and 6 percent with computers.
of the desktop users have reported for problem. However, it can
be said that laptops are more harmful than desktops.

reported that they are having shoulder pain in both

side. Whereas 10.23 per cent desktop users have
reported that they are having shoulder pain in right
side and 13.64 per cent users have reported that they
feel pain in left shoulder. (Fig.3)
Present study found that during continuous laptop

use there is increased back pain, as about 42 percent
of laptop users have reported that they are having back
pain and 22 percent of the desktop users have reported
the same. (Fig. 7)
Lower back is more prone to suffering due to use

Fig. 8. revils that 53 per cent of laptop users are suffering with
lower back pain, where as 31 perccent of the desk top users are
of computer. It may be due to bad posture or
suffering with it. continuous sitting at a particular position.
Concentration, bad posture, continuous sitting etc may
DISCUSSION effect badly on lower back. Fig. 8 revils that 53 per
cent of laptop users are suffering with lower back pain,
The result of the present study showed a significant where as 31 perccent of the desk top users are suffering
difference between working at a laptop and the with it. Thus it can be said that continuous use of laptop
desktop. The use of laptop produced more effects more on lower back than use of desktop. At the
musculoskeletal problems when compared with end the study concluded that about 78% of laptop users
desktop. The result of the study confirms a strong are suffering from musculoskeletal problems as
correlation between the length of computer use and compared to desktop (Fig.1)
suffering (.729). It has also been seen that age of
computer users is having a considerable effect on the
CONCLUSION
upper back pain (.381). It can also be seen that Length
of working hours is having a positive effect on Lower This study has highlighted some of the concern
back pain (.399). The correlation studies has also associated with laptop and desktop use, particularly
shown that if a person is having pain in one of his in term of postural discomfort and MP. It has been
shoulder, it may affect his other side also (cor is .664). seen that there is a poorer posture and greater
The same has been observed in case of forearm pain. discomfort associated with laptop then desktop users.
Concerning the study done about 78% of laptop users
Study by Kilbom and Persson (1987) found that
are suffering from neck pain and back ache whereas
those who worked at a VDT with increased forward
28% of desktop users have complained any suffering.
flexion of the neck ran a higher risk of musculoskeletal
Study also showed a high corelation between the
disorders.11 the results of a study by Bauer and Wittig
working hours and suffering (.729). it should be noted
(1998) showed that preference is to be given to a
that, where a laptop must be used for a shoter period
screen position in which the vision axis is horizontal
with proper rest period and correct ergonomics then
or inclined slightly downward when using a desktop
desktop to minimise the suffering. As this is the first
PC.11
preliminary study, it will not be proper to generalized
Fig. 1 shows the level of suffering between two type the observation. So it is recommended that further
of users of computers. Out of 47 laptop users 37 have detail studies can be done on the problem to confirm
reported that they are suffering with some pain, fatigue the result.
or numbness. i.e.78 per cent of laptop users are
As the computer technology has revolutionised and
suffering from some kind of pain in comparison to 72
will continue to revolutionise work practices and the
per cent of desktop users
trend toward miniaturisation of equipment should not
Fig.2. Shows complain of neck problem between be at the expense of the people who use it.
two type of users of computer. It can be seen that out
of 37 laptop users 19 have reported having problem at LIMITATION OF THE STUDY
their neck, whereas out of 88 desktop users 28 have
reported problem in neck. The picture depicts that 40 1. The ability to observe actual PC usage and the
percent laptop users are having problem in neck in ergonomic issues that arise in a workplace will be
comparison to 31 percent of desktop users. 21.28 difficult. Home access may not be granted by any
percent respondent, who are using laptop, have of the participants in the study.

2. Data will be collected by use of a survey, which 6. Villanuera, M.B.G, Sotoyama, M., Jonai, H.,
will be constructed by the researcher. Survey data Takeuchi, and Saita.S, (1996) Adjustment of
collection will only be as reliable as those who posture and viewing parameters of the eye to
participate in the survey. changes in the screen height of the visual display
terminal. Ergonomics 39 (7), 933-945.
REFERENCES 7. Leon Straker, Kerry J. Jones and Jenni Miller
(1995). A comparison of the postures assumed
1. Microsoft Encarta Online Encyclopedia (2008). when using laptop computers and desktop
Personal computer. Retrieved June11, 2008. computers.(1997), pp 263-268.
2. Harris, C, straker,L 2000. Survey Of Physical 8. Gerr F, MarcusM, Ensor C, Kleinbaum D, Iohen
Ergonomics Issues Associated With School S, Edward A et al, A prospective study of
Childrens Use Of Laptop Computers. J.Ind. computer users. I study design and incidence of
Ergonomics.26, 337-346 musculoskeletal symptoms and disorders. Am J
3. Saito, S., Miyao, M. Kondo, T, et al 1997. Ind Med 2002, 41: 221-35
Ergonomics evaluation of working posture of 9. Jensen C Development of neck and hand wrist
VDT operation using personal computer with flat symptoms in relation to duration of computer use
panel display. Ind. Health 35, 264-270. at work. Scand J Work Environ Health 2003, 29
4. Harbison, S, Forrestor, C., 1995. The Ergonomics (3): 197-205.
Of Notebook Computers, Problems Or Just 10. Kilbom, A. Persson J., 1987. Work technique and
Progress? J. OCCUP. Health Safety 11(5), 481-487. its consequences for musculoskeletal disorders.
5. Anna Lindblad Berkhout, Karin Hendriksson- Ergonomics30(2), 273-279.
Larsen, Paulien Bongers (2004). The effect of 11. Bauer, W., Witing, T., 1988. Influence of screen
using a laptop station compared to using a and copy holder positions on head posture,
standard laptop PC on the cervical spine torque, muscle activity and user judgment. Appl.
perceived strain and productivity. Applied Ergonomics. 29 (3): 185-192
ergonomics 35 (2004) 147-152

An Analysis of Memory Retrieval and Performance of
Physiotherapy Exercises in Younger and Older Patients
Dhiraj R. Shete
Lecturer, College of Physiotherapy, PIMS, Loni, Ahmendnagar, 413736
ABSTRACT
Introduction: Physiotherapists routinely prescribe exercises in the O.P.D. and advice the patient to
follow the same at the home. The clinical goals set by the therapist depend on the success of the
exercises programme and protocols, which the patient has to follow regularly. These study was
aimed to have a "know - how" of how far the patient remembers the sequence of exercises that are
prescribed.
Design: 90 patients were selected; patients were of common problems like Postural Neck Pain, Postural
Low Back Pain, Knee Pain. Patients were further divided into 30 each and three groups were made,
each group contains 10 of each condition and 5 younger & 5 older patients. Groups were Group I -
Verbal Instructions and Self Performance, Group II - Pictorial Diagram / Written Material and Self
Performance, Group III -Demonstration by Model and Self Performance. Exercises were told to patients
and were told to recall them on 2nd day & 5th day for short and long term memory.
Methods: Study included Younger adults aged between 20 to 40 & older adults aged between 60 to
80. Patients were prescribed exercises and asked to recall on 2nd & 5th day for short and long term
memory respectively. The outcome was measured by using "Rastall's Exercise Scoring Table". Points
allotted were 02, 03, 03, 02 respectively total 10 points - minimum scoring was 08 points. Data Analysis
was done using unpaired' test.
Results: This study proves that "demonstration by model and self performance" has better memory
retrieval of shot term and long term memory in both younger and older adult patients compare to
other two groups i.e. "Verbal Instructions and Self Performance & Pictorial Diagram / Written Material
and Self Performance".
Key words: Retrieval, Short Term Memory, Long Term Memory, Exercises
INTRODUCTION some of the factors were elaborately used. Those

factors are: Verbal Cues6, Written Cues5, Pictorial
Therapeutic exercise intervention is a health service Diagrams5, Demonstration7, Activity based or Subject
provided by the Physical therapist to the patients and Performed Tasks9. Written exercise programme may
clients 1 . Exercises are considered the core of give personalize touch to the programme to work. The
Physiotherapy practices. There are several benefits specific exercise descriptions may make perfect sense
with therapeutic exercises like, to improve physical to the clinician but confuse the patient and results in
function, health status, prevent complications improve incorrect exercise performance5.
the level of performance and recreational activities1.
Generally Physical therapy exercise intervention can Pictorial diagrams are commonly used in the clinics
be directed i.e. under Physiotherapy supervision or to teach exercises. The pictures usually demonstrate
the in from of instructional information to the patients. the exercise in the start and finish position. Arrow
By following instructions and information patient can showing the direction of movement with marks clearly
perform exercises in the home without supervision of indicating the start and the end positions can be
the Physiotherapist. Clinicians prescribing home helpful. Often pictures show positions midway
exercise programme should be aware that through the exercise and patient is unclear about the
unsuperviation of exercises hinder the patients goals. full excursion of the movement5.
So prescribing exercises for home programme is very
challenging5. Exercise performance can be enhanced Practical demonstration is another one of the most
by multiple ways. When we look into the literature commonly used clinics to teach exercises. In practical
23 dhiraj shete 2nd jan 12 (111-116).pmd 111 10/16/2012, 2:41 PM

demonstration, there will be a modeling of an action Sample Selection

either by videotape or by the teacher performing the
action, it will help the leaner to develop and helps to Stratified random sampling was used in this study.
understand the conceptual representation11 of the Sample consists of 90 subjects in the age group ranging
action. By observation the leaner can know the between 20 to 80 years. The subjects included for the
amplitude of movement, appreciate the timing and study were those who were referred to Physiotherapy
fluency of the action and relationship between the OPD. These subjects were informed about the study,
body parts12. Demonstration will provide a visual which was being undertaken. The subjects were than
impression on the minds of the people and is more suitably selected based primarily on their consent to
effective then printed one13. Lastly, Verbal instructions participate in the study and on follow regular
are most commonly used for conveying information Physiotherapy for duration of one week. Subjects
or prescribing the exercises14. Verbal instructions included in the study were assessed by using general
mainly focus on kinematics description for example assessment form; the subjects were assessed for any
angular displacement, oaths of the body parts, which impairment and/or disabilities as per inclusion/
require an understanding by the therapist of linked exclusion criteria. The total number of subjects in study
segment dynamics and biomechanical12 necessities of design was 90. For the purpose of conducting the trials
the action to be learned. Instructions are given in such these 90 subjects were divided into 3 groups. Each
a way as to present a clear goal and to reduce group comprised of 30 subjects. These 30 subjects in
uncertainly. In addition to make the goal to be pursued each group were further divided into 15/15 younger
with enthusiasm verbal instructions needs to be and older population respectively. The study design
meaningful to the individual so assist the patient in for each group(30) was now constructed as follows:-
self management and enable them to manage various
aspects of own care15. Three postures related stress syndromes were
designated for each group. This was implemented by
AIMS
providing one stress syndrome for 10 subjects. Care
To asses the retrieval capability of prescribed was taken that the 10 subjects had equal distribution
exercise in younger and older population group of younger and older age groups of 5 each. Permission
following verbal instructions, Pictorial diagrams for the study was taken from concerned authorities.
written material, and demonstration by subject, The purpose of the study was explained to all subjects.
methods and to compare efficiency of the three sets of A written and informed consent from was taken from
prescribed exercises programme and suitability for age the subjects.
groups.
Both the older and younger age group subjects
METHODOLOGY were divided into 3 groups each (i.e. the tabulated
column of groups and its demographic data are
Patient Selection explained in table below) based on first come bases.
Inclusion Criteria Table 1 . Table with type of groups, type of cases, and
1. Younger adults of age group from 20 to 40. distribution of patients of each type
2. Older adults without disabilities and impairments
Groups Younger Older Total
of age group between 60 to 80 years. adults adults
3. Subjects with postural neck pain, low back pain, Group I. Verbal
knee pain. instruction group.
Postural neck pain 5 5 10
Exclusion Criteria Postural low back pain 5 5 10
1. Neurological deficits. Knee pain 5 5 10
2. Visual impairments. Group II. Pictorial
3. Hearing impairments. diagrams written
material group.
4. Cognitive problems.
Material Used Postural low back pain 5 5 10
1. Model To demonstrate the exercises. The model Knee pain 5 5 10
was initially trained to perform the given set of Group III. Demonstration
group.
exercises for each of the three conditions. When he
was well versed with all the exercises, he was asked
Postural low back pain 5 5 10
to demonstrate same for the subjects. Knee pain 5 5 10
2. Fully equipped exercise therapy room.

Samples Verbal Instructions and Self Performance.

Pictorial Diagram Written Material and Self
The samples were drawn from the following Performance.
setting Demonstration by Model and Self Performance.
Physiotherapy Out Patient Department, Pravara Method for Verbal Instructions and Self Performance
Medical Trusts, Pravara Rural Hospital, Loni.
In this group exercises were told to the patients by
Tools for exercises performance measurement therapist verbally and asked to remember and do it.
Exercise performance scoring table 22. The exercise Patients was asked whether he or she understood
performance scoring table was developed by Maggie it properly or not and than he or she was told to recall
Rastall et al 2000. This scale measures primarily the exercises on subsequent follow up i.e. on 2nd day for
four components of an exercise. short term memory and 5th day for long term memory
They are- when asked by therapist.
1) Correct standing position of the exercise.

2) Exercise body components moving in correct plan.
3) No compensation or cheat movements.
4) Movements performed within correct range.
Every exercise performance had a maximum

scoring of 10 points. The possible 10 points were
appended in table below-
Exercise performance scoring table22.

Table 2. Contains of Maggie Rastall exercise scoring
table with points allotted.
Criteria Points
1. Correct standing position of the exercise 2
Fig. 1. Therapist Explaining Patient, exercises by Verbal
2. Exercise body components moving in
Instructions Method.
correct plan. 3
3. No compensation or cheat movements. 3
4. Movements performed within correct range. 2 Method for Pictorial Diagram Written Material and
Total 10 Self Performance.
On exercise performance a score of 8 points or In this group exercises were told to the patient by
more, was deemed to be correctly done they were therapist in form of Pictorial Diagram / Written
considered as number of exercises correctly performed Material and told to read it, remember it and do it.
by the subject.
Procedure
The subjects of three different conditions i.e.

Postural Neck Pain, Postural Low Back, and Knee Pain
were selected. The set of seven exercises were given
for each condition.
Postural Neck Pain 1set 7 exercises.

Postural Low Pain 1set 7 exercises.
Knee Pain 1 set 7 exercises.
Same set of exercises were explained to patients, in

all three medium of instructions. The exercises were
performed in three different ways, they are -
Fig. 2. Therapist Explaining Patient, exercises by Pictorial Diagram
Written Material Method.

Patient was asked whether he or she understood it Graph I Verbal Instructions and Self Performance
properly or not and than he or she was told to recall
exercises on subsequent follow up i.e. on 2nd day for
short term memory and 5th day for long term memory
when asked by therapist.
Method for Demonstration by Model and Self
Performance.
In this group exercises were demonstrated to the

patient by the help of model who demonstrated the
exercises to the patient, as told by the therapist. Patient
was told to remember and do it. Patient was asked
whether he or she understood it properly or not and
Graph II Pictorial Diagram Written Material and Self
than he or she was told to recall exercises on
subsequent follow up i.e. on 2nd day for short term Performance
memory and 5th day for long term memory when
asked by therapist.
Graph III Demonstration by Model and Self

Performance
Fig. 3. Patient been demonstrating the exercises by Model for

Demonstration by Model Method.
DATA ANALYSIS
To apply the appropriate test of significance the

instruction and self performance & pictorial diagram,
data collected was analysised at 2nd sitting (Short Term
written material and self performance methods in
Memory) and 5th sitting (Long Term Memory) for all
younger and older adults. Hence this study
three methods. For analysis of effectiveness of verbal
recommends the usage of demonstration by model and
instructions, pictorial diagram & written material,
self performance method.
demonstration by model in younger and older
individuals at both short term and long term memory,
CONCLUSION
student unrelated t test was performed. To know
whether these results been significant, highly The analysis of the data has led to following
significant and not significant the final readings were inferences:
compared with P value. (t>2.58- Highly Significant)
(P<0.05). 1) In the younger adults, demonstration by model and
self performance, verbal instruction and self
DISCUSSION performance methods showed a higher amount of
memory retrieval of exercises compared to pictorial
This study proves that demonstration by model and diagram / written material and self performance
self performance has better memory retrieval of in short term memory but all the three interventions
exercises performance, in comparison to verbal are equally effective in long term memory.

2) In older individuals demonstration by model and 8. Engel kemp, 2000, Item and Older information
self performance has given a better memory in Subject Performed Tasks and Experimented
retrieval of exercises where as verbal instruction Performed Tasks.
and self performance has given least in both long 9. Journal of Experimental Psychology, Vol 26 (3)
term and short term memory. 658 670, May 2000.
3) When both younger and older adults performances 10. Carroll and Bandura, 1982, NEUROLOGICAL
are compared, demonstration by model and self REHABILITATION: optimizing Motor
Performance, Ch-2, 34.
performance showed a better retrieval of exercises
11. Carr and Shepard 1998, NEUROLOGICAL
in long term and short term memory.
REHABILITATION: optimizing Motor
4) When both younger and older adults performances Performance, Ch-2, 34-35.
are compared, by pictorial diagram / written 12. Park K, 1997, Effect of Age event Based and time
material and self performance younger adults Based Prospective Memory, Psychological Aging,
showed a better performance than older adults at 12(2): 314 - 327, June 1997.
both short term and long term memory. 13. Newal 1981; Johnson 1984 & Gentile 1987,
NEUROLOGICAL REHABILITATION:
RESULT optimizing Motor Performance, Ch-2, 34-35.
14. Johnson et al, 2003, Written and Verbal
In younger adults exercise prescription can be done Information versus Verbal Information only for
by any of the three intervention i.e. Verbal instructions Patients being discharged from acute hospital
and self performance, pictorial diagram / written setting to home, Cochrane Database Syst Rev; (4):
material and self performance, demonstration by CD003716, 2003.
model and self performance. All three interventions 15. Witte et al (1990), Age Differences in Free Recall
are effective22. and Subjective organization, Psychology and
Aging, Vol 5(2) 307 309, June 1990.
But for the older adults demonstration by model 16. Emmy M Slujis (1993) Correlates of Exercise
and self performance is found to be most effective. Compliance in Physical Therapy, Physical
Therefore one can conclude that it is better to prescribe Therapy, Vol 73, No 11, Nov 1993.
exercise using demonstration by model and self 17. Friedrich M et al (1996), The Effect of Brochure
performance in older adults for the easy recollection Use Verses Therapist Teaching on Patients
of prescribed exercises. Performing
18. Therapeutic Exercises and on Changes in
impairment Status, Physical Therapy, 76(10): 1082
REFERENCES
1088, Oct 1996.
1. Carrie Hall, 1999, Therapeutic Exercise Moving 19. Swinburn BA et al (1998), The Green Prescription
towards Function, Chapter 2, 3, page no.9-32, Stud: A Randomized Controlled Trail of Written
33-42, Williams and Wilkins Publications, 1999. Exercise
2. Sandler 1987, Aging and Memory for Words and 20. Advice Provided by General Practitioners.
Action Events of Item Repetition and List Length: American Journal Public Health, 88(2): 288-291,
Psychology and Aging, Vol 2(3) 280 285, Sep Feb 1998.
1987. 21. Maggie Rastall et al (1999), An Investigation into
3. Slujis et al, 1993, Correlates of Exercise Younger and Older Adults Memory for
Compliances in Physical Therapy, Phys Ther, 73, Physiotherapy Exercises, Physiotherapy, Vol 85
771-782. No. 3 122-128, March 1999.
4. Lori brody, 1999, Therapeutic Exercise Moving 22. Kristin D Henry et al (1999), Effect of Number of
towards Function, Chapter 3, page no.38, Home Exercises on Compliance and Performance
Williams and Wilkins Publications, 1999. in Adults Over 65 Years of Age, Physical Therapy,
5. Friedrich et al, 1996, The Effect of Brochure Use Vol 79 No. 3, March 1999.
Verses Therapist Teaching on Patients 23.. Peggy MC Guire (2000), A Performance Frame
Performing Therapeutic Exercises and on Work for Teaching and Learning with Equipped
Changes in impairment Status, Physical Therapy, for Future Content Standards. Adventures In
76(10): 1082-1088, Oct 1996. Assessment, Vol 12, 2000.
6. Park K, 1999, Effect of Environmental Support 24. Zimmer (2000), Pop Out Into Memory: A
Implicit and Explicit Memory in younger and Retrieval Mechanism that is Enhanced with the
Older Adults, Recall of Subject Performed Tasks, Learning,
7. Gerontology Center, University of Georgia, Memory and Cognition, Vol 26(3), 658-670,
Athens 30602, 1999. May 2000.

25. Pfeiffer BA et al (2001), A Green Prescription (Amst.) 115(2-3): 143-165, Feb-Mar 2004.
Study Does Written Exercises Prescribed by a 30. Zeitlinger and swets (2003), Recall of Subject
Physician Result in Increased Physical Activity Performed Tasks. Verbal Tasks and Cognitive
among Older Adults? Journal of Aging Health, Activities across the Adult Life Span: Parallel Age
13(4): 527 538, Nov 2001. Related Deficits, Aging Neuropsychology and
26. Floratos DL et al (2002), Biofeedback versus cognition, Vol 10, No.3, 182-201, 2003.
Verbal Feedback as learning Tools for Pelvic 31. Witte (1990), Age Differences in Free Recall and
Muscle Exercises in the Early Management of Subjective organization, Psychology and Aging,
Urinary Incontinence after Radical Prostectomy, Vol 5(2) 307 - 309, June 1990.
BJU Int: 9(7) 714 719, May 2002. 32. Joseph C (1997), Gait Disorder of Aging, Ch 5:
27. Golly-Haring et al (2003), Categorical Related and Balance Decrements in Older Persons: Effects of
Order Related Information in Memory for Subject Age and Diseases, pp 79-91 Lippincott-
Performed and Experimenter Performed Action, Raven, 1997.
Journal of Experimental Psychology, Vol. 29(5) 33. Knopf et al 1989, Aging and Memory for Action
965-975, Sep 2003. Events: The Role of Familiarity, Developmental
28. Jahn et al (2003), Design Effects in Prospective Psychology, Vol 25(5) 780-786, Sep 1989.
and Retrospective Memory for Action, 34. Michael Ronnalud et al 2003, Recall of Subject-
Experimental Psychology, Vol 50(1) 4-15, 2003. Performed Tasks, Verbal Tasks and Cognitive
29. Kray et al (2004), Age Differences in Executive Activities across the Adults Life Span: Parallel
Functioning across the Life Span, the Role of Age Related Deficits, Aging Neuropsychology
Verbalization in task preparation, Acta Psychol and cognition, Vol 10, No.3, pp 182-201, 2003.

Effectiveness of Physiotherapy for the Handwriting
Problem of School Going Children
Chandan Kumar1, Poonam Mehta2, Sobika Rao3

1
Neurology-Assistant Prof, 2Paediatrics- Assistant Prof, 3 MPT Student
M.M Institute of Physiotherapy and Rehabilitation, Mullana, Ambala
ABSTRACT
Purpose: The purpose of the study is to see the effectiveness of a 12 week physiotherapeutic
intervention to improve the handwriting quality of school going children.
Methodology: This study is a randomized clinical trial of 60 school going children who have
handwriting problem as diagnosed with Handwriting Proficiency Screening Questionnaire (HPSQ).
The 60 subjects are than randomly divided into 2 groups, Group A (Intervention Group) which
consists of a set of Physiotherapeutic Exercises and Group B (Ergonomic Advice) . The Handwriting
quality was evaluated using Minnesota Handwriting Assessment (MHA).
Results: The results of the present study showed that both the groups showed significant improvement
but the group receiving 12 week physiotherapeutic intervention showed more significant
improvement.
Conclusion: Finally it can be concluded that a well planned physiotherapeutic program can help to
improve the handwriting quality of school going children over a short period of time and thus help
the child to improve his self-confidence and his academic results.
Key words: Handwriting Skills, Physiotherapy Intervention, Assessment Scales.
INTRODUCTION Writing difficulties have been documented in

children with and without disabilities. Legible
Skilled handwriting is an essential activity for handwriting constitutes to be an important skill for
school aged children that allows them to write within children to develop in elementary school and difficulty
a reasonable time and to create a readable product with this area can affect any childs proficiency at work.
through which thoughts and ideas can be Proficiency is the quality of having great facility and
communicated.1-3 Handwriting is often judged and competence at school work.7 Those children who do
seen as reflection of an individuals intelligence and not succeed in developing proficient handwriting are
capabilities as illustrated by several studies in which defined by some authors as poor hand writers and
lower marks are consistently assigned to children with by the others as dysgraphic.8
poor handwriting and higher marks are given to those
with legible handwriting despite similar content.4 In addition to legibility and timing deficits,
observations by clinicians have revealed that children
The effect of sex is also an important consideration with dysgraphia erase more, complain more about
in handwriting development..4 Girls handwriting is fatigue and hand pain, and are unwilling to write and
more legible than boys handwriting and also the girls do their homework. 1 All of these signs may be
write faster. Right handers are also faster than the left considered to represent a category of physical and
handers.5 emotional well-being.9
Factors that affect the handwriting performance The teacher is an important source of information
can be intrinsic i.e. because of lack of fine motor control, about a childs handwriting.6The perceptions of regular
improper visual-motor integration or may be extrinsic education teachers on problems with handwriting can
like sitting position, chair-desk height, blackboard provide valuable information to practioners when
position, environmental lighting etc.6 providing consultation and direct services related to
24 chandan kumar 29th aug 11 (117-121).pmd 117 10/16/2012, 2:41 PM

handwriting in school.10 4) Has good handwriting.

5) Gross motor impairments.
Besides this various handwriting assessment tools
are available. Judith E. Riesman developed the 6) Any recent trauma to upper limb.
Minnesota Handwriting Test (MHT) which has been 7) Has poor intelligence.
used in the present study. This tool is norm referenced 8) Neurological deficit.
and measures changes in handwriting performance of
9) Visual problem.
first and second graders. The interrater reliability of
the Minnesota Handwriting Test has a strong range of
PROCEDURE
0.87-0.98.11
The students selected by the teacher on the basis of
When consulted , physicians most often choose
the HPSQ who fulfilled the inclusion criteria were
physiotherapy as the preferred method to help.
randomly assigned to 2 groups. Simple random
The physiotherapeutic interventions help to improve
sampling was used to randomly allocate 30 students
the intrinsic factors related to handwriting skills. But,
in group A and 30 students in group B.
little is known about the effectiveness of
physiotherapy in treating children with such Group A (Intervention group): n=30.
disorder.
Group B (Ergonomic advice): n=30
Methodology: A total of 200 Handwriting
Proficiency Screening Questionnaires (HPSQ) were Pre-Intervention measurement was taken for both
distributed in 3 schools. The questionnaires were filled the groups using the MHA. The students were asked
by the teachers of teaching grade 1 and 2. A total of 60 to copy a sample from near point. The student sat on
children were selected to participate in this study with the desk opposite to the blackboard. The words
the aid of the standardized and validated HPSQ. These utilized were a derivative of the sentence, The quick
60 children were then randomly assigned to 2 groups. brown fox jumped over the lazy dogs. The quality of
Simple random sampling was used to randomly the sample was determined by assessing legibility,
allocate the children into 2 groups. form, spacing, alignment, and size.
Following this students in Group A (Intervention

INCLUSION CRITERIA
Group) were given a set of physiotherapeutic exercises.
1) The child is a non-proficient writer as assessed by The students received 4 sessions of physiotherapy per
the HPSQ. week, for 1 hour on alternate days for 3 months. The
students in the Group B (Ergonomic Advice) received
2) The child attends a regular elementary school.
ergonomic advice on handwriting and were taught
3) The child is in grade 1 and 2. appropriate writing posture by their parents and
4) Age b/w 5-7 years. teachers. After a period of 3 months, again the
5) Both boys and girls were included in the study. Handwriting Proficiency Screening Questionnaire
6) Has no neurological problem. (HPSQ) were filled by the school teachers and the post
intervention measurements were taken for both the
7) Has no orthopedic problem.
groups using MHA.
8) Has no developmental delay.
9) Has no physical impairment of the upper limb. Group A (Intervention Group) n=30
10)Should not have received any physiotherapeutic 1) Exercises to improve proximal stability of the upper
treatment before. limb (5 repitions each).
2) Fine motor exercises for handwriting (5 repetitions
Exclusion Criteria: each
1) Developmental delay. 3) Exercises to improve visual-motor development
(5 repetitions each)
2) Physical impairment of upper extremity
i) Exercises to improve Ocular motor control:
3) Hearing deficit. ii) Exercises to improve eye-hand coordination:

Group B (Ergonomic Advice): n=30 Table (5.3). Mean and S.D for HPSQ, Total MHA, and
MHA Subscale for Group B.
Students in the Group B were taught appropriate Pre Test Post Test t value p valued0.05
writing posture and were given ergonomic advice Mean S.D Mean S.D
only. HPSQ 48.33 7.65 44.67 7.10 6.71
MHA Total 136.73 6.97 144.13 6.88 34.00
Data Analysis:The data was tested parametrically. MHA Subscale
To determine the possible differences within and Legibility 29.23 1.13 30.83 0.98 12.99
between the groups on the pre-test and post-test Form 27.47 1.57 28.80 1.66 15.23
Alignment 27.30 1.89 28.67 1.82 11.19
measures paired t test and z test were used
Size 24.63 2.22 25.97 2.20 13.35
respectively. p value was set at <0.05 level of
Spacing 28.00 2.01 29.77 2.04 15.45
significance and SPSS software was used for analysis.
Above table is showing the scores of the HPSQ,
Results: In the present study 200 HPSQ were
Total MHA and MHA Subscale.
distributed to the school teachers of teaching grade 1
and 2. On the basis of this subjective assessment 90 It was interpreted that there is a significant
students were diagnosed by the teachers as non- improvement in the scores at 0.05 level of significance.
proficient hand writers and were included in the study.
Next MHA was filled by the students and 40 students Table (5.4): Comparison of the Mean and S.D for the
HPSQ, Total MHA Score between Group A
having a score of e30 on MHA were excluded from (Intervention Group) and Group B
the study. (Ergonomic Advice).
Table 5.1. Demographic data for the 2 groups. Group A Group B Mean diff. Zvalue p
b/w group valued0.05
GroupA GroupB Mean S.D Mean S.D
Intervention Group Ergonomic Advice HPSQ 14.17 0.08 3.67 0.55 10.50 0.43 5.932 significant
Females n = 09 n = 10 MHA Total 20.27 2.59 7.40 1.19 12.86 1.40 24.64
Males n = 21 n = 20
Age = 6years n = 05 n = 00 Above table is showing the scores of the HPSQ and
Age = 6+years n = 12 n = 14 Total MHA Score. It was interpreted that there is a
Age = 7 years n = 13 n = 16 statistically significant improvement in the scores at
Handedness n = 30 n = 30 0.05 level of significance.
Class I n = 17 n = 20
Class II n = 13 n = 10 Table (5.5) : Comparison of the mean change in the
MHA Subscale Scores between Group A (Intervention
The baseline data shows that the 2 gps did not differ Group) and Group B (Ergonomic Advice).
regarding Gender, Age, Handedness, Class MHA Group A Group B Mean diff. z value p valued
Subscale Mean S.D Mean S.D b/w group. 0.05
Table (5.2). Mean and S.D for HPSQ, Total MHA, and Legibility 3.60 1.07 1.60 0.67 2.00 0.39 8.66
MHA Subscale for Group A Form 3.70 1.34 1.33 0.47 2.36 0.97 9.09
Pre Test Post Test t value p valued0.05 Alignment 4.80 1.40 1.37 0.66 3.43 0.73 12.12 significant
Size 4.93 1.98 1.33 0.54 3.60 1.44 9.59
HPSQ 56.50 7.28 42.33 7.65 8.413
Spacing 3.32 1.87 1.77 0.62 1.46 1.25 4.07
MHA Total 135.33 5.51 155.60 4.56 42.17
MHA Subscale
Above table is showing the scores of the MHA
Legibility 29.03 0.96 32.63 0.96 18.42 Not Significant
Subscale. It was interpreted that there is a statistically
Form 26.77 1.85 30.47 1.22 15.09
Alignment 26.73 2.21 31.53 1.77 18.78
significant improvement in the scores between the
Size 25.33 2.10 30.27 2.11 13.63 2 groups at 0.05 level of significance.
Spacing 27.47 1.99 30.70 1.46 9.47
DISCUSSION
Above table is showing the scores of the HPSQ,
Total MHA and MHA Subscales. It was interpreted In this study it was observed that a 12 week
that there is a statistically significant improvement in physiotherapeutic intervention had a significant effect
the scores at the 0.05 level of significance. on improving the handwriting quality and the earlier

studies also show the same result.12 The positive is generally considered to have an important influence
results found in this study can be supported by on the efficiency of writing process and product.614,22
the sufficient evidence in the literature that So, students in group B also showed improvement in
intervention to improve handwriting would result their handwriting quality.
in greater gains than no intervention at all.8,9,16,17.
After a period of 3 months both the groups showed
The intervention was so structured that it directly an improvement in their handwriting quality but in
targeted the intrinsic components which are required comparison the students in group A (Intervention
for good handwriting. The intervention consisted of Group) showed more significant improvement as
exercises to improve proximal stability of upper limb, compared to the students in group B (Ergonomic
fine motor exercises for handwriting, and exercises to Advice).Finally it can be concluded that a well planned
improve the visual- motor control.2 The intervention physiotherapeutic program can help to improve the
targeted primarily at improving the proximal muscle handwriting quality of the children and help improve
stabilization of the upper extremity. This is supported their academic results and confidence.
by the proximal-distal muscle principle which states
that the proximal muscle stability is a pre-requisite for Clinical Implication
manipulative hand use.18
The findings of the present study can be used in
Next the in-hand manipulation skills which the schools by the teachers to improve the handwriting
included activities like rolling the balls of clay between quality of the students who have poor handwriting.
the tips of the thumb, middle and index finger ;
Limitations of the study:
pinching and sealing a zip-lock ; twisting open a small
tube of toothpaste with thumb, index and middle 1. The inclusion criteria is subjective based on HPSQ.
fingers while holding the tube with the ulnar digits; 2. Purposive Sampling was used leading to decreased
and ball squeezing exercises. All these exercises make generalizability.
use of the muscles of the thener-eminence which is 3. No individual attention was given.
considered as the skilled triad of the hand. So, the
Future Research:
in-hand manipulation skills helped to improve the fine
motor skills.. 18, 13, 19Previous studies in this field have 1. To see the effectiveness of the intervention in
revealed that the visual-motor integration i.e. the children with cerebral palsy, hyperactivity
ability to see and copy moderately to strongly relate disorder, developmental co-ordination disorder.
to handwriting skills. So, the exercises to improve the 2. Comparing the effectiveness with the other
ocular-motor control and eye-hand co-ordination available handwriting programs: Handwriting
helped to improve this skill.2, 20, 21 without Tears; Log Handwriting Program etc.
3. Effectiveness of the intervention in improving the
Another important factor was the intensity and speed of writing.
duration of the intervention used for this study. The
intervention lasted for a period of 12 weeks and was REFERRENCES
administered 4 times a week for 1 hour. This duration
of intervention for improving the handwriting quality 1. Rosenblum, Sara. Handwriting performance,
has been supported by various studies in which similar self- reports and perceived self-efficacy among
duration of intervention resulted in improving the children with dysgraphia. American Journal of
handwriting.7, 12, 19 Lastly all the activities which were Occupational Therapy, 2009 March.
included were of playful nature which the children 2. Rhoda P. Erhardt and Vickie Meade. Improving
handwriting without teaching handwriting. The
might have enjoyed and thus led to their maximum
consultative clinical reasoning process. American
participation and thus resulted in significant
Journal of Occupational Therapy 2005; 52:
improvement in the group which received
199-210.
intervention. 3. Sara Rosenblum; Shula Parush and Patrice L.
The children in Group B were taught appropriate Weiss. Computerized temporal handwriting
Characteristics of Proficient and Non-Proficient
writing posture and were given ergonomic advice
hand-writers. The American Journal of
provided by the physiotherapist to their parents and
Occupational Therapy; 57(2): 129-138.
teachers. The ergonomics and the writing posture are
4. Sasson R. Handwriting: A new perspective.
the extrincic factors related to handwriting. Cheltenham, UK: Stanley Thornes 1990.
Ergonomics 6,1,14 play an important role. Body posture

5. Steve Graham. Development of handwriting 15. Handwriting Resource Handbook: A Teacher

speed and legibility grade 1- 9.The Journal of Resource Manual. Occupational and PT
Educational Research 1998; 92(1): 42-52. Department, Student support service division.
6. Feder, Majnemer. Handwriting development, Nov 4, 2008.
competency and intervention Review. 16. Tseng and Cermak. The influence of ergonomic
Developmental medicine and child neurology factors and perceptual motor abilities on
2007; 49: 312-317. handwriting performance. American Journal of
7. Centre for child development. Child.support.in. Occupational Therapy 199347: 919-926.
8. Graham, Harris. Is handwriting causally related 17. Kline, T.J.B. Psychological Testing. London Sage
to learning to write? Treatment of handwriting 2005 ; 202-203.
problems in beginning writers. Journal of 18. Naider et al. Analysis of proximal and distal
Educational Psychology 2000; 92: 620-633. muscle activity during handwriting tasks.
9. Rosenblum, Sara. Development, reliability, and American Journal of Occupational Therapy 2007;
validity of the Handwriting Proficiency Screening 61(4): 392-398.
Questionnaire (HPSQ). . American Journal of 19. Nandine Mackay et al: The Log Handwriting
Occupational Therapy 2008; 62 : (298-307). Program Improved Childrens writing
10. Hammerschmidt, Sandra L. Teachers Survey on Legibility: A pretest-posttest study. 2010 January;
Problems with Handwriting: Referral, 64(1) : 30-36
Evaluation, and Outcomes. American Journal of 20. Cornhill & Case-Smith. Factors that relate to good
Occupational Therapy 2004. and poor handwriting. American Journal of
11. Wendy Collins, MOTS, Evidence Topic: Occupational Therapy 1996; 50: 732-739.
Handwriting Assessment 2008. 21. Arpita S Desai. Correlation between
12. Smits-Engelsman et. al. Physiotherapy for Developmental Test for Visuomotor Integration
childrens writing problems. An Evaluation and Handwriting Difficulties in Cerebral Palsy
Study. Handwriting and Drawing Research: Children. The Indian journal of occupational
Basic and Applied Issues. 1996; (227-240) therapy 2005: 2.
13. Christopher M. Boyle. An analysis of the efficacy 22. Handwriting Resource Handbook: A Teacher
of a motor skills training programme for young Resource Manual. Occupational and PT
people with moderate learning difficulties. Department, Student support service division.
14. Jill G. Zwicker. Cognitive vs Multisensory Nov 4 2008
approach to handwriting Intervention. A RCT.
The American Journal of Occupational Therapy
2009: (25)1.

Effect of Kinesio Tape in the Treatment of

Antenatal Carpal Tunnel Syndrome
Soheir M. El Kosery1, Fayiz F. Elshamy1, Hamid A. Atta Allah2

1
Department of Physical Therapy for Obstetrics and Gynecology, Faculty of Physical Therapy, Cairo University, Egypt
2
Department of Orthopedic Surgery, Faculty of Medicine (Girls), Al Azhar University, Egypt
ABSTRACT
This study was conducted to detect the efficacy of Kinesio tape on the treatment of carpal tunnel
syndrome in antenatal period. 15-primipared females at 3rd trimester of pregnancy with positive
electro diagnostic findings (MMDL >4.2 ms) participated in this study, their ages ranged between
20-35 years (27.534.47). They were received kinesio tape technique on the affected wrist for 3 days,
then day off and then another 3 days of kinesio tape / week for 4 weeks. Median motor distal latency
(MMDL) was performed before and after the treatment program for all patients. The obtained results
showed statistically highly significant (P< 0.0001) improvement in median motor distal latency at
the end of the treatment program. Accordingly, it could be concluded that the use of the kinesio tape
was found to be effective in the treatment of carpal tunnel syndrome during pregnancy.
Key words: Kinesio Tape, Antenatal, Carpal Tunnel Syndrome, Electro Diagnostic Finding.
INTRODUCTION There are several treatment options for CTS, and

they can be broadly categorized into surgical and non-
Carpal tunnel syndrome (CTS) is one of the most surgical. Non-surgical methods are effective in patients
common upper limb compression neuropathies, it with mild to moderate CTS. They are indicated in
accounted for approximately 90% of all entrapment patients with no muscle weakness, atrophy, or
neuropathies. It occurred due to an entrapment of the denervation and with only a mild abnormality on
median nerve in the carpal tunnel at the wrist1-3. nerve conduction studies 11,12.
The pregnant women are more prone to develop
Conservative treatment of about six weeks to
carpal tunnel syndrome because they retain more fluid
twelve weeks can be considered in patients with mild
during the later stages of their pregnancies. The more
disease. Lifestyle modifications, including decreasing
fluid retains, the more swelling occurs, squeezing the
repetitive activity and using ergonomic devices, have
nerves that run through the hands and fingers, also
been traditionally advocated, but have inconsistent
most women who experience pain, numbness, and
evidence to support their effectiveness. Oral
tingling in the hands for the first time due to pregnancy
corticosteroids are considered first-line therapies, with
have no idea that they have carpal tunnel syndrome4-6. local corticosteroid injections used for refractory
Carpal tunnel syndrome can hamper mother ability symptoms. Non steroidal anti-inflammatory drugs,
to perform any number of everyday tasks as shopping, diuretics, and pyridoxine (vitamin B6) have been
using a fork, or even holding a phone up to her ear. shown to be no more effective than placebo. Most
The pain can also spread to her arm, shoulder and neck conservative treatments provide short-term symptom
making hand and arm motions more painful. It can relief, with little evidence supporting long-term
even contribute to sleep problems, many women benefits. Patients with moderate to severe disease
report their pain often worsens at night and may affect should be considered for surgical evaluation. Open
mother ability to carry her baby if symptoms continue and endoscopic surgical approaches have similar five-
after delivery7-9. year outcomes13,14.
Pregnant women sometimes cant take any In physiotherapy there are several ways to treat and
medication during the pregnancy as non-steroidal anti- control carpal tunnel syndrome, this procedure should
inflammatory drugs such as aspirin and ibuprofen be directed specifically towards the pattern of pain,
which are not safe during pregnancy, so they shouldnt symptoms and dysfunction assessed by the therapist.
be used to treat carpal tunnel during this period4,10. As such, it may include soft tissue massage,
25 Fayez egypt 14th april 12 (122-126).pmd 122 10/16/2012, 2:41 PM

conservative stretches, exercises, techniques to directly B. Instrumentations used for treatment:

mobilize the nerve tissue and therapeutic ultrasonic15,16.
1. Kinesio tape:
The purpose of this study was to investigate the
effect of kinesio tape on the treatment of carpal tunnel A roll of water resistant original K T with 2 inch
syndrome during pregnancy. widths was used.
2. Cotton and alcohol:

SUBJECTS, MATERIAL AND METHODS
To clean the skin of the patients affected arm before
Subjects kinesio tape application and also before electro
diagnostic assessment to reduce the skin-electrode
The study was conducted on 15 primipara patients interface impedance.
selected randomly from the gynecology and obstetrics
department of El khazendara general hospital, Shobra, 3. Scissor:
Egypt. With mild to moderate CTS, their ages ranged
Used to cut a kinesio I strip as a Y shape.
from 20-35 years, they received a program of kinesio
tape application on the affected wrist in form of fascia Evaluation procedures:
technique application for 3 days and then one day off
and then another 3 days of application each week for A- Initial evaluation:
4 weeks.
The initial evaluation was carried out before
starting the program of treatment in form of:
Inclusive Criteria
1- Patients sheet.
Selections of the patients were according to the
following criteria: 2- Electro diagnostic evaluation.
1. All patients would not take any analgesics by any B- Final evaluation:
route during the period of study.
2. They were in the 3rd trimester of pregnancy. It was in the form of electro diagnostic evaluation
3. All patients had positive electro diagnostic findings. after 4 weeks from starting of the treatment program.
Exclusive criteria: PROCEDURE

Subjects were excluded for any of the following Before electro diagnostic assessment, the patients
criteria: were prepared as follow:
1. Patients with history of wrist or median nerve 1. The room temperature was adjusted to be 22C and
injury from trauma (e.g. contusion, fractures) or had the patient body temperature was 37C during
previous surgery on wrist. assessment.
2. Subjects who had carpal tunnel syndrome before 2. The patients were informed about the aim of the
pregnancy. tests.
3. Multipara. 3. Using alcohol to clean the skin of the patients
4. Skin over sensitivity to the tape in some patients. affected arm to reduce the skin-electrode interface
impedance. Also the therapists were abrasive the
Instrumentations: skin firmly with abrasives paper to eliminate the
dead epidermis layer.
A. Instrumentations used for evaluation:
4. The patients were allowed to rest in room for about
1. Computerized electromyography: 15 minutes before the assessment to allow them to
relax and accommodated to the room temperature.
Schwarzar, topas 2 channel version with EMG/ 5. The patients were relaxed in supine position with
NCV/EP system. It consisted of topas base unit, topas affected arm rested comfortably and exposed16.
preamplifier with cable, PC, electrical stimulator and
foot switch, this instrument made in Germany - Measuring the median motor distal latency
(Baermann strasse 38 Munich, D-81245). It was used (MMDL):
to measure (MMDL) before treatment and after 4
The active recording electrode was placed on the
weeks of treatment for all patients.
motor point of abductor pollicis brevis (APB). The

reference electrode was placed on the tip of thumb. sample T test was used for normally distributed
The bipolar stimulating electrodes was placed between quantitative variables. Validity of the used tests was
the tendons of palmaris longus and flexor carpi radialis done by calculating their sensitivity, specificity and
muscles on the course of median nerve with the predictive values. P value less than or equal to 0.05
positive electrode towards distal, and then make point was considered significant and less than 0.01 was
by skin marker on the area in which the stimulating considered highly significant19.
electrode applied. The ground electrode was placed
mid way between the stimulating and recording RESULTS
electrodes. After giving stimulus at wrist, MMDL can
be measured by recording the amount of time it takes All data had been collected and statistically
for the charge to travel from the stimulus electrode to analyzed and presented under the following headings;
recording electrode (latency) [9,17].
- Physical characteristics of the patients.
Treatment procedures:
- Median motor distal latency (MMDL).
(1) Verbal explanations about the importance of this
Physical characteristics of the patients:
research and about the treatment program were
explained to the patients. The mean values of patients age, weight, height
and BMI were 27.534.47 years, 84.69.38 kg,
(2) All patients were instructed not to take any
160.864.67 cm and 31.733.55 Kg/m2 respectively.
analgesics by any route during the study.
The differences concerning the physical
(3) All subjects were treated by Kinesio tape in form
characteristics (age, weight, height and BMI) between
of fascia technique application for three days then
subjects were compared together and there were
day off and then another three days of application
statistically non significant differences (P >0.05).
each week for four weeks during the 3rd trimester
of pregnancy, each time before applying kinesio Median nerve motor distal latency:
tape the area should be cleaned using cotton and
alcohol. An I kinesio strip was measured from the There was statistically highly significant difference
proximal palmar crease to the epicondyles of the (P<0.0001) between before and after the treatment
humerous then a Y cut on the kinesio strip was programme, the mean value of pre treatment was
made, the patients elbow should be extended with (4.650.27) and post treatment was (3.540.36) with
wrist extended and fully stretched by patients percentage of improvement of 23.87 % (Table1).
another hand ,the base of Y cut is attached to Table 1. Mean values of the patients, Median nerve
proximal palmar crease, and the medial proximal motor distal latency before & after treatment.
tail in the direction of medial epicondyle of the
Median nerve motor distal latency
humerus with light to moderate tension (25-50%)of
Pre treatment Post treatment
available tension with no tension for the last 1-2
Mean 4.650.27 3.540.36
inches, and lateral proximal tail of the Y cut in the
Percentage of improvement 23.87 %
direction of medial epicondyle of the humerus with t-value 16.66
light to moderate tension (25-50%)of available P-value 0.0001
tension with no tension for the last 1-2 inches then
*SD: standard deviation, P: probability, HS: Highly significant.
another kinesio I strip was applied to the dorsum
of the wrist with tension directly over the distal 2
inches of the ulna and the radius on the dorsum of DISCUSSION
the hand18. Carpal tunnel syndrome is a medical condition in
which the median nerve is compressed at the wrist
All patients continued to perform the study for 4
leading to parenthesis, numbness and muscles
weeks then the final evaluation was performed at the
weakness in the hand16,20.
end of the study.
Most pregnant women who experience pain,
Statistical Analysis numbness, and tingling in the hands for the first time
due to pregnancy had no idea that they had carpal
Statistical package for social science (SPSS) was tunnel syndrome. Carpal tunnel symptoms during
used for data management and analysis quantitative pregnancy tend to increase in the second and third
data were expressed as mean SD. Independent trimester due to fluid retention7,21.

Carpal tunnel syndrome (CTS) is a frequent Another study was performed by Hyland et al.,24
complication of pregnancy, with a prevalence reported to investigate the effect of kinesio tape on pain .forty
as high as 62%. The most typical symptoms were one patients with plantar heel pain were randomly
numbness and tingling in the thumb, index finger, assigned into 4 groups: (1) stretching of the plantar
middle finger, and radial half of the ring finger. Other fascia, (2) calcaneal taping, (3) control (no treatment),
common manifestations included burning dysesthetic and (4) sham taping. A visual analog scale for pain
wrist pain, as well as the loss of grip strength and and a patient-specific functional scale for functional
dexterity. Proximal radiation along the volar forearm, activities were measured pretreatment and after 1
medial arm, and shoulder, while not as common but week of treatment. At the end a significant difference
is not unusual. Symptoms were often worse at night was found post treatment among the groups for the
and could be exacerbated by forceful activity and visual analogue scale (P < 0.001). Specifically,
extreme wrist positions. It could be diagnosed to a high significant differences were found between stretching
degree of specificity via history and physical and calcaneal taping (mean + SD, 4.60.7 versus
examination. Median nerve function is impaired in 2.71.8; P<0.006), stretching and control (meanSD,
virtually all pregnant women during the third 4.60.7 versus 6.21.0; P<0.026), calcaneal taping and
trimester, even in the absence of symptoms21,22. control (meanSD, 2.71.8 versus 6.21.0; P< .001), and
calcaneal taping and sham taping (meanSD, 2.71.8
The aim of this study was to investigate the effect versus 6.00.9; P<0.001). No significant difference
of kinesio tape in the treatment of carpal tunnel among groups was found for post treatment patient-
syndrome during pregnancy. The study was specific functional scale (P<0.078).
conducted to 15 pregnant patients suffering from
carpal tunnel syndrome; they received a program of The lymphatic drainage system contains both
Kinesio tape. Electro diagnostic assessment using superficial and deep lymphatic vessels which can
median nerve motor distal latency was performed become filled in response to localized inflammation.
before and after 4 weeks from the beginning of the kinesio taping takes advantages of the mechanical
study for each patient. connection of the anchoring filaments to the
endothelial cells, by way of connection to the dermal
In the present study there was statistically highly layer the lymphatic channels can be opened up by the
significant improvement of electro diagnostic elastic qualities of the tape creating the characteristic
assessment median nerve motor distal latency in convolutions on the tape this allows for the lymph
response to the Kinesio tape program (P< 0.0001) with obligatory load to fill the lymphatic capillaries toward
percentage of improvement of 23.87%. areas of decrease pressure under the tape which allows
fluid to move more freely. The elastic property of
This comes in support with Mindy and Pou, [23].who
performed a study to investigate the effect of kinesio kinesio tape also creates a gentle massage with
taping treatment to release the median nerve, increase movement, this pressure changes and movement of
the skin open and close the initial lymphatic vessels
the wrist joints range of motion and pinch force of the
fingertips also they investigated the effect of fatigue and kinesio taping on the superficial lymphatic
on CTS patients treatment before and after application encourages edema movement, the edema reduction
removes heat and chemical substance in tissue,
of kinesio tape on right hand (CTS) and left hand
(normal). Four CTS housewives with symptoms of improving circulation and reducing trigger points.
Pain , numbness and tingling on the right hand for Decreasing pressure and chemical receptors reduce
pain and improve the return of normal sensation25,26.
more than two years served as participants for this
study and were tested for pinch force in wrist flexion,
wrist flexion with radial deviation and wrist flexion CONCLUSION
with ulnar deviation for one minute with no treatment
From the statistical point of view, it could be
and then after kinesio taping. At the end of the study
concluded that kinesio tape was found to be effective
the main results for the condition of fatigue showed
in the treatment of CTS, providing a simple, non
that the mean force of pinch in wrist flexion, mean
invasive, cheap, light, safe to be used during pregnancy
power frequency of action for flexor carpi ulnaris in
and has no harmful effects on the mothers and their
wrist flexion, mean power frequency of action for
fetus.
flexor carpi ulnaris in ulnar deviation and mean power
frequency of action for flexor carpi ulnaris in radial
deviation were significantly different (P< 0.02), the REFERENCES
treatment of kinesio tape on hand with CTS could be 1. Aroori S, Spence R. Carpal tunnel syndrome.
consistent with the performance of pinch by reduction Ulster Med j 2008; 77(1):6-17.
of the rate of muscular recruitment18.

2. Bahrami M, Rayegani S, Fereidouni M, Baghbani 16. Johns L. Analysis of effective radiating area,
M. Prevalence and severity of carpal tunnel power, intensity, and field characteristics of
syndrome (CTS) during pregnancy. WMJ 2005; ultrasound transducers. Arch Phys Med Rehabil
45 (2): 123-125. 2007; 88(1): 124-129.
3. Hedge A. Computer use and risk of carpal tunnel 17. Graham B. The Value Added by Electro
syndrome JAMA 2003; 290 (14)1854-1855. diagnostic Testing in the Diagnosis of Carpal
4. Viera A. Management of carpal tunnel syndrome. Tunnel Syndrome. The Journal of Bone and Joint
American family physician 2003; 68 (2): 265-272. Surgery 2008; 90 (12): 2587-2593.
5. Ante J, Marina B, Igor A, Sinisa D. Early onset of 18. Kase K. Clinical Therapeutic Applications of The
carpal tunnel syndrome during pregnancy 2010; Kinesio Taping Method (3rd Ed.) Ken Ikai Co.
49(1): 77-80. Ltd, Tokyo, Japan; 2003.
6. Chesnutt A. Physiology of normal pregnancy. 19. Ott R, Mark L. An introduction to statistical
Crit Care Clin 2004; 20(4): 609-615. methods and data analysis. (5th Ed.) Books/Cole,
7. Finsen M, Zeitlmann H. Carpal tunnel syndrome Pacific Grove, Cali; 2001: 221.
during pregnancy. J of Plastic and Reconstructive 20. Katz M, Jeffrey N, Simmons L, Barry P. Carpal
Surgery 2006; 40 (1): 41-45. Tunnel Syndrome. New England Journal of
8. Einar P, Wilder S, Raymond C, Erle, C. Medicine 2002; 346(23): 1807-1812.
Diagnosing carpal tunnel syndrome-clinical 21. Weimer L, Yin J, Lovelace R, Gooch C. Serial
criteria and ancillary tests. Nature Clinical studies of carpal tunnel syndrome during and
Practice Neurology 2006; 2 (7): 366-374. after pregnancy. Muscle Nerve 2002; 25(6):
9. Macdermid J, Doherty T. Clinical and electro 914-917.
diagnostic testing of carpal tunnel syndrome: A 22. Above H, Above T. Prevalence of carpal tunnel
narrative review. J Orthop Sports Phys Ther 2004; syndrome in pregnant women.WMJ 2009; 108(4):
34 (10): 565-589. 194-196.
10. Tupkovic E, Nisic M, Kendic S. Median nerve 23. Mindy L, Pou Y. The use of kinesio tape for carpal
neurophysiological parameters in the third tunnel syndrome. National Taiwan University
trimester of pregnancy 2007; 7(1): 84-89. Advance healing 2007; (3): 16-20.
11. Burke F, Ellis J, McKenna H, Bradley M. Primary 24. Hyland M, Gaffiney A, Cohen L, Lichtman P.
care management of carpal tunnel Syndrome. Randomized controlled trial of calcaneal taping,
Post Grad Med J 2003; 79 (934): 433- 437. sham taping, and plantar fascia stretching for the
12. Arle J, Zager E. Surgical treatment of common short-term management of plantar heel pain. J
entrapment neuropathies in the upper limbs. Orthop Phys Ther 2006; 36(6): 364-371.
Muscle Nerve 2000; 23(8): 1160-1174. 25. Anna L, Zbigniew S, Wojciech K, Tomasz S,
13. Leblanc K, Cestia W. Carpal tunnel syndrome. Janusz K. The influence of kinesio taping
Am Fam Physician 2011; 83(8): 952-958. applications on lymphoedema of an upper limb
14. Norvell L, Jeffrey G, Steele K, Mark L. The carpal in women after mastectomy. Orthop Traumatol
tunnel syndrome. A study of carpal canal Rehabil 2007; 7(3): 258-269.
pressures. J of Bone and Joint Surgery 2009; 63(3): 26. Slupik A, Dwornik M, Bialoszewski D, Zych E.
380-383. Effect of kinesio taping on bioelectrical activity
15. Michlovitz L. Conservative interventions for of vastus medialis muscle: preliminary report.
carpal tunnel syndrome. Phys Ther J 2004; 34 (10): Orthop Tramatol Rehabil 2007; 9(6): 644-651.
589-600.

Effect of Antenatal Exercises on Umbilical Blood Flow and
Neonate Wellbeing in Diabetic Pregnant Women
Hanan Sayed E-Mekawy1, Adly Ali Sabbour2, Mohamed Mostafa Radwan3

1,2
Assistant Professor, Department of Physical Therapy for Gynecology and Obstetrics, Faculty of Physical Therapy,
Cairo University, 3Professor of Gynecology and Obstetrics, Faculty of Medicine, El-Azhar University.
ABSTRACT
This study was conducted to determine the effects of moderate aerobic antenatal exercise on the
umbilical blood flow and neonate wellbeing in Type II diabetic pregnant women. Forty multiparous
pregnant women with Type II diabetes at 24 weeks gestation were participated in this study. Their
age ranged from 25-32 years old, their body mass index >30Kg/m2 and all of them were under
insulin therapy. They were classified into 2 equal groups (A&B). Each patient in the study group (A)
underwent moderate intensity aerobic exercise training (60% of maximum heart rate) 30 minutes, 3
times /week for 10 weeks (30 sessions) in addition to their medical treatment and advices to continue
normal daily activities, while patients of the control group (B) were only follow their medical treatment
and advices to continue normal daily activities. Fasting blood glucose level and umbilical artery
blood flow for each patient in both groups (A&B) were evaluated before starting and after the end of
the study duration (10 weeks). Also, APGAR score at 1st and 5th minutes after delivery were assessed
for all neonatal infants. Results of this study revealed that moderate intensity aerobic exercise training
caused statistically highly significant (P<0.001) improve in the placental blood flow through decreasing
umbilical artery pulsatility index (PI), resistance index (RI), systolic/diastolic (S/D) ratio and
maximum systolic velocity as well as increasing its end diastolic velocity. Also, results revealed a
statistically highly significant (P<0.001) decrease in blood glucose level for the exercised ladies and a
statistically significant (P<0.05) increase in 1st minute Apgar scores in neonatal infants of the exercising
mothers. Thus it could be concluded that aerobic exercises are effective in improving placental blood
flow offering more nutrients to the fetus in Type II diabetic pregnant women.
Key words: Type II Diabetes, Antenatal Exercises, Blood Glucose Level, Umbilical Artery Blood Flow- Apgar
Score.
INTRODUCTION for the fetus and spontaneous abortions in women with

poor glycemic control.20
Diabetes is one of the most common chronic
diseases encountered in the health care setting. It places Several researches have indicated that type II
a substantial burden on the individual, society and the diabetes is becoming an increasingly prevalent
economy1. It has been known that diabetes antedating disorder in young people all over the world26. It may
pregnancy can have severe adverse effects10 and may range from predominant insulin resistance to
result in un-favorable maternal and neonatal predominant secretory defect.25
outcomes.23
It is a general clinical observation that the
Pregnancy is a diabetogenic condition number of pregnant women with pre-gestational
characterized by insulin resistance with a type II diabetes has become more frequent in the
compensatory increase in -cell response. The placental recent years; however, little knowledge exists
secretion of hormones (progesterone, cortisol and concerning the prevalence and outcome of these
placental lactogen,) is a major contributor to the insulin pregnancies 4.
resistance, which likely plays a role in ensuring that
the fetus has an adequate supply of glucose.26 Women with type II diabetes are of greater risk of
prenatal mortality, congenital malformation, preterm
Pregnancy in patients with diabetes is associated delivery, and fetal loss before 24 weeks gestation11.
with an increased incidence of congenital anomalies Also, women who have diabetes before pregnancy
26. Hanan Egypt (127-131).pmd 127 10/16/2012, 2:41 PM

have birth defect four times greater than women who intensity aerobic exercise training (60% of maximum
got diabetes during pregnancy4. heart rate) 30 minutes, 3 times /week for 10 weeks (30
sessions) in addition to their medical, while patients
There are at least two pathological defects in of the control group (B) were only follow their medical
diabetic pregnant women, one is a decreased ability treatment. Fasting blood glucose level as well as
of insulin to act on peripheral tissue to stimulate umbilical artery blood flow for each patient in both
glucose metabolism i.e. insulin resistance. The other groups (A&B) were evaluated before starting and after
is inability of pancreas to fully compensate this insulin the end of the study duration (10 weeks). Also, APGAR
resistance21. score at 1st and 5th minutes following delivery were
assessed for all neonatal infants.
Many clinical complications of type II diabetes may
be ascribed to attention in vascular structure and Instruments
functions27. Maternal diabetes also produces alterations 1. Electronic bicycle ergometer (ECD ergometer E405)
in red blood cells, oxygen release and reduced was used for performing exercise training program.
placental as well as uterine blood flow which 2. Doppler ultrasound machine (SONY Au530
contribute to the increased incidence of intrauterine ESAOTE EIOMCIA) with a linear 5MHz probe was
growth retardation 13. used for measuring the umbilical artery blood flow.
3. Apgar score was used for quick and summarize
Umbilical artery (UA) Doppler blood flow velocity
assessment of the neonate at the 1st and 5th minutes
waveforms can be used to identify fetuses that might
following delivery.
benefit from increased surveillance or planned
delivery. Owing to difficulties encountered with
Procedures
volumetric blood flow assessment in small, pulsatile,
I. Evaluative procedures
convoluted UA, qualitative analysis of blood flow
a. Umbilical artery Doppler measurement: The
velocity waveforms, or semi-quantitative indexes, such
waveforms were only accepted when a clear
as pulsatility index (PI), resistance index (RI), and the
continuous signals corresponding to the
systolic-to-diastolic ratio (S/D) are often used14.
umbilical vein were visible in the reverse
Studies concerning the effect of exercise on diabetes channel. The maximum systolic and end
are available but the effect of exercise on maternal diastolic velocities of the umbilical artery were
blood glucose level during pregnancy still not recorded, after that S/D ratio, RI and PI were
documented11. Also, exercise have proved by many calculated.
authors to improve uterine blood flow17 as well as b. Blood samples were drawn to measure her
placental blood flow9,16 in normal pregnant and pre- fasting blood glucose level
eclamptic women. Whereas, none of the previous c. After delivery. APGAR score was used for
studies showed the exact role of exercise on blood flow assessment of the neonate wellbeing at 1st and
5th
in diabetic pregnant women7,8. minutes following delivery.
II. Aerobic exercise training program (for
As the data available seems incomplete for participants of group A):
physicians and physical therapists to prescribe safe and
effective antenatal exercise for diabetic pregnant Every session of the exercise training program (30
women. So, this study is an attempt to provide such minutes) were consisted of three stages: First stage
information by examining the effects of moderate (warming up), consisted of 5 minutes warming up in
aerobic exercise on the maternal blood glucose level the form of pedaling at a speed of 60 revolutions per
as well as umbilical blood flow and neonate wellbeing minutes without load. Second stag (Active stage),
in Type II diabetic pregnant women. consisted of 20 minutes pedaling at the same speed of
the first stage with adjusted load to achieve 60% of
SUBJECTS, MATERIALS AND METHODS her maximal heart rate (maximal heart rate= 220-age
of the woman)18. Third stage (Cooling down), which
Subjects is the same as first stage. Aerobic exercise training was
performed 3 sessions per week for 10 weeks.
Forty multiparous pregnant women with type II
diabetes at 24 weeks gestation were participated in III. Statistical analysis
this study. Their age ranged from 25-32 years old, their
body mass index > 30Kg/m2 and all of them were The data was collected and fed into computer for
under insulin therapy. analysis. Paired & unpaired t-test was carried to
compare between both groups before and after the
They were classified into 2 equal groups (A&B). end of the study program (10 weeks), at a level of
Each patient in group (A) underwent moderate significance P < 0.05.

RESULTS
Before study, blood glucose level and umbilical artery maximum systolic velocity, end diastolic velocity,
systolic / diastolic ratio, resistance index as well as palsatility index were representing no statistical difference
( P> 0.05 ) as shown in Table 1).
Table 1. The mean values of blood glucose level and umbilical artery blood flow for both groups (A&B) before
starting the study.
Variable* Group Mean + S.D Mean Difference t. value P. value Significance*
BGL A 146.45013.985 4.700 0.767 0.452 N.S
B 141.75014.348
Umbilical A 0.423 0.016 -0.003 0.655 0.520 N.S
artery MSV B 0.426 0.018
Umbilical A 0.1190.005 0.001 1. 453 0.163 N.S
artery EDV B 0.1180.005
Umbilical A 3.2110.029 -0.014 -0.412 0.685 N.S
artery S/D B 3.2250.022
Umbilical A 0.689 0.003 0.001 1.129 0.899 N.S
artery RI B 0.6880.002
Umbilical A 1.0860.039 -0.062 -1.030 0.316 N.S
artery PI B 1.1470.034
After the study,as shown in (Table 2), the blood the study group. The mean reduction represented 10%
glucose level o of the group (A) was 94.550 13.372, in group A .
while it was 140.250 12.192in group (B) this difference
equal about 32% representing a highly significant EDV was 0.1290.005 m/h in group B and
decrease (P<0.001) . increased by about 13% to reach 0.1490.004 m/h in
group A which revealed a statistically highly
MSV was 0.4230.018m/h in the control group significant (P<0.001) increase.
compared to 0.3970.016m/h in the study group after
training which revealed a statistically significant After birth, it was found that there was a
(P<0.01) decrease. Also S/D ratio was decreased from statistically significant ( P<0.05) increase in the Apgar
3.0520.057in the control group to 2.5350.066 in the score of the neonates in group A at the 1st minute
study group with a percentage of decrease equal about following delivery while there was no statistically
17%. The mean value of the umbilical artery RI was significant difference ( P>0.05) at the 5 th minute
0.6740.007in the control group and 0.6080.009 in following delivery.
Table 2. The mean values of blood glucose level, umbilical artery blood flow and Apgar score for both groups
(A&B) following the study.
Variable* Group Mean + S.D Mean Difference t. value P. value Significance*
BGL A 94.550 13.372 -45. 700 -4.179 0.001 H.S
B 140.250 12.192
Umbilical A 0.3970.016 -0.026 -3.287 0.004 S
artery MSV B 0.427 0.018
Umbilical A 0.1490.004 0.020 4.225 0.001 H.S
artery EDV B 0.1290.005
Umbilical A 2.5350.066 -0.517 -5.877 0.001 H.S
artery S/D B 3.0520.057
Umbilical A 0.6080.009 -0.066 -5.772 0.001 H.S
artery RI B 0.6740.007
Umbilical A 1.0850.039 -0.062 -4.701 0.001 H.S
artery PI B 1.1470.034
Apgar scoreAt A 9.250+0.142 0.850 2.482 0.023 S.
1st min. B 8.400+0.311
Apgar scoreAt A 9.600+0.168 0.200 1.073 0.297 N.S
5th min. B 9.400+0.133

DISCUSSION vasoconstriction which cause deficiency of placental

blood flow.
Many of clinical complications of diabetes may be
ascribed to attention in vascular structure and These results are supported by James 17 who
function23. Compared to non diabetic subjects, diabetic concluded that, when moderate exercises continued
individuals are at increased risk for coronary artery during mid pregnancy, the placenta grow faster and
diseases, increased proliferation and migration of had 15% more vessels and surface area at term. Thus,
vascular smooth muscle cells which contribute reducing the risk of intrauterine growth retardation
importantly to the formation of both atherosclerosis and intrauterine fetal death.
and restonotic lesion causing decrease in microvascular
and macrovascular blood flow3. The results are also in agreement with Clapp and
his collegues8, who studied the effect of exercise on
Diabetic pregnant women with vascular normal pregnant women and found that moderate
complication may develop fetal growth retardation exercises lead to faster placental growth as well as
and intrauterine demise as early as the second increased morphometric indices of placental function
trimester however, stillbirth have been observed most leading to decrease the risk of fetal anomalies.
often after 36th weeks of pregnancy13.
Thus it could be concluded that aerobic exercises
This study was conducted to determine the effects seem to be effective in reducing blood glucose level
of moderate aerobic exercise on reducing maternal and improving umbilical blood flow offering more
blood glucose level as well as improving umbilical nutrients to the fetus and increasing the wellbeing of
blood flow in type II diabetic pregnant women. the neonates in diabetic pregnant women.
The results of this study revealed a significant

REFERENCES
(P<0.001) reduction in blood glucose level after the
exercise training program, these results come in 1. American Diabetes Association ADA(1998):
agreement with Ross et al.,22 who had established that Economic Consequences of Diabetes Mellitus in
both acute and chronic exercise is associated with the U.S. in 1997. Diabetes Care, 21(2): 296-309.
improvements in glucose tolerance in individuals with 2. American Diabetes Association(2000): Type 2
type II diabetes. diabetes in children and adolescents. Diabetes
Care, 23: 381-392.
These results are also in agreement with Giacca et 3. American Dietetic Association(2001): Nutrition
al.,15 who conducted a study on obese subjects with Practice Guidelines for Gestational Diabetes
type II diabetes, and reported that plasma glucose Mellitus. Available from http://eatright.com,
levels decreased after engagement in moderate 2001.
aerobic exercise program. 4. American Diabetes Association(2002): Diabetes
and exercise .Diabetes Care, 25 (Suppl. 1): S64-
The improvement in umbilical artery blood flow S68.
obtained in the current study could be explained by 5. Artal, R.(1990): Exercise and diabetes mellitus in
the results obtained by Rafla and Beazely19, who related pregnancy: a brief review. Sports Med., 9: 261-265.
the decrease in the umbilical artery S/D ratio following 6. Bloomgarden, Z.T (2004).: Type II diabetes in the
exercise at the 2 nd trimester of pregnancy to the young: the evolving epidemic. Diabetes Care, 27:
decrease in umbilical blood flow resistance and the 998-1010.
increase in placental circulation. This also supported 7. Brydon, P., Smith, T., Proffitt, M., Gee, H., Holder,
by Salvesen et al.,24 who concluded that high umbilical R. and Dunne, F.(2000) :Pregnancy outcome in
artery pulsatility index (PI) occurred only when the women with type II diabetes mellitus needs to
woman exercised more than 90% of maximal HR be addressed. Int. J. Clin. Pract, 54: 418-419.
because the mean uterine artery volume blood flow 8. Clapp, J.F. and Kiess, W(2000).: Effects of
may drop to less than 50% of the initial value. pregnancy and exercise on concentrations of the
metabolic markers tumor necrosis factor alpha
These could be also explained by the results of and leptin. Am. J. Obstet. Gynecol., 182(2): 300-
Eriksson et al., 12 who reported that in diabetic 306.
individuals, exercise may cause a decrease of 9. Clapp, J.F.(2003): The effects of maternal exercise
triglycerides and low density level cholesterol, as well on fetal oxygenation and feto-placental growth.
as increase of high density level cholesterol thus, Eur. J. Obstet. Gynecol. Repord Biol., 22: (Suppl
decreasing the incidence of atherosclerosis or 1): S80-S85.

10. Devlin, J.T., Ruderman, N. and Alexandria, V.A. 19. Rafla, N. and Beazely, J(1996).: The effect of
(1995): Diabetes and exercise: the risk-benefit maternal exercise on fetal umbilical artery
profile. In The Health Professionals Guide to waveforms, Eur. J. Obstet. Gynecol. Repord
Diabetes and Exercise. American Diabetes Biol., 4: 119-122.
Association, 3-4. 20. Ray JG, OBrien TE, and Chan WS(2001):
11. Dunne, F., Brydon, P., Smith, K. and Gee, H Preconception care and the risk of congenital
(2003).: Pregnancy in women with type II anomalies in the offspring of women with
diabetes: 12 years outcome data 19902002. diabetes mellitus: a meta-analysis. QJM 94: 435 -
Diabet. Med., 20: 734-738. 444,
12. Errikson, J., Taimela, S. and Koivisoto, V(1997).: 21. Ronald, K(1994).: Insulin action, diabetogenes,
Exercise and the metabolic syndrome. and the cause of Type II diabetes, Diabetes, 43(8):
Diabetologia, 40: 125-135. 1066-1084.
13. Gabbe, G. and Bernstein, I(2006).: Intrauterine 22. Ross, R., Janssen, I., Dawson, J., Kungl, A.M., Kuk,
growth restriction. In Gabbe G.and Sympson: J.L., Wong, S.L., Nguyen-Duy, T.B., Lee, S.,
Obstetrics normal and problem pregnancies, 3rd Kilpatrick, K. and Hudson, R(2004).: Exercise-
ed. Mikki Senkarik, New York: 937-948. induced reduction in obesity and insulin
14. Ganesh, A., Tiina, E., Kaarin, M. and Juha, resistance in women: a randomized controlled
R.(2004): Relationships among Doppler-derived trial. Obesity. Res., 12:789-798.
umbilical artery absolute velocities, cardiac 23. Rouiller, D., Boulvain, M. and Ceysens G(2009).:
function, and placental volume blood flow, Am Exercise for diabetic pregnant women: Cochrane
J Physiol Heart Circ Physiol, 286: H1266-H1272. Database Syst Rev. Jul 19; 3: CD004225.
15. Giacca, A., Groenewoud, Y., Tsui, E., McClean, P. 24. Salvesen, K, Hem. E and Sundgot-Borgen, J(2011)
and Zinman, B(1998).: Glucose production, : Fetal wellbeing may be compromised during
utilization, and cycling in response to moderate strenuous exercise among pregnant elite athletes.
exercise in obese subjects with type II diabetes Br J Sports Med doi:10.1136/bjsm. 2010.080259
and mild hyperglycemia. Diabetes, 47: 1763-1770. Published Online 10 March 2011.
16. Hume, R., Bowie, J., Gall, M., Carrol, B. and 25. Schott, M., Schatz, D., Atkinson, M., Krischer, J.,
Killam, A(1990).: Fetal umbilical artery Doppler Mehta, H., Vold, B. and Maclaren, N(1994).:
response to graded maternal exercise, Am. J. Autoantibodies increase the predictability but not
Obstet. Gynecol., 163: 826-829. the sensitivity of islet cell for developing insulin
17. James, T(1998).: Exercising through your dependent diabetes mellitus, J. Autoimmunity, 7:
pregnancy, Churchill Company, New York, 345- 865-872.
355. 26. Setji TL, Brown AJ, Feinglos MN( 2005):
18. Mesquite, A., Trabulo, M., Mendes, M., Vianna, Gestational diabetes mellitus. Clin Diabetes 23:
J. and Seabra, G.(1996): The maximum heart rate 17 -24
in the exercise test: the 220-age formula or 27. Veves, A.(1998): Clinical management of diabetic
Sheffeilds table?, Rev. Prot. Cardiol., 15(2): 139- complications, Human Press Inc. Company, 2nd
144. ed., Totawa, 7-295,

Efficacy of Active Release Technique in Tennis Elbow A

Randomized Control Trial
Harneet K M1, Khatri SM2

1
Postgraduate student, 2Professor & Principal College of Physiotherapy,
Pravara Institute of Medical Sciences, Loni- 413 736, Maharashtra state
ABSTRACT
Purpose: To evaluate the efficacy of Active Release Technique on functional performance by Patient
Rated Tennis Elbow Evaluation (PRTEE) and Pain Free Grip Strength (PFGS) in patients with Tennis
Elbow.
Methodology: A total of 30 patients having symptomatic chronic tennis elbow were taken and
randomly assigned to one of the two groups. Group A received Active Release Technique (ART) and
conventional treatment, whereas Group B acted as a control group and received conventional treatment
of pulsed ultrasonic therapy at 20% duty cycle, frequency 3MHz and an intensity of 2 W/cm2 for
7 min, progressive resisted exercises and stretching. Fourteen treatment sessions are given. Baseline
measurement of PRTEE score and Pain Free Grip Strength was taken on Day 1 and then subsequently
on day 14.
Results: The data was analyzed using the software Instat. Differences were found for 2 outcome
measures: success rate at 3 weeks. Findings indicated ART was more effective than the other protocol.
After 3 weeks of intervention, improvement in Functional performance as measured on PRTEE was
more (SD=8.87) in group 1, as compared with (SD=7.41) in group 2. Improvement in grip strength as
measured by PFGS was more (SD=1.52) in group 1, as compared with (SD=1.05) in group 2.
Conclusion: The study concludes that both the Active Release Technique is effective in reducing
pain, improving strength and functional performance.
Key words: Active Release Technique, Lateral Epicondylalgia, Soft tissue Technique.
INTRODUCTION Several interventions for the management of tennis

elbow have been described, including corticosteroid
Tennis elbow is like a snail, slowly progressing and injections, use of orthotic devices, surgery, and use of
leaving behind a trail of mess. Most often associated thermal and electromagnetic modalities such as
with overuse or a repetitive stress, as opposed to an ultrasound, laser, electrotherapy and finally exercise
acute inflammatory reaction 12 . It is a common therapy consisting of muscle stretching and
pathology of both athletes and non-athletes, affecting strengthening exercises1,2. Although many treatment
1 to 3 % of the population at large. This condition is modalities may be used, few of them rest on scientific
characterized as pain on the lateral side of the elbow evidence and none have really been proven to be more
that is aggravated with movements of the wrist, by effective than the others. The paucity of evidence on
palpation of the lateral side of the elbow, or by treatments for lateral epicondylalgia may stem from
contraction of the extensor muscles of the wrist15,16. It several sources, including the self-limiting nature of
is a self-limiting complaint; without intervention, the the condition, the lack of patho-physiological data, the
symptoms will usually resolve within 8 to 12 months. methodological shortcomings of the current studies,
The peak prevalence of is in the fourth decade of life and the existence of multiple factors which may
when it is four times more common than any other influence the outcome11.
decade12,13. It is found that there is no difference in
incidence between men and women or association Many soft tissue manipulations like Mills
between the lateral epicondylalgia and the dominant Manipulation of Cyriax have been successfully used
arm14. in the treatment of lateral epicondylalgia2. Recently one
27. Harneet 7th oct 11 (132-135).pmd 132 10/16/2012, 2:41 PM

of the most popular of soft tissue techniques to gain therapist is working on the extensor carpi radialis
notoriety is Active Release Technique- ART3,6. ART is longus and brevis muscles by applying pressure to the
based on the observation of the anatomical muscles distal to their attachment at the elbow. The
arrangement of muscle fibers which makes them prone patient starts with the elbow bent and wrist straight
to reactive changes producing adhesions, fibrosis and (fig. 1). As the therapist holds the muscles, the patient
local edema and thus pain and tenderness 10 . extends the elbow and pronates and flexes the wrist
Unfortunately, clinical trials on this technique are while the therapist moves the pressure proximally,
lacking and at this point, the popularity of ART is attempting to release adhesions around and between
based largely on anecdotal evidence11. The aim of our muscle planes (fig 2). This part of the maneuver
randomized clinical pilot study was to compare the was performed approximately 15 times. The duration
effectiveness of Active Release Technique-ART with of the intervention session was approximately
the effectiveness of a conventional intervention for the 10 minutes3-8. No restrictions in the use of arm were
management of lateral epicondylalgia. imposed.
METHOD
Between September and December 2010 patients

were recruited for inclusion in our study in the College
Of Physiotherapy, PIMS, Loni, India. They were
referred to the physiotherapy OPD if the
Orthopaedician had made a diagnosis of tennis elbow.
Patients were included in the study if they complaints
being present for at least 1-3 months. Exclusion criteria
were: no limitation in range of motion, as determined
by the investigator; bilateral complaints; a definite
decrease in pain for the last 2 weeks, as described by
the patient; severe neck or shoulder problems likely
to cause or maintain the elbow complaints, as
determined by the investigator; treatment for the
current episode; and inability to fill out questionnaires.
However, because our study was a preliminary study
the number of requested patients was arbitrarily set
at 30 patients. Fig. 1. Starting Position
The patient data (eg, demographics, co-morbidities)

and baseline values of outcome measure were
obtained. After obtaining informed consent, subjects
were included in the study. Subjects were randomly
assigned to 1 of 2 groups by lottery method: (1) a group
that received Active Release Technique (interventional
group) or (2) a group that received conventional
intervention consisting of ultrasound and muscle
stretching and strengthening exercises (control group).
Procedure:
15 Subjects in the interventional group were treated

2 times per week, with a maximum of 6 intervention
sessions over the 3 week period of the study in addition
to receiving conventional therapy for a total of 14
sessions7-9. All the interventions were conducted by the
same physical therapist, as soon as the complaints
resolved, the intervention was stopped. The ART
maneuver is a type of deep massage and was
performed as follows. Each subject was seated and the Fig. 2. End Position

15 Subjects of the control group were treated using a the improvements shown in the PRTEE score (p=
protocol that was used in a previous large-scale trial 0.0464, t= 2.084; 95% CI = 0.09 to 10.8) and the PFGS
on lateral epicondylalgia. During the 3 week score between the two groups (p=0.0266, t= 2.341;
intervention period, the subjects underwent a total of 95%CI= -2.5 to -0.16).
14 intervention sessions. Every session included
pulsed ultrasound treatment around the lateral
humeral epicondyle. Pulsed ultrasound (20% duty
cycle) for 7-minutes was given with an intensity of
2 W/cm 2 . When pain subsided, subjects were
instructed in muscle strengthening and stretching
exercises by the physical therapist and were told to
perform the exercises at home twice daily. These
exercises consisted of movements against resistance,
rotational exercises, and occupational exercises. All
sessions ended with stretching exercises of the wrist
and elbow1,2,14,15. Subjects were instructed to use the
affected elbow to their pain threshold. When pain had
resolved, the intervention was stopped. Fig. 3. Comparison of PFGS score of both Groups.
Outcome Assessment:
Outcome was assessed 14 days after the start of the

intervention. The primary outcome measure was the
Patient Rated Tennis Elbow Evaluation (PRTEE). A
successful outcome was defined as a score nearer to
0.The secondary outcome measure was Pain Free
Grip Strength (PFGS) measured with Jamar Hand Held
Dynamometer, an increase in the PFGS was considered
a successful outcome.
Data Analysis:
Data were analysed using the unpairedt test to

compare the improvement between the two groups.
Pairedt test was used to determine pre and post
treatment effects. The p value was noted for the Fig 4. Comparison of PRTEE of both Groups
variable and it was taken to be statistically significant
if p<0.05. DISCUSSION
Our study showed that Active Release Technique

RESULT
might have additional treatment effects compared with
The two groups were almost similar at the baseline ultrasound, muscle stretching and strengthening
as the difference in the PRTEE scores and PFGS scores exercises for management of lateral epicondylalgia
came out to be non-significant at Day 1. over the short term. Differences between groups were
Demographically, all the two groups were also similar found for the primary and outcome measurement
in terms of percentage of males and females in each (p<0.05) after 2 weeks of intervention, indicating
group. Active Release Technique was more effective than the
other interventions.
The two groups showed improvement in PRTEE
score and PFGS scores on the subsequent day i.e. day Historically, a popular choice for treating
14.The difference of improvement with in both the tendonitis had been deep friction massages. However
groups was statistically significant between day 1 and as evidenced by the 2002 Cochrane review there is
day 14 as determined by pairedt test for simply not a large enough sample size to draw any
PRTEE(p<0.001) and PFGS scores(p<0.001). conclusions in regards to control of pain or
improvement in function. The concepts of cross-
Unpairedt test was applied to see the between- friction techniques have since evolved into an
group differences. There was statistical difference in augmented soft tissue mobilization15. Perhaps the

most popular of soft tissue techniques to gain recent REFERENCES

notoriety is Active Release Technique or ART. ART
is most commonly used to treat conditions related to 1. Vert Mooney, MD. Stretching and strengthening
adhesions or scar tissue in overused muscles 7,8. exercises are key components of care Overuse
According to ART, as adhesions build up, muscles syndromes of the upper extremity: Rational and
become shorter and weaker, the motion of muscles effective treatment.
and joints are altered, and nerves can be compressed. 2. Verhar JAN, et al. Local corticosteroid injection
versus cyriax-type physiotherapy for tennis
As a result, tissues suffer from decreased blood
elbow. J Bone Joint Surg. 1996; 78B: 128-132.
supply, pain, and poor mobility3,5,8,10. This therapy is
3. Leahy PM. Active Release Techniques?, soft tissue
based on the observation that the anatomy of the
management system for the upper extremity.
forearm has traversing tissues situated at oblique Champion Health Associates, 1996.
angles to one another that are prone to reactive 4. Dr. Ryan Tuschener. Tennis Elbow Injuries- ART.
changes producing adhesions, fibrosis and local Optimum Health,1998.
edema and thus pain and tenderness 5,8,10. During 5. Pelino, Joseph: Active Release Techniques Soft
active release therapy, the clinician applies a Tissue Management System, Practice Integration,
combination of deep digital tension at the area of Expectations and Biomechanics. Canadian
tenderness and the patient actively moves the tissue Chiropractic; Sept/Oct. 1999.
through the adhesion site from a shortened to a 6. Active Release Massage Technique. Posted on
lengthened position 5. In order to treat extensor carpi December 6,2007 www.ygoy.com
radialis brevis, the clinician applies proximal tension 7. http://healthpsych.psy.vanderbilt.edu/2008/
distal to the lateral epicondyle while the patient ART.html cited on 23 october 2008.
extends the elbow and pronates and flexes the wrist. 8. http://www.activerelease.ca/index.html
Involvement of the patient is seen as an advantage of 9. http://www.artchiro.com/art.html cited on
ART, as people who are active participants in their february 19 2002.
10. Paul Ingraham. A review of ART therapy-
own healthcare are believed to experience better
Concepts and controversies in Dr. Leahys
outcomes 3-5. A preliminary report on the use of ART
Active Release Techniques (ART) method of
for a variety of upper extremity overuse syndromes
massage therapy for chiropractors. 22 March
found a 71% efficacy rate. Unfortunately, clinical trials 2010.
on this technique are lacking and at this point, the 11. www.wikipedia.com
popularity of ART is based largely on anecdotal 12. Carol C, Garrett WE. Tendon problems in athletic
evidence3,4,5,8,10. individuals. J Bone Joint Surg Am 1997; 79: 138-
150.
CONCLUSION 13. Conrad RW, Hooper WR. Tennis elbow- its
course, natural history, conservative and surgical
Active Release Technique was found to be a management. J Bone Joint Surg Am 1973; 55:
successful treatment approach in lateral epicondylalgia 1177-1182.
and it is capable of improving the functional activities 14. Greenfield C, Webster V. Chronic lateral
and the pain free grip strength.The promising results epicondylitis. Physiotherapy 1988; 10: 578-594.
of our study need replication in a large-scale 15. Kisner C, Colby LA. Therapeutic exercise:
randomized clinical trial that would include a control foundation and techniques. 5th ed. Philadelphia:
group and longer follow-up. The trial should be FA Davis Co. 2002.
sufficiently powered and should compare Active 16. Magee DJ. Orthopedic physical assessment. 4th
Release Technique with the most commonly used and ed Saunders 2002; principles and concepts: P-7.
potentially effective conservative intervention
strategies for lateral epicondylalgia. Validated outcome
measures should be used and evaluated over the short
term, intermediate term, and long term.

Study of Cognitive Impairment in Parkinson's

Patients and its Correlation with Freezing of
Gait Episodes and Bradykinesia
Hutoxi1, Poorva Kulkarni2

1
Professor and Head of Department, P.T.School and Centre, Topiwala National Medical College & B.Y.L.Nair
Hospital, Mumbai, 2Physiotherapist, Parkinson's Disease and Movement Disorder Society (PDMDS),
Centre B.Y.L. Nair Hospital
ABSTRACT
Background: The study was carried out to assess the cognitive impairment in Parkinson's patients
and to correlate it with Freezing of gait episodes and Bradykinesia.
Subject: 60 Adults (30- Parkinson's patients; 30- Normal) between the age group of 45-81 were included
in the study.
Method: A total of 30 Parkinson's patients and 30 normal age matched adults were screened for the
inclusion and exclusion criteria and were then evaluated for cognition using Montreal Cognitive
Assessment Scale (MoCA)11. The result was correlated with Freezing of gait episodes and Bradykinesia.
Results: There was significant evidence of cognitive impairment in Parkinson's patients when
compared with normal age matched adults with Visuospatial skills, Language, Delayed recall being
most affected components of the Montreal Cognitive Assessment Scale. There is also significant
correlation of cognitive impairment in these patients with Freezing of gait episodes and Bradykinesia.
Conclusion: The result of the study emphasizes the need to assess cognition in Parkinson's patients
especially those experiencing Freezing of gait episodes and Bradykinesia to facilitate Rehabilitation
process.
Key words: Parkinson, Cognition, Bradykinesia, Freezing of gait, MoCA
INTRODUCTION functions1,5,6,12,14,18,19,20,21,22,24,26,28. In many instances these

impairments may not be clinically apparent, but are
Parkinsons disease (PD) is a common detectable with specific Neuropsychological tests. As
neurodegenerative disorder. Pathologically, PD is the disease progresses, a substantial proportion of
defined as a loss of dopaminergic neurons in the patients with Parkinsons disease develop cognitive
substantia nigra, with the formation of alpha-synuclein impairment thereby hampering the quality of life of
positive Lewy bodies (LB) within the remaining as well as the health-economic status of patients and
neurons (Braak et al., 2002). In addition to degeneration their care givers due to increased risk for nursing home
of the dopaminergic system, other ascending admission.
subcortical neurotransmitter systems are affected as
well as the cholinergic system (nucleus basalis of PD patients even those with mild disease exhibit
Meynert), the noradrenergic system (locus coeruleus), patterns of cogni-tive deficits that include decrements
and the serotonergic system (dorsal raphe nuclei) in planning, sequencing, concept formation, and
(Jellinger, 1999a). working memory. These impairments are frequently
reported by patients in terms of the disabilities they
Contrary to the claim of James Parkinson who first cause, such as difficulties in paying attention at work,
described the disease that the intellect is preserved problems handling more than one project at a time,
(Parkinson, 1817), the clear evidence from prior studies inability to sequence, plan and organize tasks at work
shows that cognitive impairment is common even in and home.
early PD and affects a variety of cognitive
28 hutoxi writer 2nd aug 11 (136-140).pmd 136 10/16/2012, 2:41 PM

Early identification of PD patients at high risk of Participants were then evaluated for cognition by
developing dementia has important clinical performing Montreal Cognitive Assessment Scale
consequences for the management of these patients. (MoCA)11 during the on period. Parkinsons patients
Therefore, as a Physiotherapist it is essential to perform were also evaluated for Freezing of gait episodes and
cognitive tests in these patients along with the motor bradykinesia during the on and off period using
assessment. It is frequently observed that cognitive the appropriate item of the Unified Parkinsons Disease
assessment is neglected in these patients. Rating Scale (UPDRS ).
There is a strong link between gait and cognition. Findings:

Executive functions seem to play a central role in gait
disorders. Clinical implication of relationship between The scores of MoCA showed statistically significant
gait and cognition are that cognitive function and differences in cognition between adults suffering from
especially executive function should be assessed in Parkinsons disease and the age matched controls.
patients with gait disorders such as freezing of gait13 Also, there is a significant correlation between
Freezing of gait episodes during on period and
Bradykinesia results from a failure of basal ganglia Bradykinesia during off period with cognition in
output to reinforce the cortical mechanisms that these patients.
prepare and execute the commands to move. There
are also abnormalities in sensory scaling and Table 1. Shows that there was no statistically
sensorimotor integration13,23. significant difference in the demographic variables of
control group and the Parkinsons group.
Hence, the need to correlate bradykinesia with
cognition in Parkinson patients. Table 1. Demographic features of study groups
Normal Patient p value
MATERIAL AND METHOD N 30 30
Age( years) 60.2 61.6 0.6269
Materials
1) Stopwatch Table 2. Shows comparison of Normal and Parkinsons

patients MoCA score
2) Table
3) Pen Parameter N mean sd p value 95% confidence Interval
Normal 30 26.73 1.43 <0.0001
Method extremely
significant Normal Patient
Patient 30 22.37 3.25 Upper Lower Upper Lower
Study design: - Observational Cross-sectional study limit limit limit limit
29.59 23.87 28.87 15.87
Procedure:
A total of 30 Parkinsons patients were selected DISCUSSION

from Nair hospital and Parkinson Disease and
Movement Disorder Society (PDMDS) and 30 normal Results of the current study show that cognitive
age matched adults were selected as a control group. dysfunction exists in patients with Parkinsons disease
The participants were then screened for the inclusion and also there was a statistically significant correlation
and exclusion criteria. of Freezing of gait episode during on period and
Bradykinesia during off period with this
Inclusion criteria: dysfunction. When assessed on several sub sets of
MoCA i.e. Visuospatial skills, Naming, Attention,
1) Patients suffering from Idiopathic Parkinsons Language, Abstraction, Delayed recall adults with
disease. Parkinsons disease showed marked dysfunction as
2) Patients having score <=10 on Hospital Anxiety and compared to normal adults while Orientation was not
Depression Scale. affected in these patients.
3) Normal adults in the age group of 45-81.
While basal ganglia pathology and degeneration
Exclusion criteria: of dopaminergic neurons in the substantia nigra is
1) Patients having score >10 on Hospital Anxiety and regarded as central to the pathogenesis of PD, theo-
Depression Scale. ries suggest that the diverse disturbanc-es present in
2) Parkinsons patients having incomprehensible this disease is likely to involve disruption in
speech. functionally segregated neuronal circuits in different
3) Stage IV Parkinson patients ( HOEHN and YAHR compo-nents of the basal ganglia, thalamus, and
staging) cerebral cortex. This model of basal ganglia function

Table 3. Mean scores of Visuospatial skills, Naming, Attention, Language, Abstraction,

Delayed recall and Orientation.
Components Group Mean Std Dev 95% C I 95% C I p value
Upper limit Lower limit
Visuospatial skills Parkinsons group. 3.1 1.185 5.97 0.73 <0.0001
Control group 4.87 0.345 5.56 4.18 Difference is significant
Naming Parkinsons group. 2.73 0.44 3.61 1.85 <0.0018
Control group 3 1.82 6.64 -0.64 Difference is significant
Attention Parkinsons group. 5.2 0.996 7.192 3.208 <0.0001
Control group 6 1.82 9.64 2.36 Difference is significant
Language Parkinsons group. 1.1 0.803 2.706 -0.506 <0.0001
Abstraction Parkinsons group. 1.83 0.46 2.75 0.91 <0.0254
Control group 2 1.83 5.66 -1.66 Difference is significant
Delayed recall Parkinsons group. 2.37 1.564 5.499 -0.758 <0.0001
Orientation Parkinsons group. 6 1.82 9.64 2.36 >0.9999
Control group 6 1.82 9.64 2.36 Difference is not significant
Table 4. Shows correlation of Bradykinesia during off period with the patient MoCA score
Parameter N Mean Std. Deviation Spearmans correlation p value
MoCA 30 22.17 3.43 -0.3869 0.0347
Bradykinesia off period 30 2.97 1.19 Significant
Table 5. Shows correlation of Bradykinesia during on period with patient MoCA score

MoCA 30 22.17 3.43 -0.2824 0.1306
Bradykinesia on period 30 1.87 1.28 Non significant
Table 6 Shows correlation of Freezing of gait during off period with patient MoCA score
MoCA 30 22.17 3.43 -0.1677 0.3757
Freezing of gait off period 30 1.33 1.21 Non significant
Table 7. Shows correlation of Freezing of gait during on period with patient MoCA score
Parameter N Mean Std. Deviation Spearmans correlation P value

MoCA 30 22.17 3.43 -0.4730 0.0096
Freezing of gait On period 29 0.45 0.87 Significant
involves five seg-regated circuits, of which threethe subject to draw a clock showing time 10 past 11.9 This
orbitofrontal, dorsolateral prefrontal, and anterior test assess the functionality of both the prefrontal
cingulateappear integral to cognitive function. While cortex and the posterior visual cortical areas.
dysfunction in the cortico-circuits may underlie Visuoperceptual skills are tested by asking the subject
cognitive deficits apparent on executive and other to copy a cube. This test assesses the functionality of
frontal tasks, the dopaminergic system is like-ly not the posterior visual cortical areas.2,7,10,27
the only neurotransmitter causing dis-ruption in this
disease.1,5,6,12,14,18,19,20,21,22,24,26,28 Naming component is also seen to be affected in
Parkinsons patients. It has been mainly correlated
Results of the present study show evidence of with cortical activity in the anteromedial and
impairment of Visuospatial skills in Parkinsons posteromedial temporal cortex. Patients with
patients and are thought to represent a dysfunction of Parkinsons had difficulty in naming word rhinoceros
fronto-straital neuronal circuit. Visuospatial as this name is used less often as compared to lion and
impairments can be further classified into camel showing difficulty in naming less commonly
Visuoconstructional skills and Visuoperceptual skills. used words. Most frequently used words are stored
Visuoconstructional skills are tested by asking the in the cache memory and are more easily retrievable.

Attention dysfunction is prominent among the with cortical regions through the cortico-subcortical
cognitive impairments described in PD and is probably loops play a central role in both movement initiation
closely related to the executive function impairment and cognitive aspects such as executive function Thus,
that is reported in these subjects. This hypothesis is a significant correlation between freezing of gait
supported by several studies showing that attention episode during on period with cognition was
dysfunction appears most usually in connection to observed in our study.3,4,13,16,17,25,29
complex tasks requiring shifting and or sustained
attention as well as mental calculations that require CONCLUSION
sustained mental tracking.20
There is prevalence of cognitive impairment in
In the Verbal fluency test patients need to use the Parkinsons patients with Visuospatial skills,
cache memory to recollect the word with letter F Language, delayed recall being most affected
that they might have come across before. Impairment components of the Montreal Cognitive Assessment
in free recall memory appears to be more related to Scale. Bradykinesia and Freezing of gait episodes
the defective use of memory stores due to working which present as motor symptoms in Parkinsons is
memory deficits, than a reduced capacity of storing/ found to be associated with cognitive dysfunction in
consolidating new information in the temporal lobes these patients emphasizing the need to evaluate
as is seen in Alzheimers disease. cognition in patients presenting with these symptoms.
There was a significant difference in abstraction Limitation of the study:
component of the MoCA scale between Normal and
Parkinsons patients. Problems in abstraction could be 1. Small Sample Size
due to delay in processing of information. 2. Convenience sampling.
Delayed recall was also proved to be affected in ACKNOWLEDGEMENTS

Parkinsons patients, possibly due to retrieval
problems as opposed to the deficient encoding as seen I express my heartfelt gratitude to the Dean of Nair
in Alzheimers disease. Hospital and the Staff and Colleagues of
Physiotherapy Department, Dr.Maria Baretto (Co-
This may thus reflect a deficiency in internally cued ordinator, PDMDS), Dr. Gajbhare, Dr. Nerulkar, my
search strategies due to the dysexecutive syndrome. family and my subjects for their support.
In some patients recognition and recall both were
affected supporting the studies that have suggested
Conflict of Interest
hippocampal pathology.15
We, Hutoxi Writer and Poorva Kulkarni, declare
Orientation is a function of the mind involving
that there are no conflicts of interest and the study
awareness of three dimensions: time, place and person.
presented here is original work of the authors.
Lesions of brain stem and the cerebral hemisphere
result in dis orientation and as these areas are not
affected in Parkinsons disease orientation is not REFERENCES
affected in them.
1. Aarsland D, Bronnick K, Williams-Gray C,
Bradyphrenia which is considered mental Weintraub D, Marder K, Kulisevsky J, Burn D,
equivalent of Bradykinesia is attributed to the slowing Barone P, Pagonabarraga J, Allcock L, Santangelo
of information process. This process of information is G, Foltynie T, Janvin C, Larsen JP, Barker RA,
similar for both motor and cognition. Thus, our study Emre M. Mild cognitive impairment in Parkinson
showed significant correlation between these two disease: a multicenter pooled analysis.
during the off period.8,13,16,23,29 Neurology. 2010 Sep 21; 75(12): 1062-1069.
2. A.G.M. Canavan, R.E. Passingham, C.D.
Gait has been traditionally considered as a simple Marsden, Prism adaptation and other tasks
automatic motor activity that was independent of involving spatial abilities in patients with
cognition. Spinal neuronal networks that include Parkinsons disease, patients with frontal lobe
motor neurons and interneurons called central lesions and patients with unilateral temporal
pattern generators allow generation of automatic and lobectomies . Neuropsychologia.1990; 28(9):
rhythmic motor activity patterns. These spinal 969-984.
networks are under the influence of basal ganglia and 3. Almeida QJ, Lebold CA. Freezing of gait in
brainstem nuclei including pedunculopontine nuclei Parkinsons disease: a perceptual cause for a
which plays a role in initiation and modulation of motor impairment? J Neurol Neurosurg
pattern generators. Basal ganglia and their connection Psychiatry. 2010 May; 81(5): 513-8. Epub 2009
Sep 15.

4. Amboni M, Cozzolino A, Longo K, Picillo M, 18. Mauro R. Piovezan; Helio A.G. Teive; Elcio J.
Barone P. Freezing of gait and executive functions Piovesan; Maria J. Mader; Lineu Cesar Werneck.
in patients with Parkinsons disease. Mov Disord. Cognitive function assessment in idiopathic
2008 Feb 15; 23(3): 395-400. Parkinsons disease. Arq. Neuro-Psiquiatr;65(4a)
5. Carmen Cristea Janvin . Cognitive impairment 19. Mona K Beyer, Carmen C Janvin, Jan P Larsen,
in patients with Parkinsons. Tidsskr Nor Dag Aarsland. A magnetic resonance imaging
Laegeforen. 2007 Oct 4; 127(19): 2517-2520. study of patients with Parkinsons disease with
6. Caviness JN, Driver-Dunckley E, Connor DJ, mild cognitive impairment and dementia using
Sabbagh MN, Hentz JG, Noble B, Evidente VG, voxel-based morphometry. JNeurol Neurosurg
Shill HA, Adler CH. Defining mild cognitive Psychiatry 2007; 78: 254-259.
impairment in Parkinsons disease. Mov Disord. 20. Muslimovic D, Post B, Speelman JD, Schmand B.
2007 Jul 15;22(9): 1272-1277. Cognitive profile of patients with newly
7. Cronin-Golomb A, Braun AE. Visuospatial diagnosed Parkinson disease. Neurology. 2005
dysfunction and problem solving in Parkinsons Oct 25; 65(8): 1239-1245.
disease. Neuropsychology. 1997 Jan; 11(1): 44-52. 21. Owen AM. Cognitive dysfunction in Parkinsons
8. Cubo E, Bernard B, Leurgans S, Raman R. disease: the role of frontostriatal circuitry.
Cognitive and motor function in patients with Neuroscientist. 2004 Dec; 10(6): 525-537.
Parkinsons disease with and without depression. 22. Owen AM, James M, Leigh PN, Summers BA,
Clin Neuropharmacol. 2000 Nov-Dec; 23(6) Marsden CD, Quinn NP, Lange KW, Robbins TW.
331-334. Fronto-striatal cognitive deficits at different
9. Donald R Royall, Jeffrey A Cordes, Marsha Polk. stages of Parkinsons disease. Brain. 1992 Dec; 115
CLOX: an executive clock drawing task.J Neurol ( Pt 6): 1727-1751.
Neurosurg Psychiatry 1998; 64: 588-594 23. Peavy GM. Mild cognitive deficits in Parkinson
10. Eva Kempsa, Arnaud Szmalecb, Andr disease: where there is bradykinesia, there is
Vandierendonckb, Luc Crevitsc. Visuo-spatial bradyphrenia. Neurology. 2010 Sep 21; 75(12):
processing in Parkinsons disease: evidence for 1062-1069.
diminished visuo-spatial sketch pad and central 24. Simon J. G. Lewis,Anja Dove, Trevor W. Robbins,
executive resources. 2005; 11(3): 44-52. Roger A. Barker, and Adrian M. Owen. Cognitive
11. Gill DJ, Freshman A, Blender JA, Ravina B. The Impairments in Early Parkinsons Disease Are
Montreal cognitive assessment as a screening tool Accompanied by Reductions in Activity in
for cognitive impairment in Parkinsons disease. Frontostriatal Neural Circuitry. The Journal of
Mov Disord. 2008 May 15;23(7): 1043-1046. Neuroscience. July 16, 2003; 23(15): 6351-6356.
12. Green J, McDonald WM, Vitek JL, Evatt M, 25. Snijders AH, Leunissen I, Bakker M, Overeem S,
Freeman A, Haber M, Bakay RA, Triche S, Helmich RC, Bloem BR, Toni I. Gait-related
Sirockman B, DeLong MR. Cognitive cerebral alterations in patients with Parkinsons
impairments in advanced PD without dementia. disease with freezing of gait. Brain. 2011 Jan;
Neurology. 2002 Nov 12; 59(9): 1320-1324. 134(Pt 1): 59-72. Epub 2010 Dec 1.
13. Iwasaki Y, Kinoshita M, Ikeda K, Takamiya K. 26. Tamaru F. Disturbances in higher function in
Cognitive function in Parkinsons disease: in Parkinsons disease. Eur Neurol. 1997; 38 Suppl
relation to motor symptoms. Int J Neurosci. 1989 2: 33-36.
Aug; 47(3-4): 295-300. 27. Uc EY, Rizzo M, Anderson SW, Qian S, Rodnitzky
14. Kulisevsky J, Pascual-Sedano B. Parkinson RL, Dawson JD. Visual dysfunction in Parkinson
disease and cognition. Neurologia. 1999 May;14 disease without dementia. Neurology. 2005 Dec
Suppl 1: 72-81. 27; 65(12): 1907-13. Epub 2005 Nov 9.
15. Levy G, Jacobs DM, Tang MX, Ct LJ, Louis ED, 28. Verbaan D, Marinus J, Visser M, van Rooden SM,
Alfaro B, Mejia H, Stern Y, Marder K. Memory Stiggelbout AM, Middelkoop HA, van Hilten JJ.
and executive function impairment predict Cognitive Impairment in parkinsons disease. J
dementia in Parkinsons disease. Mov Disord. Neurol Neurosurg Psychiatry. 2007 Nov; 78(11):
2002 Nov;17(6):1221-1226. 1182-7. Epub 2007 Apr 18.
16. Levy G, Tang MX, Cote LJ, Louis ED, Alfaro B, 29. Williams LN, Seignourel P, Crucian GP, Okun
Mejia H, Stern Y, Marder K. Motor impairment MS, Rodriguez RL, Skidmore FM, Foster PS,
in PD: relationship to incident dementia and age. Jacobson CE 4th, Romrell J, Bowers D, Fernandez
Neurology. 2000 Aug 22;55(4): 539-544. HH. Laterality, region, and type of motor
17. Lewis SJ, Barker RA. A pathophysiological model dysfunction correlate with cognitive impairment
of freezing of gait in Parkinsons disease. in Parkinsons disease. Mov Disord. 2007 Jan;
Parkinsonism Relat Disord. 2009 Jun; 15(5): 22(1): 141-145.
333-8. Epub 2008 Oct 17.

Study of Trunk Movement Deficits in Golfers with Low
Back Pain
Navneet Kalra1, Jagmohan Sing2, Masilamani Neethi3,

1
Student, MPT Sports, 2Professor & Principal,
3
Professor Gian Sagar College of Physiotherapy, Ram Nagar, Rajpura, Distt. Patiala
ABSTRACT
Improper swing mechanics and sub-optimal physical fitness have been considered to be associated
with the low back injuries in golfers. These factors may affect a golfer's back by increasing spinal
loads during the golf swing. Thus an understanding of the swing and physical characteristics
simultaneously with the loads generated by their interactions in golfers with and without LBP can be
used to analyse the mechanisms of low back injuries in golfers.
The purpose of this scientific paper is to study the prevalence of low back pain in golfers and to
assess the trunk movement deficits. The physical characteristics assessed included trunk strength &
flexibility.
The cross-section study evaluated 15 pairs of right-handed golfers matched by golf handicap equal
to or lower than 20,between the ages of 25-65 years. Group 1 (history of low back pain greater than 2
weeks affecting quality of play within past 1 year) and Group 2 (no previous such history). The
independent variable is group and the dependent variables are the trunk strength, range of motion
& flexibility.
The mean age for the golfers with LBP was found to be 44.6 years. Trunk flexors, extensors & rotators
of the subjects of LBP group showed less strength than their counterparts. The LBP group also had
flexibility deficits along with a positive hamstrings tightness. The LBP group demonstrated less ROM
in trunk rotation & an increased finger-to-floor distance on the non-lead side.
Golfers with LBP may suffer low back injuries due to the inappropriate combination of physical
characteristics that prevents dissipation of the tremendous spinal forces and moments generated by
the golf swing over time. Spinal instability may contribute to repetitive injuries and a progressive
decline of core stability.
Key words: Golf; Low Back Pain; Strength; Flexibility; Swing
INTRODUCTION to be between 25.2 and 62.0%, with minor differences

between the sexes. As per Sugaya et al, 18 the number
Golf, as we know it today originated from a game of golfers with a history of low back pain may be as
played on the eastern coast of Scotland in the Kingdom high as 55%. Both professional and amateur golfers
of Fife during the 15th century. Players would hit a could suffer from low back injuries.9,11,14 A study by
pebble around a natural course of sand dunes, rabbit Gosheger et al 9 showed that the most common injuries
runs and tracks using a stick or primitive club. in professional golfers were back injuries, followed by
As the game has become more popular, different wrist and shoulder injuries.
groups or types of golfers have appeared, including: In a study done by Lindsay and Horton, 12 a
occasional golfers; recreational golfers who play for comparison of trunk motion during the golf swing
health, pleasure, and social reasons on a regular basis; between six professional golfers with LBP and six
and professional golfers who represent only a minority professional golfers without LBP was done. Golfers
of the golfing population.2 with LBP had less trunk rotational flexibility in the
As per McCarroll et al,15 the annual prevalence of neutral standing position. As per Clark,4 Trunk and
hip muscles are considered core muscles because they
golf-related injuries in amateur players is estimated
29 Jagmohan 23rd may 11 (141-144).pmd 141 10/16/2012, 2:41 PM

work together to stabilize, move, and protect lumbo- motion occurs simultaneously in multiple planes.5
pelvic-hip complex during functional activities. During
a golf swing, the most active muscles are contralateral The upper body rotates on the hips and pelvis
external oblique, ipsilateral internal oblique and during backswing, and then uncoil forcefully for
latissmus dorsi, quadratus lumborum & rectus ball impact and follow through.
abdominis. In general, the takeaway phase has the Golf swing restricts the hip turn to build torque in
lowest overall muscle activation, while the forward
the back and shoulders during the backswing for
swing/acceleration has the highest. However, maximum club head velocity at ball impact
inefficient muscular stabilization of the lumbar spine
has been observed in patients with LBP by Hodges In backswing, left side muscles produce lumbar
and Richardson.10 axial torque to the right, causing initial twisting of
the trunk from address to the top of backswing,.
Ninety percent of all Professional Golf Association Downswing- Right side muscles create axial torque
(PGA) Tour injuries have been to the cervical and
to the left. This corresponds to the maximum spinal
lumbar spine regions. As per McCarroll,13 low back
loading of the anterior-posterior shear force, lateral
injuries range from 15.2 to 34.0% of all golf injuries, shear force, and axial torque.
and thus represent the most common musculoskeletal
complaint experienced by both amateur and Mechanism of injury involves the body being
professional golfers. pushed beyond its elastic limit, due to rapid spinal
rotation velocity during the golf swing. As per Hosea
During the 1990 competitive season, 59 % of the and Gatt,11 this increases lumbar spinal forces that
injuries reported on the PGA Tour involved the low
produce tremendous amount of force and torque that
back.16 Among amateur golfers, McCarroll et al15 may injure lumbar spine cause mechanical LBP which
reported that 244 of 708 surveyed players suffered low is generally localized to the lumbar area and associated
back injuries. Batt,1 in a survey of 461 amateur golfers,
with significant muscle spasms due to back muscle
found that 52% of men and 29% of women experienced strain or spinal ligament sprain. It may begin gradually
back injuries. Gosheger et al found that on average, with episodes of exacerbation and result in permanent
low back injuries result in disability inhibiting golf
disability. Symptoms or other types of subjective
participation for ten weeks.9 complaints are predominantly reported as coming
The spine is instrumental in accomplishing the golf from the lead side of the spine and symptom
swing. It is involved with the transmission of forces aggravation of right-side complaints usually occurs
and the coordination of activities between the upper from ball impact until the follow-through. Improper
and lower extremities. As per Gracovetsky & Farfan, swing mechanics and sub-optimal physical fitness can
in sports requiring exertion of the upper extremities produce even larger and abnormal forces to the lumbar
and trunk, such as golf, low back injuries are common.8 spine.7,11,14,17
Golf swing has three main components, backswing Injury Causing Factors:
(slow component lasting for 800-1000ms), downswing Swinging a club under sub-optimal physical fitness
(early acceleration phase -250ms & just before ball-
combined with inappropriate swing mechanics.
impact 40-60ms), release & follow-through.20 Thistle19
acknowledged two general styles of golf swing: S-Posture is characterized by Forman as an arching
modern & classic. The Modern golf swing of the lower back while standing over the ball at
emphasizes on a large shoulder turn with minimal hip address, causing a great deal of stress on the lower
turn. The Classic golf swing aims to reduce the X- back.6
factor by raising the front heel of the foot during the
backswing to increase hip turn, shortening the Golfers gait or stride involving over pronation of
backswing, or a combination of the two. It is the foot and ankle during the stride.
characterized by an erect I finish with balanced
Loss of mobility in aging golfers due to loss of X-
shoulders. X-Factor is the relative rotation of the
factor results in a progressive limitation in
shoulders as compared to the rotation of the hips
takeaways.
during the backswing. It is a key factor in the
production of swing speed and distance. In an effort to increase club head speed, golfers use
excessive lateral weight shift of the lower body at
The golf swing involves multiplanar rapid
top of backswing, rather than rotating the pelvis
movements of the trunk. Davis and Marras found that
and finally finish the swing with trunk
trunk motion plays an important role in the
hyperextension.
development of low back injuries, particularly when

Tightness in the chest muscles and/or lats, and Trunk muscle strength using Oxford scale.
limited flexibility in thoracic area.
Finger-to-floor distance & 90-90 SLR test for
Other sources of injuries include being struck by hamstrings tightness.
clubs or balls, collisions between players &
spectators or carts, falls.3 The study investigated the null hypotheses that the
trunk movement & strength deficits do not occur in
The purpose of this study was to study the golfers with LBP. Differences in measurements
prevalence of low back pain in golfers and to assess analyzed using the one tail paired t-test.
the trunk movement deficits in golfers with and
without LBP. The physical characteristics assessed Findings
included trunk strength & flexibility. The mean age of golfers with LBP was 44.6 years.
Materials & methods
Trunk strength
These comparison studies evaluated 15 pairs of
Left-tailed paired t-tests were used to determine
right-handed golfers matched by golf handicap equal significant differences in means between golfers with
to or lower than 20,between the ages of 25-65 years. and without LBP for all procedures.
Group 1 (history of low back pain greater than 2 weeks
affecting quality of play within past 1 year) and Group Table 1. Trunk Strength
2 (no previous such history). The independent variable S. Parameter t-stat t-critical at Null Hypothesis
is group and the dependent variables are the trunk No. =0.05 at d.f.=14 Accept / Reject
strength, range of motion & flexibility. 1. Flexion -8.573 -1.761 Reject
2. Extension -10.311 -1.761 Reject
3. Rotation (R) -6.874 -1.761 Reject
INCLUSION CRITERIA:
4. Rotation (L) -9.798 -1.761 Reject
Back Pain group
The null hypothesis was rejected at statistical
Subjects had symptoms of mechanical LBP within significance, = 0.05. Trunk flexors, extensors &
two years prior to testing resulted in time lost from rotators of LBP golfers showed less strength than their
golf participation. counterparts.
The worst episode of LBP had a modified Oswestry Trunk ROM & flexibility
questionnaire score equal to and greater than 24
Left tailed test used for trunk ROM & right tailed
and required treatment.
test finger to floor distance & hamstrings tightness.
LBP resulted from golf or was aggravated by golf.
Table 2. Trunk ROM
LBP localized over right or central lumbosacral S. Parameter t-stat t-critical at Null Hypothesis
area. No. =0.05 at d.f.=14 Accept / Reject
1. Trunk flexion -7.678 -1.761 Reject
Healthy group 2. Trunk extension -7.783 -1.761 Reject
3. Trunk rotation (R) -5.315 -1.761 Reject
Subjects must not have LBP within one year prior 4. Trunk rotation (L) -9.321 -1.761 Reject
to testing.
Table 3: Trunk flexibility
Exclusion Criteria: S. Parameter t-stat t-critical at Null Hypothesis
No. =0.05 at d.f.=14 Accept / Reject
History of previous back surgery, vertebral 1. Finger to Floor (R) 9.626 1.761 Reject
compression fracture, nerve root compromise 2. Finger to Floor (L) 10.800 1.761 Reject
3. Hamstring (R) 9.985 1.761 Reject
Neurologic deficits, Current or past lumbar
4. Hamstring (L) 6.239 1.761 Reject
radiculopathy, symptoms of vertigo or dizziness
After a written consent, a physical assessment was The null hypothesis was rejected at statistical
done. Group 2 filled out a modified Oswestry significance, = 0.05.
questionnaire, pain scale, and pain diagram.
In the LBP group, flexion and extension were
Following measurements were done:
reduced along with less ROM in trunk rotation of the
Lumbar range of motion- rotation using a standard non-lead side (left side). An increased finger-to-floor
goniometer, flexion &extension using tape distance was found in the LBP group that indicates
measurement of C7 to S1 as reference. demonstrates deficit in lateral flexion. Hamstrings

tightness, indicated by the knee flexion angles during 5. Davis KG, Marras WS. The effects of motion on
active knee was observed to be increased in the LBP trunk biomechanics. Clinical Biomechanics. 2000;
group. 15(10):703-717.
6. Forman B. S-Posture, Hip Flexors, and Back Pain
CONCLUSION [internet]. 2009 [cited 22 April 2011]. Available
from: http://www.golfitcarolina.com/articles/
The results of this study revealed that golfers with 29-s-posture-hip-flexors-and-back-pain.html
LBP demonstrated less trunk rotation strength, less 7. Geisler PR. Sports Injury: Prevention and
trunk extension strength. It acknowledged that during Rehabilitation. New York: McGraw-Hill Co; 2001.
swing, a flexed trunk angle must be maintained to 8. Gracovetsky S, Farfan H. The Optimum Spine.
make a proper turn back and return to the ball. Weak Spine. 1986; 11:543-573.
back extensors may not generate sufficient strength to 9. Gosheger G, Liem D, Ludwig K, Greshake O,
counteract the flexion moment produced by the Winkelmann W. Injuries and overuse syndromes
abdominal muscles, resulting in excessive loading and in golf. Am J Sports Med. 2003; 31(1):438443.
overuse injury. Additionally, the LBP group had less 10. Hodges PW, Richardson CA. Inefficient muscular
trunk rotation ROM toward non-lead side, reduced stabilization of the lumbar spine associated with
hamstring flexibility & increased finger-to-floor low back pain. A motor control evaluation of
distance. transversus abdominis. Spine. 1996; 21(22):2640-
2650.
Spinal instability may contribute to repetitive 11. Hosea TM, Gatt CJ Jr. Backpain in Golf. Clin
injuries and a progressive decline of core stability. Sports Med. 1996; 15(1):37-53.
Thus, improving core stability is important for golfers, 12. Lindsay D, Horton J. Comparison of spine motion
especially during the golf swing which can generate in elite golfers with and without low back pain. J
considerable amounts of load to the spine. Sports Science. 2002; 20(8):599-605.
Swinging a club under sub-optimal physical fitness 13. McCarroll JR. The frequency of golf injuries.
with inappropriate swing mechanics produces Clinics in Sports Medicine. 1996; 15(2):1-7.
excessive forces to the lumbar spine. An inappropriate 14. McCarroll JR, Gioe TJ. Professional golfers and
combination of physical characteristics prevents the price they pay. Phys Sports Med. 1982;
dissipation of the tremendous spinal forces and 10(7):64-70.
moments generated by the golf swing. 15. McCarroll JR, Retting AC, Shelbourne KD.
Injuries in the amateur golfer. Phys Sportsmed.
An understanding of these factors in golfers with 1990; 18(2):12226.
and without LBP can be used to analyse the 16. Pink M, Perry J, Jobe FW. Electromyographic
mechanisms of low back injuries in golfers. analysis of the trunk in golfers. American Journal
of Sports Medicine. 1993; 21(4):385-388.
REFERENCES 17. Stover CN, Wiren G, Topaz SR. The modern golf
swing and stress syndromes. Phys Sportsmed.
1. Batt M. A survey of golf injuries in amateur 1976; 4:42-47.
golfers. British Journal of Sports Medicine. 1992; 18. Sugaya H, Tschiya A, Moriya H, Margan DA,
26(1):63-65. Banks SA. Low-back injury in elite and
2. Cabri J, Sousa JP, Kots M, Barreiros J. Golf-related professional golfers: an epidemiologic and
injuries: a systematic review. European Journal radiographic study. Proceedings of the World
of Sport Science. 2009; 9(6):353-366. Scientific Congress of Golf; 1999; Champaign,
3. Cann AP, Vandervoort AA, Lindsay DM. France.
Optimizing the benefits versus risks of golf 19. Thistle S. The Lumbar Spine & Low Back Pain in
participation by older people. J Geriatr Phys Ther. Golf. Dynamic Chiropractic Canada. 2009; 2(1).
2005; 28(3):85-92. 20. Zheng N, Barrentine SW, Fleisig GS, Andrews
4. Clark MA. Integrated core stabilization training. JR. Kinematic analysis of swing in pro and
USA: National Academy of Sports Medicine, amateur golfers. International Journal of Sports
Thousand Oaks; 2001. Medicine. 2008; 29(5):487493.

A Longitudinal Study to Analyse & Quantify Functional
Capacity Post- Coronary Artery Bypass Grafting
Ruchi Katyal1, Jamal Ali Moiz2, J. Jayaprakash3,

1
Post Graduate Cardiopulmonary Physiotherapy Student, Jamia Hamdard, New Delhi
2
Assistant Professor, Centre for Physiotherapy & Rehabilitation Sciences, Jamia Millia Islamia, New Delhi
Chief Physiotherapist, Department of Physiotherapy, Artemis Health Institute, Gurgaon
ABSTRACT
Study Objective: to analyze and quantify the Functional capacity in post-coronary bypass subjects
by using six minute walk test on 6th and 13th post operative day by comparing their value with
matched normal subject.
Sample: a convenient sample of 15 patients, 12 male and 03 female age group of 40-60 years who
underwent coronary artery bypass grafting (CABG) included in this study. In group B, 15 age, sex,
height and weight matched normal subjects were also taken to compare the data of patients to analyze
the CABG patients functional capacity.
Design: a longitudinal quasi- experimental design.
Methods: the 6minute walk test (6MWD) was conducted according to standardized protocol on each
of test days. Participants were told "the purpose of this test is to see how far you can walk in six
minutes". Oxygen saturation, heart rate, blood pressure, respiratory rate and rate of perceived exertion
was taken at the start and end of six minute walk test and distance covered in six minutes noted,
similarly, 6 minute walk test was conducted on the matched normal subjects and the following distance
noted.
Results: results showed significant increase in six minute walk distance over the period of time. The
mean value of 6MWD on 6th post-operative day was 280 + 46 meter which increased to statistically
significant level of 355 + 43 meters on 13th post operative day (p=0.00). When looking at change in
6MWD covered by CABG subjects and normal subjects on 13th post-op day, indicating the decrease
in lag or improvement in 6MWD between CABG subjects and matched normal group. However,
none of the patient reached to values of normal matched group by 13th post-op day.
Conclusion : This study help us suggest that the patient with this age group following CABG achieve
functional capacity in the range of 3-5 MET's and could easily perform activities in this range by 13th
post op day. Further, understanding functional level will assist in determining patient's need for
rehabilitation services after CABG surgery.
Key words: Six Minute Walk Distance, Coronary Artery Bypass Grafting, Cardiac Rehabilitation
INTRODUCTION and almost 40% of all causes of mortality in the

developed world1. One surgical intervention available
Coronary artery disease is the leading cause of for the treatment of coronary artery disease is Coronary
cardiovascular mortality worldwide, with more than Artery Bypass Grafting (CABG)2. Although being one
4.5 million deaths occurring in the developing world of life saving procedures, it also has associated
complications like any other surgery. The aim of
cardiac rehabilitation programs is not only to prolong
Correspondence Address:
life, but also to improve physical functioning,
Jamal Ali Moiz,
symptoms, well being, health related quality of life and
MPT (Cardiopulmonary)
hence functional capacity3.
Assistant Professor
Centre for Physiotherapy & Rehabilitation Sciences, However, fatigue and activity intolerance are
Jamia Millia Islamia, New Delhi, Email : jmoiz@jmi.ac.in. reported to persist for several weeks after discharge
30 Jamal 1st june 2011 (145-149).pmd 145 10/16/2012, 2:41 PM

in most of the patients. This may be due to early classification (NYHA): II and III.
discharge which limits the time to achieve an adequate Patients with left ventricular ejection fraction e
functional level for the performance of many activities 45%.
of daily living. Alternatively, it may be related to level
of selfefficacy, in ones ability to perform physical Another fifteen, age, sex, height and weight
activity4. High selfefficacy may result in overexertion matched normal individuals were selected based on
during the vulnerable, early post discharge phase of their medical check-ups and evaluation which ruled
recovery, whereas low selfefficacy may cause under out any disease process.
exertion. Thus prior to prescribing safe and effective Exclusion Criteria
home exercise at discharge, it is essential to assess
functional level to physical activity. Six minute walk Post operative heart failure requiring ionotropes
test is an inexpensive and simpler submaximal exercise or intra-aortic balloon pump.
test commonly used for predicting one time measure Samples with ICU stay >4 days.
of functional status by measuring the distance covered ECG alert subjects with resting heart rate < 50
by walking on a hallway level within 6 minutes. beats/min or > 110 beats/min.
Marked hypo/hyper tension (systolic blood
This study was undertaken to analyze and quantify pressure<90 or >200mmHg or diastolic BP <60
the functional capacity in post- coronary bypass
mmHg or >110 mmHg).
subjects by using 6 MWT, and comparing their values Patients with resting oxygen saturation < 90%.
with values of age, sex, height and weight matched Patients with cerebro-vascular accident within last
normal subjects.
12 months, or any other neuromuscular disorders
that hinders with walking.
METHODS Intra or post operative myocardial infarction,
symptomatic angina or suspected cardiac
Subjects
tamponade: or ST/Q wave abnormalities.
A convenient sample of fifteen patients (male 12, Patients unable to follow commands or anxieted
female 03) in the age group of 40-60 years who patients.
underwent coronary artery bypass surgery were Patients presenting with unstable angina or new
included in this study. Fifteen age, sex, height and chest pain or fainting.
weight matched normal subjects were also taken to Patients with orthopedic problems in lower limb
compare the data of CABG patients to analyze the and spine.
patients functional capacity. Prior to participating in
this study, all subjects read and signed an informed Study Design
consent approved by the University Committee on
Research Involving Human Participants. A longitudinal quasi - experimental design.
Instrumentation and Procedures
Space and Location
Equipments & Scales: Siemens micro O 2
All the patients were recruited from Cardiothoracic Pulseoximeter, Timer, Microtone deluxe Stethoscope,
and Vascular Surgery unit of All India Institute Of Sphygmomanometer, Chalks or pencil to mark
Medical Sciences, New Delhi and St. Stephens distances, Modified Borg scale.
Hospital, Tis Hazari, Delhi, India.
Groups: Group A: post-coronary bypass subjects
Inclusion Criteria or age. Group B: sex, height and weight matched
normal subject.
All patients who had undergone CABG.
Outcome variable: functional capacity as measured
Age groups between 40-60 years .
by the distance walked on 6 minute walk test. Six
All subjects who had stable hemodynamics. The minute walk distance was measured on day of
criteria which was used to analyze the stability of discharge (6th day) and again 7 days after day of
hemodynamics were as follows: discharge (13th POD).
Stable arterial systolic and diastolic blood pressure,
Stable cardiac rhythm. PROCEDURE
Patients with BMI > 18and < 25. General Physiotherapy Management
Early ambulated (second postoperative day) and
independently walking patients. All CABG subjects were seen by the physiotherapist
Patients with New York Heart Association before the surgery for preoperative assessment and

were given routine instructions for the postoperative To analyse significant changes in the paired RPE
regimen. Postoperatively, all patients received regular scores , median as found by Freidman test was used
postoperative physiotherapeutic regimen from the 0 and Wilcoxon Signed Ranks Test was applied.
day itself as per the routine protocols. Following
extubation on first postoperative day, patients were RESULTS
treated and assisted to perform deep breathing
exercises, coughing and huffing through the required Fifteen post -coronary bypass subjects were
procedures/intervention, upper limb and lower limb recruited, 20% of subjects were female (n =03) and 80%
activities. Subjects were ambulated once they were able of subjects were males (n=12). Again, out of fifteen
to maintain a SpO2 of value at least 90% without matched normal subjects , 20% of subjects were female
supplemental oxygen at the room air and they were (n =03) and 80% of subjects were males (n=12). The
advised to walk twice or thrice daily as per the routine mean age of all the patients participated in this study
protocol and precautions. Thereafter, all the subjects was 51.5 7.0 with the change of minimum 40 years
followed the common exercises till 13th day. These to maximum age of 60 years.
exercises included light mobilization exercises in the
Table1. Changes in six minute walk distance within
form of different exercises and includes 10 repetitions
the coronary bypass subjects
of each exercise at moderate pace. The following are
the exercises used: 6MWD Mean S.D t p
6th POD 280.4 46.1 7.800 0.000
1. Deep breathing exercises. 13th POD 355.7 43.4
2. Incentive spirometer.
3. Arm and leg exercises. Pair-wise comparisons revealed that there is
4. Walking twice a day (for 15 20 minutes.). significant difference between the distance walked on
All the selected subjects will be informed in detail 6th post-operative day and 13th post-operative day.
about the type and nature of the study and were made (p=0.00).The mean value of six minute walk distance
to sign the informed consent. All the CABG subjects on 6th post-operative day was 280.4 46.1 which was
followed the common exercises. The 6-min walk test increased to statistically significant level of 355.7 43.4
was conducted according to a standardized protocol on 13th post-operative day (p=0.00).
on each of test days5. Oxygen saturation, Heart rate,
Blood pressure Respiratory rate and rate of perceived
exertion were taken at the start and end of the 6-min
walk test and distance covered in 6 minutes noted.
Similarly, 6 minute walk test was conducted on the
matched normal subjects and the following distance
noted.
DATA ANALYSIS
Data analysis was done using the software package

of SPSS 14. The paired t - test was applied for within
subject dependant variable. To assess the paired
differences, paired sample test was performed, the Fig. 1. Changes in Six Minute Walk Distance within the coronary
significance level set for this study was 95% (p <0.05). bypass subjects.
The unpaired t- test was used to examine the changes
in 6 minute walk distance among treated group (CABG Pair-wise comparisons revealed that there is
patients) and control group. To analyze significant significant improvement in the distance walked by
changes, least significant difference t- test for equality coronary bypass subjects compared to matched normal
of means was performed; the significance level set for group from 6th post-operative day to 13th post-operative
this study was 95%. Freidman test was used to examine day (p=0.00). The mean value of six minute walk
changes in the rate of perceived exertion (RPE) distance on 6th post-operative day by coronary bypass
variable, which was measured at 4 intervals: subjects was 280.4 46.1 and 584.9 61.7 by matched
normal subjects which was increased to statistically
pre 6 MWT on 6th post-op day
significant level of 355.7 43.4 by coronary bypass
post 6 MWT on 6th post-op day
subjects by 13th POD against 584.9 61.7 by matched
pre 6 MWT on 13th post-op day
normal subjects (p=0.00).
post 6 MWT on13th post-op day

DISCUSSION
The results of this study show that patients

following uncomplicated coronary artery bypass
surgery significantly improve in their functional
capacity but the same still does not reach the functional
capacity of matched normal people by 13 th post-
operative day. This strengthens our protocol of early
analyzing the functional capacity of the coronary artery
bypass patients which could be used in the perspective
of formulating individualized safer and effective home
exercise program.
Fig. 2. Changes in 6MWD between the CABG and the matched There was a significant improvement in functional
normal subjects. capacity as measured by six minute walk distance and
rate of perceived exertion in coronary artery bypass
patients from 6 th post-operative day to 13 th post-
operative day. The subjective rating of exertion
perceived by the person exercising is generally a sound
indicator of relative fatigue to clinically determine
intensity of exercise. The breathlessness and rate of
perceived exertion scores on 13th post-operative day
indicated that subjects find the prescribed walk test
less stressful, as they could walk more distance with
less rate of perceived exertion than on 6 th post-
operative day.
The statistically significant increase in functional

capacity was due to increase in the parasympathetic
Fig. 3. Changes in RPE, pre and post walk on 6th and 13th day in tone and an improvement in cardiovascular autonomic
CABG subjects.
control due to exercise conditioning resulting from
mobilization exercises and regular physical activity.
Table 2. Changes in Six Minute Walk Distance
Also, in these coronary artery bypass subjects, the
between groups
deconditioning of the muscles is seen which occurs
SMWD Mean S.D t p with prolonged reduction of activity causing an
6th POD CABG 280.446.1 15.2 0.000 increase in fatigue and shortness of breath on activity.
Normal Subjects 584.961.7 Evidence supports that even low- to moderate-
13th POD CABG 355.743.4 11.7 0.000 intensity activities performed daily increases
Normal Subjects 584.961.7 cardiovascular functional capacity and decreases
myocardial oxygen demand at any level of physical
The mean value of Rate of Perceived Exertion on activity.
6th POD before walk was 2.07 which increased to
statistically significant level of 3.63 post walk test. The results of this study correlated with the study
Similarly, the mean value of Rate of Perceived Exertion conducted by Jaeger AA on the functional capacity
on 13th day increased from pretest mean of 1.73 to post after cardiac surgery in elderly patients who found that
walk test mean of 2.57. However, when we look at post the functional capacity improved significantly after
test means on 6th day and 13th day, we clearly found surgery till 1 year with improvements in most
that subjects experience less exertion on 13th day than patients6. Also another study by Hirschhorn AD who
those on 6th day after 6 minute walk test. studied whether supervised moderate intensity
exercise improves distance walked at hospital
Table 3. Changes in Rate of Perceived Exertion, discharge following Coronary Artery Bypass Graft
pre and post walk on 6th and 13th day Surgery. The results showed that the walking and
RPE Mean Rank
walking/breathing exercise groups had significantly
higher 6 minute walk assessment distance than the
6th POD before walk 2.07
standard intervention group at discharge from
6th POD after walk 3.63
hospital. However, there was no significant difference
13th POD before walk 1.73
between intervention groups for 6 minute walk
13th POD after walk 2.57
assessment distance at four-week follow-up. He
concluded that physiotherapy-supervised, moderate
intensity walking program in the inpatient phase

following CABG improves walking capacity at specialty to render safer and & effective home exercise
discharge from hospital 7. program at discharge. Analyzing the functional
capacity could be used in the perspective of
Also, in our study, none of the subjects reached to formulating a personalized rehabilitation program and
the functional level of normal matched subjects by 13th more useful activity prescription to such patients.
post-operative day. Thus, emphasizing that continued Further, understanding functional level will assist in
care and cardiac rehabilitation is needed. The results determining patients need for rehabilitation services
of this study correlated with the study conducted by after CABG surgery.
DiMattio MJ who studied functional status and
correlates following coronary artery bypass graft
CONFLICT OF INTEREST
surgery in women. The results showed that women
experienced significant gains in functional status over The authors have no conflicts of interest to declare.
6 weeks, particularly between 2 and 4 weeks. Also,
none of the women completely recovered or had
REFERENCES
regained baseline functional status by 6 weeks. They
suggested that the finding that recovery is incomplete 1. Okraine Karen, Banerjee Devi K, Eisenberg Mark
by 6 weeks, should be incorporated into discharge J. Coronary Heart disease: the developing world.
planning and follow-up for this patient population8. American Heart Journal 2004; 148: 7-15.
2. Singh Ram N, Sosa Julia A, Albany NY,
Ability to walk greater distances with low rate of
Green.George E. Long term fate of the internal
perceived exertion, absence of clinically significant
mammary artery & saphenous vein grafts.
desaturation and absence of clinically significant
J Thoracic Cardiovascular surgery 1983; 86:
changes in heart rate, blood pressure and respiratory
359-363.
rate help us suggest that patients with age group 40
3. 3Michael X. Pham, Jonathan N. Myers and Victor
60 years following coronary artery bypass surgery
F. Froelicher. Cardiac Rehabilitation
could walk easily by 355.7 43.4 meters on 13th post-
Cardiovascular Medicine 2007, Section IV,
operative day. This also indicates that uncomplicated
1113-1132.
coronary artery bypass surgery patients are capable
4. 4Gerald F. Fletcher; Gary J. Balady; Ezra A.;
of performing activities requiring 3- 5 METs of
Bernard Chaitman,; Robert Eckel, MD; Jerome
energy expenditure as early as 13th post-operative day
Fleg; Victor F. Froelicher; Arthur S. Leon; Ileana
in the post operative regimen, as regards to
L. Pia; Roxanne Rodney; Denise A. Simons-
physiotherapeutic protocol and advices for such
Morton; Mark A. Williams; Terry Bazzarre.
patients.
Exercise Standards for Testing and Training: A
Statement for Healthcare Professionals From the
FUTURE RESEARCH American Heart Association. Circulation. 2001;
104: 1694-1740.
Future research is needed for analyzing the return
5. Brooks D, Solway S, Gibbons WJ.ATS statement
of functional capacity in post coronary bypass subjects
on six-minute walk test. Am J Respir Crit Care
compared to normal subjects matched on more criteria
Med. 2003 May 1; 167(9): 1287.
like co-morbid conditions and preexisting lifestyle
6. Jaeger AA, Hlatky MA, Paul SM, Gortner SR.
habits. Simulation of this protocol to the wide variety
Functional capacity after cardiac surgery in
of coronary artery bypass surgery (off pump, on pump,
elderly patients. J Am Coll Cardiol 1994 Jul; 24(1).
robotic surgery) and comparison between them can
7. Hirschhorn AD, Richards D, Mungovan SF,
be applied for future research.
Morris NR, Adams L. Supervised Moderate
Intensity Exercise Improves Distance Walked at
CONCLUSIONS Hospital Discharge Following Coronary Artery
Bypass Graft Surgery-A. Randomised Controlled
This study help us suggest that patients with age
Trial. Heart Lung Circ. 2007: Nov 28.
group 40 60 years following coronary artery bypass
8. DiMattio MJ, Tulman L. A longitudinal study of
surgery achieve functional capacity in the range of 3-5
functional status and correlates following
METs and could easily perform activities in this range
coronary artery bypass graft surgery in women.
by 13th post-operative day. This study will therefore
Nurs Res. 2003; Mar-Apr; 52(2): 98-107, Nurs Res.
help physiotherapy professionals in cardiopulmonary
2003 Jul-Aug; 52(4).

A Comparative Study Between Muscle Energy Technique

and Myofascial Release Therapy on Myofascial Trigger
Points in Upper Fibres of Trapezius
Jay Sata
Master of Physiotherapy (Sports), Lecturer, K.K Sheth Physiotherapy College, Rajkot - 7
ABSTRACT
Background: 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 upper region of
the trapezius muscle. About two thirds of people will experience neck pain at some point in their
lives. Prevalence is highest in middle age, with women being affected more than men. The prevalence
of neck pain varies widely between studies, with a 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 pain.
The myofascial trigger points have been described as a hyperirritable spot, usually within a taut
band of skeletal muscles or in the muscles fascia. The spot is painful on compression and can give
rise to characteristics referred pain, tenderness and autonomic phenomenon.
Myofascial release is a soft tissue mobilization technique, defined as "the facilitation of mechanical,
neural and psycho physiological adaptive potential as interfaced via the myofacial system. Myofascial
release which eliminates the fascia's excessive pressure on the pain sensitive structure and restores
proper alignment. Hence this technique is proposed to act as a catalyst in the resolution of trapezius
spasm.
Muscle energy technique (MET) are manipulative procedures are designed to lengthen muscle and
fascia and to mobilize joints. Because principles of neuromuscular inhibition are incorporated into
this approach, another term to describe these techniques is "post-isometric relaxation".
Objectives : To compare the efficacy of Muscle energy techniques and Myofascial release therapy on
myofascial trigger points in upper fibres of trapezius.
Methods: Study included 52 (Fifty-Two) subjects with myofascial trigger points on upper fibres of
trapezius. The subjects were randomly divided into 2 groups: Group A and Group B. Muscle Energy
Technique ware given for Group A patients and Myofascial release therapy ware given for Group B
patients. The subjects were treated for a period of 6 days a week, Once in a day. Pain was assessed by
VAS score, Neck Disability by NDI score and Pain Threshold by PPT score.
Results: There is statistically significant difference in terms of the VAS, PPT, NDI score. The myofascial
release group showed better decrease in pain, disability and increase in pain threshold.
Conclusion: Myofascial release proving better than the muscle energy techniques on myofascial
trigger points of upper fibres of trapezius.
Key words: Myofascial Release Therapy, Muscle Energy Techniques, Myofascial Trigger Point
INTRODUCTION Because the fibres of trapezius run in different

directions, it has a variety of actions. Upper trapezius
In human anatomy, the trapezius is a large performs elevation and upward rotation of the scapula,
superficial muscle that extends longitudinally from the as well as extension, lateral flexion and contra lateral
occipital bone to the lower thoracic vertebrae and rotation of the neck. The lower trapezius performs
laterally to the spine of the scapula (shoulder blade). upward rotation, adduction and depression of the
Its functions are to move the scapulae and support the scapula. The middle trapezius performs the upward
arm.
31 jay sata 21th may 11 (150-154).pmd 150 10/16/2012, 2:41 PM

rotation and adduction of the scapula. The upper MATERIALS AND METHODS
trapezius is also a secondary muscle of respiration.
Garth R Johnson et al found that the EMG activity in All patients were referred from the orthopedic Out
the upper trapezius was always prevent when Patient Department.
isometric loads were applied by shoulder shrugging 52 (fifty-two) patients in both sexes in age group of
and isometric pure moments were produced in coronal 20-50 years were divided in to two groups. Group A
plane abduction and adduction.
and Group B by simple random sampling method.
The upper trapezius is often placed in a shortened
Inclusion Criteria
position by poor ergonomics which creates shortness
in the muscle. The trapezius is also activated by Pain in neck
stressful thoughts and feeling or abnormal breathing Age group 20-50 years of either sex
pattern. With pain and tightness in the trapezius, Clinically diagnosed cases of upper trapezius
patients may have symptoms of headaches, dizziness, spasm from 3weeks to 3 months
neck pain and mid back pain. Pain felt maximally over upper trapezius region.
Active trigger point in the Trapezius
One important event, which occurs early after Participants willing to participate in the study.
injury, is muscle spasm. This feels like tightness in the
muscles in that area, and is sometimes, but not always
painful. The involvement of trigger points in almost EXCLUSION CRITERIA
all chronic pains is well established and yet many Subjects were excluded from the study if they had:
therapists either ignore or are not even aware of their
existence. The myofascial trigger point in the trapezius Age below 20 or above 50 years of either sex.
is most commonly found at the midpoint of the upper Patients having structural instability and
border of the muscle. Satellite trigger points are seen degenerative conditions of cervical spine
in temporalis, masseter, splenius, semispinalis, levator Torticollis
scapulae and rhomboid major. Fibromyalgia
Cervical spondylosis.
Myofascial trigger points can be acute due to Cervical disc prolapse.
immediate injury or chronic due to micro trauma over Subjects with impaired circulation.
a long period of time The underlying physiological Posttraumatic individuals ,neoplasms and infective
mechanism of trigger points is not clearly understood. conditions,
Several mechanisms have been proposed in the Inflammatory conditions of cervical spine like RA,
literature Trauma either acute or chronic causes spondylitis.
sarcoplasmic reticulum to tear and release calcium. Patients who have undergone surgeries in and
This calcium and ATP causes the sarcomere to contract around the cervical spine.
which shortens the muscle in a localized area Un co-operative patients.
producing taut bands. This generates high level of
metabolic activity and ischemia in the area, thus the Outcome Measures
release of substances which cause hyperirritability of
sensory nerve endings producing pain. Pain Intensity Visual Analogue Score23
Neck Disability Index24
Trigger points are typically located by palpation. Pressure Pain Threshold Pressure Algometer25
Simons described his criteria for identifying trigger
points. These criteria include identification of taut METHODOLOGY:
band, a tender spot on the taut band, referred pain or
altered sensation at least 2 cm beyond the spot, elicited Assessment
by needle penetration or pressure held for 10 seconds;
Pre-participation evaluation form consisted of VAS,
and restricted Range Of Motion in the joint cross by
NDI,PPT and assessment chart which included Age,
the muscle The clinical examination of trigger points
sex, chief complain, presence of symptoms in one or
include three types of palpation flat palpation to both sides of neck, tenderness, pain, spasm present in
locate the spot of maximum tenderness with minimum the area of upper trapezius etc.
pressure, pincer palpation to locate the trigger point
and snapping palpation to elicit a local twitch response Procedure
An algometer is a useful tool to judge the amount of
pressure that is required to produce the pain or Ethical clearance was obtained from the Ethical
referred symptoms. Clearance Committee of my College, prior to the
study. Those who fulfilled the inclusion criteria

light resisted effort (30% of the available strength) to

take the stabilized shoulder towards the ear(shrug
movement) and the ear towards the shoulder. The
double movement is important in order to introduce
a contraction of the muscle from both ends
simultaneously. The degree of effort should be mild
and no pain should be felt.
Fig. 1. Pressure algometer The contraction is sustained for 10 seconds and
were taken up for the study. A written informed released. Three repetitions with complete relaxation
consent of all the subjects was taken. of 5 seconds, the practitioner gently move the head/
neck into an increased degree of side bending,
The subjects were acquainted with the sensation of painlessly, and held in this position for atleast 10
pressure algometer on an unaffected part of the body seconds and repeated 3-4 times.
before testing for pressure pain threshold for primary
The MET treatment was given once daily for 6
trigger point. The pressure algometer was placed
days.
perpendicular to the area to be tested with the subject
sitting in chair, increasing the pressure steadily at the Group B: Myofascial Release
rate of approximately 1 Kg/sec. Each subject was asked
Positioning of the patients in sitting position.
to point on the most painful areas of the neck and
upper back, to determine the area of possible trigger Application:
points. Examiner then palpated the region of trapezius
The therapist is in standing position behind the
and marked all the trigger points that matched the
patient, Then with hands crossed with one hand
inclusion criteria with a non permanent marker.
placing on the shoulder and the other below the ear
The trigger point with the lowest pressure pain on the head of the involved side. The placement of the
threshold was considered as primary trigger point. The hands should be along the direction of the fibres .Local
mark stayed on the patients skin for 6 days required myofascial stretch for 20 seconds is given slowly and
for the completion of the study. repeated 3-4 time.
Procedure is applied once daily for 6 days.
Clinical Intervention
Study participants were requested to continue

normal activities and avoid any other forms of
treatment for the duration of the study, apart from
routine physician management. Subjects other than the
designated protocol were not permitted to administer
any other forms of electrotherapy or other techniques
(steroids, acupuncture, or taping) during the
intervention period of the trial.
Group-A :Muscle Energy Technique
In this study Post facilitation stretching was used.

Post Facilitation Stretching:
Position of patient:
The patient was in supine position with the arm Fig. 2. Muscle energy technique
lying alongside the trunk.
Application: RESULTS
The head/ neck was side bent away from the side Fifty-two subjects were randomly divided in to
being treated to just the short of the restriction barrier, 2 groups: Group A& Group B. In Group A 25 subjects
while the shoulder was stabilized with one hand and and in Group B 27 subjects.
the other hand cups the ear/mastoid area of the same
side of the head. Table 1.1 Age Distribution of the Subjects
The Post Facilitation stretch was performed with Group N Mean SD
practitioners arms crossed, hands stabilizing the Group A 25 30.80 5.36
mastoid area and shoulder. The patient introduced a Group B 27 29.44 5.38

Group A:
Scales PreMean + SD PostMean + SD TValue P Value

VAS 6.88+0.78 4.12+0.860 325 < 0.0001
NDI 17.12 + 1.50 11.40 + 2.096 325 < 0.0001
PPT 2.44 + 0.39 3.78 + 0.590 -321 < 0.0001
Group B:
Scales PreMean + SD PostMean + SD TValue p

VAS 7.222+ 0.933 3.444 + 0.640 378 < 0.0001
NDI 17.741+ 1.551 10.111+ 1.476 378 < 0.0001
PPT 2.259+0.350 4.481+0.700 -378 < 0.0001
From the above findings, which suggest that there

is stastically significant difference between the groups
Fig. 3. Myofascial Release A and B.
Table 1.2. Results of Wilcoxon signed rank test for CONCLUSION

VAS ( Within the Group)
It is concluded that there is significant difference
Group T value P value Result
in the effect of treatment between Muscle energy
Group A 325 P< 0.0001 Highly
significant techniques and Myofascial release therapy on
myofascial trigger points of upper fibres of trapezius
with myofascial release proving better than the muscle
Table 1.3. Results of Wilcoxon signed rank test for NDI
energy technique.
scale (Within the group) :
ACKNOWLEDGEMENTS
Group A 325 P< 0.0001 Highly
significant
I would like to thank Dr Mayur (Assistant
Group B 378 P<0.0001 Highly
significant Physiotherapist) and I am grateful to all my patients
for their kind cooperation and willingness to
Table 1.4. Results of Wilcoxon signed rank test for participate in this study, without whom this study
PPT scale ( Within the group) : would not have materialized.
Group A -321 P< 0.0001 Highly Conflict of Interest
significant
Group B -378 P<0.0001 Highly The authors perceive no conflict of interest in this
significant study.
Wilcoxon Sum Rank Test (Mann Whitney U Test)87
was applied for between-group comparison of Group REFERENCES
A and Group B, and it is as follows:
1. Fejer R, Kyvik KO, Hartvigsen J, The prevalence
For VAS, U=174, U=451 ,P= 0.0037.On comparing of neck pain in the world population: A Systemic
Group A and Group B for post-treatment VAS critical review of the literature, Eur Spine J 2006;
score, results showed significant difference in 15: 834-848.
improvement in terms of VAS. 2. Makela M, Heliovaara M, Sievers K et al,
Prevalence, Determinants and consequences of
For NDI, U=210.50, U=464.50, P= 0.0175. On chronic neck pain in Finland, Am J Epidemiology
comparing Group A and Group B for post- 1991; 134: 1356-1367.
treatment NDI score, results showed significant 3. Cote P, Cassidy D, Carroll L, The Saskatchewan
difference in improvement in terms of NDI. Health and Back pain survey: The prevalence of
neck pain and related disability in Saskatchewan
For PPT, U=145, U=530, P= 0.0003. On comparing adults, spine 1998; 23: 1689-1698.
Group A and GroupB for post-treatment PPT score, 4. Laura K. Smith, Elizabeth L. Weiss, L. Don
results showed extremely significant difference in Lehmukhi, Brunnstroms Clinical Kinesiology, 5th
improvement in terms of PPT. ed., 1996: 223 - 255.

5. Doug Alexander B.Sc., R.M.T., Upper Trapezius, treatments in myofascial pain syndrome. Photo
www.massagetherapypractise.com medicine and LASER surgery, 2004; 22: 306-311.
6. Simon S, David G, Travell, Janet G, Lois S. 16. Myofascial Therapy, Sam Kegerreis, MS, PT, ATC
Myofascial pain and dysfunction: The Trigger Professor of Physical Therapy Krannert School
Point Manual. Lippincott Williams & Wilkins: of Physical Therapy, University of Indianapolis.
Atlanta, GA 1999. 17. Chaitow, L (1996): Muscle Energy Techniques.
7. Travell JG, Simons DG, Myofascial pain and Churchill Livingstone, New York.
dysfunction: The Trigger Point Manual, The 18. Clark, MA (2001): Muscle Energy techniques in
upper extremities, Baltimore, Md: Williams & rehabilitation. In Prentice, WE, Voight,:
Wilkins, 1983: 5-90. Techniques in Musculoskeletal Rehabilitation.
8. Leon Chaitow, Integrated treatment of myofascial Mc Graw- Hill, New York, pg 215- 223.
trigger point. 19. Ellerin, BE, Helfet, D, Parikh , S et al (1999):
9. Nice D, Riddle DL, Lamb RL et al; Intertester Current therapy in the management of
reliability of judgments of the presence of trigger heterotrophic ossification of the elbow: a review
points in patients with low back pain, Arch Phys with case studies. Am JPhy Med Rehabil 78(3):
Med Rehabilitation, 1992; 73: 893-898. 259-271.
10. Graff Radford SB, Reeves JL, Baker RL, Chiu D, 20. Mitchell, FL (1993): Elements of muscle energy
Effects of Transcutaneous electrical nerve techniques In Basmajian, JV,Nyberg, R(eds):
stimulation on Myofascial pain and Trigger point Rational Manual Therapies. Williams and
sensitivity, pain, 1989; 37: 1-5. Wilkins, Baltimore.
11. Melzack R, Prolonged relief of pain by Brief, 21. Wilson, E, Payton, O, Donegan Shoaf, L, Dec, K
Intense Transcutaneous Somatic Stimulation, (2003): Muscle energy techniques in patients with
Pain, 1975; 1: 357-373. acute low back pain: a pilot clinical trial. J Orthop
12. Jaegar B, Reeves JL, Quantification of changes in Sports Phys Therapy 33(9): 502-512.
Myofascial Trigger point sensitivity with the 22. Kisner, C, Colby LA Therapeutic Ex Foundation
pressure algometer following passive stretch, and Techniques (5th edition).
pain, 1986; 27: 203-210. 23. Hendiani JA, Westlund KN, LAwand N, et al.
13. Lewit D, Simons DG, Myofascial pain: Relief by Mechanical sensation and pain thresholds in
post- isometric relaxation, Arch Phys Med patients with chronic arthropathies. J Pain 2003;
Rehabil, 1984; 65: 452-456. 4:203-211.[ISI] [Medline]
14. Stuart Cathcart, BA Hons et al, Reliability of pain 24. Vernon H., et al (1991) The neck disability index,
Threshold Measurement in young adults: The a study of reliability and validity
internet Journals of pain, Symptom control and 25. Reeves JL, Jager B, Graff Radford SB, Reliability
palliative care, 2005, 4. of the Pressure Algometer As A Measure of
15. Ilbuldu E, Cakmak A et al, Comparison of Myofascial Trigger Point Sensitivity, Pain, 1986,
LASER, dry needling and placebo LASER 24:313-321.

Quantifying EMG Activity of Trapezius Muscle During
Empty Can & Full Can Tests
Kanupriya1, Sumit Kalra2

1 2
Student Assistant Professor, Banarsidas Chandiwala Institute of Physiotherapy, Kalkaji, Delhi
ABSTRACT
Study Design: Correlational design.

Purpose: To quantify the EMG activity of the three fibers of the trapezius muscle during empty can
& full can shoulder exercises/ tests.
Setting: College electrotherapy laboratory.
Subjects: 50 healthy subjects, age group between 20-30 years.
Materials: Full scale goniometer, EMG equipment- NeuroTrac ETS C 0120, a laptop- Dell, Self
adhesive electrodes.
Methods: Subjects fulfilling the inclusion criteria were taken into consideration. The procedure was
explained to the subjects and a written consent was taken after explaining the benefits and clearing
the doubts of the subject regarding study. After ROM and muscle tension evaluation using manual
muscle testing (MMT), and goniometry of the cervical spine and shoulder, subjects were recruited
and electrodes were placed accordingly, for recording the trapezius muscle activity. After electrode
placement the subjects were asked to perform two shoulder rehabilitation exercises that is, empty
can & full can exercises. The subjects were instructed to perform, each of the above mentioned exercises
with, holding of the exercise position, for 30 seconds which was followed by a rest period, and
performance of the test.
Recording of the data was done, in between the exercise performance.
Data analysis: Mean and standard deviation were calculated from the EMG values, recorded for
each fiber of the trapezius muscle during empty can and full can shoulder exercises/tests.
The coefficient of variation i.e. variability was computed using the statistical values (mean & standard
deviation).
Result: The coefficient of mean variation ( variability) calculated was least for the lower trapezius
muscle during the empty can shoulder exercise/test, it suggests that the EMG values for the lower
trapezius muscle during empty can shoulder exercise/test is more compact,consistent, homogenous
& is efficient.
Conclusion: The present study concludes that during the empty can & full can shoulder exercises/
tests a scapular stabilizing muscle i.e. trapezius was also activated along with the other rotator cuff
muscles. Out of the two mentioned exercises/tests maximum activation was seen in the lower fibers
of the trapezius muscle followed by upper & middle fibers during Empty Can exercise/test. However,
during full can exercise, out of the three fibers of the trapezius muscle maximum activity was recorded
from the lower fibers followed by upper & middle fibers.
Key Words: Empty can, Full can, Muscle activation.
INTRODUCTION knowledge of specific muscle biomechanics and

function has increased, we have seen a gradual
The biomechanical analysis of rehabilitation progression towards more scientifically based
exercises has gained recent attention. As our
32. kanupriya 18th july 11 (155-161).pmd 155 10/16/2012, 2:41 PM

rehabilitation exercises. Several investigators have Description of the exercises/tests and positions
sought to describe common rehabilitation exercises used for the isometric EMG testing are as follows:
using kinematics, kinetics, and electromyography
(EMG) data in an attempt to better understand the 1. Empty can / Jobe Test or exercise: Subjects arm
implications of each exercise on the soft tissues around abducted to 90 0 with neutral (no) rotation, and
the shoulder joint.1, 2 examiner provides resistance to abduction. The
shoulder is then medially rotated and angled forward
EMG studies have confirmed that no one exercise 300 (empty can position) so that patients thumbs point
isolates the action of supraspinatus muscle from the toward the floor in the plane of the scapula. Resistance
other rotator cuff or deltoid muscles. The to abduction is again given while the examiner looks
supraspinatus muscle is effectively activated in both for weakness or pain, reflecting a tear of the
the empty can and full can exercises. Based on supraspinatus tendon or muscle, or neuropathy of the
previous electromyographic (EMG) studies the suprascapular nerve.
Empty Can (EC) and Full Can (FC) tests have been
promoted as being able to isolate activity to Isometric position: Shoulder abduction in the
supraspinatus. On this basis, the FC and EC tests have scapular plane with internal rotation and resistance
been reported as being diagnostic of supraspinatus applied at the wrist. Internal Rotation exercises for the
dysfunction. However, there is evidence to suggest shoulder will strengthen multiple stabilizing muscles.
that these positions do not selectively activate Empty can exercise is completed from a range of
supraspinatus, bringing into question the anatomic motion of 0 0-90 0 and then back down to starting
validity of these tests. This has implications for their position.
use both as a diagnostic tool and as isolated
strengthening exercises. 2. Full Can: This exercise is completed while standing.
Also ones arms at their waist, thumbs up while
In clinical practice, physical examination tests of holding a weight. The individual raises their arms up
the shoulder commonly include range of motion, from there a 30 angle anterior to the frontal plane (the
resisted muscle tests and orthopaedic special tests. frontal plane can be thought of as an imaginary sheet
Many recent publications have focused on the of paper that separates the anterior side of your body
diagnostic validity (Beaudreuil, Nizard et al., 2009; from the posterior side of your body). Once the arm is
Hegedus, Goode et al., 2008), and anatomic validity at shoulder width height, the individual pauses and
(Green, Shanley et al., 2008) of isolated clinical tests then lowers them back down to starting position.
for shoulder pain. The reviewed study adds further to
this body of evidence by investigating the anatomic Isometric position: Shoulder abduction in the
validity of the EC and FC tests for selective activation scapular plane (30 anterior to the frontal plane) with
of supraspinatus and FC tests are commonly used in external rotation and resistance applied at the wrist.
clinical examination of the painful shoulder. Since these
tests were first described, personnel from medical field A study done by Boettcher CE, Ginn KA and
have interpreted pain or weakness associated with one Cathers I (2009): on The empty can and full can
or both of these tests as being indicative of tests do not selectively activate supraspinatus, brought
supraspinatus pathology (Jobe & Moynes, 1982). Both into question the anatomic validity of the tests
these tests are also frequently used as a strengthening mentioned above i.e. the empty can and the full can
exercise for supraspinatus, with clinicians believing tests or exercises by an EMG based evidence in their
that they are primarily strengthening the results showing, While both the EC and FC tests
supraspinatus muscle. activated supraspinatus to levels approximately 90%
of their maximal voluntary contraction, eight other
The above study challenged both long-held shoulder muscles were also activated to similarly high
assumptions with some interesting results. The known levels including other rotator cuff muscles
limitations of EMG notwithstanding, the methodology (infraspinatus and upper subscapularis), scapular
of this study appears sound. Their results clearly positioning muscles (upper, middle and lower traps,
indicate substantial amounts of muscle activation in and serratus anterior), and abduction torque
all rotator cuff muscles, as well as many global producing muscles (anterior and middle deltoid). They
shoulder muscles (including all the three fibers of concluded that the EC and FC tests do not primarily
trapezius muscle) during the FC and EC tests, activate supraspinatus and therefore, do not satisfy
appearing to dispel previously held beliefs that these basic criteria to be valid diagnostic tools for
tests selectively activate the supraspinatus3. supraspinatus pathology. Therefore, these tests should

not be interpreted as definitive tests for the clinical Statement of question:

diagnosis of supraspinatus pathology, and if
prescribed as a rehabilitative exercise, should be used Is there any activity of the trapezius muscle during
with the knowledge they are not selectively activating Empty Can & Full Can Exercises/Tests?
supraspinatus.
AIMS AND OBJECTIVE
Clinically, these results suggest that the production
of pain during the EC or FC tests may implicate any In the earlier studies Supraspinatus muscle
or all of the other rotator cuff muscles, not only the activation has been demonstrated with Empty Can &
supraspinatus. This fits with previous findings of Full Can shoulder exercises/tests with no concern
reasonable levels of sensitivity (84-86%) for the FC given to the Trapezius muscle. Therefore the aim of
and EC tests in detecting supraspinatus pathology, the present study is to check and quantify the EMG
but much lower levels of specificity (50-57%) when activity of the three fibers of the trapezius muscle
compared with surgical findings (Hertel, Ballmer et (upper, middle, & lower) during Empty Can & Full
al., 1996). Combined with the lack of anatomic Can shoulder exercises/tests.
validity demonstrated in the reviewed study, it is not
surprising that the diagnostic value of these tests for METHODOLOGY
ruling-in supraspinatus pathology (specificity) is
poor. Number and Source
50 subjects were taken
Implications for use as a strengthening exercise. The study is conducted at Banarsidas Chandiwala
Institute of Physiotherapy, Kalkaji, New Delhi.
The clinical rationale for prescription of a
strengthening exercise is the presence of a strength Inclusion Criteria
deficit. In accordance with results of this study, the
Male or female within age group 20-30 years
presence of weakness with the EC or FC tests may
implicate a strength impairment affecting any of the
Exclusion Criteria
rotator cuff muscles (or combination of cuff muscles),
the scapula positioners (middle and lower trapezius Subjects with trigger points or tender point of
and serratus anterior), or the abduction torque trapezius muscle.
producers (deltoid). Subjects with any musculoskeletal disorders that
would limit performance of the trapezius action or
The prescription of the EC or FC as a strengthening ROM of the cervical spine.
exercise will therefore activate all the rotator cuff and Skin disorders which would be irritated by EMG
many scapulothoracic muscles to a significant procedures.
proportion of their maximal voluntary contraction and In presence of malignant tumours in or around the
will most likely result in similar strength adaptations cervical spine/shoulder joint.
to all these muscle groups.
In presence of recent fracture sites in or around the
It can be concluded that the EC and FC tests do not cervical spine or shoulder joint.
selectively activate supraspinatus and therefore lack Spinal deformities.
anatomic validity as a diagnostic test for dysfunction Spinal contractures.
of this muscle. Their use as a diagnostic test to rule-in All contraindications of EMG.
supraspinatus lesions is therefore limited. Given the
finding that all rotator cuff muscles are activated Instruments and Tool used
during these tests, a more appropriate interpretation Electromyographic equipment- NeuroTrac ETS
may be that these tests could assist in ruling-out C 0120
involvement of the rotator cuff given a negative test
A laptop- Dell
result. Due to high levels of activation of many rotator
Self adhesive electrodes- 4, 5050mm (VMVERITY,
cuff and scapulothoracic muscles during the EC and
Medical Ltd
FC tests, they are likely be effective strengthening
exercises for all these muscle groups; however, they Goniometer full scale
will not selectively strengthen the supraspinatus
muscle.4 Research Design
It is a correlational design.

Variables exercises with, holding of the exercise position, for 30

Electromyography seconds which was followed by a rest period, and
Exercises performance of the test.
Time period
Recording of the data was done, in between the
PROCEDURE exercise performance.
Subjects fulfilling the inclusion criteria were taken

into consideration. The procedure was explained to
the subjects and a written consent was taken after
explaining the benefits and clearing the doubts of the
subject regarding study. After ROM and muscle
tension evaluation using manual muscle testing
(MMT), and goniometry of the cervical spine and
shoulder, subjects were recruited and electrodes were
placed accordingly, for recording the trapezius muscle
activity:
Electrode placement - Bipolar surface Electrodes were
placed with a 2-cm interelectrode distance over the
upper, middle, and lower portion of the trapezius.
For upper trapezius- Electrodes for the UT were
Fig. 2. Electrode placement onto the middle & lower fibers of
placed midway between the spinous process of the
trapezius muscle
seventh cervical vertebra and the posterior tip of the
acromion process along the line of the trapezius
For middle trapezius- The MT electrodes were placed
midway on a horizontal line between the root of the
spine of the scapula and the third thoracic spinous
process.
For lower trapezius- The LT electrodes were placed
obliquely upward and laterally along a line between
the intersection of the spine of the scapula with the
vertebral border of the scapula and the seventh
thoracic spinous process.
After electrode placement the subjects were asked

to perform two shoulder rehabilitation exercises that
is, empty can & full can exercises. The subjects were
instructed to perform, each of the above mentioned
Fig. 3. Empty can exercise/test
Fig. 1. Instrumentation used Fig. 4: Full can exercise/test

DATA ANALYSIS Table 1. Mean and Standard Deviation of upper

trapezius during Empty Can & Full Can exercise/test
EXCEL 2007 is used for calculations.
Upper Trapezius
FORMULA USED
Statistical Values Empty Can Full Can
Mean 46.99 46.40
MEAN-
Standard Deviation 18.12 18.68
Mean = sum of elements / number of elements

= a1+a2+a3+.....+an/n Table 2. Mean and Standard Deviation of middle
STANDARD DEVIATION- Middle Trapezius
Statistical Values Empty Can Full Can
Mean 49.60 44.28
Table 3. Mean and Standard Deviation of lower

Middle Trapezius
COEFFICIENT OF VARIATION Statistical Values Empty Can Full Can
Mean 106.32 50.39
RESULT
Mean and standard deviation were calculated from

the EMG values, recorded for each fiber of the
trapezius muscle during empty can and full can
shoulder exercises/tests.
The coefficient of variation i.e. variability was

computed using the statistical values (mean & Graph 1. Mean & Standard Deviation of the upper fibers of the
trapezius muscle during Empty Can & Full Can exercises/test.
standard deviation) which were as follows:
During empty can-
Upper trapezius=38.6%, middle trapezius= 53.70%,
lower trapezius=36.3%
During full can-
Upper trapezius=40.3%, middle trapezius=51.3%,
lower trapezius=44.6%
Since the coefficient of mean variation ( variability)

is least for the lower trapezius muscle during the
empty can shoulder exercise/test, it suggests that the
EMG values for the lower trapezius muscle during
Graph 2. Mean & Standard Deviation of the middle fibers of
empty can shoulder exercise/test is more compact, the trapezius muscle during Empty Can & Full Can exercises/
consistent, homogenous & is efficient. test.

DISCUSSION
An early activation of stabilizing muscles at the

scapulothoracic joint could help to increase the
scapular stability to provide a stable platform during
glenohumeral movements. Furthermore, it is
suggested that the stabilizing action of the scapular
muscles is essential for an adequate performance of
the rotator cuff during upper limb elevation. If the
scapular muscles better stabilize and synchronize
scapular movements, this could increase the capacity
Graph 3. Mean & Standard Deviation of the lower fibers of the
of the rotator cuff muscles to stabilize the
trapezius muscle during Empty Can & Full Can exercises/test glenohumeral joint.Hence scapular muscle training is
an essential part of progressive shoulder rehabilitation
and injury prevention exercise programs. In general,
shoulder training is frequently performed to restore
upper extremity function or to prevent shoulder injury.
To achieve these goals, a multitude of exercises are
used in clinical practice. Traditionally, the value of an
exercise is based on the activation level at which the
different muscles are activated. More specifically, it has
been postulated that the timing of muscle activation
of the scapular muscles is an important factor in the
relationship between the dynamic muscular actions
and the scapular kinematics.
Graph 4. Mean values of all the three fibers of trapezius muscle
during Empty Can & Full Can exercises/test
CONCLUSION
The present study concludes that during the empty

can & full can shoulder exercises/tests a scapular
stabilizing muscle i.e. trapezius was also activated
along with the other rotator cuff muscles. Out of the
above mentioned exercises/tests maximum activation
was seen in the lower fibers of the trapezius muscle
followed by upper & middle fibers during Empty Can
exercise/test. However, during full can exercise, out
of the three fibers of the trapezius muscle maximum
Graph 5. Standard deviations of all the three fibers of trapezius activity was recorded from the lower fibers followed
muscle during Empty Can & Full Can exercises/test by upper & middle fibers.
LIMITATIONS OF THE STUDY

The number of subjects taken in the study was 50;
rather more than this could have been taken
The age group taken in the study is from 20-30
years; rather a larger age group should have been
taken.
Graph 6. Coefficient of variation for upper middle & lower fibers

of trapezius during Empty Can & Full Can exercises/test

Graph 7. Showing Electrical Activity of Lower & Middle Fibers of Trapezius Muscle
BIBLIOGRAPHY 3. Boettcher CE, Ginn KA and Cathers I (2009): The

empty can and full can tests do not selectively
1. Bagg SD, Forrest WJ. Electromyographic study activate supraspinatus. Journal of Science and
of the scapular rotators during arm abduction in Medicine in Sport 12: 435-439.
the scapular plane. Am J Phys Med. 1986; 65: 4. Craig E Boettcher, Karen A Ginn and Ian Cathers:
111-124. The empty can and full can tests do not
2. Ballantyne BT, OHare SJ, Paschall JL, Et al. selectively activate supraspinatus. (Journal of
Electromyographic activity of selected shoulder Science and Medicine in Sport 12: 435-439.
muscles in commonly used therapeutic exercises. Abstract prepared by Angela Cadogan).
Phys Ther. 1993; 73: 668-682.

Socio-Economic Barriers to Maternal Health Care in Rural

Bangladesh
Lori Walton1, Bassima Schbley2,

1
Associate Professor in Physiotherapy Rockhurst University Kansas City, Missouri, 2Associate Professor in Social
Work Washburn University Topeka, Kansas, USA
ABSTRACT
Objective: To outline the specific socio-economic barriers to maternal health faced by Bangladeshi
women.
Study Design: Review and Analysis of Literature
Background: Bangladesh is a country with over one third of the population living in poverty and
another one third living just above poverty level. The World Health Organization (2010) indicates
that Bangladesh has poor prenatal and postpartum care, nutritional deficiencies, high incidence of
non-skilled birth attendant utilization, and the second highest maternal mortality and morbidity
rates next to sub-Saharan Africa. Women living in Bangladesh are at high risk for maternal mortality
and morbidity in the postpartum period directly related to socio-economic status.
Conclusion: The need for socio-economic relief for women living in rural Bangladesh remains an
issue that needs to be addressed to fully address maternal health and maternal morbidities in the
postpartum period.
Key Words: Postpartum, Maternal Health, Morbidity, Mortality, Bangladesh, Socio-Economic
INTRODUCTION dysfunction, and pelvic pain. Without this information,

Bangladeshi women may be at an even higher risk for
Bangladesh is a country with over one third of the postpartum problems.
population living in poverty and another one third
living just above the poverty level.1 The World Health To determine the specific needs of this community,
Organization (WHO)2 indicates that Bangladesh has it is important to understand the medical needs, local
poor prenatal and postpartum care, nutritional practices, and perceptions of pregnancy, birth, and the
deficiencies, high incidence of non-skilled birth postpartum period and how they are affected by
attendant utilization, and the second highest maternal culture and religious beliefs. Gender-equity theories
mortality and morbidity rates next to sub-Saharan propose that empowerment for women begin with
Africa. access to social, health and nutrition services economic
opportunities.4 However, in Bangladesh, social, health,
The United Nations Millennial Development Goal nutrition, and economic opportunities are severely
5 (MDG5) for 20153 focuses on improving maternal diminished for many women.
health by improving QOL for women in developing
countries, including Bangladesh. One of the MDG5 Apart from the cultural and gender barriers for
strategic goals is to improve access to prenatal and women living in rural impoverished regions, women
postpartum programs that effectively reduce the who are at or below poverty level who need obstetric
morbidities associated with postpartum maternal services have limited access to resources because of
health. However, there is currently no information on extended travel time to the nearest hospital. 5
the specific religious, cultural and socio-economic Therefore, research is needed to determine the specific
barriers experienced by women living in Bangladesh pregnancy-related health care needs of women living
that may limit access to these programs. Bangladeshi in Bangladesh.
women are already at high risk for post-partum
disorders such as infection, hemorrhage, urologic The purpose of this paper is to shed light upon the
33.lori walton 25th may 12 (162-167).pmd 162 10/16/2012, 2:41 PM

socio-economic risk factors that compound outcomes and decrease in maternal morbidity and
postpartum morbidities of Bangladeshi women mortality in several studies. 13,14 One study
essential to developing future programs developed by recommended skilled prenatal and postpartum
governmental and non-governmental organizations, education and care as integral to reducing of the risk
physicians, physical therapists, and other health care factors for infection, pregnancy induced hypertension,
practitioners in Bangladesh. hemorrhaging, incontinence, pain, and long term
pelvic disorders as evidenced in retrospective meta-
Decreasing the Maternal Mortality and Morbidity analysis in both developing and developed countries.15
Rates
However, skilled birth attendants are mostly
A review of the literature using CINAHL, Proquest unavailable in rural areas where the majority of births
Nursing, and PubMed databases and the search terms take place in the home in the presence of a dais, a
of Bangladesh, women, postpartum, traditional birth attendant with no medical training.16
mortality, and morbidities was conducted. The
One method to improve maternal health care is the
maternal mortality rate in Bangladesh is defined as
adoption of prenatal and postpartum education and
the death of a woman during pregnancy, childbirth,
care specific to the needs of women living in
or within the 42 days after delivery.6 Women living
Bangladesh. A study by Kalim et al (2009), in
in rural Bangladesh are vulnerable to complications
80 Bangladeshi women in two different districts, found
(morbidities) during pregnancy and postpartum with
a significant relationship between maternal years of
over half of women reporting one or more
education, literacy rates, and utilization of skilled birth
complications, including: preeclampsia, UI, urinary
attendants to the maternal mortality rates of each
tract infection, and other infections according to a
community.17 The community with higher literacy and
research study utilizing three related questionnaires
education and corresponding higher utilization of
with two stage sampling approach to both rural and
skilled birth attendants (over 20%) reported
urban areas in Bangladesh and over 103,000 women.7
significantly less maternal deaths (351/100,000) in
In Bangladesh, womens skilled prenatal and Khulna compared with the lower literacy and
postpartum care is focused on those living in urban education rates and low use of skilled attendance (less
areas and in the upper wealth quintile.8 Skilled birth than 10%) for women in Syhlet (471/100,000).8 In the
attendants are mostly unavailable in rural areas with same study, Kalim et al (2009), explored the
the majority of births taking place at home in the postpartum complaints most often reported by the
presence of a family member or other unskilled birth Bangladeshi women. Pain, prolapse, prolonged labor,
attendants.9 Untrained family members and friends placental tears, hemorrhage, and eclampsia were
provided 75% of birth and immediate postpartum care among the top complications reported in the
and did not involve the services needed for safe, postpartum period, all of which relate directly to a
effective, and efficient care. In the same study, only decrease in QOL for women and place them at risk for
22% of rural Bangladeshi women and 27% of urban other maternal morbidities. While skilled birthing
Bangladeshi women in the lowest wealth quartile attendants may be sufficient to provide safe birthing
reported having medically attended care, with the high methods for women living in Bangladesh, they lack
cost of care being the most commonly cited reason for the resources and knowledge to evaluate the physical
lack of skilled care. This lack of basic skilled care places problems commonly associated with the postpartum
women at high risk for prenatal, delivery, and period.
postpartum risk of complications. Studies have been
Barriers to Maternal Health Care
performed on nutrition, cost, educating skilled birth Malnutrition & Risky Birth Practices
attendants, and prenatal programs, but little has been
done to complete the spectrum of reproductive care Malnutrition and risky birth practices compound
by addressing women in the extended postpartum the problems that exist because of a lack of prenatal
period.10 and postpartum care. The national average body mass
index (BMI) of Bangladeshi women is <18.5 (BMI norm
Maternal deaths are associated with infection, reference=19-25), overall measuring below the
pregnancy induced hypertension (preeclampsia), malnourished level, making the Bangladeshi woman
septic abortion, urinary dysfunction, and more vulnerable to postpartum complications than
hemorrhaging with over 80% occurring during the women with adequate nourishment.18 A survey of
postpartum period. 11-12 Skilled prenatal and 26,424 pregnant women living in Bangladesh and
postpartum education has been linked to improved found that 35-38% of pregnant women had a body

mass index less than 18.5, weighed 48-49 kg and over only 12% are receiving some form of postpartum care.28
50% were anemic.19 In a retrospective study by Koenig et al (2007), it was
reported that 48% of the 103,000 Bangladeshi female
Postpartum morbidity and mortality rates increase subjects studied did not receive any type of prenatal
for women with a vitamin deficiency. Vitamin D, B12, or postpartum care. Rural areas provide several
A, iron and folate deficiencies have been linked to barriers to patients that prevent women from receiving
higher maternal and infant mortality for women living prenatal and postpartum care compared to their urban
in rural areas of Bangladesh and also women living in counterparts. Distance, quality, and cost are a few of
the slum areas of Dhaka.20,21 In one study of over 2,000 the most prominent barriers that have exhibited direct
pregnant women who were calcium supplementation negative impact on maternal morbidities and mortality
given during pregnancy resulted in 60-70% decrease for patients in developing countries.21
in preeclampsia and hypertension, two of the most
common morbidities leading to maternal death for Non-skilled birth attendants are the only option for
women living in the subcontinent.22 However, another many women living in rural regions who are forced to
study involving over 4,000 non-calcium deficient give birth at home because of cultural, monetary, or
women living in the United States who were given social expectations. The risk of postpartum morbidities
calcium supplementation were studied at a later date increases because of implementation of the risky birth
and no significant reduction in preeclampsia or practices of non-skilled birth attendants. Examples of
hypertension.23 This dichotomy in research findings these practices include: multiple vaginal examinations,
may suggest a special and specific role that calcium practice of forced gagging to expel the placenta
supplementation has for women living in poorer coupled with heavy pressure (the attendants knee or
regions of the world, where malnourishment is severe. full arm with body weight) on the abdomen or utilizing
an object, internal version to change the placement of
Nutritional deficiencies play a substantial role in
the baby during delivery, pulling on the umbilical cord,
the maternal well-being, complications during the
and manual removal of the placenta.29 These practices
prenatal and postpartum period, as well as during
cause unnecessary trauma potentially creating
delivery. Nutritional deficiencies including Vitamin
postpartum complications such as damage to the
D, B12, A, iron and folate in women living in
perineum, urinary tract, uterus, and other internal
Bangladesh should be considered when studying QOL
visceral structures along with an increased risk of
for women during the postpartum period to retrieve a
infection.18
comprehensive understanding of all underlying
confounding variables that influence maternal health
Socio-economic Status & Geographical Location
and well being. Zinc may also play an important role
in reducing risk of severe birthing problems such as Rural areas provide several barriers to patients that
premature rupture of membranes, placental abruption,
prevent women from receiving prenatal and
prolonged labor and severe lacerations, although this
postpartum care compared to their urban counterparts.
has not been studied for Bangladeshi women.24,25
Distance to health care facilities, quality of services
Access available in local rural health facilities, and cost of
prenatal and postpartum care are a few of the most
In rural areas of Bangladesh, many women are prominent barriers that have exhibited direct negative
living in poverty are unable to afford medical care and impact on maternal morbidities and mortality for
most do not have access to any skilled postpartum patients in developing countries.30
care26. Furthermore, physicians in Bangladesh elect
C-section births more often than necessary as shown Socio-economic factors play an important role in
in the overall increase in C-section rates reported by birth mode choice by physicians and patients living in
the World Health Organization from 2.5% in 2004 to Bangladesh. In a retrospective study of 20,000 births
between 15-25% in 2010.27 The women who undergo in several developing countries, including Bangladesh,
such surgical procedures do not understand or women in the wealthiest quintile who had access to
overlook the resulting postpartum implications and prenatal care were more likely to undergo a C-section.
financial hardships. Another study of 2164 women regarding inequity in
maternal health services in Bangladesh, showed a
The reports on the overall health status of women substantial difference between women according to
living in rural Bangladesh indicate that nearly 40% of socio-economic status when considering skilled birth
the rural population has basic access to health care and attendance, C-section as mode of birth delivery, and

receipt of postpartum care.31 surgical options such as C-section. Wealth, defined

by the National Demographic Health Survey, is based
The National Institute of Population Research and upon household assets and divided into three
Training (NIPORT) reported that 60% of Bangladeshi quintiles: poor quintile, middle quintile, and
women complained of complications related to wealthiest quintile.36 Only women in the upper wealth
pregnancy and childbirth (National Institute of quintile have access to caesarean (C-section) services
Population Research and Training. The large number in most regions. This leaves those in the poor and
of complications reported by women living in middle quintiles without access to C-sections when
Bangladesh and the rise of C-section deliveries, may indicated, and places them at high risk for mortality
be contributing to the consistent rise in the maternal and morbidities during delivery and in the postpartum
mortality rate.32 period.
The MDG5 proposes a decrease in maternal The cost of postpartum care following C-section
mortality ratio by increasing C-sections by the year has been studied in the context of linked postpartum
2015.33 However, because of the deep socio-economic visits with type of birth mode, with results
inequalities that exist within Bangladesh, This goal indicating an increase in postpartum visits by 7%
may be disproportionately target the wealthiest socio- and increase in total cost of postpartum care when
economic quintile, who are able to pay for private C-section is performed compared to normal or
hospital care where the majority of C-sections are assisted vaginal delivery modes. Cost analysis of a
performed. The poor and undereducated tend to be sample in Madagascar showed an that C-section was
much less affected.34 cost prohibitive and although reduced maternal
In Bangladesh, choice of C-section in Matlab, a mortality rate overall, it increased infant mortality
region with over 21% CSD in 2001, were more likely rate by 18%.37
to be wealthier women with higher education, with Studies from various developing countries have
history of high number of prenatal visits, who did not
also shown a substantial burden to families when C-
necessarily have a medical need and may lose value
section is considered from a cost perspective. For
in attempts to address the maternal mortality and
example, one study of 133 post-partum women living
morbidity rates.35 This relationship of increased C-
in Islamabad, Pakistan estimated the average monthly
section with prenatal care in Matlab may indicate an
household income for families was $149 US dollar
indirect emphasis of the prenatal programs in teaching
equivalents (10,000 rupees at the time of publication)
the benefits of C-section compared to normal vaginal
and the average cost of C-section was $161 US dollar
delivery by physicians and organizations that aim to
equivalents (10,868 rupees) compared to vaginal
fulfill the goals of improving maternal care by
delivery cost of $79 US dollars (5278 rupees).38 In
providing antenatal programs for women.
another study of 438 women living in Kathmandu, the
willingness of women to pay for C-section ($157 for
Cost Comparisons by Birth Mode
normal vaginal delivery and $171 for C-section pre-
Cost of care is another prohibitive factor, especially delivery and $71 NVD and $236 CS post-delivery)
in the rural areas where transportation to a healthcare compared with vaginal delivery was studied pre and
facility may be several hours by rickshaw or cost of post birth, with resulting increase in reports of
care at the hospital may exceed the familys yearly willingness to pay for C-section birth post delivery by
income of $590. Real solutions need to be explored women indicating a perceived increased value of C-
for these women to be able to set a standard of care section.39 This study may indicate a higher perception
that will be cost effective, culturally accepted, practical, of the value of C-section by the women immediately
efficient and effective. First, however, there remains a after birth.
need to explore the actual problems that exist in the
Cost is a major prohibitive factor in delivery options
postpartum period for women outside of nutritional
and postpartum care for women living in Bangladesh.
deficiencies which have been thoroughly explored,
If postpartum care can be disseminated within the
compare the effects of mode of birth delivery among
home environment or local district region, cost
cesarean section and vaginal birth delivery on QOL
effective programs may be established by reducing
for Bangladeshi women living in rural areas.
transportation costs of the patient and creating
The literature suggests that socio-economic factors preventive programs to reduce the risk of co-
also play an important role in determining access to morbidities.

CONCLUSION Mothers in Bangladesh. Journal of Hea lth

Population Nutrition. 2008; 26(3): 325-339.
Women living in Bangladesh are at high risk 11. Li, X.F., Fortney, J.A., Kotelchuck, M., et al. The
for maternal mortality and morbidity in the postpartum period: the key to maternal mortality.
postpartum period because of socio-economic barriers. International Journal of Gynecology & Obstetrics.
Malnourishment, anemia, poverty, lack of skilled birth 2006; 54(1): 1-10.
attendants, and limited prenatal and postpartum care 13. Lieu, TA, Wikler, C, Capra, AM, et al. Clinical
are some of the issues facing women living in rural Outcomes and Maternal Perceptions of an
Bangladesh.40 There remains a need for socio-economic Updated Model of Perinatal Care. Pediatrics,
relief and policy changes, specific to maternal health 1998, 102(6): 1437-1444.
in Bangladesh, to fully address maternal mortality and 14. Felicia Lester, Nerys Benf ield, et al. Global
morbidity rates. Womens Health in 2010: Facing the Challenges.
Journal of Womens Health. November 2010,
19(11): 2081-2089.
REFERENCES
15. Li, X.F., Fortney, J.A., Kotelchuck, M., et al. The
1. World Bank Report. Poverty Assessment for postpartum period: the key to maternal mortality.
Bangladesh: Creating Opportunities and International Journal of Gynecology & Obstetrics,
Bridging the East-West Divide: Bangladesh 1996, 54(1): 1-10.
Development Series No. 26. 16. Paul, B.K., Rumsey, D.J. Utilization of health
2. World Health Organization. World Health facilities and trained birth attendants for
Statistics. 2010; 59 http:/www.who.int/whosis/ childbirth in rural Bangladesh: an empirical
whostat/EN WHS10 Full.pdf. Accessed study. Sociology Scientific Medicine. 54: 1755-
September 30, 2011. 1765.
3. World Health Organization. Improving 17. Kalim, N, Anwar, I, Khan, et al. Postpartum
Maternal, Newborn, and Child Health in the Haemorrhage and Eclampsia : Differences in
South-East Asia Region: Focus on Bangladesh. Knowledge and Care-seeking Behaviour in Two
2010. Districts of Bangladesh. Journal of Health,
4. Gill, K, Pande, R, Malhotra, A. Women delivery Population, and Nutrition. 2009; 27(2): 156-169.
for development. The Lancet, 2007; 370: 1347- 18. NIPORT. Bangladesh demographic and health
1356. survey 1999-2000. 2001, National Institute of
5. Paul, B.K., Rumsey, D.J. Utilization of health Population Research and Training: Dhaka and
facilities and trained birth attendants for Calverton.
childbirth in rural Bangladesh: an empirical 19. Faruque, A.S.G., Ahmed, A.M.S., Ahmed, T, et
study. Sociology Scientific Medicine. 54: 1755-65. al. Nutrition: Basis for Healthy Children and
6. Hogan, MC, Foreman, KJ, Naghavi, M, et al. Mothers in Bangladesh. Journal of Health
Maternal mortality for 181 countries, 1980-2008: Population Nutrition. 2008; 26(3): 325-339.
a systematic analysis of progress towards 20. Christian, Parul. Maternal nutrition, health, and
Millennium Development Goal 5. The Lancet, survival. Nutrition Reviews.2002; 60(5): S59.
2008; 10(10): 1-15. 21. Seshadri, S. Prevalence of micronutrient
7. Koenig, MA, Jamil, K, Streatfield, P, et al. deficiency particularly of iron, zinc, and folic acid
Maternal Health and Care-Seeking Behavior in in pregnant women in South East Asia. Journal
Bangladesh: Findings from a National Survey, of Nutrition. 2001; 85(2), S87-S92.
International Family Planning Perspectives. 2007; 22. Bucher, H.C., Guyatt, G.H., Cook, R.J., et al. Effect
33(2): 75-82. of calcium supplementation on pregnancy-
8. Anwar, I, Sami, M., Akhtar, N., et al. Inequity in induced hypertension and preeclampsia. Journal
Maternal Health Care Services: Evidence from of American Medical Association.1996; 275: 1113-
Home-Based Skilled Birth-Attendant Programs 1117.
in Bangladesh. Bulletin of the World Health 24. Viteri, F. Iron endowment at birth: maternal iron
Organization. 2008; 86: 252-259. status and other influences. Nutrition Reviews,
9. Paul, B.K., Rumsey, D.J. Utilization of health 2011; 69S3- 69s16.
facilities and trained birth attendants for 23. Levine, R.J., Hauth, J.C., Curet, L.B. Trial of
childbirth in rural Bangladesh: an empirical calcium to prevent preeclampsia. New England
study. Sociology Scientific Medicine. 54: 1755- Journal of Medicine. 1997; 337: 69-76.
1765. 25. Lagiou, P., Mucci, L., Tamimi, R., et al.
10. Faruque, A.S.G., Ahmed, A.M. S., Ahmed, T., et Micronutrient intake during pregnancy in
al. Nutrition: Basis for Healthy Children and relation to birth size. European Journal of
Nutrition, 2005; 44(1), 52-59.

26. Islam, M. A., et al. Factors associated with http:/ www.un.org/millenniumgoals.

delivery complications in rural bangladesh. 34. Islam, M. A., Chowdhury, R. I., Chakraborty, N.,
European Journal of Contraception & et al. Factors associated with delivery
Reproductive Health Care. 2004; 9 (4): 203-203- complications in rural bangladesh. European
13. Journal of Contraception & Reproductive Health
27. World Health Organization (2010). Improving Care, 2004; 9 (4): 203-203-13.
Maternal, Newborn, and Child Health in the 35. Anwar, I, Sami, M., Akhtar, N., et al. Inequity in
South-East Asia Region: Focus on Bangladesh. Maternal Health Care Services: Evidence from
28. Sarker S, Islam Z, Hossain SAS, Saha NC, Routh Home-Based Skilled Birth-Attendant Programs
S. Baseline Assessment of In dicators for in Bangladesh. Bulletin of the World Health
Monitoring ESP Delivery in Rural Areas of Organization. 2008; 86: 252-259.
Bangladesh: Findings from a Cross-sectional 36. Ronsmans, C, Holtz, S, & Stanton, C.
study. 2001; SP112: 1-62. Socioeconomic differentials in caesarean rates in
29. Fronczak, N., Arifeen, S. E., Moran, A. C., et al. developing countries: a retrospective analysis.
Delivery practices of traditional birth attendants The Lancet. 2006;.368(9546): 1516-1523.
in dhaka slums, Bangladesh. Journal of Health, 37. Robitail, S., Gorde, S., Barrau, K., et al. [How
Population and Nutrition, 2007;25 (4), 479-479- much does a C-section cost in Madagascar? Socio-
87. economical aspects and C-section rate in
30. Thaddeus, S., Maine, D. Too far to walk: maternal Toamasina, Madagascar. Bulletin De La Socit
mortality in context. Social Science & De Pathologie Exotique. 2004; 97(4), 274-279.
Medicine.2002; 38(8): 1091-1110. 38. Khan, A., & Zaman, S. Costs of vaginal delivery
31. Anwar, I, Sami, M., Akhtar, N., et al. Inequity in and C-section at a tertiary level public hospital
Maternal Health Care Services: Evidence from in Islamabad, Pakistan. BMC Pregnancy And
Home-Based Skilled Birth-Attendant Programs Childbirth, 2010; 102.
in Bangladesh. Bulletin of the World Health 39. Gartoulla, P., Liabsuetrakul, T., & Pradhan, N.
Organization. 2008; 86: 252-259. Change in willingness to pay for normal delivery
32. Parkhurst, J., Rahman, S. Life saving or money and C-section during pregnancy and after
wasting? Perceptions of C-sections among users delivery in Kathmandu. Tropical Medicine and
of services in rural Bangladesh. Health Policy, International Health, 2010; 15(10):1227-1234.
2008; 80(3):392-401. 40. Pena, M., & Bacallao, J. Malnutrition and poverty.
33. United Nations Milennium Development Goals. Annuals Review Nutrition, 2002; 22: 241-53.
New York: United Nations; 2006. Retireved f rom:

Effect of Sensory-Specific Balance Training in Elderly
Manjiri Puranik1, Saraswati Iyer2, Archana Gore3, Lakshmi Prabha4, Poonam Khachane5, Amita Mehta6
1,5
MPT, 2Professor, 3,4Asst Professor, 6HOD & Professor, PT School and Center, Seth GSMC & KEMH,
Parel, Mumbai-400012
ABSTRACT
Background: Postural control depends upon the ability to extract peripheral sensory inputs,
integrating this information within the central nervous system (CNS), coordinate and execute an
appropriate motor response. Age related changes in the ability to adjust to alteration in sensory
information contribute to impaired postural stability. The purpose of this study was to investigate
the effect of sensory-specific balance training on balance in elderly.
Aims: To study the effect of sensory-specific balance training on the balance in elderly.
Settings and design: Prospective longitudinal comparative study carried out at tertiary care hospital,
Mumbai.
Materials and Methods: 60 healthy elders were randomly assigned balance training and fall
prevention education group. Sensory specific balance training was given for period of 4 weeks.
Participants were reassessed at end of 4 weeks. Outcome measures were modified: Clinical Test for
Sensory Interaction on Balance, Fullerton advanced balance score, activities specific balance confidence
scale and 1 RM.
Statistical analysis: Wilcoxson Signed rank test and Mann Whitney test were used to analyze the
difference between the balance scores within group and intergroup
Results: Balance improved significantly in all four conditions of mCTSIB scale following sensory
specific balance training(p<0.001) Improvements were seen in Fullerton Advanced Balance
score(p<0.001) and Activities Specific Balance Confidence Scale score(p<0.001) but there was no
improvement in 1 RM(p>0.001)
Conclusion: From the study it can be concluded that sensory-specific balance training can bring
about a significant improvement in balance without any change in the muscle strength.
Key words: Modified CTSIB, Healthy Elderly, Sensory Specific Balance Training.
INTRODUCTION is Modified Clinical Test of Sensory Interaction on

balance.1
Postural control depends on the ability to extract
peripheral system inputs, integrate this information AIM
within the CNS, coordinate and execute an appropriate
motor response. To study the effect of sensory-specific balance
training on the balance in elderly.
In addition to showing decline in function within
the specific sensory systems, research from many MATERIAL
laboratories has indicated that some older adults have
more difficulty than younger adults in maintaining Medium density foam (10cm)
steadiness; under conditions wherein sensory Vestibular ball
information for postural control is severely reduced. Measuring tape
Metronome (100 bpm)
One method used to evaluate the contribution of Stopwatch
various sensory inputs to postural control and the Stool
integrity of the integrative mechanisms within the CNS 6 high bench
34. Manjiri 15th sept 11 (168-172).pmd 168 10/16/2012, 2:41 PM

METHOD FINDINGS
Type of study: Prospective longitudinal Kolmogorov-Smirnov test (with Lilliefors

comparative study. correction) used for normality testing of data. The data
was not found to be normally distributed hence non
Sample size: 60 community dwelling individuals
parametric tests were used for data analysis.
above the age of 65 years.
Mann-Whitney test was used for intergroup
Inclusion criteria: Healthy adults of age >65 years. comparison.
Wilcoxon Signed Rank test was used for intragroup
Exclusion criteria: Any musculoskeletal condition comparison.
involving lower limbs, neurological disorders,
cardiovascular condition, systemic disorders,
DISCUSSION
vestibular conditions
The results indicate that the ability of older adults
Use of any type of assistive device.
to reintegrate sensory inputs is augmented following
Uncorrected visual conditions
sensory specific training and this effect is, not likely
Participants over 65 years of age and healthy, be attributable to an increase in lower extremity
voluteered .They were recruited from Physiotherapy strength or activity level.
OPD after screening for inclusion criteria Assessment
The significant improvement in all conditions of
consisted of Modified Clinical Test for sensory
Modified Clinical Test for Sensory Interaction on
Interaction on Balance1, Fullerton Advanced Balance
Balance, may be argued that enhanced signal arising
Scale2, Activities Specific Balance Confidence Scale3
at level of proprioceptive receptors may account for
and 1 RM4.
participants Table 1. Comparison of age, mCTSIB, FAB & ABC

between two groups
Variables Sensory specific Fall prevention Mann Whitney test applied
balance training education
Median IQR Median IQR U p-level Diff is
Fall prevention Balance training Age (yrs) 69.00 8.00 67.00 4.00 372.5 0.252 NS*
Pre-mCTSIB 72.82 26.02 74.40 25.00 415.0 0.605 NS*
Pre-FAB 9.00 7.00 8.50 10.00 430.5 0.773 NS*
Pre-ABC 67.34 20.44 52.68 22.19 360.0 0.183 NS*
Assessment Post-mCTSIB 104.48 16.10 75.84 27.90 72.0 2.292E-08 Sig#
Post-FAB 19.50 7.00 8.50 10.00 163.0 2.205E-05 Sig#
Post-ABC 69.69 19.25 51.87 25.19 253.5 0.004 Sig#
*NS- Not significant,# Sig- Significant

Baseline Post intervention Statistical analysis of the baseline variables of mCTSIB, FAB and ABC in SSBT and FPE
group using Mann-Whitney test showed no significant difference.
Statistical analysis of post intervention variables showed statistical significant difference,
higher in SSBT group than FPE group.
Sensory specific balance classes were held 3 times
per week for 1 hour each for a period of four weeks.
The exercise protocol followed the Fall Proof Program5 Table 2. Comparison of Pre & Post hip extensors &
which emphasizes static and dynamic balance exercise abductors and Knee extensors 1RM between two groups
Variables Sensory specific Fall prevention Mann Whitney test applied
with transition between different sensory conditions. balance training education
Median IQR Median IQR U p-level Diff is
The somatosensory system was stressed by giving Pre-Hip 5.00 1.00 4.00 1.00 361.5 0.191 NS*
balance activities on a firm surface with eyes closed. extensors (kg)
Pre-Hip 6.00 1.00 5.50 1.00 325.0 0.065 NS
Vestibular system stressed by giving balance activities abductors (kg)
on compliant surface with eyes .Visual system stressed Pre-Knee 7.00 0.50 6.50 1.00 348.5 0.133 NS
extensors (kg)
by giving balance activities on compliant surface with
Post-Hip 5.00 1.00 4.00 1.00 361.5 0.191 NS
visual fixation. Progression was done by reducing the extensors (kg)
base of support, by adding a secondary task. Post-Hip 6.00 1.00 5.50 1.00 318.0 0.051 NS
abductors (kg)
Post-Knee 7.00 0.50 6.50 1.00 348.5 0.133 NS
30 participants were assigned Fall Prevention extensors (kg)
Education group. They were assessed on first day and
*NS- Not Significant
intensive fall prevention education6 was given on one Statistical analysis of baseline and post intervention variables with Mann-Whitney test
showed no significant difference. higher in SSBT group than FPE group.
to one basis and reassessed after 4 weeks.

Table 3. Comparison of Pre & Post mCTSIB conditions Table 6. Comparison of Pre & Post-conditions in
between two groups Sensory specific balance training group
Variables Sensory specific Fall prevention Mann Whitney test Variables Sensory specific Wilcoxon Signed Rank Test applied
balance training education applied balance training
Median IQR Median IQR U p-level Diff is Median IQR Z p-level Difference is-
Pre-mCTSIB 30.00 0.00 30.00 7.80 376.0 0.274 NS Pre-mCTSIB 30.00 0.00
Condition 1 (sec)
Condition 1 (sec)
-2.371 0.018 Significant
Pre-mCTSIB 25.57 9.97 22.29 7.11 367.5 0.223 NS
Post-mCTSIB 30.00 0.00
Condition 2 (sec)
Condition 1 (sec)
Pre-mCTSIB 11.23 8.08 15.03 9.97 365.5 0.212 NS
Pre-mCTSIB 25.57 9.97
Condition 3 (sec)
Condition 2 (sec)
-3.823 1.316E-04 Significant
Pre-mCTSIB 5.20 3.87 7.23 5.03 342.5 0.112 *NS
Condition 4 (sec)
Condition 2 (sec)
Pre-mCTSIB 72.82 26.02 74.40 29.94 424.0 0.701 NS
Condition total (sec)
Condition 3 (sec)
Post-mCTSIB 30.0 0.00 30.00 7.99 255.0 3.940E-03 #Sig -4.703 2.561E-06 Significant
Condition 1 (sec)
Condition 3 (sec)
Post-mCTSIB 30.00 0.00 22.80 7.00 127.0 1.795E-06 Sig
Condition 2 (sec)
Condition 4 (sec)
-4.782 1.734E-06 Significant
Post-mCTSIB 27.60 7.99 14.11 10.90 74.0 2.716E-08 Sig
Condition 3 (sec)
Condition 4 (sec)
Post-mCTSIB 20.12 7.95 7.76 6.72 87.0 8.023E-08 Sig
Condition 4 (sec)
Post-mCTSIB 104.48 16.10 75.84 27.90 62.0 9.682E-09 Sig -4.782 1.734E-06 Significant
*NS- Not Significant, #Sig- Significant
Statistical analysis of the pre mCTSIB conditions shows no statistical significance. Statistical analysis Statistical analysis was done by Wilcoxon Signed Rank Test showed statistical
of post mCTSIB condition showed statistical significance in all condition higher in SSBT than FPE significance in the pre and post intervention mCTSIB conditions in sensory
group. specific balance training group.
Table 4. Comparison of mCTSIB, FAB & ABC in

Sensory specific balance training group Table 7. Comparison of mCTSIB, FAB & ABC in Fall
Variables Sensory specific Wilcoxon Signed Rank Test applied prevention education group
balance training Variables Sensory specific Wilcoxon Signed Rank Test applied
Median IQR Z p-level Difference is- balance training
Pre-mCTSIB 72.82 26.02 - 4.782 1.732E-06 Significant Median IQR Z p-level Difference is-
Post-mCTSIB 104.48 16.10 Pre-mCTSIB 74.40 25.00 -0.3352 0.7375 Not significant
Pre-FAB 9.00 7.00 -4.791 1.659E-06 Significant PostmCTSIB 75.84 27.90
Post-FAB 19.50 7.00 Pre-FAB 8.50 10.00 0.0000 1.0000 Not significant
Pre-ABC 67.34 20.44 -4.784 1.717E-06 Significant Post-FAB 8.50 10.00
Post-ABC 69.69 19.25 Pre-ABC 52.68 22.19 -3.1082 0.0019 Significant
Post-ABC 51.87 25.19
Statistical analysis done using Wilcoxon Signed Rank Test showed significant
difference in the pre and post intervention measures for mCTSIB, FAB & Statistical analysis done by Wilcoxon Signed Rank Test showed statistical
ABC in Sensory Specific Balance Training group. significance in pre and post ABC score in fall prevention education.
Statistical analysis showed no statistical significance in per and post mCTSIB
and FAB scores in fall prevention education group.
Table 5. Comparison of Pre & Post hip extensors &
Table 8. Comparison of Pre & Post hip extensors &
abductors and Knee extensors1RM in Sensory specific
abductors and Knee extensors 1RM in Fall prevention
balance training group
education group
Variables Sensory specific Wilcoxon Signed Rank Test applied
balance training Variables Fall prevention Wilcoxon Signed Rank Test applied
education group
Median IQR Z p-level Difference is-
Median IQR Z p-level Difference is-
Pre-Hip 5.00 1.00
extensors (kg) Pre-Hip 4.00 1.00
0.000 1.000 Not significant extensors (kg)
Post-Hip 5.00 1.00 0.000 1.0000 Not significant
extensors (kg) Post-Hip 4.00 1.00
extensors (kg)
Pre-Hip 6.00 1.00
abductors (kg) Pre-Hip 5.50 1.00
- 0.577 0.564 Not significant abductors (kg)
Post-Hip 6.00 1.00 - 0.577 1.0000 Not significant
abductors (kg) Post-Hip 5.50 1.00
abductors (kg)
Pre-Knee 7.00 0.50
extensors (kg) Pre-Knee 6.00 0.50
0.000 1.000 Not significant extensors (kg)
Post-Knee 7.00 0.50 0.000 1.0000 Not significant
extensors (kg) Post-Knee 6.00 0.50
extensors (kg)
Statistical analysis was done using Wilcoxon Signed Rank Test shows showed
no significant difference in pre and post intervention measurement for hip Statistical analysis done by Wilcoxon Signed Rank Test showed no significant
extensors & abductors and knee extensors 1RM in sensory specific balance difference in per and post hip abductors & extensors and knee extensors 1RM
training group. in fall prevention education group.

postural improvements.A study performed by An interaction among sensory systems also occurs
Westlake on Sensory-specific balance training on older at higher level in the central nervous system. For
adults-Effect on position, movement and velocity sense example, due to interaction of the visual and vestibular
at the ankle7, showed a short term improvement in inputs a person perceives visually detected object
velocity sense but no improvement in movement and motion as self motion. Straube and Brandt 12 found
position sense may be achieved following a balance that, patients with lesion in the primary visual cortex
exercise intervention. With only one of three (i.e. Homonymous hemianopsia) or the vestibular
proprioceptive measures indicating improvement with cortex (e.g. Tumours) did not exhibit object motion
training, it was difficult to ascribe training effect at induced body tilt. Thus, direct visual and vestibular
peripheral level. But, without sufficient physiological sensory interactions appear to occur within the cerebral
evidence from the receptor isolation sstechniques, such cortex.
as microneurography, the possibility of an increase in
the discharge of these receptors cannot be discounted. Outputs from the vestibular nuclei and the cerebral
cortex converge in the cerebellum13. The vermal cortex
A probable explanation is an increase during the of the anterior lobe of the cerebellum is intimately
training intervention, in attention allocated to sensory related to the neuronal structure involved in the
cues (explicit learning), which eventually led to a less postural control. patient with deficits in the anterior
attentionally demanding recovery of postural stability lobe of the cerebellum have demonstrated deficits in
(implicit learning)8 the postural control. Nashner and Grimm
demonstrated that cerebellar patients lost their ability
Several authors9,10 have proposed impaired balance to adapt and control postural muscle response gains.
in elderly lies in age related changes in central Due to the fact that cerebellum receives input from
integration mechanisms. During exercise intervention both the motor cortex and spinal cord and that postural
in present study sensory inputs were manipulated by control deficits are associated with cerebellar lesions,
altering the support surface or by reducing the sensory the cerebellum could play an important role in motor
redundancy of visual and vestibular system; these learning (adaptation) and that sensory interaction
manipulation force the participants to effectively necessary for postural control.
reweigh remaining inputs within the CNS.
In current study, it was determined that older adults
Evidence of similarly enhanced central integration could significantly improve their postural stability
following sensory training has been found in studies under complex sensory training conditions.
demonstrating improved stability during the
manipulation of somatosensory, vestibular or visual This result suggests that the integrative ability of
systems or all these by use of sensory organization test. the higher brain center was enhanced. Other studies
have demonstrated that higher brain centers retain the
The neurological basis of intersensory interaction, plasticity at the molecular level and that practice can
for postural control is not fully understood. An induce the modulation of neuronal activity in the
interaction among the visual, vestibular and cerebellum.14,15
somatosensory system could occur wherever
convergence of the sensory inputs may be found. In For this study, it is possible that the older adults
turn, sensory convergence is found at many levels of were able to optimize intersensory interaction within
CNS, including the vestibular nuclei, the thalamus, the the higher brain centers, where in turn increased the
cerebellum and the cerebrum. sensory convergence occurred followed the sensory
balance training. Thus, the older adults were able to
The vestibular nuclei in the brainstem receive reweigh their sensory inputs and to select reliable
peripheral sensory information from neck sensory information for postural control under
proprioceptive afferents and the labyrinth. Visual and changing sensory conditions. Since, the cerebellum
vestibular interaction also occurs at vestibular nuclei.11 receives both the ascending inputs from the spinal cord
This effect has been correlated with the activity of the and descending inputs from the cerebrum, it is a likely
neck and the leg extensor muscles. Thus, sensory candidate as the control center for this improvement.
convergence occurs in the vestibular nuclei and
intersensory interaction result in the modulation of the The functional significance of the results of this
neuron activity and subsequent adjustment of the study is evident because of improvement in the
muscle activities related to postural control. Fullerton Advanced Balance Scale scores in the
intergroup comparison between the balance training

group and the Fall Prevention Education group. These 4. Brzycki, MStrength testing - Predicting a one-rep
results demonstrate the responsiveness to the training. max from a reps-to-fatigue. Journal of Physical
Education, Recreation and Dance.1993; 64 (1),
Improvement in postural stability and balance lead 88-90.
to increase in balance confidence post intervention in 5. Rose DJ. Fall Proof! A Comprehensive Balance
the exercise group. The decrease in balance confidence and Mobility Training for Elderly. Multisensory
in the education group may be explained by discussion training Windor, Ontario, Canada: Human
centered on effective means of reducing fall risk. An Kinetics; 2003.
increase awareness of the topic may have underscored 6. www.nari.org: Tips for Healthy ageing, Avoiding
the apprehension experienced during functional falls.
balance task until changes be implemented. Two recent 7. Westlake et al, Sensory-specific balance training
studies examining the effectiveness of fall prevention in older adults- Effect on Position, Movement and
education reported similar finding, with almost half Velocity sense at ankle. Physical Therapy Journal,
May 2007; vol 87, no. 5.
of the participants demonstrating increase in fear of
8. Orrell AJ, Eves. Implicit Motor Learning of a
falling17 and 28% increase in one or more falls18 at
Balance Task. Gait and Posture. 2006; 9-16.
follow up.
9. Fernando Ribeiro. aging effect on joint
While the study has demonstrated the proprioception:the role of physical activity in
improvement in balance following sensory specific propriception preservation.Eur Rev Aging Phy
Act. 2007; 4; 71-76.
balance training in healthy elderly, further research
10. SerrC,Borel L.Synergistic interaction and fictional
may include a group of elderly with declining balance
working range of the visual and vestibular
to assess the effect of training and also the carry over
systems in postural control; neuronal correlates
effect of the training in elderly. Prog Brain Res.1988; 76:196-203.
11. Strabe and Brandt. Importance of the visual and
CONCLUSION vestibular cortex for self motion perception in
man (circular vector). Hum Neuro Bio1987; 6
From the study it can be concluded that sensory-
211-218.
specific balance training can bring about a significant 12. Pomperiano O. Experimental Central Nervous
improvement in balance without any change in the System lesions and posture. Black FO eds.
muscle strength. Vestibular and visual control on posture and
locomotor equilibrium. Basel:Karger. 1985; 218-
REFERENCES 231.
13. Black IB, Adler JE et al. Neurotransmitter
1. Anne Shumway-Cook, Majorie Woolacott. Plasticity at the molecular level. Science.1984; 225:
Postural Control.In Shumway CC .Motor 1266-1270.
Control-Translating research into clinical practice. 14. Glibert PFC et al .Purkinje cell activity during
,Williams and Wikins, 2007: 157-257. motor learning. Brain Res.1977; 128: 309-328.
2. Rose DJ. Fall Proof! A Comprehensive Balance 15. Rucker D, Rowe BH,,et al. Education Intervention
and Mobility Training for Elderly.Windor, to reduce fall and fear of falling in patients after
Ontario, Canada: Human Kinetics; 2003. fragility fracture: results of a controlled pilot
3. Myers AM, Fletcher PC. Descriptive and study. Prev Med 2006; 42: 316-319.
evaluative properties of the Activities Specific 16. Chang JT, Morton SC, et al. Intervention for
Balance Confidence Scale J. Gerentology. Series prevention of falls in older adults: systemic
A: Bio.Sci. and Med.Sci,1998; Vol 53, Issue 4, review and meta-analysis of randomized clinical
M287-M294. trails. BMJ; 2004; 328: 680.

A Comparitive Study of Early Intervention Programme vs
Home Intervention Programme in Preterm Infants
Manpreet Mann1, C Janarthanan2, Kusum Mahajan3, Jagmohan Singh4

1
Pediatrics , Associate Professor, Gian Sagar College of Physiotherapy, Ram Nagar, Rajpura, Distt Patiala. 3Head of the
2
Department (Pediatrics), Gian Sagar Medical College & Hospital, Ram Nagar, Rajpura, Distt Patiala. 4Principal &
Professor, Gian Sagar College of Physiotherapy, Ram Nagar, Rajpura, Distt Patiala.
ABSTRACT
Background: Prematurity as defined by the World Health Organization (WHO) is a baby born before
37 weeks of gestation counting from the first day of the last menstrual period. Infants born at early
gestational ages (<32 weeks), when compared with later ages (32-36) weeks scored lower on tests of
gross motor development. So mild abnormalities detected in first few months would improve with
early intervention programme.
Methods: The preterm infants born before 37 gestational weeks and having APGAR score above 7
(after 5 minutes) were randomly selected and divided into two groups (N=15). Early developmental
intervention programme was given to one group and home intervention programme was given to
other group (control group). The outcome measure was Gross Motor Function Measure.
Results: According to the need of the study unpaired t-test was applied and significant improvement
was seen.
Conclusion: Greater improvement in motor performance of preterm infants who received the early
intervention programme when compared with home intervention was revealed.
Keywords: Preterm, Motor Development, Gross Motor Function Measure, Motor Delay, Early intervention,
Home intervention
INTRODUCTION 21%21. It has been estimated that 9.6% of all births

were preterm in 2005, which translates to about 12.9
Prematurity as defined by the World Health million birth definable as preterm. The regional toll
Organisation (WHO) is a baby born before 37 weeks of of preterm birth is particularly heavy for Africa and
gestation counting from the first day of the last Asia where over 85% all preterm birth occurs19.
menstrual period. There are three main classes: babies
born before 37 weeks are premature babies, babies born Preterm birth has been considered to be one of
between 35 and 37 weeks are moderately premature, the risk factors for developmental disabilities16,18.The
babies born between 24 and 28 weeks are very preterm infants has poor quality postural stability
premature22. Preterm infants are at greater risk of and mobility which may be related to differences in
reduced rate of physical growth, language development experiences such as longer hospital stays,
delay, balance and motor co-ordination deficits5. neurological impairment associated with medical
complications or immobility due to constraints of
Between 3% and 4% of babies are born preterm. medical technology7. The motor delay in infants has
Almost all of them weigh less than 2500 gram and capitativated the interest of researcher. Study related
therefore, also known as low birth weight babies. to physiotherapy is gaining great importance in
They provide the great majority of work in neonatal recent years to prevent motor delay and deciding
units and it is in this group that 60% of all neonatal early interventions for infants. Therefore,
deaths occur 17. Among the developing countries development programs for this preterm born infant
India has a very high evidence of preterm labor i.e. population are thought to be of value to compensate
23.3% and the rate of preterm birth is approximately for the disadvantages of their preterm birth.
35. Manpreet 27th june 11 (173-177).pmd 173 10/16/2012, 2:41 PM

Although the cause of most spontaneous preterm developed to emphasize the elements of the
birth is not identified, some predisposing factors are programs23.
known. They include: Chronic Preeclampsia (High B.P
pregnancy), chronic medical illness (Heart or Kidney), The aim and objective of the study is to evaluate
Infections (group B streptococcus, urinary tract the efficacy of early developmental intervention
infection, vaginal infection, infections of fetal / programme over the home intervention programme
placental tissue), drug use (cocaine) and alcohol, in preterm infants.
abnormal structure of uterus, previous preterm birth
maternal age below 18 years and multiple pregnancy20. METHODS
Being born prematurely places the infant at a higher
Study design: A randomized controlled trial was
risk of complications that are specific to a preterm
conducted to evaluate effect of early intervention
infant.The shorter the length of gestation the greater
programme and home intervention programme in
the risk for complications1.
preterm infants.
The preterm infants central nervous system is not Study settings: The study was performed at
fully developed at birth and the acquisition of motor outpatient department of Physiotherapy, inpatient
control and skill follows upon a progressive change in department and outpatient department of Pediatrics
the nervous system. Nerve fibres grow new at Gian Sagar Medical College and Hospital, Ram
connections between the nerve cells and Nagar, Banur
neurotransmitters become operative, brain growth is
characterized by changes in synaptic connections Procedure: Ethical approval for this study was
apparently depending upon stimulation and use 10. obtained from Institution Ethics Committee, Gian
Sagar Medical College and Hospital, Ram Nagar,
Early intervention is a term commonly used to Rajpura, Distt. Patiala. 30 preterm infants were
encompass a system of services delivered to children selected for the study. The inclusion criteria of this
with, or at risk for, developmental delays in the early study was baby born before 37 weeks gestation,
stage of life. These services include physical, APGAR score above 7, birth reflexes normal and no
occupational, psychological and speech therapy, post natal, peri natal and anti natal trauma. The
family support, counseling and education. Benefits exclusion criteria of the study included those subjects
of early intervention have been repeatedly having any congenital abnormality, twins, triplets and
demonstrated through quality research studies. Early child undergone any surgery. Subjects selected from
intervention programs are designed to enhance the pre assessment form were then allocated in to two
developmental competence of participants and to groups (N =15 in each group). All subjects care takers
prevent or minimize developmental delays. Children read and signed an informed consent form for
targeted for early intervention may either include participation in the study.
environmentally or biologically vulnerable children,
or those with established developmental deficits. Interventions: A developmental physiotherapy
There is growing concensus based on the best programme was specially selected and modified for
available evidence that early interventions can exert both the groups of preterm infants in this study.
moderate positive effects2. The protocol was once a day, thrice a week, 30-40
minutes per session for 4 months. To maintain the
Physiotherapists have several choices in consistency of intervention provided for each
providing developmental intervention for preterm infant, the number of activities per month and aims
born infants. It has been shown that appropriate of activities in each month were the same for each
activities during early period of life may play intervention infant at each specific age. Subjects in
important role in muscle fibre differentiation and group A was given with early intervention
subsequent hypertrophy as well as being effective programmme. Subjects in group B undergone home
in promoting the infants further development intervention programme.
during the first year of life9.
Outcome measure: The outcome measure was
Home programs include intervention which is Gross Motor Function Measure. The GMFM is a clinical
being taught to the parents for the benefit of their tool to evaluate change in gross motor function in
premature infants. Home programs and parent children. The motor skills in GMFM are typical of
education have been integrated into developmental normal developmental milestone. The assessment for
follow up programs. Manual for parents have been both the groups was done on monthly basis after

giving the interventions. The score sheet for each weeks, with 37.2% females and 58.9% males. The data
subject was maintained on regularly. obtained was tabulated and statistically analyzed. All
data was expressed as mean standard deviation.
Since the home intervention programme consisted Standard deviation was useful in comparing variability
of a program of home based activities, demonstrations of two series and to find out which series was more
and practice session were provided to infants primary consistent, more stable and more variable. Depending
care-givers to ensure the correct performance at home. upon the nature of study, size of sample and nature of
The first intervention was provided after the discharge hypothesis unpaired t- test was applied.
from hospital. Subsequent interventions were
provided at one, two, three and four months age. Prior
to presenting the new home programme to the care-
givers, evaluation of the previous months home
programme was being done.
Early intervention programme (Group A)

0-1 Month:- To make infant enjoy various position.
(Instruction in the use of variety of
positions like prone lying and side lying
for playing and sleeping.
1-2 Month :- To promote eye following to strengthen
Fig. 1. Comparison of mean gross motor function measure score
the neck muscles. (With the childs head after 3 months.
over the edge present him with
interesting visual and auditory stimuli, The figure is showing the difference between gross
slightly above him and also in front of motor function measure of group A (early intervention
non preferred side). group) and group B (home intervention group). The
Carrying in supported sitting position mean score of group A is 14.33 and for group B is 12.43.
over the therapist arm. The combined standard deviation and standard error
is 1.018 and 0.356 respectively. From these values t
2-3 Month :- Bring the shoulder of infant toward the calculated is 5.27 which is more than t tabulated.
spine-this provokes him to head raise.
(If the child persists in abnormal turning DISCUSSION
provokes him to head raise to one side,
then extend the shoulder girdle on the In this study, effect of intervention programme in
opposite side to provoke head turn and preterm infants was seen. The gestational age, birth
rise to that side). weight showed no significant differences between the
two groups. The mean birth weight of subjects in early
Weight bearing on forearm will also
developmental intervention group (2046.6 g) was little
help the childs head control. (Give
higher than the home intervention group (1890.625 g).
adequate support the child chest to
Other factors like triplets or more, any congenital
prevent him hunching his shoulder).
abnormality (cardiac or orthopedic) and APGAR
Home intervention programme (Group B) below 5 were excluded from the study. In short, early
intervention group and home intervention group were
0-1 Month :- To make infant enjoy various position. comparable.
(Instruction in the use of a variety of
positions for playing and sleeping). In our study the improvement in the motor
development of early intervention group was better
1-2 Month :- Assisted kicking
than home intervention group indicating the effect of
2-3 Month :- Place wedge on a table so that child can motor development programme.
see someone face when he looks up to
Early intervention in premature infants can lower
promote neck extensors.
the risk of motor delay: As a result the more immature
the brain, the greater the plasticity15. From the first day
RESULTS
of life, children begin using their bodies to learn about
The mean gestational age of subjects was 33.25 the world around them. It has been suggested that

sensory and motor experiences are the basis for all which shows both benefits and limitations of the
intellectual functioning for approximately the first 2 interventions. This study proves the benefit of early
years of life4,6. As children continue to mature, their developmental intervention in preterm infants to
reliance on physical interactions with people and facilitate motor development. Early interventions can
objects remains strong11. Motor skills are an essential prevent motor delays. This protocol can be used in low
component of development for all children. birth weight or extremely low birth weight infants. It
can be used in cerebral palsy, downs syndrome or any
Early intervention plays a significant role in neuromuscular disorder which leads to motor delay.
achieving milestone in preterm infants according to The protocol should be followed as compulsory follow
their chronological age. It helps in enhancing childs up so as to get adequate benefit of the intervention.
motor skills. Early intervention also helps in
preventing secondary problems and further
CONCLUSION
developmental delay which may otherwise result in
difficulties in feeding, inappropriate movement Effectiveness of early intervention programme and
patterns and interfering with normal development and home intervention programme was examined in
deformities. The present study therefore supports preterm infants using a randomised controlled trial.
other reports of effectiveness of intervention during Greater improvement in motor performance of
the early life of infants born preterm3,8. preterm infants who received the early intervention
programme when compared with home intervention
The beneficial effect of intervention program when was revealed. These are helpful in strengthening the
offered to a similar population of preterm born infants health of baby and also promoting the development
was also proved 12 . Another study stated the of high risk infant. Thus, the follow up early
importance of physical therapy treatment in preterm intervention programme was found to be useful in
infants6. These studies significantly support our study. promoting motor performance of pre term infants
The monthly assessment is done by Gross Motor during the early stage of life.
Function Measure. Assessment is an ongoing
procedure which identifies the childs unique needs REFERENCES
and needs related to the development of the child and
1. Allen MC (2008) Neurodevelopmental outcomes
nature extent of early intervention services that are of preterm infants. Current Opinion in
needed by the child and the childs family14. Neurology, 21 (2); 123-128.
2. Annette Majnemer (1998) Benefits of early
In infants and young children, motor development
intervention for children with developmental
and development of cognition, language, behavior and
disabilities. Seminars in Pediatric Neurology, 5(1);
emotion supplement each other and are closely related.
62-69. References and further reading may be
Therefore early rehabilitation of preterm has changed available for this article. To view references and
from the treatment of individual system to a wide further reading you must purchase this article.
range of plans, all round guidance. Regular follow up 3. Barrera ME, Cunningham CE and Rosenbaum PL
can discover beneficial results. (1986) Low birth weight and home intervention
strategies: preterm infants. Journal of
Limitations: The sample size of the study is small.
Development and Behaviour Pediatric, 7(6);
The subjects were selected as babies born before 37 361-366.
weeks of gestation. The further sub classification of 4. Bracewell M and Marlow N (2002) Patterns of
the subjects would have been done into moderate motor disability in very preterm children. Mental
preterm and extremely preterm because there is lot of retardation and developmental disabilities
difference between infant born at 35 weeks gestation research reviews, 8 (4); 241-248.
and infant born at 27 weeks gestation. More over there 5. Campbell SK, Vanderlinder DW and Palisano RJ
was certain practical difficulties during giving (2000) Physical therapy for children. WB saunders
interventions to the child like uncooperation etc. And company; Philadelphia.
due to limited resources sophisticated measures cannot 6. Cameron EC, Maehle V and Reid J (2005) The
be used for detection of motor development. effect of early physical therapy intervention for
very preterm, very low birth weight infants: a
Implication: The study can be implicated in term randomized controlled trial. Pediatric Physical
infants also where there is any chance of motor delay. Therapy, 17(2); 107-119.
Although there are several researches being done 7. Case-Smith J (1993) Postural and fine motor

control in pre term infants in the first six months. 16. Morgan AM, Koch V and Lee V (1988) Neonatal
Physical and Occupational Therapy in Pediatrics, neurobehavioral examination. Physical
13; 1-17. Therapy, 68 (1); 1352-1358
8. Chiarello LA and Palisano RJ (1998) Investigation 17. Peter GB Johnston, Kirstie Flood and Karen
of the effects of a model of physical therapy on Spinks (2003) The new born child, 2nd Edition,
mother child interactions and the motor behavior Elsevier; London.
of children with motor delay. Physical Therapy, 18. Piper MC et al (1986) Early physical therapy effect
78 (2); 180-194. on the high risk infant: a randomized controlled
9. Cole JH (1988) The evaluation of an intervention trial. Journal of Pediatric, 78 (2); 216-224.
programme of sensory motor facilitation for very 19. Ruiz MP, Fever JA and Hakanson DO (1981) Early
preterm, very low birth weight infants. Phd development of infants of birth weight less than
Thesis, The University of Queensland. 1000 grams with reference to mechanical
10. Girarda N, Confort-Gouny S, Schneider J, ventilation in new born period. Journal of
Barberet M, Chapon F, Viola A, Pineau S, Combaz Pediatric, 68 (1); 330-335.
X, Cozzone P (2007) MRI of brain maturation. 20. Stacy B, Daniel W, Lale S, Ana PB, Maria M,
Journal of Neuroradiology, 34(1); 290-310. Jennifer HR, Craig R, Ram Kumar M and Paul
11. Hemgren E and Persson K (2002) Motor FA (2010) The world wide incidence of preterm
performance and behavior in preterm and full birth : A systematic review of maternal mortality
term infant 3 year old children. Child Health and morbidity. Bull World Health Organistaion,
Development, 28(3); 219-226. 88(1); 31-38.
12. Lekskulchai R and J Cole (2001) Effect of a 21. Steer P (2005) The epidemiology of preterm
developmental program on motor performance labour. British Journal of Obstetrics &
in infants born preterm. Australian Journal of Gynaecology, 112 (1); 3-10.
Physiotherapy, 47 (1); 169-176. 22. Singh U, Singh N, Shikha S (2007) A perspective
13. Mathew TJ and Macdorman MF (2006) Infant analysis of etiology and outcome of preterm labor.
mortality statistics from the 2003 period linked The Journal of Obstetrics and Gynaecology of
birth/infant death data set. National vital India, 57(1); 48-52.
statistical reports, 54 (16); 25-30. 23. World health organization motor development
14. Milanicomparetti AM and Gidoni EA (1967) study (2006) Windows of achievement for six
Routine developmental examination in normal gross motor development milestones. Acta
and retarded children. Development Medicine Paediatrica Supplement, 450(1); 86-95.
and Child Neurology, 9( 2); 631-638. 24. World Health Organization (1993) Promoting the
15. Mohamed EL-Dib, Massaro A, Penny G & Hany development of young children with cerebral
A (2011) Neurodevelopmental assessment of the palsy: A guide for mid-level rehabilitation
new born: An opportunity for prediction of workers. Geneva: WHO.
outcome. Brain and Development, 33 (2); 95-105.

A Study to Compare the Effectiveness of Conventional

Treatment Versus Temporomandibular Joint Mobilization
in Patients with Temporomandibular Joint Disorders
Jay Sata
Master of Physiotherapy (Sports),Lecturer, K.K Sheth Physiotherapy College,Rajkot-7
ABSTRACT
Background: Temporomandibular disorders (TMDs) refers to a group of disorders affecting the

temporomandibular joint (TMJ), masticator muscles and the associated structures. These disorders
share the symptoms of pain and limited mouth opening due to oral sub mucosal fibrosis (OSMF). So
in each group taken both type of patiens,10 patients having TMJ pain and 10 patients having OSMF.
Patient having TMJ pain given conventional therapy in form of Ultrasound and isometric exercises
and patients having OSMF given Ultrasound and stretching exercises.
Mobilizations are indicated when the assessment has illuminated any of the following: pain,
progressive limitations of functional mobility, post arthroscopic TMJ surgery, reversible joint hypo
mobility, or muscle guarding or spasm.
Objectives: To study the effects of a TMJ mobilization programme in relieving pain and on improving
maximal mouth opening in patients with TM disorders.
Methods: Study included 40 patients with temporomandibular disorders between age group 20-40
years. The subjects were randomly divided into 2 groups: Group - A and Group - B. They were
treated for 3 weeks, 6 days a week once daily. Pain was assessed by Visual Analogue Scale and
maximal mouth opening was measured as an objective outcome with the special scale.
Results: Results showed significant improvement in VAS and in maximal mouth opening in both
groups. Comparison of Group A and Group B was done with Wilcoxon Rank sum test (Mann Whitney
U test) and unpaired t-test, Group B showed significant improvement in VAS (P=0.0047) and in
maximal mouth opening (P=0.0383)
Conclusion: TMJ mobilization programme along with conventional physical therapy intervention is
more effective in relieving pain and improving maximal mouth opening than conventional physical
therapy alone in patients with temporomandibular disorders.
Key words: TMJ mobilization, OSMF,TMJ Ankylosis
INTRODUCTION The three cardinal symptoms of TMJ disorders

are: facial pain, restricted jaw function and joint noise6,7.
Temporomandibular disorders (TMD), or Simple treatment, involving self-care practices,
temporomandibular joint syndrome, is the most rehabilitation aimed at eliminating muscle spasms, and
common cause of facial pain after toothache. In the restoring correct coordination, is all that is required.
past, many physicians called this condition TMJ Non-steroidal anti-inflammatory analgesics (NSAIDs)
syndrome1. should be used on a short-term, regular basis and not
Highest incidence is among young adults 1 , on an as needed basis1.
Furthermore, unlike similar diseases of other joints, The treatment of chronic TMD is difficult
which also have a greater female predilection but occur and there are various surgical treatment options
post-menopausal2, a large proportion of women with available depending the course of the disease like
TMDs are between twenty and forty years of age1,3,4. Arthroscopic surgery and Open surgery which include
The reasons for this marked sexual dimorphism and Hemi or Total plastic replacement (arthroplasty), disk
age distribution remain unclear5. repositioning and placation, and Myrhaug technique1.
36 Jay sata 23rd june 2011 (178-184).pmd 178 10/16/2012, 2:41 PM

ORAL SUBMUCOSAL FIBROSIS The Use of Manual Therapy as a Treatment

Technique: Mobilizations are indicated when the
Oral sub mucous fibrosis (OSMF) is a chronic assessment has illuminated any of the following:
debilitating disease of the oral cavity characterized by pain, progressive limitations of functional mobility,
inflammation and progressive fibrosis of the sub post arthroscopic TMJ surgery, reversible joint
mucosal tissues. OSMF results in marked rigidity and hypomobility, or muscle guarding or spasm. Shin
an eventual inability to open the mouth8,9. The buccal BC et al (2007) investigated the effects of combining
mucosa is the most commonly involved site, but any manual therapy and acupuncture on the pain and
part of the oral cavity can be involved, even the maximal mouth opening (MMO), which were
pharynx10. associated with temporomandibular joint
Symptoms of oral sub mucous fibrosis include the dysfunction.
following8 Grades I and II are primarily used for treating joints
limited by pain. The oscillations may have an
Progressive inability to open the mouth (trismus)
inhibitory effect on the perception of painful stimuli
due to oral fibrosis and scarring
by repetitively stimulating mechanoreceptors that
Oral pain block nociceptive pathways at the spinal cord or
brain stem levels. These nonstretch motions help
Dryness of the mouth move synovial fluid to improve nutrition to the
cartilage.
The treatment of patients with OSMF at a very
early stage, cessation of the habit is sufficient. Most Grades III and IV are primarily used as stretching
patients with OSMF present with moderate-to-severe maneuvers.
disease, Which is irreversible. Medical treatment is
symptomatic and predominantly aimed at improving MATERIAL AND METHODS
mouth movements10. Treatment strategies include
steroids, placental extracts11,12& hyaluronidase13. STUDY DESIGN
Surgical modalities that have been used include An interventional study
simple excision of the fibrous bands, split-thickness
skin grafting following bilateral temporalis myotomy STUDY SETTING
or coronoidectomy14, nasolabial flaps and lingual
pedicle flaps15. This study was conducted in the Institute where I
am working. All the patients were referred from
Physical therapy 1: The main goal of physical orthopedic hospitals and dental hospitals.
therapy is to stabilize the joint and restore its mobility,
strength, endurance, and function. SAMPLE DESIGN:
Stretching exercises: Physical therapy using Simple random sampling
muscle-stretching exercises for the mouth may be
helpful in preventing further limitation of mouth
movements. This is often combined with medical STUDY DURATION
and surgical therapy16. The patients were treated in physiotherapy
Ultrasonic treatment: ultrasonic waves produce department, daily (6days / week) for a period of 3
tissue heating at a deeper level than moist heat.To weeks, one session daily. The patients also performed
be effective, ultrasonic treatment should be done the exercise programmes at home.
every other day, using about 1 watt/cm2 for
approximately 10 minutes over the affected muscles SAMPLE SIZE
and joints.
The sample size of 40 patients was divided in to
Rationale and Indications for Use of Isometric two groups.
Exercise:
Group A: 20 patients. (20 patients further divided
To prevent or minimize muscle atrophy. into two subgroups of 10 patients)
To develop postural or joint stability. Group B: 20 patients. (20 patients further divided
into two subgroups of 10 patients)
To develop static muscle strength at particular
points in the ROM

INCLUSION CRITERIA: restricted mouth opening due to OSMF and

assessment which included chief complaint, history
Pain in TMJ etc & grades of mobilization.
Patients diagnosed as oral sub mucous fibrosis by
qualified dental surgeon or ENT specialist (stage CLINICAL INTERVENTION:
3)
Study participants were requested to continue
Age: 20-40 years normal activities and avoid other forms of treatment
for the duration of the study, apart from routine
Sex : both sex physician management.
Patients who are able to comprehend command GROUP A - Control group
Patients who are willing to participate in the study Patients were given Conventional therapy.
EXCLUSION CRITERIA: Total 20 patients in this group.
Fracture around TMJ 10 patients of TMJ pain given Ultrasound and
isometric exercises.
Any surgical procedure around TMJ
10 patients having OSMF given Ultrasound and
Dislocation or sublaxation of TMJ stretching exercises.
Any neurological disorder. Group B Experimental Group:
Malignancy or referred pain of cervical origin Patients were given mobilization along with
Conventional therapy.
MATERIALS USED IN THE STUDY
Total 20 patients in this group, 10 patients having
Consent form TMJ pain and 10 patients having OSMF.
VAS Scale 10 patients having TMJ pain given Maitland
mobilization and conventional therapy in form of
Millimeter Ruler
Ultrasound and isometric exercises.
Tongue blades
10 patients having OSMF given Maitland
Data collection sheet mobilization and conventional therapy in form Of
Ultrasound and stretching exercises.
Coupling gel and spirit
The treatment for each group was continued for 3
Cotton swabs weeks. Clinical examination were done with the
exactly same protocols after the treatment period i.e.
Treatment couch at the end of 3 weeks to measure VAS for TMJ pain
Paper, Pen patients and MMO in OSMF patients in both control
and experimental group.
Canon Power Shot A470 Digital Camera.
Treatment Protocol for Osmf Patients
INSTRUMENTS ULTRASOUND19: Mode: Pulsed, Frequency: 3 MHz,
Intensity: 0.5 Watt/ cm 2, Duration: 3-5 minutes/
Mouth opening device
session. The radiated area was 5 cm2 over the affected
Ultrasound Machine part of TMJ. Use of mouth opening device to provide
stretch during application of US.
METHODOLOGY
STRETCHING EXERCISES
ASSESSMENT
1) With the use of mouth opening device
Pre participation evaluation form consisted of
VAS17 for patients having TMJ pain and MAXIMAL Patients position: supine. Mouth opening device
MOUTH OPENING 18 (MMO) for patients having was placed between upper and lower teeth if there is
unilateral involvement and between incisors in

bilateral involvement and gradually open the mouth 10 times for each movement.
using lever of device .Held for 20 seconds.4-5
repetitions per session. Active mouth opening exercise MAITLAND MOBILIZATION
performed in between the stretch.
For group B along with conventional treatment
2) Active passive stretching Maitland mobilization given.
Patients Position: supine or sitting 1) Caudal glide:
The patient is instructed to actively open the mouth Patients position: supine or sitting
as wide as possible within the pain free limit, as slowly
as she/he can 2-3 times. The opening position should Therapists position: stands at patients side. Hand
be held for 5 seconds followed by relaxation in the rest and forearm are placed around patients head, Fixating
position for 5 seconds. head against the table. With the thumb in the mouth
over the left inferior molars and with the fingers
In passive stretch patient is instructed to actively outside around the patients jaw.
open the mouth. Then finger pressure is applied by
therapist to the maxillary and mandibular dentitions Movement while maintaining the forearm in a
with use of thumb and index finger. straight line, apply traction caudally.
Stretching exercises should be performed at home 2) Ventral glide :

using tongue blades for 5-10 minutes 3-4 repetitions 4
times in a day. The therapists hand placements are same as above.
The therapists hand translates the mandible

anteriorly after giving distraction.
It can be give extra orally by applying the pressure

by using the pulp of the thumbs put posterior to the
head of the mandible and applying pressure anteriorly
3) Medial- Lateral glide :
Patients position: supine or sitting
Therapist: stands at patients side. Hand and

forearm are placed around patients head, Fixating
head against the table. With the thumb in the mouth
on medial aspect of body of mandible near the right
inferior molars, with the fingers wrapped around jaw.
Movement: with the thumb force the mandible

laterally, simulataneously there is medial glide of
Fig. 1. Treatment Ptotocol For Patients Having Tmj Pain: contralateral side.
All these glides can be performed extra orally if

ULTRASOUND19:
there is insufficient mouth opening.
Mode: Pulsed
It can be given extra orally by applying the pressure
Frequency: 3 MHz from the lateral side of the head of the mandible
towards medially using pulp of the thumbs.
Intensity: 1 Watt/ cm2
2-4 repetitions of mobilization per treatment. 6-10
Duration: 3-5 minutes/ session movements.
The radiated area was 5 cm2 over the affected part
of TMJ. DOSAGE
For patients having TMJ pain grade I- II

ISOMETRIC EXERCISES mobilization. For patients having OSMF grade
III IV mobilization
Resistance applied to the opening, closing, lateral
and protrusive movements. Hold for 6-10 seconds for

Table 1.2. Age distribution of the patients having

restricted mouth opening
Age Group A Group B
Mean (years) 26.40 26.30
SD 4.401 6.334
Table 1.3. Comparison of pre treatment and post

treatment pain scores as on VAS within Group A and
Group B
Group Pre treatment Post treatment W value p value
Mean SD Mean SD
Group A 5.80 1.549 3.70 1.252 55 0.0051
Group B 4.70 1.337 1.90 0.9944 55 0.0053
Since the data was not normally distributed, Wilcoxon

matched-pairs signed test was applied for comparison
of pre treatment and post treatment pain scores as
on VAS within Group A and Group B.
For group A, the Sum of all signed ranks W = 55.00

and the two-tailed p value is 0.0051, considered
extremely significant.
For group B, the Sum of all signed ranks W = 55.00

and the two-tailed p value is 0.0053, considered
extremely significant.
Table 1.4. Comparison of post treatment VAS score
between Group A and Group B
Group Mean SD W value p value
Group A 3.700 1.252 142 0.0047
Group B 1.900 0.9944 68
Since the data was not normally distributed,

Wilcoxon ranked sum (Mann-Whitney) test was
applied for comparison of post treatment VAS score
between Group A and Group B.
Sum of ranks in group A = 142.00 and sum of ranks

in group B = 68.00.
The two-tailed p value is 0.0047, considered

significant.
Data Analysis of Maximal Mouth Opening

Table 1.5. Comparison of pre treatment and post
treatment maximal mouth opening within Group A and
Group B
RESULTS
Group Pre treatment Post treatment t value p value
maximal mouth maximal mouth
Data analysis was performed manually as well as
opening (in mm.) opening (in mm.)
by using Graph Pad Prism 5.03 software.
Mean SD Mean SD
Table 1.1. Age distribution of the patients having pain Group A 22.00 3.742 26.20 2.974 3.500 with 0.0067
9 d.f.
Age Group A Group B Group B 20.30 4.644 31.10 6.262 9.970 with <0.0001
Mean (years) 26.50 26.15 9 d.f.
SD 4.741 5.594
Paired t test was applied for comparison of pre
treatment and post treatment maximal mouth
opening within Group A and Group B.

For group A, t = 3.500 with 9 degrees of freedom for their kind co-operation and willingness to
and the two-tailed p value is 0.0067, considered participate in this study, without whom this study
extremely significant. would not have materialized.
For group B, t = 9.970 with 9 degrees of freedom

Conflict of Interest
and the two-tailed p value is <0.0001, considered
significant. The authors perceive no conflict of interest in this
study.
Table 1.6: Comparison of post treatment maximal
mouth opening between Group A and Group B
REFERENCES
Group Mean SD t value p value
Group A 26.20 2.974 2.235 with 18 d.f. 0.0383 1. Charles F Guardia III, Stephen A Berman;
Group B 31.10 6.262 Temporomandibular Disorders, Oct 11, 2010.
Unpaired t test was applied for comparison of post 2. Felson DT, Nevitt MC. The effects of estrogen on
treatment maximal mouth opening between Group osteoarthritis. Curr Opin Rheumatol 1998;
A and Group B. 10:26972.
3. Warren MP, Fried JL. Temporomandibular
t = 2.235 with 18 degrees of freedom and the two- disorders and hormones in women. Cells Tissues
tailed p value is 0.0383, considered significant. Organs 2001; 169: 18792.
4. Carlsson GE, LeResche L. Epidemiology of
FOR GROUP A: temporomandibular disorders. Seattle: IASP
Scale Pre treatment Post treatment W / t value p value
Press, 1995.
Mean SD Mean SD 5. Temporomandibular joint dysfunction (TMJD).
VAS 5.800 1.549 3.700 1.252 55 0.0051 1/1996, 11/2009, 8/2012, 8/2010.
MMO 22.00 3.7427 26.20 2.974 3.500 (9 d.f.) 0.0067 6. Dimitroulis G; Temporomandibular disorders: a
clinical update. BMJ. 1998 Jul 18; 317(7152):190-
FOR GROUP B: 4.
Scale Pre treatment Post treatment W / t value p value 7. Scrivani SJ, Keith DA, Kaban LB;
Mean SD Mean SD Temporomandibular disorders. N Engl J Med.
VAS 4.700 1.337 1.900 0.9944 55 0.0053 2008 Dec 18; 359(25):2693-705.
MMO 20.30 4.644 31.10 6.262 9.970 (9 d.f.) <0.0001 8. Cox SC, Walker DM. Oral submucous fibrosis. A
review. Aust Dent J. Oct 1996; 41(5):294-9.
On Comparing Between Group A and Group B: 9. Aziz SR. Oral submucous fibrosis:an unusual
Scale p value disease. J N J Dent Assoc. Spring 1997; 68(2):17-
VAS 0.0047 9.
Maximal mouth opening 0.0383 10. Paissat DK. Oral submucous fibrosis. Int J Oral
Surg. Oct 1981; 10(5):307-12.
The p values are significant, which suggests that
a. Sur TK, Biswas TK, Ali L, Mukherjee B. Anti-
there is statistically significant difference between the
inflammatory and anti-platelet aggregation
groups A and B.
activity of human placental extract. Act
It was concluded that TJM treatment is significantly Pharmacol Sin. Feb 2003; 24(2):187-92.
effective in relieving pain and improving mouth 11. Anil S, Beena VT. Oral submucous fibrosis in a
opening in patients with TMJ Disorders. 12-year-old girl: case report. Pediatr Dent. Mar-
Apr 1993; 15(2):120-2.
CONCLUSION 12. Kakar PK, Puri RK, Venkatachalam VP. Oral
submucous fibrosistreatment with hyalase. J
It is concluded that both the groups showed Laryngol Otol. Jan 1985; 99(1):57-9.
significant improvement in pain and mouth opening. 13. Canniff JP, Harvey W, Harris M. Oral sub mucous
But TMJ Mobilization along with Conventional fibrosis: its pathogenesis and management. Br
Therapy showed significant improvement in pain and Dent J. Jun 21 1986; 160(12):429-34.
on mouth opening than conventional physical therapy 14. Hosein M. Oral cancer in Pakistan. The problem
alone. and can we reduce it?. In: Oral Oncology. Kluwer
Academic: 1994.
ACKNOWLEDGEMENTS 15. Nayak DR, Mahesh SG, Aggarwal D, Pavithran
P, Pujary K, Pillai S. Role of KTP-532 laser in
I would like to thank Dr vinit (Assistant management of oral submucous fibrosis. J
Physiotherapist) and I am grateful to all my patients Laryngol Otol. Oct 10 2008; 1-4.

16. Arora Pooja. Indian Journal of Physiotherapy and myofascial trigger points in the masticatory
Occupational Therapy Year: 2010, Volume: 4, muscles. J Orthop Sports Phys Ther 2010;
Issue: 3 Print ISSN: 0973-5666. Online ISSN: 0973- 40(5):310-317, Epub 12 April 2010.
5674. 18. Barriere P, Zink S, Riehm S, Kahn JL, Veillon F,
17. Oliveira-Campelo NM, Rubens-Rebelatto J, Mart Wilk A. Massage of the lateral pterygoid muscle
N-Vallejo FJ. The immediate effects of atlanto- in acute TMJ dysfunction syndrome. Rev
occipital joint manipulation and sub occipital Stomatol Chir Maxillofac. 2009 Apr; 110(2):77-80.
muscle inhibition technique on active mouth Epub 2009 Jan 21.
opening and pressure pain sensitivity over latent

Effect of Home Based Low Intensity Walking Programme
on Quality of Life and Functional Capacity in Left
Ventricular Failure Patients A Randomized Control Trial
Mariya Jiandani1, Rajeshwari Reddy2, Amita Mehta3, Ashish Nabar4

1,3
Assoc Professor, Professor and Head, P.T School and Centre Seth Dhurmal Bajaj Orthopaedic Centre, Seth G.S.
Medical College and KEM Hospital Parel, Mumbai, 2Physiotherapist, 4Associate Professor, Department of cardiology
Seth G.S. Medical College and KEM Hospital, Parel, Mumbai 400012
ABSTRACT
A randomized control trial wherein 50 Left ventricular failure patients were included with ejection
fraction15-40%. A home based exercise programme was designed on the basis of 6MWD for the
training group and the control group carried out usual activities with no specified programme for 8
weeks. Outcome measures were 6MWD and QOL using LVD36 pre and post programme. In the
training group, 6MWD increased from 329.6120.63 mts to 394 122.82mts (p<.001). This increase is
highly statistically significant and indicates improvement in exercise performance. In control and
training groups, LVD-36 score decreased (p=0.011 and <0.001) suggestive of improved quality of life.
On comparison training group showed greater improvement in quality of life (p=0.001).
Key words: Left Ventricular Failure, Exercise, Walking, QOL
INTRODUCTION exercise training in Left ventricular failure patients.

Walking is an aerobic activity that is a part of every
Heart Failure is a pathological state in which an individuals daily living. It does not require specialized
abnormality of cardiac function is responsible for the equipments, setup and is cost effective and realistic.
failure of heart to pump at the rate commensurate In such situations, the effectiveness of Home Walking
with the requirements of metabolizing tissues or can Exercise programs and possible outcomes in the
so do with from an abnormally elevated filling Functional Status and Quality of life needs to be
pressures. In India, 18.8 million people (i.e.1.76% demonstrated.
population) are known cases of heart failure. The
Incidence is 1.57 million people/year (i.e.0.15% of AIM
population).It represents growing health problem.
Despite currently available pharmacological To study the Effect of Home Based walking
strategies advances in surgical management, rehabilitation on 6 Minute Walk distance and Quality
prognosis for patients with overt heart failure remains of Life in Left Ventricular Failure patients.
dismissal. About half of patients with heart failure
die within 4 years of diagnosis and among group of OBJECTIVES
advanced failure more than 50% die within one year.
In addition to development and implementation of To study and compare improvement in 6 Min Walk
cost effective program that prevent development of Distance and LVD-36 (QOL) after 8 weeks of training
heart failure, there is also need for development of in LVF.
palliative Care along with individualized and Study Design: Prospective Randomized Controlled
supportive care. To this will acknowledge the positive Trial
role of Cardiac Rehabilitation in treating Heart
Failure. Place of study: Physiotherapy Cardiopulmonary
Rehabilitation OPD, Cardiovascular and Thoracic
Need for the study: There is very limited research Centre, Seth G S Medical College & KEMH. Study
available showing the contributory role of Home was approved by the Ethics Committee of the
Walking Exercise program alone as modality of institution.
37. Mariya 26th aug 11 (185-189).pmd 185 10/16/2012, 2:41 PM

Inclusion Criteria: follow up with both the groups was maintained to

clarify questions about the prescribed protocol,
Total seventy patients were screened and the first encouraging adherence to the protocol in training
Fifty patients in NYHA Class I-III and Left ventricular group and with Control group to check the status of
ejection fraction between 15%-40% were recruited the condition in order to alleviate the psychological
from the Cardiology OPD of Seth G S Medical College impact of conversation.
& KEMH .
Exclusion Criteria: OBSERVATION AND DATA ANALYSIS
Patients with acute myocardial infarction or Baseline data (Table 1) was comparable with no
recurrent angina (in last one month), arrythmia and significant differences between the two groups.
any known musculoskeletal, neurological or systemic Intragroup change in 6 MWD and LVD-36 score before
disorders which would interfere with ambulation were and after 8 weeks was analyzed using paired t- test
excluded from the study. and intergroup analysis was done using unpaired t-
test. The data was normally distributed.
METHODOLOGY
Table 1. Baseline Demographic and Clinical
Patients were educated about the protocol and the Characteristics (N=50)
possible benefits from it. Informed consent was taken Characteristics N=25 N=25
from the patients. They were then randomly divided Training group Control group
into two groups, Training and control group. 6MWT Male/Female 23/2 23/2
was performed in an indoor corridor of 30 mts as per Age (MSD) 53.166.06 55.163.184
Etiology: Ischemic 21/25 22/25
ATS guidelines LVD-36 Questionnaire a 36 item
IDCM 4/25 3/25
questionnaire for patients with LVdysfunction.30 was
LVEF% 10-20% 6/25 7/25
used to assess quality of life. Responses to LVD 36 are 25%-30% 10/25 7/25
dichotomous, (true/ false).True responses are summed 35-40% 9/25 11/25
and expressed in % out of 36, so that 100% is the worst Mean sd 0.300.06 0.310.05
score and 0 the best. Questionnaire was filled by the NYHA CLASS-I 3 5
patient after explaining , time to complete was 5 II 17 15
minutes. III 5 5
MEDICATIONS
For 8 weeks the Training Group, underwent Home Diuretics 18/25 20/25
based walking exercise Program designed on the basis ACE inhibitors 20/25 18/25
B- blocker 21/25 11/25
of 6MWD. Home walking exercise program was
Digoxin 6/25 4/25
advised once a day, everyday. Daily walking program
Oral HGA 4/25 2/25
of 30 min with gradual progression of intensity every
2 weekly (percentage of 30 min distance calculated
from the distance covered in 6MWT) was advised. Table 2. Comparison Pre and Post 8 week
Information from the diary was used as validity check Control Group Training group
of the intervention 0- wk 8- wk p- value 0-wk 8- wk p-value

6 MWD 341.671.67 341.875.25 0.091 329.6120.63 394.2122.83 <0.001*
Control Group, underwent Usual Activity where

LVD-36 0.510.142 0.520.141 0.036* 0.5170.137 0.2080.086 <0.001*
they were instructed to maintain their normal daily
activities without any specific exercise prescription. At RPE 3.160.85 3.560.92 0.002 3.20.76 0.60.645 <0.001*
(fatigue)
the end of 8 weeks 6MWT and LVD-36 Questionnaire RPE 3.881.17 4.121.01 0.011 3.921.15 1.32.0.748 <0.001*
was repeated with both the groups and the results were dyspnoea
recorded
Table 3. Intergroup Comparison
Both the groups received an instruction sheet of Intergroup Control Training p- value
points to be noted; which included Regular comparison
medications, weight , diet, precautions, adherence to 6 MWD 341.875.25 394.2122.83 0.001*
walking Program ,time and distance covered(Training LVD-36 0.520.141 0.2080.086 0.001*
RPE( fatigue) 3.560.92 0.60.645 0.001*
group) or Usual daily activities(Control Group), daily
RPE dyspnoea 4.121.01 1.320.748 0.001*
PR, RR, and any fresh complains. Weekly telephonic

6MWD Exercise program as a mode of exercise training has

not been widely prescribed and hence lacks more
In the control group 6MWD changed from evidences30.Our study has used a low intensity home
341.671.67mts at 0 weeks to 341.8 75.25 mts at 8 walking exercise program for training purpose of left
weeks, which was statistically not significant (p=.0091) ventricular failure patients. Exercise prescription
whereas in the training group, it increased from allowed the patients to start the regime at a percentage
329.6120.63 mts to 394 122.82mts (p<.001 ). This lower than 53% of age predicted maximum heart rate
increase is highly statistically significant and indicates and then gradually progress.
improvement in exercise performance. Unpaired t test
(inter-group comparison) shows statistically highly Based on Guyatts report of a minimum important
significant increase in the 6MWD post training distance difference i.e. >99 feet(30.5 m) in patients with
(p=0.0001). heart failure, the increase of 60 m in training group is
clinically meaningful. Though all patients in Training
LVD -36: In control and training groups, LVD-36 score group showed improvement, only 20% of control
decreased (p=0.011 and <0.001 respectively) suggestive group showed increase in 6MWD which is not
of improved quality of life. On comparison training statistically significant.(p=0.091). The significant
group showed greater improvement in quality of life increase in 6 MWD of Training Group (p<0.001) can
(p=0.001). be attributed to the effects of Exercise training on
skeletal muscles metabolism and Anaerobic Threshold.
RPE Score For Fatigue and dyspnoea
Exercise training especially including lower limbs
Control group showed increase in RPE score for causes changes in cytochromal O2 uptake by muscles
fatigue and dyspnoea (p-value 0.002, 0.011) while at anaerobic threshold, hence delaying its onset and
training group showed statistically significant decrease hence delaying onset of fatigue13,14 .It improves flow
in fatigue and dyspnoea (p-value <0.001, <0.001) dependant relaxation of peripheral arteries and this
suggesting that training helps to reduce symptoms of beneficial effect can translate into increased blood flow
fatigue and dyspnoea than control group (p- value to the skeletal muscles, hence causing washout of lactic
0.001, 0.001 respectively). acid and increasing O2 uptake by the skeletal muscles.
In heart failure there is abnormal endothelial functions
DISCUSSION i.e. there is decrease in endothelium dependant
vasodilating endothelins. This is responsible for the
In Heart Failure there is inability of the heart to meet lack of peripheral vasodilataion in response to the
the demands of the tissues, which results in symptoms exercise stimuli leading to decreased blood flow to the
of fatigue and dyspnea on exertion progressing to exercising muscles1,2 With training there is increase in
dyspnea at rest. Exercise intolerance is defined as the the release of these vasodialating endothelins e.g.
reduced ability to perform activities that involve NO15,16. Increase in the blood flow to the leg muscles
dynamic movements of larger group of muscles, due helps in effective extraction of oxygen and delaying
to symptoms of fatigue and dyspnea . Factors the onset of fatigue and hence improving exercise
responsible for Decreased exercise tolerance are performance.
Central and Peripheral (Abnormal endothelial
functions 1,2 , blood flow 3,6, muscle metabolism 4,5 , The score for fatigue in control group increased in
distribution of cardiac output7), abnormal ventilatory the period of 8 weeks which is statistically
responses9,10,12altered Neuro-hormonal regulation & significant.(p=0.002) Anaerobic metabolism occurs
autonomic control11,12. early in patients with LVF .Patients of LVF show
decrease in Oxidative Type I fibres and increase in
Benefits of exercise training include improvement Glycolytic Type II fibres.In addition glycolytic enzymes
in exercise tolerance, amelioration of symptoms and also decrease especially mitochondrial enzymes.
improved quality of life. Exercise training in Heart Improvement in the scores of fatigue in the training
Failure has varied from High intensity to low group (p<0.001) is highly statistically significant and
intensity20,21 i.e. from 50% to 80% of maximal capacity. can be explained on the basis of studies 13,14 as
The modalities used for training has varied from use mentioned earlier. The score for Dyspnea in the control
of treadmill to cycle ergo meter. Modes of exercise group has shown statistically significant rise which
training has also been variable i.e. from only aerobic indicates deterioration of symptoms (p=0.011).
exercises 22,23, combined endurance and resistance Dyspnea in patients with LVF can be explained on the
training24-27, only resistance training28,29. Home walking basis of the following facts: decreased activity and

strength of of respiratory muscles leading to ventilation with other people or organizations about our work.
perfusion mismatch, presence of ergoreflex i.e.
Stimulation of arterial chemoreceptors and afferent REFERENCES
fibres originating from muscular receptors sensitive
to local metabolic products( 9,10)Training group 1. Kubo SH, Rector TS, Bank AJ, et al. Endothelium-
dependent vasodilation is attenuated in patients
showed improvement in the dyspnea scores which is
with heart failure. Circulation. 1991; 84: 1589-159
statistically highly significant.(p<0.001)
2. McMurray JJ, Ray SG, Abdullah I, et al. Plasma
The mechanism of delayed ventilatory response to endothelin in chronic heart failure. Circulation.
exercise is explained by the fact that with exercise 1992; 85: 1374-1379
training there is increase in maximal sustainable 3. Wilson JR, Martin JL, Schwartz D, et al. Exercise
intolerance in patients with chronic heart failure:
ventilatory capacity, maximal voluntary ventilation
role of impaired nutritive flow to skeletal muscle.
and these changes are attributed to attenuation of
Circulation. 1984; 69: 1079-108
Ergoreflex9,11,17,18 4. Sullivan MJ, Green HJ, Cobb FR. Skeletal muscle
The LVD-36 score in the Control group has biochemistry and histology in ambulatory
patients with long-term heart failure. Circulation.
increased to a statistically significant value(p=0.0036).
1990; 81: 518-527
Post Rehabilitation the LVD-36 Scores have decreased
5. Drexler H, Riede U, Munzel T, et al. Alterations
in the training group The components that showed of skeletal muscle in chronic heart failure.
maximum affection were the ones that reflected Circulation. 1992; 85: 1751-1759
Fatigue and Dyspnea. Scores of Fatigue and Dyspnea 6. Sullivan MJ, Knight JD, Higginbotham MB, et al.
reflect on the scores of LVD-36 .Hence in Training Relation between central and peripheral
group decrease in the scores of fatigue and dyspnea hemodynamics during exercise in patients with
has caused the decrease in the scores of LVD-36,which chronic heart failure: muscle blood flow is
is an indication of improved quality of life. reduced with maintenance of arterial perfusion
Improvement in the symptoms improves the feeling pressure. Circulation. 1989; 80: 769-781
of self support and confidence. 7. Wada O, Asanoi H, Miyagi K. Quantitative
evaluation of blood flow distribution to
CONCLUSION exercising and resting skeletal muscles in patients
with cardiac dysfunction using whole-body
From this prospective RCT it can be concluded that, thallium-201 scintigraphy.
a low level, Home Walking Exercise Program has 9. Piepoli M, Clark AL, Volterrani M.
Positive effects on function performance indicated by Contribution of muscle afferent to the
6MWD and Quality of life indicated by LVD-36 hemodynamic, autonomic, and ventilatory
Questionnaire. responses to exercise in patients with chronic
heart failure: effects of physical training.
Circulation. 1996; 93: 940-952.
Clinical Implication:
10. Iaria CT, Jalar UH, Kao FF. The peripheral neural
As this study demonstrates that a low intensity mechanism of exercise hyperpnoea. J Physiol.
Home Based Walking Exercise program for stable LVF 1959
11. Rowell LB, OLearly DS. Reflex control of the
patients is effective in improving the functional status
circulation during exercise: chemoreflexes and
and perception of symptoms leading to improved
mechanoreflexes. J Appl Physiol. 1990; 69: 407-
quality of life. Hence clinicians should consider the
418.
use of home walking exercise programs as Phase II 12. McCloskey DI, Mitchell JH. Reflex cardiovascular
cardiac rehabilitation, especially for those who cannot and respiratory responses originating in
have access to hospital based cardiac rehabilitation. exercising muscle. J Physiol. 1972; 224: 173-1862.
13. Tyni-LenneR, Gordon A, et.al. Effects of muscle
ACKNOWLEDGEMENT endurance training improves the muscle
oxidative capacity,exercise tolerance and QOL,
We are heartily thankful to all our patients, the staff AJC1997; 80: 1025-1029.
of PT School and Centre, KEM hospital, who 14. Hambrecht R, Niebauer J, Fiehn E, et al. Physical
supported us from the preliminary stages of the project. training in patients with stable chronic heart
failure: effects on cardiorespiratory fitness and
Interest of conflict: We, M.P.Jiandani, R. Reddy, Mehta ultrastructural abnormalities of leg muscles.
A and A.Nabar state that there is no conflict of interests 15. Physical training improves endothelial

functioning in patients with chronic heart failure. chronic heart failure. G Ital Cardiol. 1992; 22:
Circulation. 1996; 93: 210-214. 919-930.
16. Hambrecht R, Gielen S, Linke A, et al. Effects of 23. Kavanagh T, Myers MG, Baigrie RS, et al. Quality
exercise training on left ventricular function and of life and cardiorespiratory function in chronic
peripheral resistance in patients with chronic heart failure: effects of 12 months aerobic
heart failure: a randomized trial. JAMA. 2000; 283: training. Heart. 1996; 76: 42-49.
3095-3101. 24. Delagardelle C, Feiereisen P, Autier P, et al.
17. Mancini et al, Marco Guazzi,J.App.Phy.June 2004, Strength/endurance training versus endurance
Exercise training improves alveolar capillary training in congestive heart failure Med. Sci.
membrane diffusing capacity. Sports Exerc. 2002; 34: 1868-187
18. Coats AJ, Adamopoulos S, Radaelli A, et al. 25. Maiorana A, ODriscoll G, Cheetham C, et al.
Controlled trial of physical training in chronic Combined aerobic and resistance exercise
heart failure: exercise performance, training improves functional capacity and
hemodynamics, ventilation, and autonomic strenght in CHF J. Appl. Physiol. 2000; 88: 1565-
function. Circulation. 1992; 85: 2119-2131. 1570.
19. Radaelli A, Coats AJ, Leuzzi S, et al. Physical 26. Maiorana A, ODriscoll G, Dembo L, et al. Effect
training enhances sympathetic and of aerobic and resistance exercise training on
parasympathetic control of heart rate and vascular function in heart failure Am. J. Physiol.
peripheral vessels in chronic heart failure. Clin Heart Circ. Physiol. 2000; 279: H1999-H2005
Sci (Lond). 1996; 91: 92-94. 27. Conraads VM, Beckers P, Bosmans J, et al.
20. Dubach P, Myers J, Dziekan G, et al. The effect of Combined endurance/resistance training
high intensity exercise training on central reduces plasma TNF-alpha receptor levels in
hemodynamic response to exercise in men with patients with chronic heart failure and coronary
reduced left ventricular function. J Am Coll artery disease Eur Heart J 2002; 23: 1854-1860
Cardiol. 1997; 29: 1591-1598. 28. Pu CT, Johnson MT, Forman DE, et al.
21. Belardinelli R, Georgiou D, Cianci G, et al. Randomized trial of progressive resistance
Randomized, controlled trial of long-term training to counteract the myopathy of chronic
moderate exercise training in chronic heart heart failure J. Appl. Physiol. 2001; 90: 2341-2350
failure: effects on functionalcapacity, quality of 29. Franklin BA, Bonzheim K, Gordon S, et al.
life, and clinical outcome. Circulation. 1999; 99: Resistance training in cardiac rehabilitation J.
1173-1182. Cardiopulm. Rehabil. 1991; 11: 99-107.
22. Belardinelli R, Scocco V, Mazzanti M, et al. Effects 30. Triesta corvera and colleagues, Am. Heart.
of aerobic training in patients with moderate Journal 2004; 147: 339-346.

Effect of Exercise on Postural Kyphosis in Female after

Puberty
Hala M. Hanfy1, Mohamed A. Awad1, Abdel Hamid A. Atta Allah2

1
Department of Physical Therapy for Obstetrics and Gynaecology, Faculty of Physical Therapy, Cairo University,
Egypt, 2Department of Orthopaedic Surgery, Faculty of Medicine (Girls), Al Azhar University, Egypt
ABSTRACT
This study was conducted to determine the effect of exercise on postural kyphosis in female after
puberty. Fifty girls after puberty complained from postural kyphosis (diagnosed by orthopedist)
from preparatory and secondary schools in Giza, participated in this study. Their ages ranged from
13 to 18 and their thoracic kyphosis angle was more than 40 degrees and less than 60 degrees. Girls
evaluated by the Formetric II instrument in spinal shape analysis laboratory at the Faculty of Physical
Therapy, Cairo University, evaluation done before and after 6 weeks of the exercise program. Duration
of the study was from July 2011 to December 2011. The obtained results showed a statistically highly
significant decrease (P<0.01) in thoracic kyphotic angle after performing the exercises. Accordingly,
it could be concluded that the exercise is very effective in correcting females postural kyphosis after
puberty.
Key words: Postural Kyphosis, Puberty, Formetric II, Thoracic Kyphosis
INTRODUCTION apparent in adolescence. The onset of postural

kyphosis generally is slow. Its more common in girls
Posture is the alignment and maintenance of body than in boys. Poor posture or slouching may cause
segments in certain positions, such as standing, lying stretching of the spinal ligaments and abnormal
or sitting. It is thought that there is an optimal posture formation of the bones of the spine (vertebrae).
for any given task. Considerable deviations from Postural kyphosis is often accompanied by an
optimal posture are thought to be aesthetically exaggerated inward curve (hyperlordosis) in the
unpleasant, adversely influencing muscle efficiency lumbar spine. Hyperlordosis is the bodys way of
and predisposing to musculoskeletal or neurological compensating for the exaggerated outward curve in
pathologic conditions1. the upper spine. Although rare, kyphosis can lead to
Kyphosis which occurs to compensate the breast serious health problems, such as physical deformity,
development in girls after puberty due to carrying breathing difficulties or damage to internal organs that
heavy schoolbags, participating in competitive sports are affected by the postural changes. Adolescent girls
and wrong posture can be cured with early diagnosis. with poor posture are at a greater risk of postural
If this kyphosis isnt cured with an early diagnosis it kyphosis. Postural kyphosis doesnt progress and may
can cause psychosocial problems2. improve on its own. Exercises to strengthen back
muscles, training in using correct posture and sleeping
Postural kyphosis, the most common type, on a firm bed may help. Pain relievers may help
normally attributed to slouching, can occur in both the alleviate any pain4.
old and the young. In the young, it can be called
slouching and is reversible by correcting muscular Adolescent girls between the ages of 9.5 and 14.5
imbalances. In the old, it may be called hyperkyphosis years have a period of rapid bone growth. The onset
or dowagers hump. About one third of the most of menses contributes to the acquisition of peak bone
severe hyperkyphosis cases have vertebral fractures. mass and is improved by regular balanced exercise and
Otherwise, the aging body tends towards a loss of good diet. Postural kyphosis is rather easily corrected
musculoskeletal integrity, and kyphosis can develop with education about proper posture and some
due to aging alone3. retraining on how to sit and stand correctly. Treatment
does not need to include casting or bracing. However,
Postural kyphosis is a type that mainly becomes strengthening the back muscles can help with proper
38. Mohd Awad 12 th march 12 (190-194).pmd 190 10/16/2012, 2:41 PM

posture. Learning correct body mechanics to maintain ups to monitor changes. However, the decision to carry
erect posture that counteracts the effects of the out the procedure can be very difficult due to the
kyphosis. Doing regular non-jarring exercises, such as potential risks to the child. A congenital kyphosis can
swimming and maintaining high levels of activity are also suddenly appear in teenage years, in children with
thought to be useful advice in the management of cerebral palsy and other neurological disorders10.
postural kyphosis5.
Nutritional kyphosis can result from nutritional
9louching and poor posture can stretch the spinal deficiencies, such as in cases of vitamin D deficiency
ligament, thus increasing the natural curve of the spine. which leads to thinning in the bones and resulting in
This postural kyphosis usually begins to develop curving of the spine as the childs body weight
during adolescence. It is more common among girls increases5.
than boys and it rarely causes pain5.
Positions and postures usually adopted by women
Postural kyphosis may occur in both old and young can become habitual patterns. Early education and
people. In the young, it can be called slouching and training of body mechanics normally tend to help in
is reversible by correcting muscular imbalance. In the forming positive postural habits, optimal muscle
old, it may be called hyperkyphosis or dowagers balance and skeletal alignment. Adolescent girls have
hump. About one third of the most severe a period of rapid bone growth between the ages of 9.5
hyperkyphosis cases have vertebral fractures. and 14.5 years. It is important to choose an exercise
Otherwise, aging process tends to cause loss of the for kyphosis that corrects the weakness in the muscles
musculoskeletal integrity. Kyphosis can develop due extending up to the spine as well as forward head
to aging alone7. posture, to achieve good postural alignment and
reduce strain on the muscle of the back9.
Scheuermanns kyphosis is a type that is seen in
some families and it appears during the teenage Competitive sports can stress the musculoskeletal
years8. It is significantly worse cosmetically and can system of adolescent and young adult women, causing
cause pain. It is considered a form of juvenile injuries and pain with the development of postural
osteochondrosis of the spine, and is more commonly changes. Conditions commonly associated with this
called Scheuermanns disease. It presents a age group are patellofemoral problems, traction
significantly worse deformity than postural kyphosis. apophysities, ankle injuries, compartment syndromes
A patient suffering from Scheuermanns kyphosis and other acute and overuse injuries. Spinal problems
cannot consciously correct posture because apex of the include scoliosis, thoracic kyphosis and
curve located in the thoracic vertebrae is quite rigid. spondolythesis. Adolescents are particularly
The patient may feel pain at this apex that may be susceptible to growth plate injuries, especially in the
aggravated by physical activity and long periods of mid-pubertal period, in addition to long-bone stress
standing or sitting. This can have a significantly factors and avulsion fractures5.
detrimental effect on such patients, as their level of
activity is curbed by their condition; they may feel
isolated or uneasy amongst peers if they are children, SUBJECTS, MATERIALS AND METHODS
depending on the level of deformity. Whereas in
postural kyphosis the vertebrae and disks appear Fifty patients after puberty complained from
normal, in Scheuermanns kyphosis they are irregular, postural kyphosis (diagnosed by orthopedist and
often herniated and wedge shaped over at least three confirmed by Formetric II instrument) selected from
adjacent levels. Fatigue is a very common symptom, preparatory and secondary schools in Giza shared in
most likely because of the intense muscle work that this study. The design of this study was one-group
has to be put into standing and/or sitting properly. pretest post-test design. Informed consent form had
The condition seems to run in families9. been signed from each patient before participating in
the study. Duration of the study was from July 2011 to
Congenital kyphosis is a type that some babies are December 2011. Their thoracic kyphosis angles were
born with because their spinal column did not develop more than 40 degrees and less than 60 degrees. All
correctly in the womb. Vertebrae may be malformed patients were free from chest diseases, scoliosis and
or fused together and can cause further progressive previous trauma to the spine, pelvis and lower limbs.
kyphosis as the child develops. Surgical treatment may All patients did not take any medications that might
be necessary at very early stage and can help maintain affect the neuromuscular functions at least three
a normal curve in coordination with consistent follow months before or during the study course. Weight-

Height Scale was used for measuring the body weight c. Hamstring muscle stretching from long sitting
and height of each girl participating in the study to position.
calculate the subjects body mass index. The diagnosis 3. Thoracic spine mobilization exercises:
of postural kyphosis was done for each patient by a. Thoracic extension from relaxed prone lying
orthopedist before the beginning of the study and was (Sphinx position).
confirmed by measuring thoracic kyphosis angle by b. Thoracic extension from sitting position.
Formetric II instrument. The design of this study was
c. Thoracic extension from standing position.
one-group pretest post-test design. Duration of the
4. Resistance training exercises:
study was from July 2011 to December 2011. The
patients were evaluated by the Formetric II instrument a. Stabilization exercise for the scapulae from
in spinal shape analysis laboratory at the Faculty of prone lying position.
Physical Therapy, Cairo University, before and after b. Back extensors from prone lying position.
performing an exercise program for 6 weeks, Fig.1. 5. Cooling down phase for 10 minutes.
a. Diaphragmatic breathing from crock lying
position.
b. Costal breathing from crock lying position.
6. Advices for good posture:
a. Ideal sitting position on a stool.
b. Ideal standing position.
c. The right way of lifting a weight.
The Student t- test was used to compare between

pre and post treatment results.
RESULTS
A- Physical characteristics of the girls.
The ages of the girls ranged from (13-18) yrs, with

a mean value of (15.431.70) yrs; their weight ranged
from (50-59) kgs, with a mean value of (54.772.36)
Fig. 1. The scanning of the spine (Posterior view). kgs, their height ranged from (148-163) cms, with a
mean value of (154.803.69) cms, and their body mass
Exercise Program
index (BMI) ranged from (21.35 - 24.56) kg/m2, with a
Each patient participated in a daily supervised 6 mean value of (22.860.87) kg/m2 (Table 1).
weeks exercise program.
Table 1. Demographic data of the girls.
1. Warming up phase:
Variables Minimum Maximum Mean Std. Deviation
a. Diaphragmatic breathing exercise from crock Age (yrs.) 13.00 18.00 15.43 1.70
lying position. Weight (kg.) 50.00 59.00 54.77 2.36
b. Posture correction exercises: Height (cm) 148.00 163.00 154.80 3.69
BMI (Kg/m2) 21.35 24,56 22.86 0.87
i) Posture correction exercise from crock lying
position.
B- Kyphotic angle (MAX) of the girls.
ii) Posture correction exercise from supine lying
position. Before starting the treatment program the thoracic
iii) Posture correction exercise from sitting kyphotic angle ranged between (41- 45) degrees with
position. a mean value of (43.13 1.31), while after the treatment
iv) Posture correction exercise from standing program it was ranged between (36-44) degrees, with
position. a mean value of (39.67 2.02) (Table 2, Fig. 2).
2. Stretching exercise: Table 2. Mean value of kyphotic angle (MAX) measured
a. Pectorals major muscles stretching from sitting pre- and post-exercise in the girls.
position. Pre-exercise Post-exercise t-value p value
b. Hip flexors stretching from standing position. Mean SD 43.13 1.31 39.67 2.02 15.879 0.01**

adaptive mechanisms fail, an adolescent round

shoulders may be present with a neck projected
forward and exaggerated thoracic kyphosis. That was
stated in the study which had been done by this author
to study the effect of the early education on practicing
good postures in daily living and all activities early
before puberty in the middle aged school girls.
The results of the current study are also supported

Fig. 2. Mean value of kyphotic angle (MAX) pre- and by those of Hawes, Nies and Kershaw, Ashton and
post-exercise in the girls. Schultz3,5,15 who have found that following growth
spurts and body development, particularly breasts
DISCUSSION development could increase thoracic kyphosis, trunk
The results of this study found that, there was a length, shift the centre of gravity away from the spine,
statistically highly significant decrease (P<0.01) in and increase muscular effort required to maintaining
thoracic kyphosis angle and trunk length after the balance. Early education and training in body
performance of the exercise program on the girls. mechanics can help to form positive postural habits
and help in developing and maintaining optimal
The results of this study agree with those of Kendall muscle balance and skeletal alignment.
and Mccreary11 who found that adolescent postural
kyphosis leads to increase in thoracic kyphosis and Also the results of the study were supported by
trunk length through the unnecessary tension that Weiss and Turnbull [4], who found that adolescent girls
comes from the stretching of the para spinal muscles have a period of rapid bone growth between the ages
especially the erector spinae muscle and the elongation of 9.5 and 14.5 years. The onset of menses contributes
of the posterior longitudinal ligament, supraspinous to the acquisition of peak bone mass and is enhanced
and intraspinous ligaments of the thoracic spine. That by regular exercise and good diet.
was concluded by those authors in the study The results of this study disagree with the results
conducted in one of the preparatory school girls to of Gatterman16, who found that postural kyphosis in
determine the prevalence of postural kyphosis in girls after puberty will not get any worse with time
middle aged adolescents by using the inclinometer as and does not need any therapeutic intervention.
a way of measurement to the thoracic kyphotic angle.
Results of this study agree with those of Fardon12, CONCLUSION

who found that a combination of posture correction
On the basis of the data obtained in the present
exercises and breathing exercises could help in
study, we conclude that exercise is very effective in
decrease tension and pain associated with postural
correcting females postural kyphosis after puberty.
kyphosis and establish good posture habits in girls
after puberty.
REFERENCES
The results also agree with those of Stephen et al.13
1. Young A, Michael L. A review on postural
who recommended stretching the pectorals major
realignment and its muscular and neural
muscle to maintain flexibility, decrease thoracic
components. Elite Track, Retrieved July 2003; 19:
kyphosis and trunk length in cases of adolescent 07.
postural kyphosis together with back mobilization 2. Kendail F, McCreary E, Provance P. Muscles:
exercises and specific resistive training to strengthen testing and function. London, Philadelphia,
the scapular muscles and back extensors muscles. Williams and Wilkins, 4th ed. 1993; 69-118.
3. Hawes M. Impact of spine surgery on signs and
The results of this study also, agree with those of
symptoms of spinal deformity. Pediatr Rehabil.
Magee14, who found that, during the adolescent spurt Oct-Dec; 2006; 9(4): 318-339.
of growth, changes in body proportions occur to adjust 4. Weiss H, Turnbull D. Kyphosis (Physical and
to gravity. The pelvic tilt decreases to 20-30 degrees. technical rehabilitation of patients with
The knees are slightly bent, but the earlier hyper Scheuermanns disease and kyphosis). In: JH
extension of the spine is not necessary to balance a Stone, M Blouin, editors. International
prominent abdomen. Posture becomes less mobile and Encyclopedia of Rehabilitation 2010.
the postural patterns become stabilized. If proper 5. Nies M, Kershaw T. Psychosocial and

environmental influences on physical activity and 11. Kendall F, Mccreary E. Thoracic Curvature in
health outcomes in adolescent female, American standing and sitting in two types of chairs: A
journal of physical medicine 2002; 34(3): 243-249. guide to preventive and rehabilitation, Australian
6. Ohenba B, Baron L. Spinal deformity. Pediatric journal of physiotherapy 1990; 70(10): 616.
Clinics of North America 1996; 43(4): 883-897. 12. Fardon D. Back School. In Rehabilitation of the
7. Kado D, Prenovost K, Crandall C. Narrative Spine: Science and Practice. Ed. Hochschuler SH
review: hyperkyphosis in older persons. Ann. and Richard GG. St. Louis: Mosby-Year Book
Intern. Med 2007; 147 (5): 330-338. 1993; 725 and 731.
8. Baker K. Scheuermanns Disease. A review. 13. Stephen J, Deed H, Donald D. Structural
Australian Journal of orthopedic surgery. 1988; rehabilitation of the spine and posture: rationale
34(3): 165-169. for treatment beyond the resolution of symptoms.
9. Keller TS, Harrison D, Colloca C, Harrison D, Journal of Manipulative and Physiological
Janik T. Prediction of osteoporotic spinal Therapeutics 1998; 21(1): 716.
deformity. Spine 28, 2003; (5): 455-462. 14. Magee D. Thoracic spine: In: Orthopedic physical
10. Pfeifer M, Begerow B, Minne H. Effects of a new assessment. 4th ed., New York: Saunders, Elsevier
spinal orthosis on posture, trunk strength, and 2002; 425-463.
quality of life in women with postmenopausal 15. Ashton J, Schultz A. Basic orthopedic
osteoporosis: a randomized trial. American biomechanics. 2 nd ed., Lippincott-Raven,
journal of physical medicine & rehabilitation/ Philadelphia 1997; 202-210.
Association of Academic Physiatrists 2004; 16. Gatterman M. Chiropractic Management of Spine
83(3):177-186. Related Disorder. 2nd ed., Gatterman MI et al.
Baltimore: Williams and Wilkins 1990; 413.

Effect of Nerve Mobilization on Vibration Perception
Threshold in Diabetic Peripheral Neuropathy
Pankaj Preet Singh1, Supreet Bindra1, Sandeep Singh2, Rohit Aggarwal3, Jagmohan Singh4
1
MPT Student, 2Lecturer, Punjabi University, Patiala, 3Consultant Endocrinologist, Amar Hospital, Patiala,
4
Professor & Principal, Gian Sagar College of Physiotherapy, Banur, Patiala.
ABSTRACT
Purpose of the study: To determine the effects of Nerve Mobilisation on Vibration Perception
Threshold (VPT) in Diabetic Peripheral Neuropathy.
Materials and Methods: 30 male subjects with VPT > 25, mean height of 175.93 and mean weight of
82.53 kg on the basis of thorough assessment and after signing informed consent were randomly
divided into experimental and control group. The vibration perception Threshold was measured on
all the four points on the plantar aspect of the foot i.e. pulp of the toe and 1st, 3rd and 5th metatarsal
heads bilaterally for both the groups on Day 1 prior to treatment.
The subjects in the experimental group were given Tibial nerve mobilization bilaterally. This procedure
was continued for a total of 21 days. The subjects in the control group were not given any intervention.
Dependent Variables: VPT readings at great toe and 1st, 3rd and 5th metatarsal head.
The subjects in both the groups were reassessed for Vibration Perception Threshold on the 21st Day.
The post- test measurements of VPT were then compared with the pre - test ones and the appropriate
data analysis was done.
Results: It was found that the subjects who were given tibial nerve mobilization showed reduction
in VPT scores .
Conclusion: Nerve mobilisation may be an effective technique for delaying the diabetes related
peripheral neuropathy, if detected at its earlier stages. This will ultimately help in preservation of the
vibration sense of the foot and consequently reduce or delay the incidence of the devastating effects
such as foot ulceration which may lead to foot amputation.
Key words: Diabetic Peripheral Neuropathy, Vibration Perception Threshold, Nerve Mobilization.
INTRODUCTION for ulceration and subsequent lower extremity

amputations5.
Diabetic Peripheral Neuropathy (DPN) is a common
complication estimated to affect 30-50% of individuals The lifetime risk of a person with diabetes
with diabetes. Chronic sensorimotor distal symmetrical developing a foot ulcer may be as high as 25% whereas
polyneuropathy is the most common form of Diabetic the annual incidence of foot ulcers is 2% 6 . Non
Peripheral Neuropathy. Polyneuropathy can lead to traumatic lower-extremity amputations are a
sensory loss, muscle weakness and pain1,2. The typical devastating complication of diabetes. As many as 15%
presentation includes burning sensation and numbness of people with diabetes will have such amputations
in the feet. The onset is so gradual that the disease may during their lifetime.
go undetected for years. Neuropathic pain may be
severe when present; however it is reported to occur in AIMS OF THE STUDY
only 11.1% to 32% of individuals with polyneuropathy3,4.
Diabetic Peripheral Neuropathy leads to a number of To determine the effects of Nerve Mobilisation on
impairment and functional limitations, individuals with Vibration Perception Threshold in Diabetic Peripheral
Diabetic Peripheral Neuropathy are at highly vulnerable Neuropathy.
39. Pamkaj Preet Singh 6th aug 10 (195-201).pmd

195 10/16/2012, 2:41 PM
METHODOLOGY 1. Dorsiflexion of the foot,

2. Eversion of foot along with extension of the toes
30 male subjects with the Vibration Pressure and stretch on the plantar fascia, followed by
Threshold > 25, mean height of 175.93 cm (SD: 6.87) 3. Straight leg raise (amplitude was adjusted
and mean weight of 82.53 kg (SD: 9.29) on the basis of according to the subjects response to stretch).
thorough assessment and with the following criteria
were recruited from the outpatient department at The tibial nerve was mobilized for a total duration
Amar Hospital, Patiala. of 10 minutes once in a day. Each repetition was held
for a duration of 30 seconds with one minute rest
Inclusion Criteria
interval between them. This procedure was continued
1. Age 40-65yrs
for a total of 21 days.
2. Vibration perception threshold e 25 volt
3. Subjects having diabetes since three years. The subjects in the Control group were not given
4. Presence of bilateral distal peripheral neuropathy any intervention. The subjects in both the groups were
5. Subjects on antihyperglycemic drug (glimepride) reassessed for Vibration Perception Threshold on the
6. Type-2 Diabetes Mellitus. 21st Day. All the subjects were educated about the foot
care and no follow up was kept. The post- test
Exclusion Criteria
measurements of VPT were then compared with the
1. Poor glycemic control.
pre - test ones and the appropriate data analysis was
2. Bakers cyst
done.
3. Autonomic disease
4. History of Trauma
5. Any neurological disorder
6. Leprosy/ skin disease
7. Nerve sheath ganglia
8. Any skin lesion
9. Claudication
10. Smoking
11. Alcohol
12. Allodynia.
The subjects who met the inclusion/exclusion

criteria were made to sign an informed consent & then
randomly recruited to following groups:
Group I : Experimental group
Group II: Control group Fig. 1. The Vibration Perception threshold reading at great toe.
The vibration perception threshold was measured

on day 1 prior to treatment for which the subject was
made to lie supine on the treatment couch. His both
feet were exposed and examined for the presence of
any skin lesion. Then the machine was held with the
traction balanced vertically on the various points of
the foot such as pulp of the toe and 1st, 3rd and 5th
metatarsal heads bilaterally. After this the voltage was
gradually increased on the base unit until the patient
could perceive the vibration. If the subject was unable
to detect the vibration at the maximum voltage of 50
Volts, then a value of 51 Volts was used for statistical
analysis. A value of 25 Volts and above was considered
as indicative of a subject at the risk of foot ulceration.
Tibial Nerve Mobilisation

The subject was made to lie supine on the treatment
couch. The tibial nerve mobilization was given in the
Fig. 2. Tibial Nerve Mobilisation (Dorsiflexion+Eversion+SLR)
following steps for each foot.

196 10/16/2012, 2:41 PM
DATA ANALYSIS For the right 3rd metatarsal head, the t value (1.535)
is statistically non significant.
Paired t test was used to calculate the significant
difference between pre and post intervention within For the left 3rd metatarsal head, the t value (1.306)
same group & Unpaired t test was used to calculate is statistically non significant.
the difference between pre and post intervention in
different groups.
RESULTS
For the right great toe, the t value (1.429) is

statistically non significant.
For the left great toe, the t value (1.149) is

Graph 3. VPT (V) values on the initial (1st day) and final (21st
day) in the control group Right and Left 3rd metatarsal head.
For the right 5th metatarsal head, the t value (1.636)

is statistically non significant.
For the left 5th metatarsal head, the calculated t

value (1.006) is statistically non significant.
Days
day) in the control group Right and Left great toe.
For the right 1st metatarsal head, t value (2.416) is

greater than the critical value of t (2.14) this indicates
that the differences between two value is statistical
significant.
For the left 1st metatarsal head, t value (0.650) is

day) in the control group Right and Left 5th metatarsal head.
For the right great toe, the t value (5.557) is greater

than the critical value of t (4.140) which shows
statistically highly significant changes.
For the left great toe, the t value (2.499) is greater

Graph 2. VPT (V) values on the Initial (1st day) and Final (21st than the critical value of t (2.14) ) which shows
day) in the control group Right and Left 1st metatarsal head. statistically highly significant changes.

197 10/16/2012, 2:41 PM
Graph 5. Comparison of Pre and Post Vibration Perception

Threshold (VPT) values (volt) Pre and post tibial nerve Graph 7. Comparison of Pre and Post Vibration Perception
mobilization(both) for right and left great toe. Threshold (VPT) values (volt) Pre and post tibial nerve
mobilization (both) for Right and Left 3rd Metatarsal head.
For the right1st metatarsal head, the calculated t
value (3.748) is greater than the critical value of t (2.977) For the right 5th metatarsal head the t value (3.062)
which shows statistically significant changes. is greater than the critical value of t (2.977) which shows
statistically highly significant changes.
For the left 1st metatarsal head, the calculated t value
(5.244) is greater than the critical value of t (4.140) For the left 5th metatarsal head the the critical value
which shows statistically significant changes. of t (4.140) which shows statistically highly significant
changes.
Graph 8. Comparison of Pre and Post Vibration Perception

Graph 6. Comparison of Pre and Post Vibration Perception Threshold (VPT) values (V) Pre and post Tibial nerve
Threshold (VPT) values (volt) Pre and post tibial nerve mobilization (both) for Right and Left 5th Metatarsal head.
mobilization (both) for Right and Left 1st Metatarsal head.
For the right 3rd metatarsal head, the t value (2.285) At right great toe, the difference in value of t is
is greater than the critical value of t (2.145) which shows (4.677) is greater than the critical t value (3.674) which
statistically significant changes. shows statistically highly significant changes.
For the left 3rd metatarsal head, the t value (4.181) At left great toe, the difference in the value of t is
is greater than the critical value of t (4.140) which shows (3.081) is greater than the critical t value (3.674) which
statistically highly significant changes. shows statistically highly significant changes.

198 10/16/2012, 2:41 PM
Graph 11. Compares the difference between initial and final VPT
(V) scores for control and experimental group at right and left
3rd metatarsal head.
great toe.
At right 5ths metatarsal head, the difference in the
value of t is (3.555) is lesser than the critical t value
At right 1st metatarsal head, the difference in the (3.674) which shows statistically highly significant
value of t is (4.517) is greater than the critical t value changes.
(3.674) which shows statistically highly significant
changes. At left 5th metatarsal head, the difference in the
value of t is (5.989) is greater than the critical t value
At left 1st metatarsal head, the difference in the value (3.674) which shows statistically highly significant
of t is (3.081) is greater than the critical t value (3.674) changes.
which shows statistically highly significant changes.
5th metatarsal head.
(V) scores for control and experimental group at right and left 1st
metatarsal head.
DISCUSSION
At right 3rd metatarsal head, the difference in the
This study was conducted on the subjects having
value of t is (3.159) is lesser than the critical t value
type 2 diabetes mellitus. The study was carried out
(3.674) which shows statistically highly significant
for 21 days. Compliance of the subjects for such a
changes.
period was a problem especially in the light of the fact
At left 3rd metatarsal head, the difference in the that some patients may not be able to control their
value of t is (4.324) is greater than the critical t value sugar levels as per the standards of Medical Council
(3.674) which shows statistically highly significant of India. The various reasons for this could be
changes. psychological stress, lack of diet control, sedentary life

199 10/16/2012, 2:41 PM
style and the resistance of the body to the drugs. This diabetic peripheral neuropathy using VPT
loss of glycemic control can lead to macro and micro measurements followed by mobilization of whole
vascular complications such as Retinopathy, Peripheral length of tibial nerve so that the progressive nature of
neuropathy, Nephropathy, Cerebrovascular accidents the neuropathy can be delayed up to some extent.
(stroke), Coronary artery disease. The present study
is an attempt to know the effects of nerve mobilization Lundborg, (1970) in their study concerning the
in diabetic peripheral neuropathy which may help effect of stretching on peripheral nerves has revealed
prevent its progression and overcome its devastating that blood supply is completely blocked when neural
effects such as foot ulcers. tissue is excessively stretched thus a procedure must
correspond to the patients condition and should never
The intragroup comparison indicates that there was cause pain. The number, duration, frequency of
a significant improvement in the Vibration Perception impulses is determined on the basis of subjects
threshold on all the four points bilaterally in the response. Similar procedure was followed in the
subjects of Experimental group at the end of 21st Day present study as amount of stretch was determined
whereas no significant changes were found in the by the subjects response.
control group except on 1st metatarsal head on right
side. Sarkari and Multani (2007) in their study have
found neural mobilization to be effective in reducing
The intergroup comparison indicates that there was pain and improving ROM.
a significant difference of Vibration Perception
Threshold in the experimental group as compared to Antonella et al., (2002) have concluded that both
the control group. the rearfoot and forefoot pressures are increased in the
diabetic neuropathic foot, however, forefoot is more
The findings of the study were supported by involved in severe diabetic neuropathy which leads
Robert and Butler, (2005). In their review article they to foot ulceration. Keeping this in view in the present
have summarized that the symptoms associated with study we have attempted to mobilize the tibial nerve
peripheral neuropathy are produced by sensitized as it branches to supply most of the forefoot which is
nociceptors in neural connective tissues, a sensitized susceptible to foot ulceration.
pain neuromatrix, myelin changes and axonal
degeneration. The consequent endoneural edema and CONCLUSION
intraneural fibrosis leads to marked degradation in
myelin content and axon structure. They proposed that The conclusion of the present study is that nerve
neurodynamic mobilization techniques can be effective mobilization may be an effective technique for
in addressing peripheral neuropathic states. It is delaying the diabetes related peripheral neuropathy,
hypothesized that these therapeutic movements can if detected at its earlier stages. This will ultimately help
have a positive impact on symptoms by improving in preservation of the vibration sense of the foot and
intraneural circulation, axoplasmic flow, neural consequently reduce or delay the incidence of the
connective tissue, viscoelasticity and by reducing devastating effects such as foot ulceration which may
sensitivity of abnormal impulse generating sites. This lead to foot amputation.
may have lead to changes in the VPT in the present
study. REFERENCES
1. Boulton AJ (1997) Foot Problems in Patient With
Gary et al., (1993) have found that peripheral nerves
Diabetes Mellitus. In: Pickup J, Williams G ed.
healed faster when they were stretched. On histological
Textbook of Diabetes. London. United Kingdom:
assessment they confirmed an increase in myelin
Blackwell Science: 1-58.
synthesis. This finding may account for the 2. Boulton AJM., Kubrusly DB, Bowker JH, Skyler
improvements seen in the present study. JS and Sosenko JM (1986) Impaired vibratory
perception and diabetic foot ulceration. Diabet
In their study on principles of Michael et al., (2007)
Med. 3: 335-337.
have recommended that neuromobilization be
3. Vinik AL, Master RE, Mitchell BD and Freeman
performed in the earliest possible stage of disease i.e.
R (2003) Diabetic Autonomic Neuropathy. Diabet
before the occurrence of irreversible morphological Care. 26: 1553-1579.
changes. Neuromobilization should involve the entire 4. Vinik AL, Park TS, Stansberry KB and Pitteneger
length of the nerve trunk. In the present study an GL (2000) Diabetic neuropathies. Diabetolgia: 43:
attempt has been made to detect the early changes of 957-973.

200 10/16/2012, 2:41 PM
5. Apelqvist J, Larsson J and Agardh CD (1993) 14. Sarkari E and Multani NK (2007) Efficacy of
Long-term prognosis for diabetic patients with Neural mobilisation in India. J Execise Science
foot ulcers. J inter med. 233, 485-491. Physiother. 3(2): 136-141.
6. Singh N, David G and Benjamin A (2005) 15. Colette R, Jane G and Nicola J (2004) Effect of
Preventing Foot Ulcers in Patient with Diabetes. straight leg raise examination and treatment on
JAMA. 293: 217-228. vibration thresholds in the lower limb: a pilot
7. Baker PF, Ladds M and Rubinson KA (1977) study in asymptomatic subjects, Manual Therapy,
Measurement of the flow properties of isolated 10: 2: 136-143.
axoplasm in a defined chemical environment 16. Antonella C, Hau P, Johan M, David G and
Journal Physiology. 269(1): 10-11. Aristidis V (2002) The Forefoot to Rearfoot Plantar
8. Robert J and David Butler (2006) Management of pressure Ratio is increased in severe Diabetic
peripheral neuropathic pain: Integrating Neuropathy and Can predict Foot Ulceration.
neurobiology, neurodynamic and clinical Diabet Care 25: 1066-1071.
evidence. Physical Therapy in Sports.7: 36-49. 17. Abe Y, Doi K and Kawai (2005) An experimental
9. Gary D, Hall GD, Van Way CW and Kung FT model of N erve adhesion in rabbits. British
(1993) Peripheral nerve elongation with tissue Journal of Plastic Surgery, 58(4): 533-540.
expansion techniques, J Trauma, 34(3): 401-405. 18. Andrew JM, Boulto, RA, Malik, JC and Jay M S
10. Michal D, Dariusz B, Izabela K and Zbigniew W (2004) Diabetic Somatic Neuropathies. Diabet
(2007) Principles of neuromobilization for Care. 27: 1458-1486.
treating musculoskeletal disease. Medsportpress, 19. Butler D (2005) The neurodynamic techniques.
2(6); 9: 111-121. Adelaide, Australia: Noigroup Publication.
11. Lundborg G and Dahlin LB (1992) The 20. Butler D (1991) Mobilisation of the nervous
pathophysiology of nerve compression. Hand system Melbourne, Australia: Churchill
Clinic, 8(2): 215-27. Livingstone.
12. Lundborg G and Ryedvik B (1973) Effects of 21. Cade WT (2008) Diabetes related Microvascular
stretching the tibial nerve of the rabbit: a and Macrovascular disease in the Physical
prelimnary study of the intraneural circulation Therapy setting. Physical therapy, 88: 1322-1335.
and the barrier circulation of the perineurium. J 22. Young MJ, Breddy JL, Veves A and Boulton AJ
Bone Joint Surg. 55: 390-401. (1994) The Diabetic Neuropathic Foot Ulceration
13. Lundborg G (1988) Intraneural microcirculation. using Vibration Perception Thresholds. A
Journal Orthop Clin North Am,19(1): 1-12. prospective study. Diabet Care. 17(6): 557-560.

201 10/16/2012, 2:41 PM
A Study of Immediate Effects of Taping in Patients with

Knee Osteo-arthritis
Pooja Arora1, Shilpa Arya2, Sujata Yardi3

1 3
Lecturer, Professor & Director, Pad. Dr. D.Y. Patil College of Physiotherapy Nerul, Navi Mumbai
ABSTRACT
Introduction:
Osteoarthritis - or degenerative joint disease (DJD) - is a common rheumatological disorder. In view

of limited cure of the disease, management of symptoms is the mainstay of treatment which aims at
reducing pain and limiting functional impairments. Knee taping is believed to relieve pain by
improving alignment of the patello-femoral joint and/or unloading inflamed soft tissues.
Material & Method:
Aims & Objectives: To study the immediate effects of taping on pain in patients with osteoarthritis
of the knees by assessing the VAS score on four activities of daily living: walking, squatting,
ascending and descending stairs and on functional disability tests like walking speed, Time Get
Up and Go test and step test.
Study Design: Hospital based Longitudinal Study
Subjects:
Inclusion criteria: Patients with unilateral or bilateral knee pain, clinically and radiologically
diagnosed grade 1 and grade 2 osteoarthritis, (according to Kellgren and Lawrence classification)
as patello-femoral and/or tibio-femoral osteoarthritis of knees were included. Exclusion criteria:
Knee instability, acute stage osteoarthritis, Rheumatoid and other knee arthritis.
Study Factors:
Intervention: Patellar Taping by McConnell technique and Tibio-femoral taping by Mulligan

Technique.
Outcome factors: Post taping Pain measurement by VAS Scale, Observed Disability Measures like
TUG (Timed Get Up and Go test), Walking speed, and Step test.
Results: Sixty subjects enrolled with mean age of 57.17 years. Pain relief using VAS scores on the
4 activities i.e. walking, squatting, ascending stairs and descending stairs, TUG scores, Step test scores
and Walking Speed showed statistically significant improvements after taping in both unilateral and
bilateral OA knee subjects.
Conclusion: Knee taping significantly improve pain and disability in individuals with osteoarthritis
of the knees as an immediate effect.
Key words: Knee Osteoarthritis, Taping, McConnell Technique, Mulligan Technique
INTRODUCTION
Pooja Arora Akhtar, Osteoarthritis is a common degenerative joint
2A, Achraj Towers I, Y Point, Chaoni, disease affecting approximately 4% of the worlds
Nagpur 440013 populace, predominantly observed at the age of 50
Mobile: 098665038090 years in men and 40 years in women. Pain and physical
40. Pooja Arora Akthar 15th june 11 (202-207).pmd

202 10/16/2012, 2:41 PM
disability are apparent in almost half of the patients Study Factors

with radiographic disease 1. Since limited progress has History and clinical examination regarding
been made towards curing the disease, management swelling, posture, gait of patient, patellar
of symptoms is the mainstay of treatment which aims tracking and rotational abnormalities were
at reducing pain and limiting functional impairments.2 noted.
Clarkes test was performed to confirm patello-
The patello-femoral compartment in knee
femoral arthritis.
osteoarthritis can cause severe pain, particularly when
the patient is using stairs, squatting, or kneeling. Mal- INTERVENTION
alignment of the patella, with consequential abnormal Taping for patella
force distribution on the lateral facet, is the cause of Before taping, patellar shifts, tilts, rotations were
this symptom.3 Knee taping relieves pain by improving checked. The restricted glides were noted and
alignment of the patello-femoral joint and/or the patella was taped accordingly. McConnell
unloading inflamed soft tissues. Taping benefits not medial patella taping was done to realign the
only pain but various physical impairments in patients patella. In addition, a second strip of tape was
with Patello-femoral Pain Syndrome2, 4. The present applied to correct tilts. (Figure 1)
study evaluates the effectiveness of knee taping in Mulligan taping for the knee
improving the disability in knee OA via beneficial A diagonal tape was applied as per the Mulligan
effects on pain and physical impairments. method of taping the knee. (Figure 2)
MATERIAL & METHODS
Aims & Objectives

To evaluate the immediate effect of taping on
pain in patients with osteoarthritis of the knees
by assessing the VAS score on four activities of
daily living: walking, squatting, ascending stairs
and descending stairs.
To evaluate the immediate effects of taping on

the walking speed, Timed Get Up and Go test
and step test in patients with osteoarthritis of
the knees.
Study design
This was a Tertiary care Hospital based Lateral View Anterior View
Longitudinal Study Fig. 1. Mulligan Taping For The Knee
Subjects:
Inclusion criteria
Clinically and radiologically diagnosed cases of

patello-femoral and tibio-femoral osteoarthritis of both
Unilateral and bilateral knees were included.
Exclusion criteria
1. Knee instability
2. Acute stage osteoarthritis
3. Grade 3 and 4 osteoarthritis
4. Rheumatoid arthritis
5. Psoriatic arthritis
6. Gout
7. Previous knee surgery
8. Cutaneous diseases preventing taping Fig. 2. McConnell Medial Patella Taping

203 10/16/2012, 2:41 PM
OUTCOME FACTORS squatting, ascending stairs and descending stairs was

Pain measurement done prior to taping and improvement in pain was
Pain relief was assessed on 0-10 Visual evaluated immediately. The pain scores showed
Analogue Scale (VAS) on each of the four statistically significant improvements after taping.
activities: walking, squatting, ascending stairs (Table 1)
and descending stairs.
Table 1. Showing Improvement in the VAS on walking,
Observed Disability Measures: squatting, ascending stairs and descending stairs in
Walking speed Unilateral OA knee
Parameters N Mean Standard Error Standard t value p value
Reduced gait velocity is a common feature of Deviation
loco motor disability in knee OA, walking Pre Post Pre Post Pre Post
speed was measured at a self-selected pace on Walking 30 5.017 2.567 0.3718 0.2418 2.036 1.324 10.466 < 0.0001
(HS)
a level surface. Participants walked bare- Squatting 30 6.417 3.833 0.3270 0.2997 1.791 1.642 13.060 < 0.0001
footed along an 8m walkway. A stopwatch was (HS)
used and the distance covered by the patient Ascending 30 5.733 2.933 0.4412 0.3241 2.417 1.775 8.764 < 0.0001
Stairs (HS)
in 1 minute was noted. Walking velocity was Descending 30 5.467 2.767 0.4308 0.3123 2.360 1.711 10.386 < 0.0001
calculated by the formula distance/time in Stairs (HS)
meters/second.2
The Observed disability measures i.e Timed Get
Step test Up and Go Test (TUG), Step Test and Walking Velocity
Step test is a functional, dynamic test of showed statistical improvement in all 3 disability
standing balance with known reliability and measures, post-taping. (Table 2)
validity. Bare-footed in front of a 15 cm step, Table 2. Improvement in the TUG, Step test and Walking
participants stood on the osteoarthritic limb, Velocity in unilateral OA knee
whilst stepping the opposite foot on and off Parameters N Mean Standard Error Standard t value p value
the step as many times as possible over 15 Deviation
seconds. The number of times the participant Pre Post Pre Post Pre Post
could place the foot on to the step and return TUG Test 30 13.413 10.970 0.7122 0.6242 3.901 3.419 8.526 < 0.0001
(HS)
it to the floor was recorded, with higher scores Step Test 30 6.900 8.667 0.2267 0.2726 1.242 1.493 12.504 < 0.0001
indicating better balance. (HS)
Walking 30 0.7903 0.9547 0.02652 0.03378 0.1452 0.1850 10.574 < 0.0001
Timed up and go (TUG) velocity (HS)
TUG is a validated and reliable test of function Bilateral Osteoarthritis

in older individuals. Participants were
instructed to rise from a standard arm chair, Statistically significant improvements in Pain
walk for 3 meters, come back and return to Scores (Table 3) and observed disability measures
the chair and sit down again, whilst being (Table 4) were observed post tapping in Bilateral
timed by a stop watch. Participants performed Osteoarthritis cases also.
the test barefoot, once only and at their own
pace. Table 3. Improvement in the VAS on walking, squatting,
ascending stairs and descending stairs in Bilateral OA
Knee
STASTICAL ANALYSIS
Parameters N Mean Standard Error Standard t value p value
The pre and post taping parameters were compared Deviation
Pre Post Pre Post Pre Post
using parametric Students t-test for statistical change
Walking 30 5.967 4.250 0.3939 0.4045 2.157 2.216 9.428 < 0.0001
in the outcome. (Right) (HS)
Walking 30 6.083 4.283 0.3524 0.3463 1.930 1.897 10.883 < 0.0001
FINDINGS (Left) (HS)
Squatting 30 7.100 5.533 0.3694 0.3737 2.023 2.047 7.560 < 0.0001
Total 60 subjects were enrolled with the mean age (Right) (HS)
of 57.17 years, with range 35-95 years and male female Squatting 30 7.000 5.300 0.3620 0.3625 1.983 1.985 8.823 < 0.0001
(Left) (HS)
ratio of 1:4.
Ascending 30 6.633 4.867 0.3850 0.3850 2.109 2.109 9.231 < 0.0001
Stairs(Rt) (HS)
UNILATERAL OSTEOARTHRITIS Ascending 30

Stairs(Left)
6.533 4.733 0.3737 0.3712 2.047 2.033 8.523 < 0.0001
(HS)
Pain Relief Descending 30

Stairs(Rt)
6.900 4.900 0.4189 0.4127 2.295 2.261 9.270 < 0.0001
(HS)
Descending 30 6.650 4.833 0.3754 0.3747 2.056 2.052 7.966 < 0.0001
Pain relief using VAS on the 4 activities i.e. walking, Stairs(Left) (HS)

204 10/16/2012, 2:41 PM
Table 4. Showing Improvement in the TUG, Step test repositioned, the associated reduction in pain
and Walking Velocity in Bilateral OA knee cases experienced by the individual may allow a more
Parameters N Mean Standard Error Standard t value p value comfortable quadriceps contraction.
Deviation
Pre Post Pre Post Pre Post
Another hypothesis is that patellar taping improves
TUG Test 30 15.057 11.957 1.175 0.5254 6.433 2.878 4.101 =0.0003
(HS) proprioception and the sense of mechanical stability
Step Test 30 7.133 8.500 0.3242 0.3135 1.776 1.717 9.256 <0.0001 of the patella to promote normal knee function.10 Under
Right (HS)
Step Test 30 6.933 8.433 0.2874 0.3058 1.574 1.675 10.019 <0.0001
the influence of patellar taping, altered afferent input
Left (HS) from the muscular, ligamentous, articular, and
Walking 30 0.7413 0.9183 0.02888 0.03326 0.1582 0.1822 10.938 < 0.0001 Cutaneous structures in and around the patello-
velocity (HS)
femoral joint may improve proprioceptive functions
DISCUSSION in patients with patello-femoral pain syndrome. 22,24,25
The improved knee joint biomechanics, such as
Knee osteoarthritis is prevalent worldwide.5,6 and extensor moment and power, quadriceps torque, and
almost half of the patients with radiological disease knee flexion angles, have been reported in several
have symptoms like pain and physical disability.7 The studies.9,17-19 The altered neural input implicated in
interventions range from oral medications, these findings does not necessarily equate with
physiotherapy management to knee replacement. The improved muscle function, but it does appear that
conservative management is aimed to reduce pain and patellar taping is associated with an increased ability
limit functional impairment, which needs inexpensive to generate muscle performance regardless of the
interventions with minimum side effects. Knee taping mechanism of pain alteration, it does appear that
is one such strategy which has been evaluated in the clinicians may effectively and immediately reduce
present study. patello-femoral pain with patellar taping.
Knee taping improves disability by its beneficial Dynamic standing balance, as evaluated by Step
effects on pain and physical impairments and test, also improved significantly in the present study,
improving quadriceps force, knee joint kinematics and which is similar to Hinman study.2 This improvement
onset timing of vasti,8-12 which was observed in the could not be attributed to concurrent pain reduction
present study, as evaluated by VAS on four activities but could be due to sense of support after therapeutic
namely walking, squatting, ascending stairs and tape which improves confidence in knee, resulting in
descending stairs in both unilateral and bilateral taking more steps with contra lateral limb or limb with
osteoarthritis. less pain while standing on symptomatic limb. Similar
improvement was noted in the study done by P.L. Chen
Patello-femoral joint degeneration predominantly et. al.26, wherein it was concluded that taping can
affects the lateral compartment, leading to patellar mal- reduce pain and improve the ratio of Vastus Medialis
alignment, and this is in turn associated with increased Oblique/Vastus Lateralis for the mechanism of patellar
peak patello-femoral contact pressures and loading of stability in patients with patello-femoral pain
the lateral facet. Therapeutic tape may ease pain by syndrome during stair climbing.
improving patellar alignment.13-18 Taping may provide
neural inhibition via large fiber input to the anterior Timed Up and Go test and walking velocity, also
knee because large fiber input sensory signals are show significant improvement in the present study.
transmitted faster to the brain than pain signals, the Powers et al18, investigated the effects of patellar taping
large fiber input from the tape may override the pain on stride characteristics and joint motion in patients
signals. Therefore the patient may experience a with patello-femoral pain syndrome. Patellar taping
decrease in the perceived pain. Obviously, this is had a small but statistically significant increase in
speculative and further study is needed to determine loading-response knee flexion under all conditions.
the effect of patella taping on neural inhibition (eg. The authors stated that this increase in loading-
Hoffman reflex). 19 Some have suggested that the response knee flexion may have enhanced the patients
mechanical advantage of the quadriceps is maximized willingness to load the knee joint, which may improve
because of increased leverage by the patella via a shock absorption, quadriceps activity, and tolerance
medial shift as it returns to the trochlear groove of the to increased patello-femoral joint reaction force.
femur.20-23
Our study have limitations like absence of a
Although a mechanical advantage may be comparative group, non calculation of sample size and
achieved by the quadriceps when the patella is not providing rest time between test conditions. The

205 10/16/2012, 2:41 PM
cumulative effect of multiple testing procedures could 9. Powers CM, Landel R, Sosnick T et al. The effects
have resulted in participant fatigue and symptom of patellar taping on stride characteristics and
exacerbation causing alterations in the results. joint motion in subjects with patellofemoral pain.
Journal of Orthopaedic & Sports Physical
CONCLUSION Therapy 1997; 26: 286-291.
10. Ernst GP, Kawaguchi J, Saliba E. Effect of patellar
To conclude knee taping significantly improve pain taping on knee kinetics of patients with
and disability in individuals with osteoarthritis of the patellofemoral pain syndrome. Journal of
knees as an immediate effect. Knee taping is a simple Orthopaedic & Sports Physical Therapy 1999; 29:
and inexpensive strategy. It provides an additional 661-667.
option to physiotherapists in conservatively managing 11. Gilleard W, McConnell J, Parsons D. The effect
osteoarthritis of the knees. Knee osteoarthritis is a of patellar taping on the onset of vastus medialis
obliquus and vastus lateralis muscle activity in
chronic disease, hence evaluation of long term effects
persons with patellofemoral pain. Physical
of knee taping is recommended.
Therapy 1998; 78: 25-32.
Conflict of Interest: None 12. Werner S, Knutsson E, Eriksson E. Effect of taping
the patella on concentric and eccentric torque and
EMG of knee extensor and flexor muscles in
BIBLIOGRAPHY
patients with patellofemoral pain syndrome.
1. Carol & Richard Eustice. About.com Guide to Knee Surgery, Sports Traumatology, Arthroscopy
arthritis [Online]. 2010 April 09. Available from: 1993; 1: 169-177.
URL:http://osteoarthritis.about.com/od/ 13. McAlindon TE, Snow S, Cooper C, Dieppe PA.
osteoarthritis101/a/what_is_OA.htm Radiographic patterns of osteoarthritis of the
2. Hinman RS, Bennell KL, Crossley KM, knee joint in the community: The importance of
McConnell J. Immediate effects of adhesive tape the patellofemoral joint. Annals of the Rheumatic
on pain and disability in individuals with knee Diseases 1992; 51: 844-849.
osteoarthritis. Rheumatology 2003; 42: 865-869. 14. Ledingham J, Regan M, Jones A, Doherty M.
3. J Cushnaghan, C McCarthy, P Dieppe. Taping the Radiographic patterns and associations of
patella medially: a new treatment for osteoarthritis of the knee in patients referred to
osteoarthritis of the knee joint. BMJ 1994; 308: 753- hospital. Annals of the Rheumatic Diseases 1993;
755. 52: 520-526.
4. Rana S Hinman, Kay M Crossley, Jenny 15. Iwano T, Kurosawa H, Tokuyama H, Hoshikawa
McConnell, Kim L Bennell. Efficacy of knee tape Y. Roentographic and clinical findings of
in the management of osteoarthritis of the knee: patellofemoral arthritis. Clinical Orthopaedics
blinded randomized controlled trial. BMJ 2003 Jul and Related Research 1990; 252: 190-197.
19; 327: 135. 16. Elahi S, Cahue S, Felson DT, Engelman L, Sharma
5. Felson DT, Naimark A, Anderson J, Kazis L, L. The association between varusvalgus
Castelli W, Meenan RF. The prevalence of knee alignment and patellofemoral osteoarthritis.
osteoarthritis in the elderly. The Framingham Arthritis & Rheumatism 2000; 43: 1874-1880.
Osteoarthritis Study. Arthritis Rheum 1987;30: 17. Harrison MM, Cooke TDV, Fisher SB, Griffin MP.
914-918. Patterns of knee arthrosis and patellar
6. Bagge E, Bjelle A, Eden S, Svanborg A. subluxation. Clinical Orthopaedics and Related
Osteoarthritis in the elderly: clinical and Research 1994; 309: 56-63.
radiological findings in 79 and 85 year olds. 18. Grabiner M, Koh T, Draganich L.
Annals of the Rheumatic Diseases 1991; 50: 535- Neuromechanics of the patellofemoral
539. joint.Medicine and Science in Sports and Exercise
7. Odding E, Valkenburg HA, Algra D, 1994; 26: 10-21.
Vandenouweland FA, Grobbee DE, Hofman A. 19. Bockrath K., C. Wooden, T. Worrell, C.D.
Associations of radiological osteoarthritis of the Ingersoll, J. Farr. Effects of patella taping on
hip and knee with locomotor disability in the patella position and perceived pain. Med. Sci.
Rotterdam Study. Annals of the Rheumatic Sports Exerc. 1993; 25(9): 989-992.
Diseases 1998; 57: 203-238. 20. Lee Herrington. The effect of patella taping on
8. Handfield T, Kramer J. Effect of McConnell taping quadriceps strength and functional performance
on perceived pain and knee extensor torques in normal subjects. Physical Therapy in Sport
during isokinetic exercise performed by patients 2004; 5(1): 33-36.
with patellofemoral pain syndrome. 21. Herrington L. The effect of patellar taping on
Physiotherapy Canada 2000; 52: 39-44. quadriceps peak torque and perceived pain: a

206 10/16/2012, 2:41 PM
preliminary study. Physical Therapy in Sport 25. Salsich Gretchen B, Brechter Jacklyn H, Farwell
2001; 2: 23-28. Daniel, Powers Christopher M. The Effects of
22. Ng GYF, Cheng JMF. The effects of patellar taping Patellar Taping on Knee Kinetics, Kinematics, and
on pain and neuromuscular performance in Vastus Lateralis Muscle Activity During Stair
subjects with patellofemoral pain syndrome. Ambulation in Individuals With Patellofemoral
Clinical Rehabilitation 2002; 16: 821-827. Pain. Journal of Orthopaedic & Sports Physical
23. Callaghan MJ, Selfe J, Bagley PJ, Oldham JA. The Therapy 2002 Jan; 32(1): 3-10.
Effects of Patellar Taping on Knee Joint 26. P.L. Chen, Wei Hsien Hong, C.H. Lin, W.C. Chen.
Proprioception. Journal of Athletic Training 2002 Biomechanics Effects of Kinesio Taping for
Jan-Mar; 37(1): 19-24. Persons with Patellofemoral Pain Syndrome
24. Christou EA. Patellar taping increases vastus during Stair Climbing. Proceedings of the 4th
medialis oblique activity in the presence of Kuala Lumpur International Conference on
patellofemoral pain. Journal of Biomedical Engineering 2008, BIOMED 2008 Jun
Electromyography and Kinesiology 2004; 14: 25-28; Kuala Lumpur, Malaysia; Vol 21; 395-397.
495-504.

207 10/16/2012, 2:41 PM
The Effects of Upper Limb Exercises on Hand Writing

Speed
Nilukshika KVK1, Nanayakkarawasam PP2, Wickramasinghe VP3

1
Undergraduate, Lecturer, Allied Health Science unit, 3Senior Lecturer Department of Paediatricss, Faculty of
2
Medicine, University of Colombo, Sri Lanka.
ABSTRACT
Introdution: Hand writing is an essential tool required by students. It is a complex process which
involves close coordination between musculo skeletal and nervous systems.
Objective: To assess the effectiveness of upper limb exercises on handwriting speed.
Methodology: An interventional prospective study involving undergraduate students. Structured

exercise programe was held five days a week (for about 20 minutes) for 4 weeks. Writing speed,
strength of palmar pinch grip and upper limb coordination was measured at beginning, two and
four weeks later.
Results: At the beginning hand writing speed was 23.9 wpm. The pinch grip strength and coordination
of upper limb were, 3.8kg and 8.6 (pegs/15 seconds) respectively. Exercise programme showed
statistical significant improvement in all 3 areas measured. There was a 21% improvement in hand
writing speed, 41.7% improvement in Pinch grip strength of dominant hand and 11.9% improvement
in upper limb coordination.
Conclusions: Uppers limb exercise programmes can be used to improve the hand writing speed.
Key Words: Upper Limb Exercise, Hand Writing Speed,
INTRODUCTION extremity, general health, mental acuity, writing

instrument and surface. 1 During the process of
Writing is one of the most unique features of handwriting most of the movements come from the
humans cultural development. Writing continues to forearm while shoulder provides the power with
be an essential life skill, in daily-life, as a form of minimum movement occurring at fingers and wrist.2
communication, archiving, expression of creativity and
knowledge. Therefore it is an essential skill one should Strength and flexibility of the muscles, the position
possess in todays context and it forms an integral part of the pen grip and the overall posture of the writer,
of a students life whether primary, secondary or affects the final output. The most common pen-holding
tertiary. position, is by keeping the pen between the index and
middle fingers, and held in place by the thumb using
Handwriting is a complex, fine motor skill, where palmar pinch grip. Joint position sensation is the most
fine, precise, coordinated movements occurs in the important factor in determine handwriting.2 Though
extremity. It is a complex integration of muscular, it seems paradoxical, since small muscles having better
skeletal and neurological systems together. Many control, the shoulder-girdle group, once trained, does
factors influence handwriting such as anatomy of the job better.2
Correspondence Address Handwriting speed varies with age. Study on a
Wickramasinghe VP group of Australian school children showed that hand
Department of Paediatrics, writing speed to be 33, 34, 38, 46 and 52 (wpm) for
University of Colombo, Kynsey Road,
students of grade 3, 4, 5, 6 and 7 respectively.3 It also
Colombo 08, Sri Lanka.
showed that skills such as word spacing and letter size
Tel: +94 112688748 Fax: +94 112691581
decreased gradually with advancing age.
(Email: pujithaw@yahoo.com)
41. pujitha (208-213).pmd 208 10/16/2012, 2:41 PM

Writing speed of teenagers improve rapidly parallel approved by the ethical review committee of faculty
to their physical maturity. Girls on average achieve a of Medicine, University of Colombo. Informed
maximum writing speed earlier than boys. The average written consent was obtained.
rate is 14.7 wpm for girls and 13.8 wpm for boys.4 A
range of writing speeds between 10 and 20 wpm is Writing speeds of the subjects were measured at
considered normal for normal a 15 year old. Hedderly the beginning, at two weeks and at the end (4 weeks)
called one with and an average speed of around 15- of the exercise programme. Exercises were designed
wpm as those pupils writing at a speed.5 Those with to strengthen the muscles involved in handwriting.12
a speed of 8 wpm or less will almost certainly be Each subject did ten types of exercises for about
handicapped. 5 20 min. on each day, 5 times a week (Appendix 1).
According to teacher estimates, approximately Strength of palmar pinch grip was measured using
11% to 12% of female and 21% to 32% of male school- pinch grip dynamometer13 and coordination of upper
aged children have handwriting difficulties.2 Slow limbs was measured by using Perdue peg board test,14
Handwriting may be due to delays in information at same time hand writing speed was measured. All
processing, difficulties with spelling, improper motor assessments were done by a single investigator
co-ordination and adopting labor intensive writing (KVKC).
styles6 Furthermore, research has indicated that slow Hand writing speed measurement
handwriting leads to avoidance of writing thus
resulting in low self-esteem, evading school work and Subjects were given a single audio recording in
possibly ending with learning difficulties and English medium, and were asked to transcribe on a
behavior problems.7 Better hand writing speeds will A4 sheet in two minutes. Test was done in a single
help in quick assimilation of knowledge and perform lecture room with similar writing surface and seating
well at examinations thus achieving higher academic facilities. At the end the number of words was counted
grades.8 However, unfortunately the efforts taken by and writing speed was calculated.
teachers, parents and students to improve hand
Pinch grip force measurement
writing skills and speed are poor and schools lack
necessary tools.5 Pinch Grip dynamometer, ranging from 0-10 Kg,
was used for the measurement. Subjects stood in up
Graham et al9 showed that training could improve
right posture in front of the examiner with shoulders
handwriting speed and legibility in Grades 1-9
abducted to 0 and neutrally rotated, elbow flexed to
students. Similar results were shown by Kao10 when
90 and the wrist and forearm kept in neutral position.
he studied a group of twelve undergraduates. Nadine
and co workers studies 16, first and second grade At each time three measurements of the pinch grip
Australian students in a handwriting training session of the dominant upper limb was measured. The
at school for 45 minutes once a week for 8 weeks and median value was obtained. A single dynamometer
showed that legibility, form, alignment, size, spacing, was used throughout the study.
and speed improved.11
Coordination measurement
This study attempts to find the effects of
strengthening and coordination exercises of distal The Perdue peg board was used for the
upper limb muscles on handwriting speed in a group measurement of coordination of dominant upper limb.
of undergraduate students of University of Colombo, Subject sat on a chair in upright posture in front of the
Sri Lanka. table. The non dominant hand was rested on the
ipsilateral thigh. The number of pegs placed on the
MATERIAL AND METHODS peg board in 15 seconds was measured. At each
occasion it was done three times and median value
Study design was taken. Same instrument was used throughout the
test. Both Pinch grip dynamometer and Perdue peg
The descriptive cross sectional experimental study
board test had been validated for such use.15
involving randomly selected 40 (20 male and 20
female physiotherapy undergraduate students of Data analysis
University of Colombo. Any student with a
congenital or acquired anatomical or functional defect Descriptive statistics were used to present data.
of either upper limb was excluded. The study was Measurements at the beginning and at the end were
41. pujitha (208-213).pmd 209 10/16/2012, 2:41 PM

compared using paired t- test. A p<0.05 (2-tailed test) increased to 5.31.9kg. Table 3 shows the data of the
was considered to be significant. Correlation between assessment of coordination of dominant upper limb
hand writing speed and exercise parameters were of the study population, Mean coordination of
calculated by Pearson rank order correlation. Data are dominant upper limb of study population was 8.61.5
presented according to gender as well as whole pegs/15sec. At the end of 4 weeks it improved to
population. Statistical analysis was done using SPSS 10.10.97 pegs/15sec.
version 17 for windows XP.
Table 4 shows the results of the comparison of the
RESULTS three measurements for the whole population at the
beginning and end of 4-week exercise programme. All
The study population consisted of 40 showed statistically significant improvement. When
physiotherapy undergraduate students (males 20). The data of individual genders were compared, they also
mean age of the study population was 23.4(1.1) years showed statistically significant improvement (data not
and the mean age of the male and female subjects were shown). Similar comparison was done for all three
23.2(1.1) and 23.6(1.0) years respectively. Thirty eight measurements at beginning and at 2 weeks after
were right hand dominant and 2 male subjects were commencement of the programme. They also showed
left hand dominant. statistically significant improvement in all 3 areas in
both gender groups (data not shown).
Table 1 shows the mean hand writing speed of the
study population and for each gender at different time The whole study group showed a 21.1%
intervals of the study period. At the beginning the improvement in hand writing speed with the male
overall mean hand writing speed was 23.95.1 wpm. subjects showing 25.1% and the female subjects
After four weeks of exercise it increased to 28.94.7 showing a 17.2% improvement. Pinch grip strength of
wpm. Table 2 shows the results of the Pinch grip the whole population improved by 41.7%.
strength analysis of the study population. Mean Pinch Improvement was higher in female students (44.9%)
grip strength of the dominant hand of the study than in male students (39.9%). Coordination of the
population was 3.81.7kg. At the end of 4 weeks it upper limb showed an 11.9% improvement in the
Table 1. Hand writing speed of all subjects, and by gender at beginning, midpoint and end of intervention.
Whole group Male Female
N 40 20 20
Mean(SD) Range Mean(SD) Range Mean(SD) Range
Beginning of study 23.9(5.1) 14.5-33.0 23.5(5.1) 15.0-31.0 24.3(5.1) 14.533.0
Middle of the study 26.8(4.5) 18.0-36.0 28.34(4.54) 21.0-36.0 25.3(4.01) 18.0-33.0
End of study period 28.9(4.7) 19.5-40.5 29.4(5.7) 19.5-40.5 28.5(3.54) 21.5-34.5
Table 2. Pinch grip strength of all subjects, and by gender at beginning, midpoint and end of intervention
Pre-Strength-All(kg) Pre-Strength- Male (kg) Pre-Strength- Female (kg)
N 40 20 20
Beginning of study 3.8(1.7) 1.0-7.0 4.8(1.5) 1.0-7.0 2.7(1.3) 1.0-5.5
Middle of the study 4.8(1.7) 1.5-8.0 5.8(1.4) 3.0-8.0 3.8(1.3) 1.5-6.0
End of study period 5.3(1.9) 2.0-8.5 6.7(1.3) 3.5-8.5 3.9(1.2) 2.0-6.0
Table 3. Coordination of the dominant hand of all subjects, and by gender at beginning, midpoint and end of
intervention.
Coordination All Coordination Male Coordination Female
(pegs/15sec.) (pegs/15sec.) (pegs/15sec.)
N 40 20 20
Beginning of study 8.6(1.5) 5-12 9.1(1.3) 7-12 8.1(1.6) 5-11
Middle of the study 9.7(1.3) 8-13 10.1(1.3) 9-13 9.3(1.2) 8-12
End of study period 10.1(0.97) 8-12 10.2(1.0) 8-12 10.1(0.94) 8-12
41. pujitha (208-213).pmd 210 10/16/2012, 2:41 PM

Table 4. Comparison of Pre and post (end of 4 weeks) hand writing speed, pinch grip strength and coordination for
the whole group.
Mean N SD SE Mean T Df p
Hand Writing Speed Pre 23.91 40 5.07 0.802
-7.876 39 <0.001
Post 28.95 40 4.71 0.745
Pinch grip strength Pre 3.77 40 1.72 0.272
-7.529 39 <0.001
Post 5.35 40 1.87 0.295
Coordination of the Pre 8.58 40 1.50 0.237
dominant hand -7.658 39 <0.001
Post 10.13 40 0.97 0.153
whole group and 12.7% and 24.07% in male and female speed and legibility need to be identified. In our study
respectively. All were statistically significant. all had clear hand writing but we did not make a
formal evaluation.
There were insignificant positive correlations
between hand writing speed with pinch grip strength Despite the small sample size, our data has
(r=0.052, p=0.752) and hand writing speed and upper confirmed that exercise improves hand writing.
limb coordination (r=0.218, p =0.176). Shoemaker et al, observed an 11.8% improvement in
handwriting speed after 18 exercise sessions.17 Similar
to our data Zivani and co workers reported higher
DISCUSSION hand writing speeds in boys.18 Pinch grip strength
showed a 41.7% (1.6kg) improvement (P<0.005)
Handwriting is an essential skill required in the following 4 weeks of exercise. Rogers and co workers
educational setting and the speed of handwriting will in their work showed an increase of 3.6 kg (p < 0.002)
have an impact on outcomes. 6 Only ten types of and 2.9 kg (p < 0.0005) in right and left hand isometric
exercises were included in our exercise programme grip respectively.19 Literature shows that function of
considering the feasibility and compliance. Exercises the hand can be improved by exercise not only in
were user friendly and participants enjoyed. There healthy individuals but also in disease conditions as
were no exercise related complications. well.15
Hand writing speed is commonly measured as the Although at the beginning, males (9.1 pegs/15
average number of words written per minute.16 Our seconds) demonstrated higher value of coordination
data were in agreement with data produced by than females (8.1 pegs/15 seconds), at the end of the
Graham and co workers.9 In that study females had a training programme females had a better coordination
higher handwriting speed (24.3 wpm) compared to than their male counterparts. The overall improvement
males (23.5 wpm). Also it was reported that legibility in coordination was 24.07% in females and 12.7% in
was higher in girls and speed was higher in right males. Work by Satheesha and co workers showed
handers than left handers. There were only 2 left improvement in dominant hand coordination in a
handers in our study and was not possible to compare. group of patients recovering from cerebral tumor.20 The
However, the two in our study showed considerable positive relationship between handwriting speed with
increase in writing speed (by 4 & 8 wpm) following pinch grip strength and upper limb coordination are
the exercise programme. The reason why a left hander in agreement with other studies.21
has a slower speed is not clear. Probably the direction
of writing could have made an influence. Conventional Due to many factors this study was confined to
writing direction, left to right, is set for the right hand 4 week duration and limited to 10 exercises. It would
person who will write away from the body, but a left be interesting to find out the outcomes by increasing
hand person has to write towards the body and that the duration of exercise period and also by changing
could make some obstruction during the latter part of the number of exercises and identifying the best. Less
completion of a line hindering the speed. Researching number of exercises would increase the compliance
more on this area would enable to identify appropriate and especially if such programmes are intended to
positioning of the hand and instruments to improve introduce to school children.
speed. Improved legibility may, however, result in
reduced speed, thus taking more time to complete an According to Peterson and Nelson, improving
assignment.9 Therefore, a correct balance between legibility should precede attempts to improve writing
41. pujitha (208-213).pmd 211 10/16/2012, 2:41 PM

speed. 22 Even thought current study focused on 3. Ziviani, J. Some elaborations on handwriting
handwriting speed it is important to identify legibility speed in 7- to 14-years old: Perceptions and.
which is an important component in handwriting Motor Skills.1984; 58(2): 535-539.
parameters perhaps difficult to correct at this age. 4. Alston J. Assessing and Promoting Writing Skills.
Nasen Publication.1995.
Summery 5. Hedderly R. Assessing Pupils with Specific
Learning Difficulties for Examination Special
Handwriting speed, pinch grip strength and upper Arrangements at GCSE, A-level and Degree-
limb coordination can be improved after upper limb level. Educational Psychology in Practice. 1996;
exercise programme. While males showed greater 12: 36-44.
improvement in handwriting speed, females 6. Wallen M, Bonney MA, Lennox L. The
demonstrated greater improvement in pinch grip Handwriting Speed Test. Adelaide, Helios
strength and upper limb coordination. Although not Art.1996.
significant, positive correlations were seen between 7. Berninger VW, Amtmann D. Preventing written
handwriting speed with pinch grip strength and upper expression disabilities through early and
limb coordination. These data need to be affirmed by continuing assessment and intervention for
studies involving more subjects from different age handwriting and/or spelling problems: Research
groups, especially primary school children to into practice. In H. L. Swanson, K. R. Harris, & S.
incorporate such training programmes in their school Graham (Eds.), Handbook of learning disabilities.
curricular. Similarly it would be interesting to study New York: Guilford. 2003; pp. 345-363.
8. Galbraith D, Roaf J, Rutherford SC., The role of
how such structured programmes would be useful in
handwriting in raising achievement [internet].
training individuals with different handicap states.
2009 [cited 2009 May 02]. Available from: http:/
Appendix 1- Types of exercises used in the /www.literacytrust.org.uk/research/
programme writingreviews.html
1. Strengthening exercise for Brachioradialis 9. Graham S, Berninger V, Weintraub N, Schafer W.
dumbell exercise Development of Handwriting Speed and
2. Strengthening exercise for wrist extensors - dumbell Legibility in Grades 1-9. Journal of Educational
Reseach. 1998; 92(1): 42-52.
exercise
10. Kao HSR. The Effects of Hand-Finger Exercise
3. Strengthening exercise for Biceps - dumbell exercise
on Human Handwriting Performance.
4. Coordination exercise for hand muscles crumble
Ergonomics.1973; 16: 171-175.
a piece of cloth 11. Nadine M, McCluskey A, Mayes R. The Log
5. Endurance exercise for hand muscles finger meld Handwriting Program Improved Childrens
6. Endurance exercise for hand and forearm muscles Writing Legibility: A PretestPosttest Study. The
praying exercise American journal of occupational therapy. 2010;
7. Endurance exercise for hand muscles straight 64(1): 30-36.
finger flexion 12. Singh I. Muscles of Upper Extremity. In Anatomy
8. Coordination exercise for hand muscles and Physiology for physiotherapists, New Delhi,
reciprocal movement of the fingers Jaypee Brothers. 2005; 197-217.
9. Coordination exercise for hand and forearm 13. Daniel ME, Froude EH. Reliability of
muscles drawing exercise occupational therapist and teacher evaluations of
10. Coordination exercise for hand and forearm handwriting quality of grade 5 and 6 primary
muscles -clapping school children: Australian Occupational
Therapy Journal.1998; 45(2): 48-58.
14. Rubin N, Henderson SE. Two sides of the same
coin: variations in teaching methods and failure
REFERENCES
to learn to write. British Journal of Special
Education.1982; 9(4):17-24
1. Koppenhaver KM. Factors that cause changes in
15. Aldehag AS,.The effects of hand training in
Handwriting. In Forensic document
patients with Walander distal myopathy and
Examination. New Jersey, Humana Press Inc.
Myotonic dystrophy type 1 [PhD thesis].
2007; pp27-36.
Stockholm: Karolinska Institute; 2009.
2. Lawson DA. Tips for improving your
16. Rosenblum S, Weiss PL, Parush S. Handwriting
handwriting [internet]. 2011 Feb 28 [cited 2 Mar
evaluation for developmental dysgraphia:
2011]; Available from: http://
Process versus product. Reading and writing.
www.paperpenalia.com/handwriting.html.
2004; 17(5): 433-458.
41. pujitha (208-213).pmd 212 10/16/2012, 2:41 PM

17. Schoemaker MM, Niemeijer AS, Reynders K, training on intermanual transfer to sub dominant
Smits-Engelsman BCM. Effectiveness of hand in patients with cerebral tumors: Indian
Neuromotor Task Training for Children with Journal of Physiotherapy and Occupational
Developmental Coordination Disorder: A Pilot Therapy. 2010; 4(2): Absract.
Study: Neural plasticity. 2003; 10(1-2): 155-163. 21. Bumin G, Kavak ST. An investigation of the
18. Zivani J, Watson-Will A. Writing speed and factors affecting handwriting performance in
legibility of 7-14-year old school students using children with hemiplegic cerebral palsy.
modern cursive script: Australian Occupational Disability and Rehabilitation. 2008; 30(18): 1374-
Therapy Journal.1998; 45(2): 59-64. 1385.
19. Rogers MW, Wilder FV. The Effects of Strength 22. Peterson CQ, Nelson DL. Effect of an
Training among Persons with Hand occupational intervention on printing in children
Osteoarthritis: a Two-Year Follow-up Study. with economic disadvantages: American Journal
Journal of Hand Therapy. 2007; 20(3): 244-250. of Occupational Therapy, 2003; 57(2): 152-160.
20. Satheesha D, Ajay S. Effect of dominant hand
41. pujitha (208-213).pmd 213 10/16/2012, 2:41 PM

To Study the Effect of Gluteus Maximus Activation in Sub

Acute Mechanical Low Back Pain
Rajiv Sharma1, Subhash Mahajan2, Jagmohan Singh3

1
Assisstant professor, Gian Sagar College of Physiotherapy, Ram Nagar, Distt. Patiala (PUNJAB)
2
Professor, Gian Sagar Medical College and Hospital, Ram Nagar, Distt. Patiala (PUNJAB)
3
Professor and Principal Gian Sagar College of Physiotherapy, Ram Nagar, Distt. Patiala (PUNJAB)
ABSTRACT
Introduction: Patients with low back pain (LBP) present at different points in its genesis, with symptom
severity and effects on quality of life a major factor in the timing of presentation. Gluteus maximus,
biceps femoris along with paraspinal muscles are the most important muscles of the group. There is
group action of all these muscles in a particular sequence which is necessary for smooth spinal
movements and stabilized spine during dynamic state of the body.
Methodology:
Study design: Experimental
Study setting: Gian Sagar Medical College and Hospital Patiala
Sampling: Random sampling technique
Sample size: 30 patients in group A which is control group and 30 patients in group B which is
experimental group.
30 patients were included in 2 groups each group 1 was treated with routine physiotherapy as control
group whereas group 2 was treated with routine physiotherapy along with gluteus maximus activation
(isometric contraction of gluteus maximus in lengthened position). Outcome measures were taken in
terms of VAS scale before and after the treatment daily for 10 days.
Result: Group 2 treated with gluteus maximus activation got relief early than group 1 although
group 1 also got relief but took more number of days when compared with group 2.
Conclusion: Gluteus maximus activation should also be considered while treating mechanical low
back pain.
Key words: Mechanical low back pain, Gluteus maximus activation, Lumbopelvic junction.
INTRODUCTION Patients may be particularly concerned about the

level of pain, which seems to them to indicate a
Patients with low back pain (LBP) present at serious problem. Where appropriate, patients can be
different points in its genesis, with symptom severity reassured that LBP episodes typically resolve without
and effects on quality of life a major factor in the permanent sequelae. The history and physical
timing of presentation. LBP of up to 4 weeks duration examination remain the primary tools for assessing
may be considered acute because of the relatively patients with LBP because most patients will not
slow recovery experienced by some patients, most of demonstrate appreciable findings on imaging or other
whom nonetheless suffer no permanent sequelae. studies such as laboratory tests. The history is
Episodes of LBP lasting longer than 12 weeks are possibly more useful than the physical examination
generally considered chronic. Even when LBP is in ruling out occult serious diseases as recommended
consistent with a minor soft-tissue strain, it can be by Roger C, (2007) in recommendations for low back
severely painful, occurring with associated spasm pain which were approved by American College of
that may remarkably limit functional capacity. Physicians and the American Pain Society.
42. Rajiv Sharma 21st july 11 (214-218).pmd 214 10/16/2012, 2:41 PM

Lifting tasks and forward flexion movements are REVIEW OF LITERATURE

often related to lower back problems. It is possible that
those who suffer back problems have a different The lumbar spine is composed of bone, cartilage,
muscle activity pattern during these types of ligaments, nerves, and muscle. These anatomical
movements than those who have healthy backs. components give the spine form and function. The
Leinonen et al (1998) examined the electromyographic alignment of the lumbar spine is con-trolled by its bony
(EMG) activity of the gluteus maximus (GM) biceps and ligamentous struc-tures. This architecture enables
femoris (BF) and paraspinal (PS) muscles and they the lum-bar spine to achieve its characteristic lor-dotic
observed that there is certain pattern of muscle action appearance. This form is given functional
during flexion and extension of the spine. Gluteus characteristics by actions of the lumbar spine muscles.
maximus, biceps femoris along with paraspinal Pope MH, DeVocht JW (1999) observed that these mus-
muscles are the most important muscles of the group. cles are typically grouped into two differ-ent types:
During the early phase of forward flexion the primary or secondary muscles. The primary lumbar
paraspinal and biceps femoris muscles get activated muscles insert di-rectly into the bony elements of the
together. By the end of flexion, all three muscles are spine, resulting in control of spinal motion. The
active and during extension all three are also active. secondary lumbar muscles aid in lumbar motion
However, the key difference between back patients and without a direct insertion into the spinal bony
the healthy controls is the amount of gluteus maximus structures. They control mul-tisegmental gross
activity. During flexion gluteus maximus activity is movements and gener-ate the force necessary to
significantly shorter and during extension the gluteus perform many functional activities. Veeling A et al
maximus activity ends earlier. This means that the (1995) also studied global muscle system and described
gluteus maximus of the back patients switch on later the integrated sling systems in low back which
and turns off sooner during the flexion extension establishes the role of gluteus maximus in dynamic
movement. lumber control. They observed the firing pattern of
the lumber muscles during walking and other
This study will explore the effect of isometric movements and concluded that gluteus maximus
contractions of gluteus maximus in patients of low plays vital role during flexion and extension of lumbar
back pain on the level of pain on VAS scale. There are spine, especially when the spine is moving from flexed
recommendations of including gluteaus maximus position to extended position. Same kind of work was
strengthening in the rehabilitation of the patient with also done by Lewitt K (1995). He explained firing
low back pain but there is no data on the immediate pattern of gluteus maximus, hamstrings and erector
effect of isometric contraction of this muscle especially spinae during hip extention in his book manipulative
when there is spasm of spinal and surrounding therapy in rehabilitation of the motor system. It was
muscles. observed that during the hip extension hamstring,
gluteus maximus and erector spinae contract in the
Problem Statement: sequence. Joshua C (1999) also researched the
Need Of Study: In routine physiotherapy treatment relationship between low back pain and piriformis and
protocols the importance of gluteus maximus gluteus maximus irritation. He observed that running
activation is overlooked. This study will help in or sitting lead to irritation of these two muscles and
establishing the efficacy of gluteus maximus activation produce sciatica like symptoms. Nadler S F (2002)
in relieving pain in sub acute mechanical low back worked on athletes to correlate the incidence of LBP
pain. and the relationship with hip muscle imbalance. Hip
strength of the athletes was measured during
Aim Of The Study:
preparticipation, physical examinations. Occurrence
To establish the role of gluteus maximus strengthening of LBP was monitored throughout the year. Following
in sub acute low back pain. the 1999-2000 preparticipation physicals, all athletes
HYPOTHESIS: began participation in a structured core-strengthening
program, which emphasized abdominal, paraspinal,
Null hypothesis: and hip extensor strengthening. Incidence of LBP and
Gluteus maximus activation does not help in reducing the relationship with hip muscle imbalance were
the pain in mechanical low back pain. compared between consecutive academic years. The
Alternate hypothesis: core program, however, seems to have had a role in
modifying hip extensor strength balance.
Gluteus maximus activation helps in reducing pain
mechanical low back pain.

Roger C (2007) recommended that patients who do slump test) were excluded from the study.
not improve with self-care options, clinicians should 3. Patients with radiating pain to lower limb were
consider the addition of nonpharmacologic therapy excluded from the study.
with proven benefitsfor acute low back pain, spinal 4. Those who had structural deformity in lower limb
manipulation; for chronic or subacute low back pain, or spine were also excluded.
intensive interdisciplinary rehabilitation, exercise 5. Patients having any neurological condition and
therapy, acupuncture, massage therapy, spinal who were not well oriented to time, place and space
manipulation, yoga, cognitive-behavioral therapy, or also excluded from the study.
progressive relaxation. So it can be concluded that 6. Patients who experienced pain during the gluteal
gluteus maximus has immense impact on the function maximus isometric contraction maneuver were
of spine. Edmond L, (1995) in her book joint excluded.
mobilization/manipulation has explained the
technique of activation of gluteus maximus which also PROCEDURE
glides iliac crest over sacrum posteriorly by reversing
the origin and insertion of the muscle. This technique Two groups of 30 patients each were taken. Group
is used for correcting anterior rotation of ilium over A was control group and was given routine
the sacrum. This technique is also explained in the book physiotherapy which constituted SWD, TENS, spinal
authored by Kamala S, and Marc O S, (1999) Exercise mobilization (grade 1 PA glide on hypomobile
prescription, Foundation of therapeutic exercise segment). Group B was the experimental group in
classification and prescription. This technique is used which patients were given routine physiotherapy as
in our research to activate the gluteus maximus and in group A along with gluteal maximus isometric
its effects are being evaluated. contractions in lengthened position. Patients were
made to lie down in supine. Knee and hip joint were
METHODOLOGY flexed to the maximum in a pain free range. Then
patients were told to do hip extension against the
Study design: Experimental resistance given by the therapist. Patient was told to
hold the contraction for 10 seconds. This maneuver
Study setting: Gian Sagar Medical College and
Hospital Patiala was repeated for 6 times (3 sets). Those patients who
experienced pain during the maneuver were excluded
Study duration: 2 months
from the study. Readings were noted on the visual
Sampling: Random sampling technique analogue scale of pain (0 to10). Readings were taken
Sample size: 30 patients in group A which is control immediately after every session. Treatment was given
group and 30 patients in group B which is experimental till the reading on VAS scale was 0. Some patients were
group. on NSAIDs and they continued the same treatment
INCLUSION CRITERIA during the whole study period. Conventional
physiotherapy treatment also continued during the
1. Pain in low back (acute or sub acute). whole study period.
2. Age group : 20-40 years
3. Pain should not be radiating to lower limb. RESULT
4. All the neurological tests should be negative.
5. Sensation of the patient should be normal.
6. All the reflexes should be normal.
7. There should not be any finding of structural
changes in the spine.
8. Patient should be co-operative and well oriented
to time, place and space.
9. Patient should not be having any neurological
condition.
EXCLUSION CRIERIA
Data was statistically evaluated. This data shows
1. Patients those who were having clinical and
that group 2 which was treated with gluteal maximus
radiological findings suggestive of disc prolapse
activation got relief earlier than group 1 although
were excluded from the study.
group 1 also got relief but took more number of days
2. Any patients who had neurological tests (SLR,
when compared with group 2.

DISCUSSION therefore, extra stress is put on the lumbar spine

leading to low back pain. The average strength of the
The lumbar spine is an elegant structure with a lumbar spine is approximately 200Nm depending on
complex local supporting system. Unlike the thoracic age. The lumbar spine muscles are not strong enough
spine, it lacks the stabilizing strength provided by to overcome the flexion moment during a heavy lift
associated ribs. In acute LBP, a strain may occur in one and usually need the muscles of the posterior hip and
or more of the supporting soft tissue structures. Local thigh (gluteus maximus and hamstrings) for this
muscle spasms that occur secondarily are often the function. Trained weight lifters lift heavy loads without
primary finding on physical examination. Patients a concomitant degree of acute low back injuries. They
presenting with LBP as their primary complaint can use the gluteus maximus during the early stage of the
be divided into three broad groups. The smallest but lift, perhaps contributing to earlier development of
most worrisome group has LBP as a consequence of a force. This process would stabilize the pelvis and
potentially serious and often occult condition, such as permit the erector spinae to extend the trunk more
a neoplasm. In the absence of identified anatomic or efficiently.
physiologic abnormalities, terms such as nonspecific
back pain or mechanical back pain may be used to Moreover as per the observations of Vleeming and
describe the symptoms experienced by most patients. Stoeckart (1995) with the single leg stance phase on
These are diagnoses of exclusion consistent with a right leg, the pelvis girdle translates anteriorly and
presumptive soft tissue strain or sprain. This second adducts on the right femoral head. The right
group of patients often present with a history of an innominate starts to anteriorly rotate, whereas the left
acute injury from an unsafe lifting practice or a history innominate rotates posteriorly both relative to the
of repetitive overuse. They usually deny radiation of sacrum. During this movement biceps femoris relaxes
pain. The third group is the approximately 4% of while the gluteus maximus tightens along with
patients with acute LBP who have radiating sensations latissimus dorsi. Both the muscles contracting at the
to the lower extremities secondary to nerve same time stabilizes the pelvis during the gait. If there
impingement. Radiating sensations can include pain, is relative weakness of gluteal maximus it can lead to
numbness, weakness, or paresthesia. the potential risk of sacro iliac dysfunction which in
turn can put over strain on lumbopelvic junction which
Studies have been shown that unloaded inactivity is the weak link of lumbo-pelvic-hip complex.
induces atrophy and functional de-conditioning of
skeletal muscle, especially in the lower extremities. As So patients complaining mechanical low back pain
with most sedentary individuals, lower back pain is a (sub acute or chronic) can respond to the gluteal
common association with inactivity and prolonged maximus strengthening if done in lengthened position
sitting. Lower back pain that is categorized as (muscles generate maximum force from lengthened
mechanical pain will typically involve musculoskeletal position).
factors that may be influenced by lifestyle, activity and
body composition. Other types of low back pain are CONCLUSION
structurally specific to the spine and involve conditions
such as arthritis, disc herniations, and degeneration. From the data analysis it is concluded that gluteus
In mechanical low back pain, muscular length-tension maximus activation helps the patients better in terms
relationships change over time in relation to the stress of pain relief although routine protocol also relieves
put on the body. For example, in the seated position, pain but there is less number of days required for the
the hip flexors are in a constant shortened state and physiotherapy treatment.
the knee flexorsprimarily the gastrocnemius remains
shortened. To exacerbate the effects of prolonged REFERENCES
sitting, poor posture such as slouching, shoulder
1. Borenstein DG and Weasel S W (1995) Low back
protraction, and cervical flexion, cause the erectors of
pain: Medical Diagnosis and Comprehensive
the back to become overactive and fatigue causing the Management, W B saunders Co. London Page 189.
associated creep. The gluteals remain inactive in a 2. Joshua C (1999) Injury Management Update.
seated position. Sitting for long periods can lead to www.dubinchiro.com.
the gluteal muscles atrophying through constant 3. Kamala S and Marc O S (1999a) Exercise
pressure and disuse. Movements that require the prescription, foundation of therapeutic exercise
gluteal muscles become more difficult (such as classification and prescription, Medical
climbing stairs or rising from a seated position); Publishers, Philadelphia Page 38.

4. Kamala S and Marc O S (1999b) Exercise 8. Roger C (2007) Diagnosis and Treatment of Low Back
prescription, foundation of therapeutic exercise Pain: A Joint Clinical Practice Guideline Portland,
classification and prescription, Medical American College of Physicians and the
Publishers, Philadelphia Pages 42-43. American Pain Society.
5. Lewitt K (1995) Manipulative therapy in 9. Susan L Edmond (2006) Joint mobilization/
rehabilitation of the motor system. Butterworths manipulation, extremity and spinal techniques.
London. Second edition Mosby, Elsevier, St Louis,
6. Leinonen V (2000), Back and hip extensor Missouri.
activities during trunk flexion/extension: effects 10. Veeling A and Stoeckart, (1995) The posterior
of low back pain and rehabilitation. Arch Phys layer of the thoracolumber fascia: its function in
Med Rehabil ; 81: 32-37. load transfer from spine to legs. Spine 20: Pages
7. Nadler S F (2002) Hip muscle imbalance and low 753-758.
back pain in athletes: influence of core 11. Pope MH, DeVocht JW (1999), Low back pain.
strengthening. Med. Sci. Sports Exerc., Vol. 34, No. The clinical relevance of Biomechanics. Neurol
1, pages 9-16. Clin; 17: 18-41.

Epidemiology of Cerebral Palsy in Jalandhar
Raju Sharma1, A.K.Purohit2, E. RajinderaKumar3, S. Perssona4, A.G.K.Sinha5, S.K. Tripathy6

1
Head, Department of Physiotherapy, Lyallpur Khalsa College Road, Jalandhar, 2Prof.& Head, Department of
Neurosurgery, NIZAM, Hyderabad, 3Lect., Department of PM&R, NIZAM, Hyderabad, 4Resident, Department of
Neurosurgery, NIZAM, Hyderabad, 5Head & Reader, Department of Physiotherapy, Pbi Uni. Patiala, 6P & O E,
Orthotech Appliances, New Delhi
ABSTRACT
Objective: Cerebral palsy is primarily a disorder of movement and posture. The purpose of this
study was to find out the various etiological factors, associated handicaps, clinical profile and nature
of treatment taken by children having cerebral palsy through a screening camp.
Method: Total 193 children between the age of one year to thirteen years were registered in a camp
held at Lyallpur Khalsa College, Jalandhar, Punjab for two days in the month of February, 2007.Clinical
findings of each child was recorded in a predeveloped format consisting of birth history, motor
assessment, associated problems, gross motor function, deformity, gait and nature of treatment taken.
Result: Out of 193 children reported at the camp, 154 were identified as having cerebral palsy. Spastic
subtype of cerebral palsy constituted the predominant group(65.8%) followed by mixed type
(5.18%),dystonic(4.7%), athetoid (2.5%) and flaccid(1.5%). 40.93% children had some associated
problems like convulsion disorder (17.61%) subnormal intelligence (9.8%)and speech defects(13.46%).
Majority of the children (36.26%) were at sitting level and only 12.43% had achieved independent
ambulation. Equinus foot and knee flexion deformity were commonly observed among diplegics
(39.89%).
Conclusion: Prematurity and birth asphyxia found to be the most common contributing factors for
cerebral palsy. Spastic diplegia constituted predominant presentation. Convulsion disorders were
observed as an associated problem in majority of children having cerebral palsy.
Key words: Incidence, Cerebral Palsy, Spasticity, Muscle Tone.
INTRODUCTION as muscle tone,strength,reflexes and range of motion.

Significant activity limitations can also be present
Cerebral palsy comprises a complex, multi- (e.g., dressing, feeding, functional mobility) as well as
dimensional group of non-progressive movement restricted participation (e.g. playing, participation
disorders resulting from damage to the brain in school) in social and community roles for the child.
prenatally, perinatally, or early in childhood. It is one The long term disability and costs to the health care
of the three most common lifelong developmental system and society associated with cerebral palsy are
disabilities, the other two being autism and mental significant.
retardation causing considerable hardship to affected
individuals and their families. 1 The worldwide One of the important challenges in providing
incidence of cerebral palsy is 2-2.5 per 1000 live rehabilitation services to this group of children is to
births2.Recent advances in the neonatal management ascertain the dimension of disability in terms of
in obstetric care have not shown the decline in prevalence, clinical spectrum etc. which help to
incidence of cerebral palsy3. On the contrary, with a formulate policy and to implement and monitor
decline in the infant mortality rate, there has actually programs related to rehabilitation and prevention .
been an increase in the incidence and severity of Responding to this constant need of information the
cerebral palsy. From the viewpoint of the International population based registers are maintained in the
classification of Functioning, Disability and western countries which keeps a tab on the child birth
Health(ICF-6),cerebral palsy presents with and other related data (Pharoah, et al. 1998) However
impairment in the body function and structure such Obtaining epidemiological data in Indian situation
43. raju sharma 26th june 11 (219-222).pmd 219 10/16/2012, 2:41 PM

poses far greater problems. The idea of cerebral palsy Activities in the camp:
or childhood disability register is non existent in most
of the hospitals of India. Therefore the Information on Each child was evaluated for tonal dysfunction;
the prevalence and epidemiology of disability in tone distribution,deformity, gait and any speech,
children is not available from routine health service learning problem by a team of Neurosurgeon,
data systems. In addition, the absence of rehabilitation Physiatrist, Physiotherapist, Speech Therapist, Special
services in majority of geographical locations, non Educator and an Orthotist.Tone assessment was done
reporting of cerebral palsy children in the using Passive Motion Testing (OSullivan
Rehabilitation centers due to various factors etc. SB 5 2007)whereas deformity was evaluated by
further complicates the task of obtaining reliable observation and measurement of active and passive
information on the prevalence of cerebral palsy. In this joint range of motion(Levitt S6 1995).Gait of each child
situation population surveys remains the only was also assessed by observational method. After
methods to obtain the epidemiological information. evaluation of each child parents were advised
In India camp approach is a very popular method to accordingly for the need of therapy,antispastic
identify and to provide treatment advice to patients medication, orthosis or surgical intervention.
who are spread in a certain diversified geographical
Statistical analysis: The data is presented as
area. We have attempted to combine the elements of
absolute number and percentage.
MICS methodology and Camp approach to obtain the
epidemiological data related to the clinical profile of
cerebral palsy, associated handicaps and the nature RESULT
of management of children with cerebral palsy in and
A total number of 193 children having cerebral
around Jalandhar town of Punjab.
palsy reported to the camp, out of which 154 were
identified as having cerebral palsy. 39 children had
METHODOLOGY
other afflictions such as PPRP, meningomyelocele, HSP,
A database of children having cerebral palsy was and muscle dystrophy. Table -1 presents the
prepared through one month advance advertisement distribution of the cerebral palsy children as per the
for two days camp on TVand Radio.The information tone abnormalities.
about the camp was also distributed in the community
Table 1. Distribution according to the muscle tone
using pamphlets, and local contacts of social abnormality and other causes (n=193)
organizations in the Jalandhar and adjoining areas. Tone abnormality No. of children percentage
Two days camp for children having cerebral palsy was spastic 127 65.8%
organized in the month of February 2007 at Lyallpur athetoid 5 2.5%
Khalsa College, Jalandhar, Punjab. The content of dystonic 9 4.7%
advertisement was based on MICS module (Durkins mixed 10 5.18
et al.1994) which is designed to identify children, in flaccid 3 1.5%
any cultural and social setting, who have congenital Other(PPRP, meningomyelocele, 39 20.2%
HSP, muscle dystrophy)
and developmental disabilities.
Total 193 100%
Procedure
Spastic type of cerebral palsy constituted the
Prior registration was done using a predeveloped predominant group (65.8%) followed by mixed type
evaluation format for each child which consisted of (5.18%).dystonic (4.7%), athetoid (2.5%) and flaccid
demographic profile, complaints, birth history, clinical (1.5%). The analysis of the associated problems
profile i.e. motor assessment, gross motor function, recorded in the cerebral palsied children revealed that
deformity, gait and treatment history. At the time of Convulsion disorder was reported in 34
registration each childs demographical profile, birth children(17.61%) majority of them were spastic type.
history, treatment history and associated problems
Table 2. Distribution of associated problems
were recorded through interviewing the parents and
Associated problem No of children percentage
from medical records available to them .Gross motor
Seizure disorder 34 17.61%
function was assessed using GMFM-88(Russel et
Mental retardation 19 9.8%
al41989, 1933) and score was converted into percentage Speech delay 12 6.21%
using gross motor function measure estimator dysarthria 14 7.25%
software.

Subnormal intelligence was another common On GMFM scale only 12.43% cases achieved
handicap (9.8%) among the children.13.46%children independent ambulation. However maximum
among flaccid, mixed and spastic variety had speech children in this category belonged to different
defects. (Table 2). pathology group. Majority of the children (36.26%)
were at sitting level. 6.68% among flaccid variety were
Table 3. Distribution according to the etiology of
at lower milestone level. (table-5)
cerebral palsy (n=139)
Etiology No. of patients percentage Table 6. Percentage distribution of common deformities
Prematurity (<37 wks gest.) 56 29.01% in upper/ lower limbs
kernicterus 10 5.18% Lower limb deformity percentage
Birth asphyxia 34 17.61% foot equinus 56%
IVH 2 1.03% Equinus+inversion 34%
PVL 2 1.03% valgus 4%
RSD 2 1.03% knee flexion 47%
Unknown etiology 48 24.87% recurvatum 6%
Other 39 20.2% hip adduction 34%
Internal rotation 34%
The information on the etiologies summarized in flexion 12%
table -3 Prenatal, natal and post natal factors were Upper limb
found in 56(29.01%), 34(17.61%),and 16 (8.27%) cases wrist Flexion 28%
respectively. In 48 (24.87%) cases the prenatal, natal Elbow +forearm Flexion+ pronation 57%
and post natal history was normal . shoulder Adduction+internal rotation 29%
Table 4. Distribution according to topographical Equinus foot and knee flexion deformity were
presentation (n=193) commonly observed among diplegics (39.89%) in
Tone abnormality presentation no percentage lower limbs. Hip joint and knee joint deformity in
Spastic/athetoid/mixed/flaccid quadriplegic 49 25.38%
lower extremity and elbow, wrist joint deformities
Spastic diplegic 77 39.89%
triplegic 9 4.6%
were common in quadriplegic and hemiplegic group.
hemiplegic 10 5.18% (table-6)
dystonic focal 3 1.5%
general 6 3.1% Table 7. Distribution according to treatment measures
Other etiology general 39 20.2%
taken (n=193)
Among spastic type of cerebral palsy, spastic Treatment measures No. of percentage
children
diplegia was the most common clinical presentation Surgical interventions 12 6.21%
in 77children(39.89%) followed by spastic hemiplegia Botox injections 24 12.43%
(5.18%). quadriplegic presentation (25.38%) was Medications only(antispastics) 34 17.61%
common among mixed and athetoid variety. Therapies(PT,OT,aids) 70 36.26%
Generalized dystonia was observed in 3.1% cases only No treatment 14 7.25%
(table-4). other 39 20.2%
Table 5. Distribution according to milestone achieved Out of 154 cases, only 14(7.25%) cases had not taken
(n=193) any kind of treatment which belonged to very remote
Milestones No.of children percentage area. Majority of urban population were taking some
(As per GMFM score)
kind of treatment regularly.18.64% of cases had
Neck holding 3 1.5%
undergone for advanced form of surgical interventions
rolling 10 5.18%
creeping 20 10.36%
and botox injections for the management of spasticity
sitting 70 36.26% also.
crawling 14 7.25%
DISCUSSION
Kneel standing 27 13.98%
Kneel walking 5 2.5% In the present study, spastic type of cerebral palsy
Half kneeling 3 1.5% was the predominant group (65.8%) and spastic
Sq. to standing 9 4.6%
diplegia (39.89%) was the most common clinical
standing 8 4.16%
presentation. Prematurity was the major factor
walking 24 12.43%
Total 193 100%
involved in the causation of the cerebral palsy. A large
number of subjects had convulsions and mental

retardation as associated handicaps. These CONCLUSION

observations are in agreement with the other Indian
studies (Singhi et al., 1996; Sharma et al., 1991; Laisram The present study revealed that spastic subtype
et al., 1992). constituted the major type of cerebral palsy and
prematurity and birth asphyxia were found to be major
Singhi et al7 (1996) reviewed 1000 children with predisposing factors in its development. Most of the
cerebral palsy to study their clinical profile, aetiological children having cerebral palsy had convulsion disorder
factors and associated problems. Spastic quadriplegia as an associated problem. Spastic diplegia was
constituted the predominant group followed by spastic commonest clinical presentation of cerebral
diplegia and dyskinetic cerebral palsy. Sharma et al8 palsy.Equinus foot and crouch knee deformities were
(1991) conducted a retrospective study involving 480 common. Most of the urban parents were aware about
cases of cerebral palsy to examine their clinical profile various treatment options available, whereas rural
and predisposing factors. In their series the spastics parents were ignorant about therapies and other
constituted predominant group (77.9%) followed by treatment options.
hypotonic (8.5%), athetoid (5.8%), mixed (3.9%) and
ataxic (0.6%). History of perinatal asphyxia was found ACKNOWLEDGMENT
in 48.7% and in 6% cases postnatal infection was major
cause among predisposing factors. Subnormal We are thankful to the college management and all
intelligence was common associated handicap in 74.2% the BPT interns who helped us in organizing and
cases followed by speech defects (53.8%) convulsions managing the patient population during camp days.
(25.6%) and ocular defects (35.8%). Laisram et al 9
(1992) studied 540 cases of cerebral palsy to find out REFERENCES
the etiology. They found toxemia (1.29%) and 1. Shankar C, Mundkur N. Cerebral Palsy-
microcephaly (1.84%) were the most common Definition, Classification, Etiology and Early
etiological factor in prenatal category. Among the natal Diagnosis. Indian J Pediatr 2005; 72(10): 865-868.
causes (24.45%), birth anoxia was most common factor 2. Rosen MG, Dickinson JC. The Incidence of
and infections constituted the common postnatal cause Cerebral palsy.Am J Obstet Gynecol 1992; 167:
(17.1%). The present study also focussed on obtaining 417-423.
information on the level of motor function among 3. Nelson K .B. Can we prevent cerebral palsy? N
cerebral palsied population, common deformities and Engl J Med 2003; 349: 1765-1769.
mode of treatment taken. 4. Russell D J, Rosenbaum P L, Cadman D T. The
Gross Motor Function Measure: A Means to
We had combined the camp approach and Evaluate the effects of physical therapy. Dev.
childhood disability screening questionnaire to obtain Med. Child. Neurol 1989; 31: 341.
information regarding the clinical profile and 5. OSullivan SB, Schmitz TJ. Physical
associated handicaps and found that majority of the Rehabilitation. 5th ed.Philadelphia: F A Devis
subjects reported to the camp had symptoms comp; 2007. chapter 8, Examination of Motor
mentioned in the questionnaire. Camp is the common Control and Motor Learning; 233-236.
6. Levitt S. Treatment of Cerebral palsy and Motor
practice in our country for creating awareness against
Delay. London: Blackwell Science ltd.; 1995.
any problem and for mass level treatment or advices.
7. Singhi P D, Ray M, Suri G. Clinical spectrum of
We observed that this approach can also be used as a
cerebral palsy in North India- A Analysis of 1000
tool of data collection for epidemiological studies. The cases. J Trop Pediatr 2002; 48(3): 162-166.
only drawback in this approach is poor follow up or 8. Sharma P, Sharma U, Kabra A.Cerebral Palsy-
exactness of database. Studies conducted in other clinical profile and predisposing factors. Indian
countries like by Liu et al10 (1999) and Robertson et al11 Pediatrics 1999; 36: 1038-1042.
(1998)on the prevalence of cerebral palsy included 9. Laisram N, Srivastava VK, Srivastava RK.
surveys through the cerebral palsy registers Cerebral palsy-an etiological study. Indian J
maintained at government levels whereas in India pediatr 1992; 59: 723-728.
provision of such registry do not exist . This acts as a 10. Liu J M, Li S, Lin Q,Li Z. Prevalence of cerebral
major obstacle in obtaining accurate information on palsy in China. International Journal of
the prevalence and incidence of cerebral palsy. The Epidemiology 1999; 28: 949-954.
epidemiological data is necessary for designing 11. Robertson CM, Svenson LW, Joffres M R.
preventive and curative measures. The camp approach Prevalence of cerebral palsy in Alberta. Can J
can be used successfully however with some planning Neurol Sci 1998; 25(2): 117-122.
to gather epidemiological data.

Modified Quadriceps Strengthening Maneuver for Patients
Undergoing ACL Reconstruction-surface Electromyogrphic
Analysis
JAY SATA
Master of Physiotherapy (Sports), Lecturer, K.K Sheth Physiotherapy College, Rajkot-7
ABSTRACT
Introduction: Quadriceps femoris muscle setting is isometric quadriceps femoris exercise which can
be widely used in early knee rehabilitation.However this exercise cannot obtain enough co-contraction
of the hamstrings. We succeeded in developing a simple training maneuver that is effective in obtaining
co-contraction of the hamstrings-a modified maneuver for the quadriceps femoris (MQS) muscle
setting.
Aim of Study: To analyze the effect of MQS muscle settings by Electromyographic (EMG) analysis.
Methodology: It is an experimental study including 50 normal healthy subjects (Age: 20-30, Sex:
Male) from the K.K Sheth Physiotherapy College, Rajkot. Orthopaedic, Neurological, Cardiovascular
and Un co-operative patients were not included in the study. The subjects underwent 2 Quadriceps
settings. One was the normal quadriceps femoris muscle setting (NQS) and the other was MQS.
Moreover, subjects had worn a sand bag of 2 or 5 kg on the ankle of the raised lower limb in MQS
(MQS2, MQS5). EMG activity was recorded from surface electrodes on the vastus medialis, vastus
lateralis, semitendinosus and biceps femoris.Statistical processing on four movements were conducted
using repeated measures ANOVA. Significant differences were identified using the Fishers least
significant difference test.
Results: The activities of the hamstrings were greater in MQS than in NQS, and co-contraction of the
quadriceps femoris and hamstrings was obtained in the MQS maneuver.
Discussion: In MQS, the hamstrings work with quadriceps femoris. The activities of rectus femoris
declined as the load to the raised lower limb progressed from NQS to MQS5. While in NQS induce
contraction of the quadriceps femoris alone.
Conclusion: This study suggests that effective co-contraction of the hamstrings can be obtained in
MQS.
Key words: NQS, MQS, EMG
INTRODUCTION translation, it is useful for the stabilization of the

tibia1-4. But the application of CKC exercise is difficult
Quadriceps femoris muscle setting is isometric in the early stage of knee rehabilitation with ACL
quadriceps femoris exercise which can be widely used injury.5-8
in early knee rehabilitation. However this exercise
cannot obtain enough co-contraction of the Physical therapists use a combination of
Hamstrings. The co-contraction of the quadriceps and quadriceps femoris muscle setting (QS) and SLR to
the Hamstrings that takes place during closed kinetic strengthen the quadriceps femoris muscle in the early
chain exercise (CKC) has made this exercise of choice stage of knee rehabilitation with ACL injury. These
for rehabilitation after anterior cruciate ligament (ACL) exercises are easy isometric quadriceps femoris
reconstruction. As this hamstring co-contraction contraction exercises and OKC exercises. As these
during CKC exercise has been confirmed to reduce the exercises produce minimum co-contraction of the
tendency of the quadriceps to induce anterior tibia1 Hamstrings, the isolated contraction of the
44. Jay Sata 24th april 12 (223-226).pmd 223 10/16/2012, 2:41 PM

quadriceps femoris imposes maximum strain to the (long head) of the leg on which quadriceps muscle
ACL. setting was performed. Surface electromyography
was performed. At the same time EMG Parameters
We successfully developed a simple training were Filter-10khz,Sensitivity 200uV/D Sweep speed
maneuver that produced sufficient co-contraction of 10ms/D. Each movement was performed for 5 s. and
the hamstrings to strengthen the quadriceps femoris the derived electromyographic activity from each
in the early stage of knee rehabilitation. This maneuver, muscle was rectified, smoothed and integrated for 3
quadriceps femoris muscle setting (MQS), is a s between movements.
conventional maneuver for quadriceps femoris
performed with one leg raised while the other leg is The value of % MVIC of each muscle in each
exercised. In this paper, we present data on an EMG movement was expressed by mean and standard
quantification of the effects of this maneuver. deviation.Statistical processing on four movements
was conducted using repeated measures ANOVA.
MATERIALS AND METHODS Significant differences were identified using the
Study Design: Observational Study Fishers least significant differences test. The level of
Study Setting: This study was conducted in significance was 5%.
K.K Sheth Physiotherapy College.
Sample Selection: 50
Study Duration: One Session Study
INCLUSION CRITERIA
1. Normal Healthy Individuals BMI (18.6-24.9 KG/M2)
2. Age Group: Between 20-30 yrs
3. Only male participants
4. Participants willing to participate in the study.
EXCLUSION CRITERIA
1. Present or past history of hip, knee or ankle injury.
2. Positive findings on patella-femoral or tibio-
femoral tests
3. Hyper-extension of knee.
4. Un co-operative patients
Outcome Measures:
ELECTROMAYOGRAPHIC ANALYSIS
EMG instrument (RMS EMG)
EP MK-II, Version 1.1), Measure tape, Weighing-
machine, Fig. 1. Surface Emg For Vmo
Height-scale, sketch-pen, spirit, pen, electrode gel.
Cotton, Micropore tape, Universal Goniometer and
Couch
METHOD
The subjects underwent two Quadriceps settings

(QS). One was the normal quadriceps femoris muscle
setting (NQS) that is performed in a supine position,
leg extended. The other was a QS which maintained
the opposite lower limb raising position at a hip
flexion of 90 0 and knee flexion of 90 0 (MQS).
Moreover, subjects wore a steel belt of 2 or 5 kg on
the ankle of the raised lower limb in MQS (MQS2,
MQS5). Surface electromyography was performed on
the quadriceps femoris (vastus medialis, vastus
lateralis), the semitendinosus and the biceps femoris Fig. 2. Surface Emg For Hamstring

hamstrings with quadriceps femoris setting. In a

radiographic study of 20 healthy subjects, Yasuda
et al. calculated the shear force (anterior drawer force)
during isometric knee extension at various knee angles
and concluded that isometric knee extension at angles
in the range of 0-45 0 should not be performed
immediately after ACL injury because of the significant
shear force generated by the quadriceps femoris
contraction. Hirokawa et al. studied the load-
elongation of the ACL and concluded that isolated
contraction of the quadriceps femoris leads to
significant anterior displacement of the tibia in the
range of 0-800 knee flexion9. Several previous studies
on quadriceps femoris muscle setting and SLR have
Fig. 3. Modified Quadriceps Setting (Wt 2kg) examined the positions and methods that produce
effective quadriceps femoris activity10-12, but none of
RESULT these studies examined the activity of the hamstrings.
The activities of the hamstrings were greater in For early rehabilitation of knee disease, we have
MQS than in NQS, and co-contraction of the studied a simple quadriceps femoris muscle force
quadriceps femoris and hamstrings was obtained in augmentation training maneuver effective in obtaining
the MQS maneuver (p<0.05). Both of these tendencies co-contraction of the hamstrings. We confirmed that
were enhanced in proportion to the increase of the co-contraction of the hamstrings was achieved in the
weight load imposed on the raised lower limb (MQS2, quadriceps femoris muscle setting position with the
MQS5). contra-lateral lower limb raised. The raised lower limb
was positioned at a hip flexion of 900 and knee flexion
The % MVIC of the and hamstrings in MQS2 and of 900 to prevent excessive lordosis of the lumbar spine
MQS5 showed a greater increase than that in NQS by means of the forward pelvis slant.
when the load to the raised lower extremity was
increased. The activities of the Vastus medialis and In MQS, the hamstrings work with quadriceps
Vastus lateralis declined as the load to the raised lower femoris setting. However, they also work without
limb progressed from NQS to MQS5, though not to a quadriceps femoris setting when the position of the
statistically significant extent. contralateral lower limb is raised. The hamstring co-
contraction obtained in MQS was achieved by a
forward bending moment of the pelvis generated by
the weight of the raised opposite lower limb (In Fig
4,Rt lower extremity).To counter this moment, the
subject produces an opposing moment in the anti-
rotatory direction on the pelvis by pushing his or her
heel to the bed (In figure 4, left lower extremity). The
hamstrings and gluteus maximus work at this point
in the procedure.
DISCUSSION
Isolated quadriceps femoris contraction in knee

extension imposes severe strain to ACL. Henning
et al. recommended that patients in their first year after
injury or reconstruction avoid quadriceps femoris Fig. 4. The generation mechanism of the hamstrings co-
exercise near full-extension angles. In MQS, the contraction in MQS.

Limitation: Small Sample Size. anterior cruciate ligament deficient knee. Am J

Sports Med 1993: 21: 49-54.
CONCLUSION 5. Baratta R, Solomonow M. Zhou BH, Letson D,
Chuinard R. DAmbrosia R. Muscular
Our study suggests that MQS exercise is a useful, coactivation. The role of the antagonist
safe, and simple maneuver for quadriceps femoris musculature in maintaining knee stability. Am J
muscle augmentation that can be performed without Sports Med 1988; 16: 113-122.
producing severe strain to ACL in the early stages of 6. Kvist J, Gillqtiist J. Sagittal plane knee translation
knee rehabilitation with ACL injury. and electromyographic activity during closed and
open kinetic chain exercises in anterior cruciate
ACKNOWLEDGEMENTS ligament-deficient patients and control subjects.
Am J Sports Med 2001; 29: 72-82.
I would like to thank Dr Vinit Modi (Assistant 7. Morrissey MC, Hudson ZL. Drechsler WI. Coutts
Physiotherapist) and I am grateful to all my patients FJ, Knight PR, King JB. Effects of open versus
for their kind cooperation and willingness to closed kinetic chain training on knee laxity in the
participate in this study, without whom this study early period after anterior cruciate ligament
would not have materialized. reconstruction. Knee Surg Traumatol Arthrosc
2000 : 8: 343-348.
Conflict of Interest Nil 8. Yack HJ, Collins CE, Whieldon TJ. Comparison
of ciosed and open kinetic chain exercise in the
REFERENCES anterior cruciate ligament deficient knee. Am J
Sports Med 1993: 21: 49-54.
1. Lutz GE, Palmitier KA, An KN, Chao EY. 9. Hirokawa S, Solonionow M. Lu Y, Lou ZP,
Comparison of Tibio-femoral joint forces during DAmbrosia R. Anterior-posterior and rotational
open-kinetic-chain and closed-kinetic- chain displacement of the tibia elicited by quadriceps
exercises. J Bone Joint Surg [Am] 1993; 75: contraction. Am J Sports Med 199220: 299-306.
732-739. 10. Dontigny RL. Terminal extension exercised for
2. OConnor JJ. Can muscle co-contraction protect the knee. Phys Ther 1972; 52: 45-46.
knee ligaments after injury or repair? J Bone Joint 11. Signorile JF, Kacsik D, Perry A, Robertson B,
Surg [Br] 1993; 75: 41-48. Williams R, Lowensteyn I, et al. The effect of knee
3. Palmitier RA, An KN, Scott SG. Chao EY. Kinetic and foot position on the electromyographical
chain exercise in knee rehabilitation. Sports Med activity of the superficial quadriceps. J Orthop
1991; l 1: 402-423. Sports Phys Ther 1995: 22: 2-9.
4. Yack HJ, Collins CE, Whieldon TJ. Comparison 12. Soderberg GL, Cook TM. An electromyographic
of ciosed and open kinetic chain exercise in the analysis of quadriceps femoris muscle setting and
straight leg rising. Phys Ther 1983; 63: 1434-1438.

A Comparison Between Land-based and Water-based
Balance Training Exercise Program in Improvement of
Balance in Community Dwelling Elderly Population
Ramandeep Walia, Shefali

Neurology, ISIC Institute of Rehab. Sciences, New Delhi
ABSTRACT
Background and Purpose: Specific balance training exercise program have been shown to play an
important role in the improvement of balance and function. Water has been identified as a low risk,
safe and supportive medium to perform these exercises. The purpose of this study was to investigate
whether water acts as a better medium than land for training balance exercises in community dwelling
elderly population.
Study Design: A pre-post experimental design was used in this study.
Subjects: 60 community dwelling elderly adults (60 years of age) participated in the study. These
subjects were randomly allocated to one of the two groups: Group 1 (n=30) was administered with
the balance exercises on land & Group 2 (n=30) was administered with the balance exercises in an
indoor pool.
Methods: The balance performance of the subjects was evaluated on the Berg Balance Scale and
Timed Up and Go Test. Each group performed a comparable program of balance training exercises
which was divided into a warm-up period, a conditioning period and a cool-down period.
Results: Both the land-based and water-based exercise groups were benefited from the balance training
exercise program with a significant improvement in post-intervention balance scores on Berg balance
scale and Timed up and go test as compared to their pre-intervention scores. However, on comparison
between the two groups, there was no statistically significant difference between post-intervention
scores of Berg balance scale and Timed up and go test.
Conclusion and Discussion: Regardless of the exercise medium, significant improvement in the
balance scores was achieved by the subjects in both the groups following the balance training exercise
program. Thus, concluding that balance training exercise program in either medium may be equally
effective in improving balance in the elderly population.
Key Words: Balance, Fall, Exercise.
INTRODUCTION older adults fall each year4. The incidence of falls rises
exponentially with age in the elderly and is higher in
Biological functions decline with age. Deterioration women than in men5,6. There is a greater than linear
of balance is a well-documented hallmark of the ageing increase in the rate of falls between the ages of 60 to 65
process1. The cause of age-related balance decline is and 80 to 857. Fall is the cause of increasing morbidity
related to a combination of decreased sensory input, and mortality from limb bone fractures and their
slowing of motor responses, and musculoskeletal complications (especially fractured neck of femur and
impairments2. pulmonary embolism)8.
Balance and mobility disorders are the single largest Participation in a regular exercise program is an
cause of chronic disability in individuals 60 years or effective intervention to reduce or prevent a number
older1 and is often manifested as falls and fall-related of functional declines associated with ageing9 thereby
injuries3. Approximately 30% of community-dwelling acting as an effective means to reduce falls in the
45. ramandeep (227-233).pmd 227 10/16/2012, 2:41 PM

elderly10,11. About 10 to 25% of falls are associated with a mean age of 64.07 + 4.29 years. The two groups were
poor balance and gait abnormalities12. Thus, balance comparable with respect to age, height and weight.
training exercise program have an important role to
play in falls prevention. Meta analysis of seven of the Table 1. Demographic Data: Comparison between
FICSIT trials revealed that balance training had a Group 1 and 2
beneficial effect on fall incidence13. In another study, Variables Group1(n=30) Group 2(n=30)
specific balance strategy training was found superior Mean S.D. Mean S.D.
to traditional exercises for improving function and Age, yr 64.97 5.52 64.07 4.29
balance14. Height, cm 161.25 9.58 161.76 10.12
Weight, kg 67.32 8.47 67.73 8.49
Though balance training on land may improve Sex Male = 12 Male = 10
Female = 18 Female = 20
balance in elderly people, it may be risky or
intimidating for those who are afraid of falling15 as fear
Group 1: Land-based balance exercise program
of a further or more injurious fall tends to limit exercise
Group 2: Water-based balance exercise program
gains16. The goal of an effective intervention should
always be to maximize functional independence
within the margins of safety 17 . Owing to the The study was conducted in the year 2007-08 & the
physiological properties of water such as buoyancy, subjects were gathered through a Geriatric camp
viscosity and density water acts as a low risk and safe organized at Indian Spinal Injuries Center, Vasant Kunj.
exercise environment for the elderly18 particularly for Residents of Vasant Kunj, New Delhi and relatives of
those who have entered downward spiral of decreased in-patients of Indian Spinal Injuries Center volunteered
activity19. for the study. Subjects who fulfilled the inclusion
criteria and were ready to attend the exercise program
It is suggested that exercise in water allows larger regularly were selected. The inclusion criteria for the
bandwidth of movement in which participants could subjects included the following: Healthy
error, receive the feedback and then correct for that asymptomatic elderly aged 60 yrs and above who were
error without an increase in their fear of fall and independent in ambulation18,22 and in activities of daily
injury18. Clinical evidence has supported benefit from living18,22 and able to attain a score of more than 24 on
aquatic therapy in function, joint mobility, strength, Mini-Mental Status Examination (MMSE)23. Exclusion
flexibility21, balance21, pain, self-efficacy and affect criteria for the subjects included: Receipt of physical
among older adults20. Exercising in water has also therapy at the same time or enrollment in any other
shown significant improvement in cardio-respiratory formal exercise program22, any uncorrected hearing
fitness, body composition, blood lipids, and agility in and visual impairment24, Menieres disease24, Benign
older adults. Therefore, water-based exercise can be Paroxysmal Positional Vertigo24, any neurological24 or
considered a safe and beneficial mode of exercise for musculoskeletal25 impairment, any medical illness that
older adults21. may interfere with the participation in the exercise
Although many studies18,20,21 have stated beneficial program25 and any obvious contraindication to aquatic
effects of water-based exercises, not many studies have therapy (Infections, incontinence, fever, wounds)26.
been conducted to compare the effectiveness of land-
Procedure: The subjects were invited to participate in
based and water-based balance training exercise
the study and were then randomly assigned to one of
program in elderly adults. Keeping this in view this
the two groups. A detailed explanation of the
study was designed with the purpose to identify the procedure was given after which the subjects signed
most appropriate medium for balance training in the informed consent. Subjects were then assessed on
community-dwelling elderly people with active two balance scales: Berg balance scale (BBS)27 and
lifestyle. Timed up and go test (TUGT) 28.
METHODOS The balance exercise program29 given to both the

groups was comparable and divided into a 10 minute
Subjects: 60 older adults took part in this study. warm-up period which consisted of stretching of major
The group receiving the balance exercise program on muscle groups, this was followed by a 40 minute
land (Group 1) consisted of 12 males and 18 females conditioning period of various activities of balance
with a mean age of 64.97 + 5.52 years while the Group performance such as weight transference / reaching
2 receiving balance exercise program in the aquatic activities, fast walking, side-stepping, walking
therapy pool consisted of 10 males and 20 females with backwards, upper limb range of movement exercises,
45. ramandeep (227-233).pmd 228 10/16/2012, 2:41 PM

resisted upper limb exercises, lower limb range of RESULTS

movement exercises, hopping and jumping in circle
formation, team games like over ball relays and a 10 A students t-test was used to compare the
minute of cool-down period consisting of stretching, performance of subjects of Group 1 and 2 on Berg
deep breathing and floating. balance scale (BBS) and Timed up and go test (TUGT)
prior to the intervention program. The analysis of pre-
The subjects of Group 1 performed the exercises intervention scores of Berg balance scale between
on land in the Rehabilitation department of Indian Group 1 (Mean = 51.53, S.D. = 1.20) and Group 2 (Mean
Spinal Injuries Center. These subjects performed the = 50.97, S.D = 3.09) did not show any significant
cool down period consisting of stretching and deep difference (t-value = 0.94, p=0.353) indicating that both
breathing in supine lying. groups were matched in terms of Berg balance scale
scores. The pre-intervention scores of Timed up and
Group 2 performed the exercises in the indoor go test also showed no significant difference between
aquatic therapy pool of Indian Spinal Injuries Center both the groups (Group 1: Mean = 11.01, S.D. = 1.08;
with a water temperature of 35 + 2 C 26, room Group 2: Mean = 11.01, S.D = 1.21) with t-value = 0.03
temperature of 25 C30 and relative humidity of 55% and p=0.975.
to 65%26.
The comparison of post-intervention scores of Berg
Subjects assigned to water exercise group were balance scale between Group 1 (Mean = 55.07, S.D.
familiarized with the pool environment one day before =0.91) and Group 2 (Mean =55.10, S.D. =1.32) revealed
the beginning of the exercise sessions26. The subjects no significant difference with t-value = 0.11 and
exercised at a water level between their waist and p=0.910. Similar results were seen for post-intervention
nipple line22,18. scores of Timed up and go test. (Group 1: Mean = 9.17,
Each session comprised of 6-8 subjects31 in both the S.D. = 1.00; Group 2: Mean = 9.10, S.D. = 1.19) with t-
groups and a therapists assistance was taken. After value=0.25 and p=0.805.
an intervention of two weeks with five sessions per
week23, the subjects were again assessed on both the
mentioned balance scales.
Fig. 2.
Fig. 1. The subjects are performing team games (over ball and
relays).
Data Analysis: Statistics were performed using SPSS

software version 10.5. A students t-test was used to
analyze the difference between the balance
improvements in group 1 and group 2. Intragroup
analysis between pre-intervention and post-
intervention scores was also done for both the groups. Fig. 3.
A significance level of p <0.05 was fixed.
45. ramandeep (227-233).pmd 229 10/16/2012, 2:41 PM

Table 2. Comparison of Berg Balance Scale (BBS) and Table 3. Intra-Group comparison of Berg balance scale
Timed Up and Go Test (TUGT) Post-intervention scores (BBS) and Timed up and go Test (TUGT) Scores
between Group 1 and 2. Variables Pre-intervention Post-intervention t -value p-value
scores scores
Variables Post-intervention Post-intervention t -value p-value
scores Group 1 scores Group Mean S.D. Mean S.D.
(n=30) 2(n=30)
Group 1 BBS 51.53 1.20 55.07 0.91 22.49* 0.000
Mean S.D. Mean S.D.
TUGT 11.01 1.08 9.17 1.00 10.82* 0.000
Berg Balance 55.07 0.91 55.10 1.32 0.11N.S 0.910
Group 2 BBS 50.97 3.09 55.10 1.32 11.55* 0.000
Scale
(BBS) TUGT 11.01 1.21 9.10 1.19 19.42* 0.000
Timed up and 9.17 1.00 9.10 1.19 0.25N.S 0.805
* = Significant
Go Test
Group 1, n=30: Land-based balance exercise program
(TUGT)
Group 2, n=30: Water-based balance exercise program
N.S = Not significant

Group 1: Land-based balance exercise program DISCUSSION
Group 2: Water-based balance exercise program
This study was designed to compare the
Within the group there was significant difference effectiveness of similar balance training exercise
in the pre-intervention and post-intervention scores program in a land versus water environment. The
of Berg balance scale for Group 1 (t-value = 22.49 and results obtained reveal that subjects in both the groups:
p=0.000) and Group 2 (t-value = 11.55 and p=0.000). Land-based and Water-based exercise group were
Pre-intervention and post-intervention scores of Timed benefited from the balance training exercise program
up and go test scores also showed significant difference with a significant improvement in post-intervention
for both Group 1 (t-value = 10.82 and p=0.000) and balance scores on Berg balance scale and Timed up
Group 2 (t-value = 19.42 and p=0.000). and go test as compared to their pre-intervention
scores. This can be seen in figures 4, 5 and Table 3.
Thus, indicating that both the groups showed
marked improvement in the balance scores following This improvement in balance function may be
balance training exercise program in either of the attributed to the presentation of repetitive motor tasks
medium. that produce an improvement in performance called
adaptation, which is an important element of balance
function32. Thus, although the balance of older persons
initially is poor, repetitive trials lead to a major
improvement in performance1.
Moreover, a balance specific exercise program was

employed in this study, which might have resulted in
improvement of balance scores of the elderly adults.
In this study, the balance training exercise program
for both Land-based and Water-based exercise group
was carried out in groups. This would have led to
improvement in the balance performance as belonging
to a group seems to promote better adherence to an
exercise program. Also, a supervised class seems to
Fig. 4.
allow faster progression of training, greater individual
feedback, a secure environment, peer support, an
opportunity for social interaction, and a reduction in
feelings of isolation33,34,35.
On comparison between Land-based and Water-

based exercise group, there was no statistically
significant difference between post-intervention scores
of Berg balance scale and Timed up and go test. Thus,
indicating that regardless of the exercise medium,
significant improvement in balance performance were
achieved by the subjects in both the groups. These
findings are consistent with the conclusions of Douris
and colleagues22. The main finding from their study
Fig. 5.
45. ramandeep (227-233).pmd 230 10/16/2012, 2:41 PM

was that balance ability in older adults can be Clinical Implications: These data suggest that balance
improved through the use of either land-based or training exercise program leads to improvement in
aquatic-based therapeutic exercise. Eleven subjects balance performance in community dwelling elderly
completed this study where both land and aquatic people. Regardless of the exercise medium (land or
based exercise groups did a comparable set of lower water), balance training exercise program can result
body exercises twice a week for 6 weeks. Regardless in improvement of balance performance in
of the treatment medium, significant improvements community dwelling elderly population. Thus,
balance ability in older adults could be improved
were evidenced on the Berg balance scale between pre-
through the use of either land-based or water-based
intervention and post-intervention scores22.
balance training exercise program.
Similarly, Taunton et al concluded that the type of
Considerations of availability, cost, and
exercise venue (land vs. water) did not have a
maintenance of the therapeutic pool will guide the
significant effect in improving cardio-respiratory
clinician in the decision making process for balance
fitness, body composition, forward trunk flexion and
re-training in the elderly.
strength measurements of elderly women aged 65 to
75 years36. Limitations of the study: Small sample size and
The results of a recent study conducted on thirty- shorter duration are the major limitations of the study.
Increasing the sample size would have increased the
four patients aged 50 years and above with coronary
statistical power of the study. Also, most of the
artery disease also demonstrated that both the water
participants belonged to the same community and
exercise and land exercise programs were effective in
were leading an active lifestyle. Thus, results obtained
increasing the exercise tolerance and muscular strength cannot be generalized for all population types
with similar favorable adaptations on lipid profile and including the frail and institutionalized.
body composition. Thus, indicating that water based
exercise may be a useful alternative for low risk
patients with coronary artery disease37. Future Research: This study was conducted on a
small sample of active and healthy community
Literature suggests that because of waters low dwelling elderly population. However, had it been a
impact and reduced risk nature, water exercise frail, kyphotic and osteoporotic population it might
provides a viable alternative for older persons who have encountered difficulties in participating in the
are unable to participate in land-based exercise land-based balance training exercise program. Thus,
programs because of limiting arthritis, significant water might be considered beneficial to those elderly
mobility limitations, severe balance impairments or adults who are frail, suffer from pain, or are severely
other disabilities18,21,29,25. The buoyancy of water allows kyphotic. Future researches can thus consider frail and
these elderly people to undertake exercises and institutionalized elderly population.
movements that they could not perform on land29
thereby allowing people with various levels of ability As mentioned earlier, this study used only a small
and disability to participate at their own pace38,34. sample of subjects and that too from the same
community. The relevance of this study can be
Thus, the factor that might have contributed to the increased by taking a larger sample of subjects from
findings of the present study is that the population of different sectors of the society.
elderly people participating in this study was leading
an active lifestyle and was community-based and that Re-assessment of the subjects at different intervals
was not frail and institutionalized. to determine the duration of the gains made during
training, or when the significant gains were achieved,
Although a larger sample of 60 subjects was would be beneficial. Increasing the duration of the
employed in the present study as compared to the study can add further relevance to the results
above mentioned studies, the results obtained reveal obtained.
no significant differences in either of the medium in
improvement of balance performance in community CONCLUSION
dwelling elderly population.
Regardless of the exercise medium, significant
Thus, water exercise is an evidence-based improvements in balance scores were achieved by the
alternative method of balance training and postural subjects in both the groups after the balance training
re-education for the elderly population19. exercise program.
45. ramandeep (227-233).pmd 231 10/16/2012, 2:41 PM

Thus, concluding that Balance training exercise 12. Nelson, R.C & Amin, M.A. (1990). Falls in the
program in either medium may be equally effective in elderly. Emerg Med Clin North Am, 8, 309-324.
improving balance in the elderly population. 13. Province, M.A., Hadley, E.C., Hornbrook, M.C.,
Lipsitz, L.A. (1995). The Effects of exercise on falls
ACKNOWLEDGEMENT in elderly patients: A preplanned Meta-analysis
of the FICSIT Trials, Journal of American Medical
I wish to thank our Principal and all the faculty Association, 273, 1341-1347.
members of ISIC-Institute of Rehab Sciences. 14. Nitz, J.C. and Choy, N.L. (2004). The Efficacy of a
specific balance- strategy training programme for
Lastly, my thanks are due to all the participants of preventing falls among older people: a pilot
the study and my friends without whose cooperation randomized controlled trial, Age and Ageing,
this study would not have been successfully 33:1, 52-58.
completed. 15. Sanders, M.S. (2003). Splash! Catch a wave for
better balance on land. The Journal on Active
REFERENCES Ageing, Sep-Oct, 51-54.
16. Skeleton, D.A. (2001). Effects of physical activity
1. Masdeu, J.C., Sudarsky, L., Wolfson, L. (Ed), 1997, on postural stability, Age and Ageing, 30-S4,
Gait Disorders of Aging: Falls and Therapeutic 33-39.
Strategies, Lippincott-Raven, 37, 79, 321, 355, 395. 17. Chandler, J.M. Balance and falls in the elderly:
2. Tideiksaar, R. Disturbances of gait, balance, and Issues in evaluation and treatment. Chapter-18,
the vestibular system. Chapter 39, Brocklehursts Geriatric Physical Therapy, Edition (2), Mosby,
Textbook of Geriatric Medicine and Gerontology, 280-292.
Edition (5), 595-609. 18. Simmons, V. and Hansen, P.D. (1996).
3. Lord, S.R. (2005). Vision, Balance and falls in the Effectiveness of water exercise on postural
elderly, Geriatric Times, Nov/Dec, 4:6. mobility in the well elderly: An experimental
4. Newton, R.A. (1997). Balance screening of an study on balance enhancement, J of Gerontology,
inner city older adult population, Archives of 51A:5, M233-M238.
Physical Medicine and Rehabilitation, 78, 587-591. 19. Nitz, J.C. and Hourigan, S.R. (Ed.) (2004).
5. Cwikel, J. (1992). Falls among elderly people Physiotherapy Practice in residential aged care,
living at home: Medical and Social factors in a Butterworth-Heinemann, 51, 53, 57,159,161, 163,
national sample. Isr. J. Med. Sci., 28, 446-453. 259, 260, 262.
6. Campbell, A. J., Spears, G. F., Borrie, M.J. (1990). 20. Geytenbeek, J. (2002). Evidence for effective
Examination by logistic regression modeling of hydrotherapy, Physiotherapy, 88:9, 514-529.
the variables which increase the relative risk of 21. Takeshima, N., Rogers, M.E., Watanabe, E.,
elderly women falling compared to elderly men. Brechue, W.F. (2002). Water-based exercise
J Clin Epidemiology, 43:12, 1415-1420. improves health related aspects of fitness in older
7. Nickens, H. (1985). Intrinsic factors in falling women, Med. Sci. Sports Exc., 33:3, 544-551.
among the Elderly, Archives of Internal Medicine, 22. Douris, P., Southard, V., Varga, C., Schauss, W.,
145, 1089-1093. Gennaro, C., Reiss, A. (2003). The effect of land
8. Nevitt, M.C., Cummings, S.R., Kidd, S. and Black, and aquatic exercises on balance scores in older
D. (1989). Risk factors for recurrent nonsyncopal adults. Journal of Geriatric Physical Therapy, 26,
falls- A prospective study, Journal of Am. 3-6.
Med.Asso., 261, 2663-2668. 23. Silsupadol, P., Siu, K.C., Shumway cook, A. and
9. Mazzeo, R.S., Cavanagh, P., Evans, W.J., Woollacott, M.H. (2006). Training of balance
Fiatarone, M. (1998). ACSM Position Stand on under single- and dual-task conditions in older
Exercise and physical activity for older adults, adults with balance impairment, Physical
Med. Sci. Sports Exerc., 30:6, 992-1008. Therapy, 86:2, 269-281.
10. Tinetti, M.E., Williams, T.F. and Mayewski, R. 24. Devereux, K., Robertson, D. and Briffa, N.K.
(1986). Fall risk index for elderly patients based (2005). Effects of water- based program on
on number of chronic disabilities, The Am J. of women 65 years & over: A randomized controlled
Medicine, 80, 429-434. trial, Aust. J. of Physiotherapy, 51, 102-108.
11. Buchner, D.M, Cress, M.E., Lateur, B.J., Esselman, 25. Lord, S.R., Matters, B., George, R.S., Thomas, M.,
P.C. (1997). The Effect of strength & endurance Bindon, J., Chan, D.K.Y., Collings, A. and Haren,
training on gait, balance, fall risk and health L. (2006). The effects of water exercise on physical
services use in community-living older adults, J functioning in older people, Australasian J. on
of Gerontology, 52A:4, M218-M224. Ageing, 25:1, 36-41.
45. ramandeep (227-233).pmd 232 10/16/2012, 2:41 PM

26. Golland, A. (1981). Basic Hydrotherapy, by Dynamic Posturography, J of Gerontology,

Physiotherapy, 67:9, 258-262. 49:4, M160-M167.
27. OSullivan, S.B. (2001). Assessment of motor 33. Hauer, K., Specht, N., Schuler, M., Bartsch, P and
function. Chapter-8, Edition (4), Physical Oster, P. (2002). Intensive physical training in
Rehabilitation Assessment and Treatment, geriatric patients after severe falls and hip
Jaypee Publishers, 177-212. surgery, Age and Ageing, 31, 49-57.
28. Podsiadlo, D. and Richardson, S. (1991). The 34. Rissel, C. (1987). Water exercises for the frail
Timed Up & Go: A test of basic functional elderly: A pilot programme, The Australian J. of
mobility for frail elderly persons, J of American Physiotherapy, 33:4, 226-232.
Geriatric Soc, 39, 142-148. 35. Young, A. and Dinan, S. (1994). Fitness for older
29. Lord, S.R., Mitchell, D. and Williams, P. (1993). people, British Medical Journal, 309, 331-334.
Effect of water exercise on balance & related 36. Taunton, J.E., Rhodes, E.C., Wolski, L.A., Donelly,
factors in older people, Aust. J. of Physiotherapy, M., Warren, J., Elliot, J., McFarlance, L., Leslie, J.,
39:3, 217-222. Mitchell, J. and Lauridsen, B. (1996). Effect of
30. Campion, R, M. (2000). Key features of pool land- based and water-based fitness program on
design and caring for the pool, Chapter-2, the cardiovascular fitness, strength and flexibility
Hydrotherapy: Principles and Practice, of women aged 65-75 years, Gerontology, 42,
Butterworth-Heinemann, 5-13. 204-210.
31. Barnett, A., Smith, B., Lord, S.R., Williams, M. and 37. Volaklis, K.A., Spassis, A.Th., Tokmakidis, S.P.
Baumand, A. (2003). Community-based group and Greece, K. (2007). Land versus water exercise
exercise improves balance and reduces falls in at- in patients with coronary artery disease: Effects
risk older people: a randomized controlled trial, on body composition, blood lipids, and physical
Age and Ageing, 32:4, 407-414. fitness, Am Heart Journal, 154, 560.e1- 560.e6.
32. Wolfson, L., Whipple, R., Derby, C.A., Amerman, 38. Heyneman, C.A. and Premo, D.E. (1992). A water
P. and Nashner, L. (1994). Gender differences in walkers Exercise Program for the elderly, Public
the balance of healthy elderly as demonstrated Health Reports, 107:2, 213-217.
45. ramandeep (227-233).pmd 233 10/16/2012, 2:41 PM

Effect of Aerofic Exercise on Functional Capacity in

Asymptomatic Coronary Artery Disease
Risk Factors Subjects
Ravinder Narwal1, Gurpreet Chawla2

1
Ortho, MPT-Cardiopulmonary, Lecturer, HIHT University, Dehradun-UK.
2
Cardio, MPT-I/C Physiotherapist,Kaushal Hospital,Mohali- Punjab
ABSTRACT
Aim & Objective: Coronary Artery Disease (CAD) accounted for 43% in India in 2001and the burden
of this chronic non-communicable disease is going to increase day by day. Moreover, current prediction
estimate that by the year 2020, CAD will become the leading global cause of total disease burden in
the form of mortality and morbidity. Fortunately, Coronary Heart Disease can be prevented or
controlled. This fact sheet gives an overview of Coronary Heart Disease and its prevention, diagnosis,
and treatment. This study is a part of cardiovascular disease preventive rehabilitation program and
is based on three time-honored classical coronary heart disease (CHD) risk factors: hypertension
stage-1, overweight, and smoking.
Methods: Sample of 30 asymptomatic subjects with 30-40 years age group were allocated and
assigned into three groups- Overweight Group(OWG), Smoking (SM) and Hypertensive Group (HTG).
Vo2 Max,Heart rate, blood pressure were measured by treadmill test and pacer test to compare the
effect of four weeks endurance exercise training period. Data was analyzed by using SPSS. T-test
and ANOVA was used. The level of significance was set at p>0.05.
Results: esults of our study suggested that four weeks of aerobic exercise training improve the aerobic
capacity in all the three cardiac risk factor groups' subjects. The mean difference of all the three
groups shows significant changes in aerobic capacity (VO2 max & pacer test) in four week training of
a proper schedule and protocol. The aerobic exercises show marked changes in overweight subjects
followed by hypertension subject and the least in smokers.
Discussion: Present study results provide important clues in understanding the cause for low aerobic
capacity (VO2max and pacer test) in smokers is due to not stopping smoking. Result of this study
has proved the beneficial effects of aerobic exercise training to improve functional aerobic capacity in
all risk factors groups . So aerobic exercise may be prescribed as regular therapy for long period of
time to all risk factors for a better future health out come. Results of our study have suggested that
pacer test can be used to check the improvement in aerobic capacity.
Conclusion: Aerobic exercise is the basic tools of preventive cardiac rehabilitation to protect the
heart against harmful cardiac events by improving the aerobic capacity and main emphasis must be
given on smoking group rehabilitation.
Key words: CAD- Coronary artery disease, OWG- Overweight Group, SM-Smoking Group, HTG-
Hypertensive Group. VO2max, Pacer Test.
INTRODUCTION risk factor for coronary heart disease. People from

Indian, Bangladeshi, Pakistani, or Sri Lankan
Prevention of Coronary Artery Disease (CAD) at background have a higher premature death rate from
early stage is recognized as one of the major health coronary heart disease compared to other countries
challenges in the twenty first centuary. So efforts need due to the major prevalence of sub-clinical or
to be focused on early detection. It is recently added symptomless CAD risk factors1.
that inactivity has been accepted as an independent
46 ravin naval 29th july 11 (234-239).pmd 234 10/16/2012, 2:41 PM

Risk factors are the pre exposed condition that the aerobic capacity after endurance exercise as an
increases the chance for CAD. CAD risk factors include index of fitness in risk factor subjects.
in this study are Overweight, Smoking and Stage-1
Hypertension2. CAD risk factors subjects face many physiological
changes & these changes complicate their life.
Overweight is the most common prevalent Therefore aim of our study is to design, asses and to
conditions in India as compare to others countries and provide a better aerobic exercise regime which is easy
it is considered as major contributor to many health & effective for CAD risk factors adults' so that CAD
problems, including CAD. risk factors subjects can adopt & get benefits of it for
better quality of life in future6.
The American Heart Association has been
documented that approximately 66% (or two thirds) This study is a part of cardiovascular disease
adults are overweight or obese. Reviewed studies preventive rehabilitation program and is based on
concluded that 26% males and 40% females three time-honored classical coronary heart disease
with overweight are responsible for coronary (CHD) risk factors: hypertension stage-1, overweight,
artery disease4. Overweight on BMI scale is 25 to 29.9 and smoking. This study would be able to elaborate
Kg. /m2 3. the significance of endurance exercise in daily life and
play a important role in reducing the burden of
Smoking increases the risk of heart disease, coronary artery at early age by improving the aerobic
peripheral vascular disease and lung cancer. Research capacity for healthy life.
has shown that smoking increases heart rate, tightens
major arteries, raises blood pressure, and can create
METHODOLOGY
irregularities in the timing of heartbeats, all of which
make heart proven for CAD. According to the.Risk of 30 male subjects between 30-40 years were screened
developing CAD drops 50% relatively soon after from 300 populations for this experimental Study. All
quitting of 1 year of not smoking. subjects were allocated in three (10 subjects/ groups
on the bases of their risk factors), group A
Hypertension is the leading cardiovascular disease (Hypertension) group B(Smokers) group C
in industrialized nations of world. It commonly begins (Overweight).
in young adulthood and occurs in 5% to10% of people
aged 20 to30 years. The incidence of hypertension All the subjects were screen for data collection
continues increasing with age and is found in 20% to before and after 4 weeks of aerobic exercise again
25% in middle-aged adults and 50% to 60% over 65 Balke-Ware Protocol on Technogym Run Race 1400 HC
years of age. Hypertension, whether labile or fixed, treadmill and field PACER test or Beep test to get the
mild or severe, or systolic/ diastolic in character & baseline or the initial reading. The subjects were made
occurring at any age, is a powerful Independent to do the aerobic exercises with intensity 50 - 60% of
contributor to CVD4. maximal aerobic capacity (VO2 max), 30 minute, 4
times a week for 4 weeks.
Suddenly increasing CAD in younger patients
draws attention toward the risk factors earlier than Data were collected with variable of VO2Mx, BP
before. In this study the aim is to screen, to treat and / HR / Beep test completed stage by Polar heart rate
to make the subjects aware about CAD. Aerobic monitor, Stethoscope, Sphygmomanometer, Audio
exercise protocol improves the health fitness at Tape and Compact Disc.Initial reading were compared
younger age so that the chances are reduced or with the final reading for the improvement of aerobic
decreased if the subjects continue the exercises without capicity7.
relying on medical treatment.There is a lake of dearth
available about the studies related with asymptomatic
young age individuals having CAD risk factors and
making comparison among CAD risk factors subjects
on the basis of aerobic capacity5.
So the purpose of this study is to compare the

aerobic capacity effect of endurance exercise
asymptomatic coronary artery disease risk factors
subjects. The main objective of this study is to evaluate Fig. 1. Subject for Pacer or Beep Test

RESULTS
Thirty subjects have taken in three groups for

aerobic exercise with Mean age 36 for group A(HTN),
35for group B(SM), 34 for group C( Overweight).
Comparison of VO2max pre treatment, post 4 week

for all the three Subjects group -A (HTN, Table 1, Fig.
3) ,Group B (SM, Table 2, Fig. 4), of group C(OW, Table
3, Fig. 5).
Table 1. Comparison mean SD of the Group A (HTN)
between pre treatment & after 4th week period
Fig.4. Endurance exercise effect on OW group
VO2 max Mean SD t-Value p-Value
Pre 33.606.56 -9.49 0.001 Table 4. Comparison mean SD of VO2max between
4th week 45.206.59 pre treatment & post 4 week among all groups Subjects
Level of significance p<0.05 of-HTN, SM, OW by ANOVA & Post hoc
Bonferroni.(POB)
ANOVA Mean SD F Value p- value
HTN 456.59
SM 385.51 23.57 0.001
OW 565.55
POB MSD F- Value p- Value
HTN 11.63.86
SM 4.71.15 29.70 0.001
OW 19.16.00
Level of significance p<0.05
Fig. 2. Endurance exercise effect on HT group
Table 2. Comparison mean SD of the

Group Group B (SM) between pre treatment & after
4th week period
VO2max Mean SD t-Value p- value
Pre 33.505.68 -12.81 0.001
4th week 38.205.51
Fig. 5. Comparison of aerobic exercise effect on all groups
Comparison of Beep test data between pre

treatment & post 4 weeks for all the three Subjects
group -A (HTN,Table 5,Fig 7 ) ,Group B (SM, Table 6,
Fig 8), of group C(OW, Table 7, Fig 9)
Table 5. Comparison mean SD of Group A (HTN)
Between pre treatment & after 4th week period
Fig3. Endurance exercise effect on SM group Beep test MeanSD t-Value p-Value
Pre 3.450.62 -5.39 0.001
Table 3. Comparison mean SD of the group C(OW) 4th week 4.800.46
between pre treatment & after 4th week period Level of significance p<0.05
VO2max Mean SD t-Value p- value
Pre 36.105.02 -9.87 0.001
4th week 56.205.55

Table 8. Comparison of Mean SD of Beep test

between pre treatment & post 4 week period of all 3
group subjects - HTN, SM ,OW. by ANOVA
& post hoc Bonferroni (PHB)
ANOVA Mean SD F Value p- Value
HTN 4.8.46
SM 3.9.45 51.96 0.001
OW 6.9.98
PHB Mean SD F Value p- Value
HTN 1.350.79
SM 0.550.33 26.23 0.001
OW 3.241.20
Fig. 6. Pacer test of HT group
Table 6. Comparison mean SD of Group B (SM)

Between pre treatment and after 4th week period.
Beep test MeanSD t-Value p-Value
Pre 3.380.57 -5.20 0.001
4th week 3.930.47
Fig. 9. Pacer test of all groups(Means)
Table 9. Comparison of mean differences

data of VO2max (4th week) among all the 3 groups by
Post Hoc test
Groups Mean p-value
HTN Smokers 7.0 .044
Overweight -11.0 .001
Fig. 7. Pacer test of SM group Level of significance p<0.05
Table 7. Comparison mean SD of Group C (OW)

Between pre treatment and after 4th week period
Beep test MeanSD t-Value p-Value
Pre 3.720.621 -8.53 0.001
4th week 6.960.98
Fig 10. Treadmill test data differences of all groups (MD)
Table 10. Comparison of mean differences

data of Beep test (4th week) among all
the 3 groups by Post Hoc test
Groups Mean p-value
HTN Smokers .87 .029
overweight -2.16 .000
Fig. 8. Pacer test of OW group Level of significance p<0.05

A. Ehsani et al. showed that the aerobic exercise

training reduces SBP & DBP by 10 mm hg in
individuals with mild hypertension. Regular exercise
helps keep arteries elastic (flexible), increase in muscle
capillaries, greater capacity venous system in the
trained person. This, in turn, ensures good blood flow
and maintaining heart-healthy levels of fitness11.
Smoking: Aerobic exercise protocol in this group

also shows significant improvement in aerobic capacity
in the form of VO2 max and pacer complete stages.
The readings are significantly higher than the baseline
Fig 12. Pacer test data differences of all groups (MD)
readings taken initially on day 0.
Ravin et al. have proved that the prevalence of

DISCUSSION CAD in smokers is 4 times more than the non smokers
This study result have taken three CAD risk factors and the prevalence reduces when the smoker quits
groups for analysis with mean age of 34 years and smoking. American college of sports medicine proved
sample said to be homogenous in character. the beneficial effects of aerobic exercise training to
improve functional aerobic capacity and reduces
Aerobic exercise protocol is design in this study clinical symptoms in smoker risk factors12.
with frequency four days/weeks/30 minutes for one
week. Experts recommend engaging in moderate Results of our study have proved that pacer test
physical activity for at least 30 minutes five to seven can be used to check the improvement in aerobic
days of the week to achieve benefits8. capacity. Similarly, it also provide to the
physiotherapist and exercise physiologists personnel,
Overweight: When scheduled aerobic exercise a guide for exercise prescription and help evaluate the
protocol is followed in overweight subjects for 4 weeks physical fitness status of an individual13.
for 4 times a week, then the result showed significant
improvement in aerobic capacity in the form of VO2 The mean difference of all the three groups shows
max and pacer complete stages. The readings are significant changes in aerobic capacity (VO2 max &
significantly higher than the baseline readings taken pacer test) in four week training of a proper schedule
initially on day 0. and protocol. The aerobic exercises show marked
changes in overweight subjects followed by
Steven et al. have proved that endurance hypertension subject and the least in smokers. The
exercises improve aerobic capacity (vo2 max) and cause for low aerobic capacity (VO2max and pacer test)
reduce 10-20% chances of CAD by improving vessel in smokers is due to not stopping smoking. Chronic
caliber with collaterals circulation formation. Thus the nicotine exposure in smokers is the main responsible
development of collateral helps in reducing, delaying points to blame that smoker are worse condition as
and prevention of Coronary Artery Disease at an early compare to others groups14.
stage. Klijn et al. have also showed that aerobic exercise
effectively improved aerobic performance of So result of the study suggested that smoking is
adolescents with obesity and in addition, suggested the main factor responsible for suddenly increasing
that aerobic fitness is an important predictor of CAD in younger age as compare to other risk factors.
mortality9. Result of the study draws our attention toward its
importance for rehabilitation by following a proper
Hypertension : Aerobic exercise protocol also aerobic exercise protocol continuing for the long period
shows significant improvement in aerobic capacity on more than four weeks.
treadmill exercise test , Beep test in the form of VO2
max and complete stages in pacer test. Emmanuel G. Result of our study support the general view that
Ciolac has concluded in their study that sedentary physical activity is important, not only for the
people have a 35% greater risk of developing high prevention but also in the management of
blood pressure than physically active subjects. Schotte, cardiovascular disease. So from the results of our study
J.A Raffo et al. have proved that aerobic exercise it can be summarized that childhood participation in
increase the VO2 max and helps in better controlling physical activity is appropriate for prevention of
the blood pressure, obesity10. cardiovascular disease in future and complement

treatment of existing cardiovascular risk factor intensity physical activity. In: Leon AS, ed.
including hypertension, smoking and overweight. Physical Activity and Cardiovascular Health: A
National Consensus. Champaign, Ill: Human
CONCLUSION AND FUTURE RESEARCH Kinetics; 1997: 55-66.
7. Farrell SW, Kampert JB, Kohl HW, 3rd et al.
Physical activity should be a permanent lifestyle Influences of cardiorespiratory fitness levels and
to enhance health and prevention of cardiovascular other predictors on cardiovascular disease
disease. An exercise prescription and the physio's mortality in obese men. Med Sci Sports
advice to increase physical activity are very strong Exerc.1998; 30: 899-905
motivators and an important component of a 8. Robin Parks, MS "Cigarette smoking and
successful exercise program for the subjects. coronary artery disease" Medical review: the
Stanford Coronary Risk Intervention Project
Whether the same findings apply to other ethnic (SCRIP). Circulation. . 1994; 89: 975-990.
groups of different age & other risk confirmed will be 9. King AC, Sallis JF, Dunn AL, et al. Overview of
in future studies. Additional physiological based the Activity Counseling Trial (ACT) intervention
research is recommended for further studies to provide for promoting physical activity in primary health
the scientific rationale supporting the importance of care settings: Activity Counseling Trial Research
physical activity in asymptomatic young subjects. Such Group. Med Sci Sports Exerc. . 1998; 30:
1086-1096.
research should address the mechanisms by which
10. The sixth report of the Joint National Committee
exercise reduces CAD risk as well as explore other
on prevention, detection, evaluation, and
medical conditions effectively managed by exercise
treatment of high blood pressure. Arch Intern
training15. Med. . 1997; 157: 2413-2446.
11. J.A Raffo et al . Physical activity and incidence of
REFERENCES hypertension in college alumni. Am J Epidemiol.
. 1983; 117: 245-257
1. Powell KE, Thompson PD, Caspersen CJ, et al.
12. Fletcher BJ, Dunbar SB, Felner JM, et al. Exercise
Physical activity and the incidence of coronary
testing and training in physically disabled men
heart disease. Annu Rev Public Health. . 1987; 8:
with clinical evidence of coronary artery disease.
253-287.
ACSM. . 1994; 73: 170-174.
2. Leon AS, ed. Physical Activity and
13. Haskell WL. The efficacy and safety of exercise
Cardiovascular Health: A National Consensus.
programs in cardiac rehabilitation. Med Sci Sports
Champaign, Ill: Human Kinetics; 1997.
Exerc. . 1994; 26: 815-823.
3. Berlin JA, Colditz GA. A meta-analysis of physical
14. Hambrecht R, Schuler GC, Muth T, Grunze MF,
activity in the prevention of coronary heart
Marburger CT, Niebauer J, Methfessel SM, Kbler
disease. Am J Epidemiol. 1990; 132: 612-628.
W. Greater diagnostic sensitivity of treadmill
4. M.E. Cupples, A. Mc Knight in "Randomized
versus cycle ergometry exercise testing of
controlled trial of health promotion in general
asymptomatic men with coronary artery disease.
practice for patients at high cardiovascular risk"
Am J Cardiol (1992) 70: 141-146.
BMJ 1994; 309; 993-996.
15. King AC, Blair SN, Bild DE, et al. Determinants
5. Hartley LH. Exercise and cardiac rehabilitation.
of physical activity and interventions in adults.
Proc N Engl Cardiovasc Soc. . 1976; 28: 37-40.
Med Sci Sports Exerc. 1992; 24: S221-236.
6. Leon AS. Contribution of regular moderate-

Clinical Outcome in Adult Ventilated Patients Using

Multimodality Chest Physiotherapy as Treatment
Approach: A Single Blinded Randomized Clinical Trial
Renu B Pattanshetty1, Gajanan.S Gaude2

1
Asst.Prof., KLE University's Institute of Physiotherapy, Belgaum, Karnataka.
2
Prof & HOD, Department of Pulmonary Medicine Jawaharlal Nehru Medical College Belgaum, Karnataka
ABSTRACT
Background & Aims: Mechanical ventilation is commonly required for critically ill patients. Evidence
suggests that preventive measures reduce the high rates of morbidity and mortality in critically ill
patients. However effect of multimodality chest physiotherapy on clinical outcome has been least
studied. The present study aimed to investigate the effect of multimodality chest physiotherapy on
clinical outcome in adult ventilated patients.
Methods and Materials: Trial was carried out in 150 bedded ICU of a teaching tertiary care hospital.
125 adult mechanically ventilated patients were included and randomly allocated to 2 groups. Manual
hyperinflation (MH) and suctioning was given to the patients in control group (n= 63) and positioning
and chest wall vibrations in addition to MH plus suctioning were given to the patients in study
group (n= 62) till they were extubated. Both the groups were treated twice a day. Standard care in the
form of routine nursing & pharmacological care as advised by intensivist was followed throughout
the intervention period.
Results: Data was analyzed using Chi Square test, student t test and z tests. Mean GCS scores were
higher in the study group (p=0.000). Rate of ventilator associated pneumonia increased in control
group (p=0.032). The rate of successful outcome was higher in the study group (p= 0.000) with
66.1%.Conclusion: Twice daily multimodality chest physiotherapy may be used as a routine
therapeutic option to improve outcome and prevent complications.
Key words: Multimodality Chest Physiotherapy, Mechanical Ventilation, Complications, Outcome, Mortality
INTRODUCTION It has been observed that aggressive preventive

measures reduce the high rates of morbidity and
Mechanical ventilatory support is commonly mortality in critically ill patients who are intubated
required for critically ill patients. Although life saving, and ventilated 3. There is evidence that various
it is invasive, expensive and associated with a variety combinations of chest physiotherapy assist in the re-
of serious complications. Reducing the time a patient expansion of lung and confer short term improvement
spends receiving mechanically ventilator support is a in lung compliance and flow rates4. However, the effect
worthy approach to both improving patient care and of multimodality chest physiotherapy on clinical
reducing its related costs1. outcome in adult ventilated patients has been least
studied. The present study was conducted to evaluate
Numerous reports pertaining to the outcome of
the effect of multimodality chest physiotherapy on
mechanically ventilated patients have appeared in the
clinical outcome in mechanically ventilated adult
scientific literature. Studies have been typically
patients.
performed in relatively small populations comprising
on or several units of a hospital, and occasional, a
group of hospitals. There is much controversy MATERIAL AND METHODS
regarding outcomes in mechanically ventilated
A total of 125 patients who were mechanical
patients and it is difficult to extrapolate conclusively
ventilated for > 48 hrs from adult ICUs were recruited
from existing reports2.
into the study using convenient sampling. Exclusion
criteria included untreated pneumothorax, acute
47 renu shaivanad kori 17th nov 10 (240-243).pmd

240 10/16/2012, 2:41 PM
myocardial infarction, cardiac arrhythmias, extubation/ at the end of the treatment were higher in
hypovolemia, haemodialysis, unstable cardio-vascular the study group which was statistically significant
or neurological function or injury preventing (p=0.000). The rate of successful outcome was higher
positioning for chest physiotherapy, open heart in the study group than the control group which was
surgeries, admission with tracheostomy and HIV statistically significant. (p=0.000). Among the
patients. Random allocation of patients to either group complications encountered by patients during
was done using envelope method. Ethical approval ventilation, rate of ventilator associated pneumonia
was obtained from the Institutional Ethical Research increased in control group which was statistically
Board of the University before the commencement of significant.(p=0.032). Other complications included
the study. All patients recruited to this study were atelectasis, pleural effusion, pneumothorax, cardiac
ventilated by Servo Ventilator-900C and Servo arrest and septicemia. (Table 3). Among the weaning
Ventilator 300. After obtaining written consent from characteristics, PaO2 was statistically significant in
the patients or the patients' relatives, baseline data weaned group (p=0.00).Duration of mechanical
including age, gender, admission diagnosis, ventilator ventilation was more in non weaned patients of study
mode, and Glasgow Coma score of all the patients were group as compared to control group which was
noted. Clinical Pulmonary Infection Score was used statistically significant. (p=0.01) Length of duration in
for diagnosis of Ventilator associated pneumonia4. ICU of non weaned patients in study group was higher
as compared to control group which was statistically
Manual hyperinflation was administered as significant. (p=0.04)
described by Suh-Hwa Maa6. The MH procedure was
given for a period of 20 min at each session twice a DISCUSSION
day (9.30 am and 3.30 pm) daily. After MH,
immediately chest vibrations were employed 7 . A total of 125 adult ventilated patients with 63
Suctioning was done as described by Jessica SP Choi patients in the study group and 62 patients in the
& Alice YM Jones8 Positioning was given to patients control group were treated with males to female ratio
as described by Frownfelter D9. At the end of treatment of 3.6:1(Table 1) Previous studies have suggested that
session, the head end was elevated to about 30-45 a patient's sex may influence the provision and
degrees. Change in position from supine to lateral was outcomes of critical care. In a retrospective cohort
done by nursing staff by turning the patients every 2 conducted by Fowler R A et al10 where 24, 778 critically
hourly. ill adult patients were admitted and association
between sex, age and admission to the ICU. Use of
Standard care in the form of routine nursing care mechanical ventilation, length of ICU, and hospital and
& pharmacological therapy was followed throughout death were extensively studied. They concluded that
the intervention period. Ventilator parameters were among patients 50 years or older, women appeared
adjusted by the intensivist. Patients in both the groups less likely than men to be admitted to an ICU and to
were treated with chest physiotherapy by the receive selected life supporting treatments and more
investigator twice a day (9.30 am and 3.30 pm) till likely than men to die after critical illness. Raine R et
patients were weaned off from the ventilator. Patients al studied influence of patient gender on admission to
were assessed at the end of 72 hrs, 7 days and at the intensive care in 46,587 adult patients and found no
end of extubation days. Primary outcome were gender differences on admission or in mortality11. Age
oxygenation status, mortality rates and length of is clearly a relevant factor in outcome from serious
hospitalization. Secondary outcome were illness12. Hugo R et al observed that older women had
development of atelectasis and pneumonia. We higher mortality rate than men13 Similar observations
considered < 10 cms of H2O as low PEEP and > 10cms have been seen by Kollef et al.14 Scott and Van Vuong
of H2O as high PEEP. Standardized weaning criteria conducted a prospective observational study in 580
were used to wean the ventilated patients. adult patients and found no differences in hospital
mortality rates between mechanically ventilated men
RESULTS and women15.
Data of 125 patients was analyzed using SPSS The ratio of partial pressure of oxygen in arterial
windows 0.9. Chi-square test, Student paired and blood (PaO2) to the inspired oxygen fraction (FiO2)
unpaired 't' test and 'Z' test was used compare the (PaO2/FiO2) has been used to quantify the degree of
statistical significance.Both groups were well matched abnormalities in pulmonary gas exchange before and
for age, duration of mechanical ventilation, length of after therapeutic intervention. The PaO2/FiO2 ratio
ICU stay, GCS baseline scores, and the weaning has also been used in the clinical setting to classify
modes.(Table1). Majority of patients were started on patient's pulmonary gas exchange status, including the
volume control mode during the initiation of definitions ALI/ARDS16. PaO2/FiO2 ratio depends on
mechanical ventilation as compared to the other modes both FiO2 level and the arterial saturation level.
of ventilation. Mean GCS scores at the time Criteria for acute lung injury and ARDS, the FiO2

241 10/16/2012, 2:41 PM
levels at which the PaO2/FiO2 ratio is measured The administration of positive end expiratory
should be defined when quantifying effects of pressure (PEEP) is aimed at preventing the end
therapeutic interventions or when specifying expiratory collapse of diseased pulmonary areas in
diagnostic criteria for ALI and ARDS16-18. order to reverse the severe hypoxemia resulting from
pulmonary shunting, a hallmark of ARDS. There have
Table 1. Demographic characteristics at been various randomized clinical trials to study the
baseline in both groups effects of high versus low PEEP in ARDS in suggesting
S. Variables Study Control "t" DF 'p' value
No. group group further clinical trials to fully elucidate the role of higher
n=62 n=63 than traditional PEEP levels in patients with ARDS19-21
1. Age (years) 49.6415.86 49.5216.62 0.042 123 0.967
In the present study, it was observed that the mean
2. Males : Females 47:15 51:12 X2=0.0489 0.0485
4. Duration of s 9.2710.75 7.094.80 1.467 123 0.145 levels of PEEP at the initiation of mechanical
mechanical ventilation was slightly higher in the control group.
ventilation (days)
5. Length of ICU 11.4311.43 9.666.45 1.067 123 0.288
stay(days) Traditionally, PEEP values of 5 cms to 12 cms of
6. FiO2 (%) 0.66 .19 0.60.18 4.060 0.23 0.000 H2O have been used in the ventilation of patients with
7. PEEP (cms of H2O) 7.412..35 8.752.14 3.260 123 0.001
8. PaO2 (mm Hg) 80.485.74 79.355.78 1.099 123 0.274
ARDS resulting in improved oxygenation22. In the
9. PaO2/ FiO2 ratio 202.175.02 151.1 66.02 4.04 123 0.000 present study, higher levels of PEEP did not show any
10. No of Admissions 34 (54.83%) 28 (44.44%) reduction in the mortality rate. Meade O M et al
in MICU
11. No of Admissions 08 (12.90) 11 (17.46) studied 983 patients with ALI/ARDS and observed
in SICU X3= 7.756 0.051
12. No of Admissions 09 (14.52) 19(30.15)
that no significant harm or increase risk of barotrauma
in NSICU was noted despite use of higher PEEP. High PEEP or
13. No of Admissions 11 (17.74) 05(7.93)
in ICCU "open Lung" strategy showed to improve oxygenation
Initial mode of ventilation with fewer hypoxemia related deaths and a lower use
14. Volume control 21 39
mode(VC)
rescue therapies by the treating clinicians23. hence
15. SIMV+ PS mode 28 20 X2 =8.384 0.004 suggesting that higher PEEP levels may be used as an
16. Baseline GCS Score
alternative to the established low PEEP or low tidal
Weaning mode 3.870.87 3.900.092 123 0.927
17. CPAP 13 02 X2= 1.178 0.178
volume strategy24.
18. T-piece trial 28 16
19. Weaning duration(days) 1.880.72 20.84 0.537 57 0.580 A variety of volume and pressure modes of
(n=41) (n=18)
Global outcome
ventilation are used to improve oxygenation,
20. death 16 (25.8%) 29(46%) X2= 18.477 0.000 ventilation and acid-base status. In volume control
21 Successful outcome 41(66.1%) 18 (28.6%) modes, traditionally large volumes have been shown
22 Against medical advice 05 (8.1%) 13 (20.6%)
23. Discontinued 00 03(4.8%)
to cause "volume trauma" 24 . Pressure modes of
24. GCS at the time 8.933.007 6.3013.30 4.662 123 0.000 ventilation have characteristics that make them
of extubation
attractive for use in patients with non compliant lungs.
Table 2. Indications for mechanical ventilation However, the ARDS Network Group suggests the use
S. Baseline diseases for Study group Control group 'p' value of low volume targeted ventilation rather than pressure
No. mechanical ventilation (n=62) (n=63) targeted ventilation which protects the lungs of the
1. Respiratory diseases 15(24.19%) 08 (12.69%) 0.101 patients24.
2. Neurological conditions /
Neurosurgical conditions 19 (30.64%) 26 (41.26%) 0.218
3. Musculoskeletal conditions/
Physiotherapy intervention is regarded as an
Trauma 00 06 (9.52%) 0.013 internal component in the management of patients in
4. Post-surgical respiratory 07 (11.29%) 06 (9.52%) 0.749 intensive care and has been demonstrated to be
diseases
beneficial. Interventions like positioning, manual
5. Cardiac diseases 10 (16.12%) 05 (7.93%) 0.158
6. Other medical conditions 10 (16.12%) 12 (19.04%) 0.667
hyperinflation and suctioning have been suggested as
safe25.
Table 3. Complications in ventilated patients
in both the groups To conclude, this trial had positive effect in terms
S. Complications after Study group Control group 'p' value of clinical outcome with success rate of 66.1% with
No. intubation and mechanical (n=62) (n=63) multimodality chest physiotherapy in the study group.
ventilation
1. Ventilator associated 18 (29.03%) 30 (47.61%) 0.032
The study also suggested use of multimodality chest
pneumonia physiotherapy in reducing the incidence of VAP. This
2. Atelectasis 05 (0.06%) 02 (3.17%) 0.234 study suggests future trials with larger sample size,
3. Pleural effusion 01 (1.61%) 01(1.58%) 0.992
4. Pneumothorax 01 (1.61%) 00 0.312
using APACHE scores.
5. Cardiac arrest 04 (6.45%) 05(7.93%) 0.756
6. septicemia 02 (3.22%) 01(1.58%) 0.548
TOTAL 31 (50%) 39 (61.90%) 0.180

242 10/16/2012, 2:41 PM
REFERENCES 14. Epstein SK, Vuong Van- Lack of influence of

gender on outcomes on mechanically ventilated
1. Marelich R G,Murin S,Battistella F,Inciardi J, medical ICUs patients, 1999, Chest, 116: 732-739.
Vierra T and Roby M- Protocol weaning of 15. Karbing DS, Kjrgaard S, Smith BW , Espersen
mechanical ventilation in medical and surgical K, Allerod C, Andreassen S, and Rees S E -
patients by respiratory care practitioners and Variation in the PaO2/FiO2 ratio with FiO2:
nurses, 2002, Chest, 118: 459-467. Mathematical and experimental description and
2. Cohen Laurence I and Lambrinos J - Investigating clinical relevance,2007,Crit Care,11: 1- 8.
the impact of age on outcome on mechanical 16. Augustyn B- Ventilator associated pneumonia-
ventilation using a population on mechanical Risk factors & Prevention, 2007, Crit Care Nurse,
ventilation using a population of 41,848 patients 27: 32-39.
from state wise database, 1995, 107: 1673-1680. 17. Ntoumenopolous G,Presneil JJ, Mc Elholum M,
3. Kathy Stiller. Physiotherapy in intensive care. Cade JF- Chest physiotherapy for prevention of
Towards evidence based practice Chest 2000: ventilator associated pneumonia,2002,Int Care
1801-1813. Med; 28: 850-856.
4. Pujin J. Clinical signs and scores for the diagnosis 18. Rouby JJ, Lu Q and Goldstein I- Selecting the right
of ventilator associated pneumonia. Minnerva level of positive end expiratory pressure in
Anesthesiol, 2002: 261-265. patients with acute respiratory distress
5. Chang DW -Textbook of Clinical application of syndrome, 2002,Am J Respir Crit Care Med, 165:
mechanical ventilation in Chapter 14-Weaning 1182-1186.
from weaning mechanical ventilation- by Chang 19. Grasso S, Fanelli V,Cafarelli A,Anaclerio R,
WD and Hiers JH,2ndedition, Delmar Thompson Amabile M,Ancona G & Fiore T-Effects of high
Learning. versus low postive end expiratory pressure in
6. Suh-Hwa Maa. Manual hyperinflation improves acute respiratory distress syndrome,2005,Am J
alveolar recruitment in difficult to wean patients. Crit Care Med; 171: 1002-1008.
Chest 2005: 2714-2724. 20. Cereda M, Foti G, Sparacino ME & Pesenti A -
7. Mc Carren B, Jennifer A, Alison and Rober D, Positive end expiratory pressure prevents the loss
Herbert. Vibration and its effect on respiratory of respiratory compliance during low tidal
system. Aust. J .Physiother, 2006: 39-43. volume ventilation in acute lung injury
8. Jessica SP Choi, Alice YM Jones .Effects of manual patients,1996; Chest ,109: 480-485.
hyperinflation and suctioning on respiratory 21. Mercat A, Richard J. C., Vielle B. , Jaber S, Osman
mechanics in mechanically ventilated patients D, Diehl J. L. , Lefrant J. Y, Prat G. , Richecoeur
with Ventilator-associated pneumonia, Aust. J J., Nieszkowska A., Gervais C, Baudot J.,
.Physiother 2005 - 25-30. Bouadma L. and Brochard L. - Positive end
9. Donna Frownfelter. Body Positioning in expiratory pressure setting in adults with acute
Principles and Practice of Cardiopulmonary lung injury and acute respiratory distress
Physical Therapy,3rd Edition, Mosby -Year Book syndrome: A randomized controlled trial , 2008;
Inc. 1996. JAMA, 299: 646-655.
10. Fowler R A, Sabur N, , Li PJuurlink D N, , Pinto 22. Girard DT, Bernard RG - Mechanical ventilation
R, Hladunewich M A, Adhikari N K J, William J. in ARDS, 2007, Chest ;131: 921-929.
Sibbald W J, and Martin CM - Sex and age based 23. Meade OM, Cook JD, Guyatt GH, Slutsky
differences in the delivery and outcomes of SA,Arabi MY, Cooper JD et al -Ventilation
critical care ,2007,Canandian Medical Association strategies using low tidal volumes, recruitment
Journal; 177: 1513-1519 maneuvers and high positive end expiratory
11. Raine R,Goldfrad C,Rowan K,Black N -Influence pressure for acute lung injury and acute
of patient gender on admission to intensive care, respiratory distress syndrome, 2008, JAMA, 299:
2002, J Epidemiol Community Health , 56: 637-664.
418-423. 24. Risley JG, Jones MO- Physiotherapy in Intensive
12. Chernow B - Variables affecting outcome in Care. In Bersten AD,Soni N,Oh TE(Eds) Oh's
critically ill patients, 1999, Chest , 115: 71S-76S. intensive care manual (5th Edition), 2003,
13. Hugo R,Carlos A, Vincent LJ- Effect of patient sex London: Butterworth Heinnmann- 33-40.
on intensive care unit survival , 2004,Arch Intern 25. Litza Zeppos, Patman S, Berney S, Adsett A
Med;164:61-65.Kollef MH,Jeana D O Brien, Silver J,Bridson J M & Paratz JD-Physiotherapy
P- The impact of factor on outcome from intervention in intensive care is safe: an
mechanical ventilation,1997,Chest ; 111: 434 - 441. observational study,2007,Aust. J of Physiother; 53:
279-283.

243 10/16/2012, 2:41 PM
Efficacy of Low-Intensity Pulsed Ultrasound on Bone

Mineral Density in Osteoporotic Postmenopausal Women
Ali A. Thabet1, Omar F. Helal2, Shamekh M. El-Shamy2

1
Department of Physical Therapy for Obstetrics and Gynecology, Faculty of Physical Therapy, Cairo University.
2
Assistant Professor of Physical Therapy, Faculty of Applied Medical Sciences, Umm Al- Qura University
ABSTRACT
Purpose of this current study was to investigate the effect of low intensity pulsed ultrasound on bone
mineral density (BMD) of lumbar vertebrae in osteoporotic postmenopausal women. Thirty
postmenopausal women suffer from lumbar vertebrae osteoporosis were selected from Umm El
Masryeen General Hospital received ultrasound therapy three time / week for six weeks. DXA was
used for assessment of BMD before and after treatment. The results of the study demonstrate significant
increase in lumbar BMD. It was concluded that low intensity pulsed ultrasound is effective modalities
in increasing bone mineral density (BMD) of lumbar vertebrae in osteoporotic postmenopausal
women.
Key words: Postmenopausal, Bone Mineral Density, Low Intensity Pulsed Ultrasound, Osteoporosis
INTRODUCTION It is evident that low bone mass is the most potent

factor leading to fracture. Estrogen deficiency is well
Osteoporosis is a metabolic bone disease established as a risk factor for osteoporosis. There are
characterized by low bone mass, which increases the several risk factor reported in the literature which
bone fragility and the risk of fracture 1. More cancellous accelerate the development of osteopenic process
than cortical bone is lost following the menopause due includes negative calcium balance, sedentary life style,
to bone trabeculae being more sensitive to estrogen immobilization, menopause (surgical or natural),
deficiency than cortical bone, leading to a loss of amenorrhea, family history of osteoporosis, high
connectivity and an increase in its porosity2. Bones, alcohol intake, smoking, high caffeine consumption
such as proximal femur, distal radius and the and steroid therapy5.
vertebrae, are composed of a large amount of
trabeculae bone. Thus, treatments to prevent or to Therapy should be directed primary toward
stabilize the osteoporosis are important3. Alternative increasing physical activity, reducing the risk of falling
treatments are options for those people with an and secondarily toward stabilizing bone mass.
increased risk of osteoporosis development but with Reversing the osteoporotic process require therapy in
restrictions for the ordinary treatments already in the form of hormonal replacement. Calcitonin which
existence1. is peptide hormone mediator for estrogen action,
produce inhibition of osteoclasts activity and therefore
Recently postmenopausal osteoporosis has become decrease the bone resorption4. Also maintaining a high
an area of interest in terms of medical, social and dietary intake of calcium, vitamin D, reduction of
economic costs. It is a significant cause of women's excessive consumption of protein and phorphorous
morbidity and mortality leading to fractures of the hip, are indicated as therapeutic options2. Calcium must
spine and wrist. Osteoporosis is a primary metabolic be given with sodium fluoride to allow mineralization
disease of bone and a major public health problem that of the new osteoid. Problems with this modality
mostly occurs in the elderly3. include the questions of abnormal bone architecture
and the high incidence of side effects5.
There are two types of osteoporosis, type I due to a
decrease in cumulating estrogens which affects The impact of physical activity on BMD was
trabecular bone (especially vertebral bone) and affects established via reducing and/or preventing the
females more than males in a ratio of 1:6. Type II, senile volitional bone loss in both recently postmenopausal
osteoporosis, which is age related and occurs in cortical and very elderly women3. The role of electrotherapy
and trabecular bone, affects females and males in a in the management of menopausal osteoporosis is very
ratio of 2:14. limited in the literature. It was concluded that pulsed
48 Shamekh Mohd egypt (244-248).pmd 244 10/16/2012, 2:41 PM

electromagnetic field has an effect to slow down the imaging test that measures bone density (the
bone mass loss in osteoporosis induced by ovariectomy amount of bone mineral contained in certain
in rats and clinical application of the same current in volume of bone) by passing x-rays with two
women's osteoporosis was also reported4. different energy levels through the bone. It is used
The ultrasound is a form of mechanical energy to diagnose osteoporosis.
which promotes local bone microdeformations, as the 2. Ultrasonic (US) device (Enraf Nonius -
natural mechanical incentive, and which is crucial in Sonoplus590): was used to deliver low -intensity
stimulating the bone formation6,7. Several studies have pulsed ultrasound therapy. The apparatus
already shown that low-intensity ultrasound is capable provided the following options: I MHz frequency
of accelerating the healing of fresh fractures, delayed with transducer having an affective radiating area
healing and nonunion. Furthermore; recent of 5.0 cm2, intensity up to 1.5 W/cm2 in continuous
experimental studies have shown the ultrasound mode, 3W.cm2 in pulsed mode. Gel was used as a
benefits on large bone defects and on spine fusion. coupling media.
However, there are no studies which relate the action
of low-intensify ultrasound in cases of osteoporosis PROCEDURES
without fractures8.
A. Evaluation
Ultrasound (US) represents a potential intervention
for osteoporosis. US refer to a high-frequency no Initially a screening test including careful history
audible acoustic energy that travels in the form of taking and gynecological examination were conducted
mechanical waves. A mechanical wave is one in which for each subject before entry in this study. After that
energy is transmitted by the movement of particles BMD of lumbar spine (L1-5) was measured by DXA
within the medium through which the wave is densitometry. Evaluation of lumbar BMD was
traveling. As these waves travel as a relatively focused performed before and after the end of six weeks of
beam (typical effective radiating area = 5 cm2). US can treatment.
be directed onto specific regions to exert a local
mechanical stimulus5. B. Treatment
All subjects in- this study underwent 5 minutes US

METHODS application, three sessions per week for six successive
Subjects weeks period of treatment. The treatment procedure
was explained to all subjects. Skin was cleaned with
Thirty postmenopausal women were selected from alcohol to remove fat. During ultrasound application,
Umm El Masryeen General hospital. The criteria for the position of the subjects was the same for both
inclusion were as follows: (a) DXA diagnosis of normal groups (prone lying position with a pillow under her
BMD and osteoporosis in lumbar vertebrae with no abdomen). Ultrasound therapy was applied to the
evidence of vertebral compression fractures, (b) age lumbar vertebrae (L1-5) using 3 cm ultrasound head.
between 57 to 65 years (to avoid inclusion of older
patients with multiple medical problems), (c) no C. Statistical analysis
history of cancer, renal disease, gastrectomy, metabolic Data were collected and statistically analyzed using
bone disease or any condition (such as a neurogenic, the arithmetic mean, standard deviation pre -post t test
myopathic or connective tissue disorder) that could at level of significance of 0.05.
cause secondary osteoporosis, (d) no intake of any
medications associated with accelerated bone loss
RESULTS
(steroids) or any medications affected bone metabolism
(estrogen, calcium, vitamin D, ...etc), (e) body mass In the present study, the response of BMD to low
index not exceeding 30 Kg/m2, non smoker, parity intensity pulsed ultrasound was investigated. The data
from 1-3 times and led sedentary life style without collected after six weeks of ultrasound treatment were
participation at any exercise training during this study, compared with the pre treatment.
and, (f) had natural menopause at least 1 year before
entry into the study with no history of ovariectomy. As revealed from table (1) and figure (1) there was
a highly statistically significant increase (P>0.0001) in
Instrumentation the mean value of lumbar T- Score between pre and
l. Dual x-ray Absorptiometry (DXA) (Model QDR- post treatment.
1000W, Hologic, Inc., Waltham, MA) was used for As revealed from figure (2) While comparing pre
the qualitative assessment of BMD in the vertebral treatment and post treatment, the improvement
bodies of the lumbar spine for both groups. An

percentage was 14.40% and statistically difference capable of producing changes within the cell
(P>0.0001) was highly significant. membrane. This is illustrated by ultrasound's capacity
to alter cell membrane permeability to ions and to alter
Table 1. The comparison between pre & cell membrane electrophysiological properties.
post mean values of the T-score
Ultrasound can cause an immediate decrease in
Pre-ttt Post-ttt MD Imp. % t value P value Significance
intracellular potassium content in thymocytes a
Mean 3.0167- -2.5833 -04333 14.4 -6.500 0.0001 Highly
Significant reversible increase in the intracellular level of calcium
SD 9.129 0.3957 in chondrocytes), and an increase in calcium
incorporation into differentiating cartilage and bone
cell cultures 7.
It is not clear if these changes are brought about by

a direct mechanical deformation of the cell membrane,
deformation of cell receptors, or indirectly as a
consequence of cavitation, microstreaming, or a
combination of these or other effects9.
It has been argued that the beneficial effect of

ultrasound on bone healing is due to the piezo-electric
phenomenon5. Bone is piezo-electric, which means that
electric potentials are produced in bone when it is
subjected to mechanical stress. Since Wolff's law
basically states that bone remodels according to
Fig. 1. The mean value of T-score of pre treatment relative to those functional demands, it is assumed that the stress-
of post treatment
generated potentials in bone serve as a signal which
controls bone remodeling10.
Ultrasound is a biophysical intervention that is

capable of generating piezo-electric effects in bone and
increasing electric potentials in bone Using 1.27-MHz
ultrasound with a very low intensity of 0.00383 W/
cm-2 on bone, measured an electric potential of 64 V
at the ultrasound frequency in vivo10.
Fig. 2. The improvement % of the mean values of T-score of post Evidence that osteogenesis is stimulated by
treatment ultrasound can be found in vitro studies. Osteoblasts
can be stimulated to increase collagen production20 and
DISCUSSION increase the production of prostaglandin E 2, an
important bone-healing mediator that exert different
The primary problem in postmenopausal with effects on bone cells in the same microenvironments,
osteoporosis is thought to be enhancement of bone such as inhibiting mature rat osteoclasts from resorbing
resorption, with consequent net loss of bone mass as bone and stimulating osteoblasts for bone formation11.
osteoblasts fail to repair the defect completely which
increase the risk to fracture. The basic problem in the Elbialy et al.12, studied effects of ultrasound modes
remodeling of bone is directly related to the on mandibular osteodistraction and they found that
stimulation, multiplication and proliferation of the earlier stages of bone healing were enhanced more by
extraperiosteal, periosteal and medullar connective continuous, whereas late stages were enhanced more
tissue that form reparative blastemas leading to the by pulsed ultrasound.
consolidation of the bone.
Warden et al.13, studied efficacy of low-intensity
Dual X-ray absorptiometry was used for pulsed ultrasound in the prevention of osteoporosis
assessment of bone density .The results of DEXA following spinal cord injury and they found that
revealed a highly significant increase in lumbar BMD alternate doses of US may have beneficial effects on
of postmenopausal osteoporotic women with low intact bone. These effects are likely to be restricted to
intensity pulsed ultrasound compared to pre treatment the outer bone cortex.
lumber BMD.
Sheng Sun et al., 14 studied in vitro effects of low
Pulsed-wave US at low (<100 mW/cm2) spatial- intensity ultrasound stimulation on bone cells and they
averaged temporal-averaged in ten ultrasound is found that low intensity ultrasound treatment may

have a stimulatory effect on bone healing processes as CONCLUSION

the concentration of PGE2 in the culture medium
significantly increased after ultrasound stimulation Although osteoporosis is a primary metabolic
which stimulate bone cell metabolism. disease of bone and a major public health problem that
mostly occurs in postmenopausal period, there is no
Chang et al., 15 who studied cytokine release from cure of it. Therapy should be directed primarily toward
osteoblasts in response to ultrasound stimulation, they increasing physical activity, reducing the risk of falling
found that increase in osteoblasts growth due to and secondarily toward stabilizing bone mass. The
mechanical stimulation of ultrasound and enhance results of this study demonstrated the superiority of
osteoblasts population together. Monici et al., 16 who low intensity pulsed ultrasound to increase BMD of
studied the effect of low intensity ultrasound lumbar vertebrae in postmenopausal women with
stimulation on model of osteoclastic precursor, they osteoporosis.
found that ultrasound inducing enhancement of the
osteoclastic function and impairment of osteoclastic Although the findings of this study are highly
one at the same time makes ultrasound a potential tool significant, but treatment of low bone mass might not
to counteract osteoporosis. be effective enough to guarantee that any gains in mass
will be of sufficient magnitude to reduce fracture risk
Ramas et al.,17 who studied stimulating bone significantly, so further research is required to examine
growth using piezoelectric ultrasound transducers on long term effectiveness of this treatment and combine
the edentulous jaw and they found that ultrasound it with physical activity that reported its effectiveness
activating bone growth through the mechanical stress on bone repair in literatures.
induced by the propagation of ultrasound into the
bone. ACKNOWLEDGEMENT
Tsumaki et al., 18 who studied low-intensity pulsed The authors would like to express their appreciation
ultrasound accelerates maturation of callus in patients to all patients who participated in this study with all
treated with opening-wedge high tibial osteotomy by content and cooperation.
hemicallotasis and they found that low-intensity
pulsed ultrasound applied during the consolidation Conflict of interest
phase of distraction osteogenesis accelerates callus
maturation after opening-wedge high tibial osteotomy The authors declare no conflict of interest.
by hemicallotasis in elderly patients.
REFERENCES
Eung et al.,19 studied the effects of low intensity
ultrasound stimulation on the proliferation of alveolar 1. Mary G., Jon M. and Michael P.:" Diagnosis and
bone marrow stem cells and they found that the Treatment of Osteoporosis", American Family
alveolar bone marrow stem cell counts were Physician, 2009; 79(3):193-200.
significantly increased that indicate low-intensity 2. Cauley J., Robbins J. and Chen Z.: "Investigators.
ultrasound stimulation enhanced bone regeneration. Effects of estrogen plus progestin on risk of
fracture and bone mineral density: the Women's
Rutten et al.,20 who studied low-intensity pulsed Health Initiative randomized trial" JAMA. 2003;
ultrasound increases bone volume, osteoid thickness 290(13):1729-1738.
and mineral apposition rate in the area of fracture 3. Willim C.:"Osteoporosis: causes, symptoms,
healing in patients with a delayed union of the diagnosis, treatment and prevention",
osteotomized fibula and found that increased Osteoporosis Int, 2005; 16: 78-85.
osteoblast activity, at the front of new bony callus 4. Ringe J., Faber H., Farahm P. and Dorst A:"
formation. Efficacy of risedronate in men with primary and
secondary osteoporosis: results of a 1-year study",
Stein and Lerner, 21 who studied How does pulsed
Rheumatol Int. 2006; 26(5):427-431.
low-intensity ultrasound enhance fracture healing and
5. Sheng, S.; Hong C., Walter H. and Chen L.:"In
found that Pulsed low-energy ultrasound, a non-
vittro effects of low intensity ultrasound
invasive therapeutic treatment modality, may improve
stimulation on the bone cells", Inc. J. Biomed
callus formation and enhance fracture healing by
Mater Res, 2001; 57:449-456.
initiating enhanced angioneogenesis.Carvalho and
6. Nolte P, Klein-Nulend J; Albers G., Marti R,
Cliquet, 22 who studied the action of low-intensity
pulsed ultrasound in bones of osteopenic rats and Semeins C, Goei S. and Burger, E:" Low intensity
found that the low-intensity ultrasound can interfere ultrasound stimulates endochondral ossification
in a positive way on osteoporosis. in vitro", J Orthop Res 2001;19:301-307.
7. Duncan R. and Turner, C: "Mechanotransduction

and die functional response of bone to mechanical 16. Monici M, Antonio P, Basile V, and Romano
strain", Caicif Tissue Int, 1995; 57:344-358. G:"Can ultrasound counteract bone loss? Effect
8. Aynaci O, Onder C, Piskin A, and Ozoran Y:" The of low intensity ultrasound stimulation on a
effect of ultrasound on the healing of muscle- model of osteoclastic precursor", Acta
pediculated bone graft in spine fusion", Spine, Astronautica, 2007; 60:383-390.
2002; 27:1531-5. 17. Ramas T, Roberge S, Eschbach M, and Nesbitt R:"
9. Mayr E, Frankel V, and Rter A:" Ultrasound-an Stimulating bone growth using piezoelectric
alternative healing method for nonunions?" Arch ultrasound transducers on the edentulous jaw",
Orthop Trauma Surg 2000; 120:1-8. Bioengineering Conference, IEEE 35th Annual
10. Hadjiargyrou M, Mcleod K, Ryaby J. and Rubin Northeast, 2009.
C:" Enhancement of fracture healing by low 18. Tsumaki N, Kakiuchi M, Sasaki J and Ochi T:"
intensity U.S Clin Orthop; 1998, 355:216-29. Low-Intensity Pulsed Ultrasound Accelerates
11. Doan, N, Reher P, Meghji S. and Harris, M.: "In Maturation of Callus in Patients Treated with
vitro effects of therapeutic ultrasound on cell Opening-Wedge High Tibial Osteotomy by
proliferation, protein synthesis, and cytokine Hemicallotasis", J Bone Joint Surg Am. 2004; 86-
production by human fibroblasts, osteoblasts, A (11):2399-405.
and monocytes", J Oral Maxillofac Surg 1999; 19. Eung T, Taek L, Chong S, Jang H. and Hyun M:"
57:409-419. Effects of Low Intensity Ultrasound Stimulation
12. El-Bialy T, Elgazzar R, Megahed E. and Royston on the Proliferation of Alveolar Bone Marrow
T:" Effects of Ultrasound Modes on Mandibular Stem Cells", Biological Engineering. 2009; 2(1): 47-
Osteodistraction", J. of Dental Res, 2008; 52.
87(10):953-957. 20. Rutten S, Nolte P, Korstjens C. and Klein J:" Low-
13. Warden S, Bennell K, Matthews B, and Brown intensity pulsed ultrasound increases bone
D;"Efficacy of Low-intensity Pulsed Ultrasound volume, osteoid thickness and mineral apposition
in the Prevention of Osteoporosis Following rate in the area of fracture healing in patients with
Spinal Cord Injury", Bone, 2001;29:431-436. a delayed union of the Osteotomized fibula",
Bone. 2008; 43(2):348-54.
14. Sheng S, Hong C, Walter H, and Chen L:"In vittro 21. Stein, H. and Lerner, A.:" How does pulsed low-
effects of low intensity ultrasound stimulation on intensity ultrasound enhance fracture healing?
the bone cells", Inc. J. Biomed Mater Res, 2001; Orthopedics Oct; 2005; 28(10):1161-3.
57:449-456. 22. Carvalho D. and Cliquet A:" The action of low-
15. Chang J, Lin J, Ruann R, and Liu H:" cytokine intensity pulsed ultrasound in bones of
release from osteoblasts in response to ultrasound osteopenic rats", Artif Organs, 2004; 28(1):114-8.
stimulation", J.K. Lie Biomaterials, 2003; 24:2379-
2385.

Cardiovascular Co-morbidity and role of exercise in

Rheumatoid Arthritis: A Review
Anwer Shahnawaz1, Equebal Ameed2

1
M.P.T. (Orthopaedics), Physiotherapist, Department of Physiotherapy
2
MD (PMR), Assistant Director (Training), Department of Physical Medicine & Rehabilitation
National Institute for the Orthopaedically Handicapped (NIOH), B.T.Road, Bonhoogly, Kolkata (WB)
ABSTRACT
Patients with rheumatoid arthritis have an increased risk of cardiovascular disease (CVD).
Cardiovascular event rates are markedly increased in rheumatoid arthritis (RA). Data from population-
and clinic-based epidemiologic studies of rheumatoid arthritis patients suggest that individuals with
rheumatoid arthritis are at risk for developing clinically evident congestive heart failure (CHF). The
vasculature plays a crucial role in inflammation, angiogenesis, and atherosclerosis associated with
the pathogenesis of inflammatory rheumatic diseases. There is overwhelming evidence that, in the
general population and several at risk subpopulations, exercise provides significant physical and
psychosocial benefits, and facilitates management and improvements of outcome in Rheumatic
disease. There is increased recognition of the need for structured preventive strategies to reduce the
risk of CVD in patients with RA. In this review, the research agenda for understanding and preventing
CVD co-morbidity in patients with rheumatoid arthritis is discussed.
Key words: Rheumatoid Arthritis, Cardiovascular Disease, Inflammation, Exercise
INTRODUCTION potential additional contributors to cardiovascular

events in this disease, markers of current and
Cardiovascular disease is an increasingly cumulative inflammation (white cell counts and
recognized contributor to excess morbidity and radiographic joint damage, respectively) are associated
mortality in rheumatoid arthritis (RA)1-3. The most with ultrasonographically determined subclinical
probable cause of cardiac death in rheumatoid arthritis, atherosclerosis - a predictor of cardiovascular events6.
as in the general population, is atherosclerotic coronary
artery disease leading to ischaemic heart disease4. The use of methotrexate is associated with a
Rheumatoid arthritis, which is characterized by significantly lower risk for cardiovascular (CV) events
inflammatory polyarthritis with progressive joint in RA patients compared with patients who had never
damage, occurs in about 0.5%-1% of adult population used disease-modifying antirheumatic drugs
in most countries5. Several studies have shown a higher (DMARDs)7. Suissa and colleagues8 found a negative
incidence or prevalence of ischaemic cardiac association between the rate of myocardial infarction
pathologies such as myocardial infarction, congestive and the current use of any DMARD in a case control
heart failure, and coronary deaths in patients with study. A study from Sweden9 suggested that the risk
rheumatoid arthritis than in the general population3. for developing first CV events in RA was lower in
patients who were treated with tumour necrosis factor-
Traditional cardiovascular risk factors do not alpha (TNF-) blockers. In this review we examine the
adequately account for the extent of cardiovascular evidence of risk for CVD in patients with rheumatoid
disease in RA3. Although hypertension and age are arthritis and the suggested underlying mechanism and
discuss the role of exercise for the prevention and
Correspondence Address management of CVD in such patients.
Shahnawaz Anwer
Indoor Physiotherapy department, EPIDEMIOLOGY OF CARDIOVASCULAR DISEASE
National Institute for the Orthopaedically handicapped IN PATIENTS WITH RHEUMATOID ARTHRITIS
(NIOH) B.T. Road, Bonhoogly, kolkata (WB)-700090
Mobile no: 07890580612 Fewer statistics on incidence and prevalence rates
E-mail: anwer_shahnawazphysio@rediffmail.com for Congestive heart failure (CHF) in patients with RA
49 Shanawaj 2nd feb 11 (249-253).pmd 249 10/16/2012, 2:41 PM

are available and are derived from a handful of that excess CVD mortality was confined to patients
population-based10 and clinic-based RA cohorts11. In a who were rheumatoid factor positive14. These markers
follow-up retrospective review of the same cohort of inflammation and inflammatory burden confer
extended to 1995, now using the Framingham additional risk of CVD death in those with RA after
diagnostic criteria for CHF, Nicola et al.10 confirmed adjusting for traditional CVD risk factors and
an increased risk of incident CHF in both rheumatoid comorbidities15.
factor (RF) negative and positive RA patients (hazards
ratio 1.34 and 2.29, respectively) compared to non-RA Severity of disease has consistently been associated
controls adjusted for age, sex, and CV risk factors. with an increased risk of CVD events in RA. Patient
Incident CHF risk remained elevated after further with severe extra articular RA manifestations are at
adjustment for comorbid ischemic heart disease an increased risk of developing coronary artery
(hazards ratio 1.28 and 2.59 for RF negative and disease16 as well as peripheral vascular disease17; and
positive RA patients, respectively), although the risk severe extra articular RA is a predictor of both overall
relationship was no longer statistically significant for mortality18 and cardiovascular mortality19, indicating
RF negative patients in this model10. that systemic inflammation is a major determinants
of vascular comorbidity in RA. In contrast with the
In a combined cohort of RA patients from general population, a low body mass index (BMI),
community-based practices and drug safety rather than obesity, has been associated with increased
monitoring studies (n = 9093), Wolfe et al.2 estimated CVD in patients with RA19.
an adjusted lifetime relative risk of CHF in patients
with RA of 1.43 (95% CI 1.24-1.33) compared with OA Role of exercise in Rheumatoid arthritis and
Cardiovascular disease
controls. The adjusted lifetime prevalence of CHF in
the RA population was 2.34% compared to 1.64% in Exercise is one of the most important behavioral
OA controls. Data were collected via patient survey of interventions that can have a major beneficial impact
self reported, physician-diagnosed CHF, and on the likelihood to develop, suffer symptomatically
confirmed by review of a random sample of medical or die from CVD. Any physical activity is better than
records in 50% of patients reporting CVD events. In a no, or little, physical activity. There is overwhelming
subsequent analysis11, in which the drug safety cohort evidence that, in the general population and several
represented a third (n = 4,307) of the total sample (n = at risk subpopulations, exercise provides significant
13,171), Wolfe et al. reported an adjusted frequency of physical and psychosocial benefits, and facilitates
CHF of 3.9% (95% CI 3.4-4.3%) in RA patients management and improvements of outcome in
compared to 2.3% (95% CI 1.6-3.3%) in controls with Rheumatic disease. It helps maintain a healthy life-
knee or hip OA. Factors associated with prevalent and style, reduce CVD risk factors including obesity20,
incident CHF were those typically associated with CHF dyslipidaemia21, hypertension22, diabetes mellitus23
in the non-RA population (e.g., age, male gender, and possibly even inflammation24; it is also effective
hypertension, coronary artery disease, diabetes, and for preventing acute coronary syndromes25. Moreover,
smoking) while RA-related measures (patient-reported exercise helps the management of established CVD:
disability, pain, and RA global severity) were also both aerobic exercise 26 and resistance training 27
associated with prevalent and incident CHF. improve myocardial contractility and quality of life in
patients with chronic heart failure and produce
Risk factors for cardiovascular events in patients
with rheumatoid arthritis significant functional benefits in people with
intermittent claudication28. More importantly, cardiac
Traditional risk factors for vascular disease such exercise rehabilitation programmes are an important
as, smoking, hypertension, diabetes and hyper part in the management of patients after an acute
lipidemia are important for the increased risk of CVD coronary syndrome (ACS)29 and lead to significantly
in subjects with RA12. However, traditional risk factors improved quality of life and reduced mortality rates30.
alone do not fully explain the excess CVD risk in RA.
Other non-traditional factors are hypothesized to play The overall physiological adaptations that occur as
a role, in particular the burden of inflammation as a result of exercise31 provide protection against CVD
indicated by the C-reactive protein (CRP) and/or mortality, even in the presence of well-established CVD
erythrocyte sedimentation rate (ESR) 13 . In a risk factors32. CVD mortality is lower in highly fit than
community-based cohort of patients with in moderately fit individuals 33 , while physical
inflammatory polyarthritis, Goodson, et al also noted inactivity is an independent risk factor for the
development of CVD34. Even though cardiorespiratory

fitness may have a familial component35, it can be heart failure, and coronary deaths in patients with
increased significantly by exercise training, regardless rheumatoid arthritis than in the general population.
of age, gender, race and initial fitness levels36. The Severity of disease has consistently been associated
required activity levels can be accrued through formal with an increased risk of CVD events in RA. CVD
training programmes or leisure-time physical mortality was more confined to patients who were
activities37. Moreover, supervised exercise programmes rheumatoid factor positive. Role of exercise in the
are more effective compared with non-supervised management and prevention of CVD in RA patients is
exercise38, most likely due to greater adherence. very important yet neglected area of RA patients
treatment programmes. As this review shows, there is
Great controversy still exists about the optimum accumulating evidence that in patients with RA,
amount of exercise for eliciting the greatest exercise therapy is effective in improving the
cardiovascular benefit. Different exercise intensity39 prognostic risk factor profile. There is little has been
and duration40, as well as various combinations of investigated and published on the role of exercise as a
them41, may have different impacts on the magnitude means to control risk and manage CVD in individuals
of cardiorespiratory fitness improvement. Most with RA. More research is required to identify the
authors agree that there is a dose-response relation optimal regimens, timing and environment for
between the amount of exercise, all-cause and exercise, as well as educational and behavioural
cardiovascular mortality39, 40. The greatest potential for intervention that will facilitate long term adherence
reduced mortality is in sedentary individuals (such as to an active life style and/or structured exercise.
many RA patients), in whom even slight increases in
daily physical activity are beneficial42; for more active
REFERENCES
individuals, higher levels of intensity should be
pursued42. Depending primarily on the starting levels 1. Solomon DH, Karlson EW, Rimm EB, Cannuscio
of physical activity, cardiovascular fitness has been CC, Mandl LA, Manson JE, et al. Cardiovascular
reported to increase by 8-51% following an exercise morbidity and mortality in women diagnosed
intervention40,42. with rheumatoid arthritis. Circulation 2003; 107:
1303-1307.
Moderate-intensity exercise of long duration 2. Wolfe F, Freundlich B, Straus WL. Increase in
appears to elicit the most benefit on CVD risk and cardiovascular and cerebrovascular disease
mortality39,41-42. Current guidelines by the American prevalence in rheumatoid arthritis. J Rheumatol
College of Sports Medicine (ACSM) suggest that an 2003; 30: 36-40.
individual should engage in exercise at least three 3. del Rincon ID, Williams K, Stern MP, Freeman
times a week, at an intensity of 60-80% of maximum GL, Escalante A. High incidence of cardiovascular
oxygen uptake (VO2max), for at least 20-30 min, in events in a rheumatoid arthritis cohort not
order to experience significant improvements in explained by traditional cardiac risk factors.
cardiorespiratory fitness and optimum cardiovascular Arthritis Rheum 2001; 44: 2737-2745.
4. Kitas GD, Banks M, Bacon PA. Cardiac
benefits43. In terms of caloric expenditure, this can be
involvement in rheumatoid disease. Clin Med
translated to 1000-2000 kcal/week44. These calories can
2001; 1: 18-21.
be expended in either continuous exercise or
5. Silman AJ, Hochberg MC,.Epidemiology of the
accumulated from several short bouts of exercise Rheumatic diseases. Oxford; Oxford University
during a day 44,45 . Aerobic exercise is the most Press. 1993.
appropriate, but this can be supplemented by low-to- 6. Belcaro G, Nicolaides AN, Ramaswami G,
moderate intensity resistance training45. The exercise Cesarone MR, De Sanctis M, Incandela L et al.
regimen should be reconsidered regularly, usually Carotid and femoral ultrasound morphology
every 4-6 weeks, based on the principles of exercise screening and cardiovascular events in low risk
periodization46 so that participants continue to improve subjects: a 10-year follow-up study (the CAFES-
their performance. CAVES study (1)). Atherosclerosis 2001; 156:
379-387.
SUMMARY 7. Van Halm VP, Nurmohamed MT, Twisk JWR,
Dijkmans BAC, Voskuyl AE. Disease-modifying
There is strong evidence that persons with antirheumatic drugs are associated with a
rheumatoid arthritis are at high risk for developing reduced risk for cardiovascular disease in patients
cardiovascular disease. Several studies have shown a with rheumatoid arthritis: a case control study.
higher incidence or prevalence of ischaemic cardiac Arthritis Res Ther 2006; 8: R 151.
pathologies such as myocardial infarction, congestive 8. Suissa S, Bernatsky S, Hudson M. Antirheumatic

drug use and the risk of acute myocardial 21. Svendsen OL, Hassager C, Christiansen C. Effect
infarction. Arthritis Rheum 2006; 55: 531-536. of an energy-restrictive diet, with or without
9. Jacobsson LT, Turesson C, Gulfe A, Kapetanovic exercise, on lean tissue mass, resting metabolic
MC, Petersson IF, Saxne T et al. Treatment with rate, cardiovascular risk factors, and bone in
tumor necrosis factor blockers is associated with overweight postmenopausal women. Am J Med
a lower incidence of first cardiovascular events 1993; 95: 131-140.
in patients with rheumatoid arthritis. J Rheumatol 22. Kelemen MH, Effron MB, Valenti SA, Stewart KJ.
2005; 32: 1213-1218. Exercise training combined with
10. Nicola PJ, Maradit-Kremers H, Roger VL, antihypertensive drug therapy. Effects on lipids,
Jacobsen SJ, Crowson CS, Ballman KV et al. The blood pressure, and left ventricular mass. JAMA
risk of congestive heart failure in rheumatoid 1990; 263: 2766-2671.
arthritis: A population-based study over 46 years. 23. Wallberg-Henriksson H, Rincon J, Zierath JR.
Arthritis Rheum 2005; 52: 412-420. Exercise in the management of noninsulin-
11. Wolfe F, Michaud K. Heart failure in rheumatoid dependent diabetes mellitus. Sports Med 1998;
arthritis: Rates, predictors, and the effect of anti- 25: 25-35.
tumor necrosis factor therapy. Am J Med 2004; 24. Kasapis C, Thompson PD. The effects of physical
116: 305-311. activity on serum C-reactive protein and
12. Solomon DH, Curhan GC, Rimm EB, et al. inflammatory markers: a systematic review. J Am
Cardiovascular risk factors in women with and Coll Cardiol 2005; 45: 1563-1569.
without rheumatoid arthritis. Arthritis Rheum 25. Shaw DI, Hall WL, Williams CM. Metabolic
2004; 50: 3444-3449. syndrome: what is it and what are the
13. Snow MH, Mikuls TR. Rheumatoid arthritis and implications? Proc Nutr Soc 2005; 64: 349-357.
cardiovascular disease: the role of systemic 26. Haykowsky M, Vonder Muhll I, Ezekowitz J,
inflammation and evolving strategies of Armstrong P. Supervised exercise training
prevention. Curr Opin Rheumatol 2005; 17: improves aerobic capacity and muscle strength
234-241. in older women with heart failure. Can J Cardiol
14. Goodson NJ, Wiles NJ, Lunt M, Barrett EM, 2005; 21: 1277-1280.
Silman AJ, Symmons DP. Mortality in early 27. Levinger I, Bronks R, Cody DV, Linton I, Davie
inflammatory polyarthritis: cardiovascular A. The effect of resistance training on left
mortality is increased in seropositive patients. ventricular function and structure of patients
Arthritis Rheum 2002; 46: 2010-2019. with chronic heart failure. Int J Cardiol 2005; 105:
15. Kremers HM, Nicola PJ, Crowson CS, Ballman 159-163.
KV, Gabriel SE. Cardiovascular death in 28. Leng GC, Fowler B, Ernst E. Exercise for
rheumatoid arthritis: a population based study. intermittent claudication. Cochrane Database
Arthritis Rheum 2005; 52: 722-732. Syst Rev 2000; CD000990.
16. Turesson C, McClelland RL, Christianson TJ. 29. Clark AM, Hartling L, Vandermeer B, McAlister
Severe Extraarticular disease manifestatios are FA. Meta-analysis: secondary prevention
associated with an increased risk of first ever programs for patients with coronary artery
cardiovascular events in patients with disease. Ann Intern Med 2005; 143: 659-672.
rheumatoid arthritis. Ann Rheum Dis 2007; 66: 30. Mears S. The importance of exercise training in
59-64. patients with chronic heart failure. Nurs Stand
17. Liang KP, Liang KV, Matteson EL. Incidence of 2006; 20: 41-47.
noncardiac vascular disease in rheumatoid 31. Bassuk SS, Manson JE. Physical activity and the
arthritis and relationship to Extraarticular disease prevention of cardiovascular disease. Curr
manifestation. Arthritis Rheum 2006; 54: 642-648. Atheroscler Rep 2003; 5: 299-307.
18. Gabriel SE, Crowson CS, Kremers HM. Survival 32. Farrell SW, Kampert JB, Kohl HW 3rd. Influences
in rheumatoid arthritis: a population based of cardiorespiratory fitness levels and other
analysis of trends over 40 years. Arthritis Rheum predictors on cardiovascular disease mortality in
2003; 48: 54-58. men. Med Sci Sports Exerc 1998; 30: 899-905.
19. Kremers HM, Nicola PJ, Crowson CS. Prognostic 33. Eaton CB. Relation of physical activity and
importance of low body mass index in relation cardiovascular fitness to coronary heart disease,
to cardiovascular mortality in rheumatoid Part II: Cardiovascular fitness and the safety and
arthritis. Arthritis Rheum 2004; 50: 3450-3457. efficacy of physical activity prescription. J Am
20. Bensimhon DR, Kraus WE, Donahue MP. Obesity Board Fam Pract 1992; 5: 157-165.
and physical activity: a review. Am Heart J 2006; 34. Myers J, Prakash M, Froelicher V, Do D,
151: 598-603. Partington S, Atwood JE. Exercise capacity and

mortality among men referred for exercise 40. Kraus WE, Houmard JA, Duscha BD. Effects of
testing. N Engl J Med 2002; 346: 793-801. the amount and intensity of exercise on plasma
35. Bouchard C, An P, Rice T. Familial aggregation lipoproteins. N Engl J Med 2002; 347: 1483-1492.
of VO2max response to exercise training: results 41. Jakicic JM, Marcus BH, Gallagher KI, Napolitano
from the HERITAGE Family Study. J Appl Physiol M, Lang W. Effect of exercise duration and
1999; 87: 1003-1008. intensity on weight loss in overweight, sedentary
36. Skinner JS, Jaskolski A, Jaskolska A. Age, sex, women: a randomized trial. JAMA 2003; 290:
race, initial fitness, and response to training: the 1323-1330.
HERITAGE Family Study. J Appl Physiol 2001; 42. Duscha BD, Slentz CA, Johnson JL. Effects of
90: 1770-1776. exercise training amount and intensity on peak
37. Fletcher GF, Balady G, Blair SN. Statement on oxygen consumption in middle-age men and
exercise: benefits and recommendations for women at risk for cardiovascular disease. Chest
physical activity programs for all Americans. A 2005; 128: 2788-2793.
statement for health professionals by the 43. ACSM. ACSM's Guidelines for Exercise Testing
Committee on Exercise and Cardiac and Prescription. Seventh edn, 2005: Lippincott
Rehabilitation of the Council on Clinical Williams & Wilkins, USA.
Cardiology, American Heart Association. 44. Pescatello LS. Exercise and hypertension: recent
Circulation 1996; 94: 857-862. advances in exercise prescription. Curr
38. Bendermacher BL, Willigendael EM, Teijink JA, Hypertens Rep 2005; 7: 281-286.
Prins MH. Supervised exercise therapy versus 45. Pescatello LS, Guidry MA, Blanchard BE. Exercise
non-supervised exercise therapy for intermittent intensity alters postexercise hypotension. J
claudication. Cochrane Database Syst Rev 2006; Hypertens 2004; 22: 1881-1888.
CD005263. 46. Koutedakis Y, Metsios GS, Stavropoulos-
39. Oguma Y, Shinoda-Tagawa T. Physical activity Kalinoglou A. Periodisation of exercise training
decreases cardiovascular disease risk in women: in Sport. In: Whyte G, ed. The physiology of
review and meta-analysis. Am J Prev Med 2004; training, Philadelphia: Churchill Livingstone,
26: 407-418. Elsevier, 2006:1-21.

Physiotherapy-supervised Mobilization and

Exercise Following Total Knee Arthroplasty Surgery:
a Questionnaire Survey
B.Sankarmani1, V.Seetharaman2
1
Professor, KJPCP, Sumandeep University, Piparia, Waghodia (TK), Vadodara
2
Professor, SRIPMS, 395, Sarojini Naidu Road, Coimbatore
ABSTRACT
Background: Limited published data are available on how patients are mobilized and exercised
during the postoperative hospital stay following total knee arthroplasty. The aim of this survey was
to determine current practice of physiotherapy-supervised mobilization and exercise following total
knee arthroplasty.
Methods: A prospective survey was carried out among physiotherapists treating total knee
arthroplasty patients. A total population sample was identified and postal questionnaires were sent
to the 33 physiotherapists currently working at the departments of orthopedics. In total, 29
physiotherapists (response rate 88%) from eight hospitals completed the survey.
Results: The majority (90%) of the physiotherapists offered preoperative information. The main
rationale of physiotherapy treatment after total knee arthroplasty was to prevent and treat
postoperative complications, improve range of motion and promote physical activity. In general, one
to three treatment sessions were given by a physiotherapist on postoperative day-1 and one to two
treatment sessions were given during postoperative days 2 and 3. During weekends, physiotherapy
was given to a lesser degree (59% on Saturdays and 31% on Sundays to patients on postoperative
day-1. The routine use of early mobilization and knee range of motion exercises was common during
the first postoperative days, but the choice of exercises and duration of treatment varied. There were
great variations of instructions to the patients concerning weight bearing and exercises involving the
quadriceps. All respondents considered physiotherapy necessary after total knee arthroplasty, but
only half of them considered the physiotherapy treatment offered as optimal.
Conclusions: The results of this survey show that there are small variations in physiotherapy-
supervised mobilization and exercise following total knee arthroplasty. Comparison with surveys in
other remaining centers in India is warranted to improve the physiotherapy management and
postoperative recovery of the total knee arthroplasty patients.
Key words: Total Knee Arthroplasty, Mobilization, Questionnaire
INTRODUCTION most frequently performed orthopedic procedure1,2. In

a recent meta-analysis of largely osteoarthritic patients,
Total knee arthroplasty has become the standard TKA was found to be associated with substantial
of care for patients with end-stage knee OA and is the functional improvements and pain relief3. In patients
with RA and avascular necrosis, TKA has also resulted
Correspondence Address in recovery of function compared to the pre-surgical
B.Sankarmani state 3.
Professor & Principal,
KJPandya College of Physiotherapy, Physiotherapy treatment is often prescribed to
Sumandeep Vidyapeeth, patients undergoing total knee arthroplasty, in order
Piparia, Vadodara, India-391760. to prevent or diminish postoperative complications15.
Mobile: +91 9443015419; The physiotherapy treatment during the hospital stay
Email:bsankarmani2007@yahoo.co.in generally consists of early mobilization, range of
50 Shankar mani 31st dec 10 (254-258).pmd 254 10/16/2012, 2:41 PM

motion exercises and breathing exercises. The value clinical practice. The questionnaire was developed for
of postoperative physiotherapy has recently been this specific study and constructed following a detailed
established and accepted, but it is still unclear which review of the literature concerning physiotherapy
treatment techniques are the most effective. In the treatment after total knee arthroplasty and previously
literature a wide variety of treatments have been developed questionnaires17. A range of both closed and
suggested14. Many strategies and diverse therapies are open questions, about pre-operative and postoperative
applied postoperatively and these differ within and physiotherapy-supervised mobilization and exercise
between centers20. Early mobilization and physical following total knee arthroplasty were included in the
activity is often the first choice of treatment, but questionnaire. Respondents were also invited to make
evidence as to the optimal intensity, timing and choice comments at the end of the survey.
of exercises is scarce.
The study was performed during January 2009 and
There are only limited published data on how the April 2009. All physiotherapists working at a
total knee arthroplasty patient should be mobilized Department of orthopedics where knee arthroplasty
and exercised during the first postoperative period in procedures routinely done total were sent a postal
hospital. However, we found no such study performed questionnaire. The questionnaire was addressed
in India. This survey was carried out to establish personally to the physiotherapists identified. The letter
current clinical practice of physiotherapy-supervised included a cover letter and prepaid, self-addressed
exercise and mobilization, during the hospital stay, for response envelope. After 3 weeks, reminder letters
patients having undergone total knee arthroplasty. A with a copy of the questionnaire were sent to those
postal questionnaire survey was sent to all physiotherapists who had not yet returned the
physiotherapists in south India working with this questionnaire.
patient group, to determine which methods and
treatments are used. PARTICIPANTS
METHODS Physiotherapists working at hospitals performing

total knee arthroplasty surgery in south India were
A cross-sectional, descriptive study was carried out selected. The names and addresses of the
to examine the physiotherapy management and physiotherapists had been identified and updated by
mobilization routines of total knee arthroplasty in the author. The names were double-checked via phone
selected centers in south India. The study design was or mail at each hospital just before the start of the study.
a postal questionnaire survey sent to all 36
physiotherapists working at total knee arthroplasty. STATISTICAL ANALYSIS
The routine postoperative physiotherapy management
of patients undergoing uncomplicated total knee Descriptive statistics were used to analyze the
arthroplasty was studied. Treatment of patients results, and means, medians and ranges were
undergoing soft tissue repair with total knee calculated. SPSS 15.0 was used for the statistical
arthroplasty or other types of associated knee surgical analysis.
procedures was not studied. The care of patients
developing neurological symptoms, circulatory RESULTS
instability, prolonged intubation, or other conditions
Of the 33 identified physiotherapists working at the
requiring individualized programme was not
departments of orthopedic surgery in December 2008.
considered. Physiotherapists who only treated patients
Responses were received from all hospitals to which
undergoing total knee arthroplasty procedures were
the survey was sent. In total, 29 replies were received
asked to return the questionnaire answered.
(giving an 88% response rate) out of the 33
questionnaires sent out. The physiotherapists were
THE QUESTIONNAIRE aged 358 years and the mean work experience as
Questions were asked about pre- and postoperative physiotherapist at a department of orthopedic surgery
physiotherapy-supervised mobilization and exercise was 64 (range 1-16) years. Seventy-six per cent of
for hospital patients following total knee arthroplasty. respondents were men. Written physiotherapy
The routine pre- and postoperative care of a guidelines or protocols for physiotherapy management
hypothetical, "everyday patient" undergoing total knee of the orthopedic surgery patient were available for
arthroplasty was considered to determine the standard 21 (72%) of the respondents.

All physiotherapists declared that they considered MOBILITY ASSESSMENT

physiotherapy necessary after orthopedic surgery and
55% considered the physiotherapy treatment offered The following mobilization and exercise abilities
at their department of orthopedic surgery optimal, were routinely assessed or recorded during
while 31% found it not optimal and 14% said they did physiotherapy treatment: mobility, Quadriceps
not know. Reasons for the treatment not being optimal strength(100%), getting in and out of bed/the chair
were too many patients, lack of resources, shortness (100%), knee effusion(78%), circulation exercises for
of care time, and increased care load. the lower extremities (62%); range of motion, knee and
the lower extremities (72%); range of motion, hip and
ankle(59%); functional activities of daily living scores
PREOPERATIVE INFORMATION
(21%); and gait training used with walker/crutches
The majority (90%) of the physiotherapists offered (17%).
preoperative information to all patients undergoing
total knee arthroplasty surgery. The following topics POSTOPERATIVE MOBILIZATION
were most frequently covered in the preoperative AND EXERCISES
information: early mobilization (90%), post-operative
Mobilization and exercises usually provided to the
restrictions (90%), risk of postoperative pulmonary
patients on the first postoperative days after surgery
complications (40%), techniques for getting in and out
are presented in Tables 1-2. Instructions for range of
of bed/the chair (80%), quadriceps exercise (80%) and
motion exercises for the knee were provided to the
information about exercising the lower extremities
patients on postoperative day 1 by six
(69%). The preoperative information was usually given
physiotherapists, on postoperative day 2 by 22, and
to a group of patients by the physiotherapists (76%).
on postoperative day 3 by 25 of physiotherapists.
Postoperative group training for the patients during
POSTOPERATIVE PHYSIOTHERAPY
the hospital stay were provided by 62% of the
TREATMENT
physiotherapists. Physiotherapy - supervised
In total, 26 respondents answered that the standing/ walking was practiced postoperatively,
physiotherapist automatically met all patients according to 79% of the physiotherapists.
undergoing total knee arthroplasty while three said
Table 1. Physiotherapy-supervised mobilization
that they only met certain patients, with special needs, usually provided to total knee arthroplasty patients
postoperatively. The physiotherapists reported that during the first postoperative days
during weekdays they routinely treated patients on POD-1 POD-2 POD-3 POD-4
postoperative day 1 (90%), postoperative day 2 (93%), Mobilization
postoperative day 3 (69%) and postoperative days 4 Quadriceps exercises 97% 52% 48% 34%
and 5 (28%). The patients usually had between one
#CPM used 93% 55% 48% 34%
and three treatment sessions with a physiotherapist
Knee range of motion exercises 28% 69% 79% 34%
on postoperative day 1, one to two treatment sessions
Cryo cuff used 66% 66% 28% 41%
on days 2 and 3, and typically one treatment on days 4
Sitting on edge of bed or in chair 24% 28% 10% 10%
and 5. On Saturdays, physiotherapy treatment was
Standing/walking using with 0% 0% 21% 38%
reported to be routinely given to patients on their first assistive devices
postoperative day by 59%, and only if needed by 41%, Data shown as % of respondents (n=29)
of the physiotherapists. The corresponding figures POD=Postoperative day
were 31%, and 14%, respectively, for Sundays, while #CPM-Continuous Passive Motion apparatus
55% of physiotherapists never gave treatment on

Instructions for moving in, and out of, bed were
Sundays. On the second postoperative day,
given to the patients using a "standard technique" by
physiotherapy treatment on Saturdays was generally
90% of the physiotherapists. The most commonly
provided routinely by 17%, and only if needed by 83%,
described technique for getting out of bed was lying
of the physiotherapists. If the second postoperative day
on the side, placing one or both hands in front of the
fell on a Sunday, 48% of the physiotherapists
body, leaning forward and pushing up to a sitting
responded that they would give physiotherapy
position.
treatment to patients if needed or advised from
physicians.

POSTOPERATIVE INFORMATION questionnaires and reminders were sent out where the
questionnaires had not been returned.
Before discharge from the department of
orthopedic surgery all physiotherapists provided The study of a total population sample and the high
information to the patients about physical activity, response rate gives the study good external validity,
exercises and rehabilitation. Instructions to the patients even if some important questions may have been
to continue range of motion exercises after discharge overlooked and the exact description of the actual
from the hospital were as well given by all clinical practice, in observational studies, is warranted
physiotherapists. The time that patients were in the future.
recommended to continue the exercise programme
varied between 1 and 8 weeks. An intrinsic selection bias in questionnaire studies
is a risk if only the most motivated physiotherapists
Table 2. Precautions recommended for the healing respond. Since only four physiotherapists failed to
period during the first postoperative weeks answer, we found this risk of bias fairly low. To
after total knee arthroplasty
improve the content validity of the survey, information
n (%)
from earlier questionnaires used in similar studies as
Use of biofeedback and neuromuscular
well as pilot testing was used to construct the
electrical muscle stimulation 5 (17%) questionnaire. Despite these limitations we believe that
Use of Knee immobilizer 28 (97%) the result from this survey provides a good overview
a rollator (rolling walker) 12 (41%) of the physiotherapy treatment given to total knee
a walker 0 (0%) arthroplasty patients.
crutches 19 (66%)
Data shown as number (n) and as % of respondents (n = 29). The majority (90%) of the physiotherapists offered
preoperative information to all patients undergoing
DISCUSSION total knee arthroplasty surgery. Routine physiotherapy
for patients on their first postoperative day was given
Most of the physiotherapists, in total 90%, declared more often on Saturdays (59%) than on Sundays (31%).
that they routinely met all patients undergoing total This result indicates that there is a discrepancy in
knee arthroplasty, while 10% responded that they only treatment of patients depending on which weekday
treated certain patients, with special indications or they are operated. Today there is an agreement as to
special needs. The physiotherapy treatment was most the value of early mobilization and functional activities
frequently given on the first seven postoperative days. after total knee arthroplasty, despite the risk of
On day 1 the patients usually received one to three postoperative complications like knee effusion, wound
treatment sessions by the physiotherapist, and on day infection, hematoma formation etc. Almost all
2, they were given one to two treatment sessions. The physiotherapists in our study mobilized their patients
main purpose of physiotherapy after total knee with regard to sitting on postoperative day-1.
arthroplasty was mostly seen as preventing and
treating postoperative complications, improving Of course, it is the individual strength and
pulmonary function and encouraging physical activity. cardiovascular status of the patient that decides the
Written local physiotherapy guidelines or protocols for level and intensity of mobilization. In this study the
physiotherapy management of total knee arthroplasty average mobilization routines performed by a
patients were available, according to 21 out of the 29 physiotherapist of a hypothetical "everyday" patient
respondents. was determined. The actual mobilization of individual
patients has not been the focus of the present study.
The components of postoperative physiotherapy Despite the frequent use of early mobilization, the
treatment, assessment of physiotherapy given to all benefit of mobilization in preventing postoperative
patients (89%), and mobilization and breathing complications has not been studied .
exercises. In total, 29 replies were received out of the
33 questionnaires sent out. Since the questionnaires Instructions in range of motion exercises for the
were comprehensive the response rate of 88% can be knee and lower extremities were mostly started on
considered high. A high response rate is important and postoperative days 2 and 3. Only six of the
various strategies were used to improve the response physiotherapists started these exercises on the first
rate. Comprehensible instructions were given, the postoperative day. It is currently not known how these
questionnaires were printed on colored paper; exercises should be performed. How many times the
stamped, addressed envelopes were included with the patients were instructed to perform the exercises

varied between one and three times a day. Knee range 6. Bin SI, Nam TS. Early results of high-flex total
of motion exercises, to be continued after discharge, knee arthroplasty: Comparison study at 1 year
were given by all physiotherapists. Recommendations after surgery. Knee Surg Sports Traumatol
for continuing the exercise programme varied between Arthrosc 2006.
1 and 8 weeks. 7. Scott RD. Total Knee Arthroplasty. Saunders and
Elsevier, 2006.
A guideline for physiotherapy treatment for 8. Scott RD, Santore RF. Unicondylar
patients undergoing major surgery is currently under unicompartmental knee replacement in
development, but was not available during the study osteoarthritis. JBJS 1981; 63: 536-544.
period. In spite of this, the physiotherapy management 9. Tria AJ, Coon TM. Minimal incision total knee
given in the different departments, by different arthroplasty: early experience. Clin Orthop 2003;
physiotherapists, was fairly similar. This survey 416: 185-190.
provides information that may be useful in research 10. Aglietti P, Baldini A, Giron F, Sensi L. Minimally
invasive total knee arthroplasty: is it for
as well as development and implementation of clinical
everyone? HSSJ 2006; 2(1): 22-26.
practice guidelines in physiotherapy. It is also very
11. Haas SB, Manitta MA, Burdick P. Minimally
important to widen this knowledge and formulate
invasive total knee arthroplasty; the mini
internationally accepted guidelines for total knee midvastus approach. Clin Orthop 2006; 452:
arthroplasty patients. 112-116.
12. Dutton AQ, Yeo SJ, Yang KY et al. Computer-
CONCLUSIONS assisted minimally invasive total knee
arthroplasty compared with standard total knee
The results of the survey indicate that there are only arthroplasty. JBJS 2008; 90: 2-9.
small variations in physiotherapy-supervised exercise 13. Orest MR. Total Joint Replacement Literature
and mobilization following total knee arthroplasty in Review. Acute Care Perspectives 2004; spring:
south India. Further research and development of 8-10.
high-quality clinical guidelines as well as comparison 14. Hughes K, Kuffner L, Dean B. Effect of weekend
with routines in nationwide is needed to confidently physical therapy treatment on postoperative
promote the postoperative recovery of the total knee length of stay following total hip and total knee
arthroplasty patient. arthroplasty. Physiother Can. 1993; 45: 245-249.
15. Shoji H, Solomonow M, Yoshino S, D'Ambrosia
REFERENCES R, Dabezies E. Factors affecting Postoperative
flexion in total knee arthroplasty. Orthopedics
1. Nizar MN, Barrett J, Katz J, Baron JN, Wright J et 1990; 13: 643-649.
al. Epidemiology of total knee replacement in the 16. Avramidis K, Strike PW et. al. Effectiveness of
United States Medicare population. JBJS 2005; electrical stimulation of the vastus medialis
87(6): 1222-1228. muscle in rehabilitation of patients after total knee
2. American Academy of Orthopedic Surgeons. arthroplasty. Arch Phys Med Rehabil 2003; 84:
Orthopedic Patients and Conditions. 1850-1853.
Availableat:http://www.aaos.org/wordhtml/ 17. Jane Kim, BA1, Jess H. Lonner, MD2, Charles L.
research/stats/patientstat.html. Nelson, MD1 and Paul A. Lotke, MD1 Response
3. Kane RL, Saleh KJ, Wilt TJ, Bershadsky B. The Bias: Effect on Outcomes Evaluation by Mail
Functional Outcomes of Total Knee Arthroplasty. Surveys after Total Knee Arthroplasty. The
JBJS 2005; 87(8): 1719-1723. Journal of Bone and Joint Surgery (American)
4. Sarokhan AJ, Scott RD, Thomas WH, Sledge CB, 2004; 86: 15-21.
Ewald FC, Cloos DW. Total knee Arthroplasty in 19. Harris I, Mulford J, Solomon M, van Gelder J,
juvenile rheumatoid arthritis. JBJS 1983; 65: 1071- Young J: Association between compensation
1080. status and outcome after surgery: a meta-
5. Seldes RM, Tan V, Duffy G, Rand JA, Lotke PA. analysis. JAMA 2005 293: 1644-1652.
Total knee arthroplasty for steroid induced
osteonecrosis. J Arthroplasty 1999; 14: 533-537.

The Effect of a Single Session of Static and Ballistic

Stretching on Lower Limb Power in Sedentary Individuals
Sharmella Roopchand-Martin1, Domonique Freckleton2

1
Lecturer Section of Physical Therapy, 2BSc. candidate Section of Physical Therapy,
The University of the West Indies 126, Mona P.O. Kingston 7, Jamaica W.I.
ABSTRACT
Background: To date there is a lot of controversy regarding the optimal type of stretch to improve
lower limb power. Furthermore, the majority of studies have been conducted in an athletic population.
A large percentage of patients treated by physical therapists are sedentary and it is important to
understand the impact of different types of stretches on this population.
Purpose of the study: The objective of this study was to determine the effect of a single session of
static and ballistic stretching on lower limb power in young sedentary individuals.
Material and methods: A total of 44 sedentary university students participated in this study. Lower
limb power was assessed with the vertical jump test. Baseline measurements for the vertical jump
test were taken and subjects' height and weight were recorded. Following this three repetitions of
either ballistic or static stretching were done for the hip flexors, hamstrings and gastrocnemius muscles.
Immediately after completing the stretches the vertical jump test was repeated. Subjects were allowed
to rest for one day and the next day the same procedure was repeated but using the stretching technique
that was not done previously.
Findings: Both ballistic and static stretching produced an increase in lower limb power but this was
only statistically significant for the ballistic stretch. There was no significant difference in the change
in power obtained by the two types of stretches when they were compared. Conclusion: Ballistic
stretching produces slightly higher gains in lower limb power of sedentary individuals compared to
static stretching, however the evidence is inadequate to support the use of one over the other.
Key words: Ballistic Stretching, Static Stretching, Lower Limb Power, Vertical Jump Test
INTRODUCTION
Power refers to the ability to produce the greatest Research investing the effects of stretching on jump
amount of force in the shortest amount of time. It is performance has been variable. Powers 4 in 2004
believed to be predictive of performance in activities reported that static stretching led to an immediate
that requires stretch shortening properties of a muscle decrease in force output however vertical jump
tendon unit, such as vertical jump or sprinting 1. distance remained unchanged. Similar findings were
Explosive power is thought to be generated by observed in trained women, where neither static nor
increased elastic energy stored in the muscle fibers2. It ballistic stretching resulted in any significant changes
is therefore believed that exercise or stretches that in jump performance during a series of counter
increases this elastic energy will result in increased movement and drop jumps 5 . Woolstenhume 6
explosive power for that group of target muscles3. investigated the effects of six weeks of training
consisting of different warm up protocols followed by
Correspondence Address basketball play on a variety of factors including vertical
Sharmella Roopchand-Martin jump performance. It was noted that none of the
Lecturer Section of Physical Therapy,
groups had a significant change in vertical jump height
The University of the West Indies,
immediately after the warm up period; however, after
P.O. Box 126, Mona P.O. Kingston 7,
basketball play the group that used ballistic stretching
Jamaica W.I. tel (876) 927-2235,
for the warm up had a significant difference in jump
e mail sharmella3@hotmail.com.
51 Sharmella 19th july 11 (259-262).pmd 259 10/16/2012, 2:41 PM

performance compared to the groups that used static the board with the painted finger. After this they were
stretching, sprinting or basketball shooting. Static asked to stand with the knees bent and then jump as
stretching was reported by other authors to result in a high as possible upwards and touch the board with
decrease in lower limb power7-12. the painted finger. The distance between the initial
mark and final position was recorded. This was
The majority of studies that have looked at the effect repeated three times and the highest distance recorded
of stretching on power were conducted in different was used for calculating peak anaerobic power using
athletic populations. Experimental designs and Sayers equation (PAPw (watts) = 60.7 jump height
outcome measures were quite varied therefore making (cm) + 45.3 body mass (kg) - 2055)14,15.
it difficult to come to any conclusion regarding the
benefit of any one type of stretching on power. In Once ethical approval was obtained for the study
addition the athletic population is also exposed to students were recruited from the halls of residence and
many other factors that can influence their through presentations done in some of the classes. All
performance. who indicated an interest to participate were screened
for the inclusion and exclusion criteria and were
Most individuals in their daily lives require some required to sign consent forms. Baseline measurements
degree of power for independent functioning. The for height and weight were obtained after which the
ability to rise quickly from a chair, ascend a flight of subjects did a five minute warm up consisting of brisk
stairs or cross the street at traffic lights requires power walking. After the warm up baseline measurements
from the lower limbs. A larger proportion of the for the vertical jump test was obtained and subjects
patients treated by physical therapists are sedentary were exposed to one of two stretching protocols (static
and it is therefore important for studies to be conducted or ballistic). The order for the stretching protocols was
to determine the impact of various types of stretching randomly assigned using a computer programme.
techniques on these individuals. In an attempt to add Immediately after completing the stretching protocol
to this body of literature this study looked at the the vertical jump test was repeated. Subjects were
immediate effects of a single session of static and allowed a one day rest period and the following day
ballistic stretching on peak anaerobic power of the the testing protocol was repeated however this time
lower limbs using the vertical jump test. It was hoped they completed the stretching protocol that was not
that the information would help to guide therapists previously done. All subjects were tested in the
regarding selection of stretching techniques prior to afternoon period and all assessments were done by
other rehabilitation activities requiring lower limb the same evaluator who was blinded to the stretching
force generation in sedentary clients. protocol that was being conducted.
MATERIAL AND METHODS The static and ballistic stretching was done
bilaterally for the following muscle groups:
A single group pretest posttest balanced cross over hamstrings, hip flexors and gastrocnemius. For all
design was used to conduct this study with the target stretches subjects were given practical demonstrations
population being sedentary university students in addition to verbal instructions. Each stretch was
between the ages 18 to 33 years. Sedentary was defined performed three times with a 20 second rest period
as not being engaged in any form of exercise or between stretches. For the static stretching the subjects
sporting activity for the last two years. Students were were required to move into the required direction until
excluded if they had any pathology of the lower they felt a stretching sensation or slight discomfort but
extremities, upper extremities or spine that was a not pain. The position was held for 15 seconds and
contraindication for performing the vertical jump test. then repeated for a total of three stretches. Ballistic
Subjects were also excluded if they appeared to be at stretching was done in the same positions as the static
high risk for cardiovascular problems based on their stretching, however once the subject reached the initial
responses on a brief screening questionnaire from the stretched position, they were asked to bounce up and
American College of Sports Medicine13. down or back and forth at a pace of one bounce per
second within the range in which they felt the
The vertical jump test was used to measure peak stretching sensation.
anaerobic power for the lower limbs. It is
recommended for use by the American College of For the seated bilateral hamstring stretch subjects
Sports Medicine and studies have been conducted to began in a long sitting position on the plinth. They
determine its validity in predicting peak power14,15. then reached forward to try and touch their toes. The
Subjects were instructed to dip their middle finger in spine was kept straight and they were asked to bend
washable paint and stand with their dominant side from the hips. The knees were kept straight by tensing
against a wall. They were asked to reach up as high as the Quadriceps muscle. The subject was required to
possible keeping the feet flat on the ground and touch hold the end position for 15 seconds for the static

stretch or bounce for 15 seconds for the ballistic stretch. and hip flexor muscles. It is possible that the slightly
higher gains obtained with ballistic stretching may be
For the calf stretch using a step subjects were asked due to the differences in the mechanisms by which
to stand with the toes on the step and the heel of the different types of stretches are thought to affect muscle
leg to be stretched hanging off the step. It was ensured properties. Static stretching has been shown to affect
that they had something to hold on to for stability. They both mechanical 16-19 and neurophysiological 20-22
were then asked to lower the heel off the step until properties of muscles. The changes in the viscoelastic
they felt a stretch and hold the position for 15 seconds. properties could potentially reduce the effectiveness
They were also instructed that if the intensity of the of the muscle with regards to force generation. Ballistic
stretch decreased to lower the heel further until they stretching on the other hand is believed to have to have
felt the stretch once more. For the ballistic stretch they an effect primarily through neurophysiological
were instructed to bounce up and down for 15 seconds. mechanisms23,24. It is possible that the bouncing that
occurs with ballistic stretching enhances the
For the standing quadriceps stretch subjects were
proprioceptive response of the muscle tendon unit thus
asked to assume a lunge position with one leg in front
making it more responsive to the stretch that occurs
of the other and then bend the forward leg and while
just prior to the takeoff phase when performing a
keeping the back leg extended. They were then told to
vertical jump. Sedentary individuals would potentially
lean their trunk forward until they felt a stretch at the
be more responsive to these small changes compared
front of the thigh of the back leg. They were instructed
to a well trained athlete.
to hold the position for 15 seconds and the same was
repeated on the other side. For the ballistic stretch they Young and Behm25 reported a decrease in explosive
were instructed to bounce back and forth for 15 force following static stretching, whilst running and
seconds. practice jumps led to significant increases in explosive
force. This research appears to indicate that the
A paired t-test was done to determine if the mean specificity of the activity that is to be done should be
change in anaerobic power was significant considered when making decisions regarding which
immediately following a single session of static stretching technique to use. Ballistic stretching is a
stretching and ballistic stretching. A student's t-test was more dynamic stretch which trains the muscle in a
done to determine whether there was a difference in manner that is more similar to the way the muscles
the mean change in power between the two function during activities requiring jumping. This may
techniques. All testing was done at an level of 0.05. be an important factor for therapists to consider when
planning their treatment approach. For example when
FINDINGS working on a sit to stand transfer or ascending stairs
patients are required to generate significant lower limb
A total of 44 subjects participated in the study (5 power in the extensors in order to create an upward
males, 39 females). Subjects' ages ranged from 19 to 33 propulsive force. In this case working on some ballistic
years with a mean age of 21.75 3.17 years. The mean stretches prior to these activities may actually improve
height of the subjects was 170.06 18.65 cm and mean performance. If the therapist is working on endurance
weight was 64.53 16.76 kg. Both ballistic and static and reaching activities however, static stretching of
stretching led to immediate improvements in peak the relevant muscle groups prior to the activity training
anaerobic power of the lower limbs when compared may improve performance. These are some areas that
to baseline values however, this change was only require further investigation.
significant with the ballistic stretch (mean change in
power with ballistic stretching = 922.20 759.90 watts, The participants in this study were between the
p = 0.004, mean change with static stretching = 921.30 ages 19 to 33 and therefore the results of this study
759.34 watts, p = 0.24 ). A comparison of the two cannot be applied to the population outside of these
types of stretches showed no significant differences age ranges. The largest percentage of the participants
between the gains in power that was obtained with was females and one would want to exercise caution
each technique. when applying the results to males. Studies should be
The participants in this study were sedentary conducted to investigate the effect of stretching in an
university students however the results of the study older sedentary group since they form a large
were similar to those that looked at recreational and proportion of the patients that are seen by physical
competitive athletes where minimal or no difference therapists. It may also be useful to focus on the
were found between different types of stretching outcomes related to performance of specific functional
techniques and lower limb power4-6. In this study the activities such as time to cross a traffic light or to ascend
subjects performed stretches for the calf, hamstring, a set number of stairs.

CONCLUSION 11. Marek SM, Kramer JT, Fincher AL, et al. Acute
effects of static and proprioceptive
The results of this study showed that there is no neuromuscular facilitation stretching on muscle
difference between the effects of a single session of strength and power output. J Athletic Training.
static and ballistic stretching on jump performance in 2005; 40(2): 94-103.
sedentary individuals, however further research is 12. Yamaguchi T, Ishii K, Yamanaka M, Yasuda K.
required in this area. Acute effect of static stretching on power output
during concentric dynamic constant external
Conflict of interest resistance leg extension. J Strength Cond Res.
2006; 20(4) 804-810.
There was no conflict of interest in the conduct of 13. Whaley MH, Brubaker PH, Otto RM, editors.
this study. ACSM guidelines for exercise testing and
prescription. 7th ed. USA: Lippincott Williams &
REFERENCES Wilkins; 2006.
14. McArdle WD, Katch FI, Katch VL. Essentials of
1. McMillan D, Moore J, Halter B, Taylor, D. exercise physiology. 3rd ed. USA; Lippincott
Dynamic vs static stretching warm up: the effect Williams & Wilkins; 2006.
on power and agility performance. J Strength 15. Sayers SP, Harackiewicz DV, Harman EA,
Cond Res. 2006; 20(3): 492-499. Frykman PN, Rosenstein MT. Cross validation of
2. Asmussen E, Bonde-Petersen F. Storage of elastic three jump power equations. Med Sci Sports
energy in skeletal muscles in man. Acta Physiol Exerc. 1999; 31(2) 572-577.
Scand. 1974; 91(3): 385-392. 16. Magnusson SP, Simonsen EB, Agaard P, Sorensen
3. Fowles JR, Sale DG, MacDougall JD. Reduced H, Kajer M. A mechanism for altered flexibility
strength after passive stretch of the human in human skeletal muscle. J Physiol. 1996; 497(1):
plantarflexors. J Appl Physiol. 2000; 89: 1179-1188. 291-298.
4. Power K, Bhem D, Cahill F, Carroll M, Young W. 17. McNair P, Dombroski EW, Hewson DJ et al.
An acute bout of static stretching: effects on force Stretching at the ankle joint: viscoelastic responses
and jumping performance. Med Sci Sports Exerc. to holds and continuous passive motion. Med Sci
2004; 36(8): 1389-1396. Sports Exerc. 2000; 33: 354-358.
5. Unick J, Kieffer HS, Cheesman W, Feeney A. The 18. Kubo K, Kanehisa H, Fukunaga T. Effects of
acute effects of static and ballistic stretch on transient muscle contractions and stretching on
vertical jump performance in trained women. J the tendon structures in vivo. Acta Physiol Scand.
Strength Cond Res. 2005;19(1):206-212. 2002; 175: 157-164.
6. Woolstenhulme MT, Griffiths CM, 19. McHugh MP, Magnusson S, Liem G, Nicholas J.
Woolstenhulme EM, Parcell AC. Ballistic Viscoelastic stress relaxation in human skeletal
stretching increases flexibility and acute vertical muscle. Med Sci Sports Exerc. 1992; 24: 1375-1382.
jump height when combined with basketball 20. Rosenbaum D, Henning E. The influence of
activity. J Strength Cond Res. 2006; 20(4): 799-803. stretching and warm-up exercises on achilles
7. Cornwell A, Nelson AG, Heise GB, Sidaway B. tendon reflex activity. J Sports Sci. 1995; 13:
Acute effects of passive muscle stretching on 481-490.
vertical jump performance. J Hum Mov Stud. 21. Guissard N, Duchateau J, Hainaut K.
2001; 40: 307-324. Mechanisms of decreased motoneuron excitation
8. Cornwell A, Nelson AG, Sidaway B. Acute effects during passive muscle stretching. Exp Brain Res.
of stretching on the neuromechanical properties 2001; 137: 163-169.
of the triceps surae muscle complex. Eur J Appl 22. Ribot-Ciscar E, Tardy-Gervet M, Vedel J, Roll J.
Physiol. 2002; 86: 428-434. Post contraction changes in human muscle
9. Young WB, Behm DG. Effects of running, static spindle resting discharge and stretch sensitivity.
stretching and practice jumps on explosive force Exp Brain Res. 1991; 86: 673-678.
production and jumping performance. J Sports 23. Vujnovich A, Dawson N. The effects of
Med Phys Fitness. 2003; 43: 21-27. therapeutic muscle stretch on neural processing.
10. Wallmann HW, Mercer JA, McWhorter JW. J Orthop Sports Phys Ther. 1994; 20: 145-153.
Surface electromyographic assessment of the 24. Zehr EP, Sale DG. Ballistic movement; muscle
effect of static stretching of the gastrocnemius activation and neuromuscular activation. Can J
muscle on vertical jump performance. J Strength Appl Physiol. 1994;19(4): 363-378.
Cond Res. 2005; 19(3): 684-688.

Autonomic Adaptation and Functional Capacity Outcomes

after Hospital-Based Cardiac Rehabilitation Post Coronary
Artery by Pass Graft
Sherin Hassan Mohammed Mehani

Lecturer Physical Therapy, Department for Cardiovascular/ Respiratory Disorder and Geriatrics
Faculty of Physical Therapy, Cairo University, Giza, Egypt
ABSTRACT
Background and purpose: secondary prevention of coronary heart disease and increased exercise
tolerance in patients who received coronary artery by pass graft (CABG) are the main goals of cardiac
rehabilitation.
The aims of the present study were to evaluate the effect of in-patient cardiac rehabilitation program
on autonomic recovery after CABG and on functional capacity.
Subjects and methodology: fifty male patients with coronary artery disease who had been operated
upon CABG were involved in the present study. They were randomly divided into two groups;
group A (training group) who participated in ten steps cardiac rehabilitation program with adjusted
intensity about 85% of maximal heart rate. Group B (control group) continued to perform mild walking,
calisthenics, breathing exercises without adjustment for exercise intensity. Heart rate recovery and
resting, mean six minute walking distance and estimated peak VO2 were measured preoperative,
4th day after operation and after the end of the rehabilitation program.
Results: there was a statistical significant effect of time and the in traction of time by group. Also
there was a statistical significant difference between both groups except for resting heart rate.
Conclusion: In patient cardiac rehabilitation for patients who had been operated for CABG is
beneficiation for improving autonomic balance and functional capacity.
Key words: Autonomic Adaptation; Functional Capacity; Coronary Artery Bypass
INTRODUCTION augment the sensation of exertion during physical

activities performed during the early phase of
Inherent factors to myocardial revascularization recovery2. Because of the strong association between
surgery, such as anesthesia, hypothermia, cardioplegia HRR and mortality, and the link between HRR and
and peri-aortic sympathetic lesion, potentially lead to exercise capacity or physical activity patterns, HRR has
cardiovascular dysfunction in the postoperative the potential to be an additional marker of training
period1. Specifically, modulation of the autonomic efficacy and risk stratification in patients undergoing
nervous system, producing an abnormal increase in cardiac rehabilitation3-6. Although 6 MWT is commonly
heart rate, myocardial oxygen consumption, may used to assess the functional status of patients with
severe cardiopulmonary disease; few studies have
Correspondence Address tested its value in cardiac rehabilitation. Despite the
Sherin Hassan Mohammed Mehani growing number of older patients undergoing cardiac
Physical Therapy, surgery, there is little evidence of the use of 6 MWT in
Department for Cardiovascular/ Respiratory Disorder and this group of cardiac patients7. Therefore, the aims of
Geriatrics, Faculty of Physical Therapy, the present study were to evaluate the effect of
Cairo University, Giza, Egypt inpatient cardiac rehabilitation program on heart rate
Mobile : 01003378217 recovery as a marker of autonomic recovery after
E-mail : sherinhassin@yahoo.com CABG, resting heart rate, and functional capacity
52 Sherin 8th june 12 (263-267).pmd 263 10/16/2012, 2:41 PM

measured by using distance walked in 6 MWT and the test, the patient's resting heart rate and blood
the estimated peak oxygen consumption (Peak VO2). pressure was monitored. Immediately after completion
of the 6 MWT, the heart rate in the first minute of
METHODS recovery was recorded from sitting position. The test
was repeated for three times with rest interval in
Study population between about half an hour, and then the mean
The study population consisted of fifty male 6-minute walking test was calculated.
patients with coronary artery disease, their age ranged Heart rate recovery (HRR)
from 45 to 60 years old. All of them had been operated
upon CABG. Criteria for eligibility were as follows; Heart rate recovery was defined as the decrease in
male patients with sinus rhythm and ejection fraction the heart rate from the end of peak walking test to the
> 50% as determined at preoperative cardiac first minute of recovery. As the test was repeated three
catheterization and by Echocardiograph examination times, the mean recovery heart rate was calculated by
postoperatively before the enrollment in the pulse oximeter.
rehabilitation program. Exclusion criteria were as Mean peak VO2
follow: unstable angina, valve disorders, peripheral
vascular diseases, arterial blood pressure > 180/ 100 The following equation10 was used to accurately
mmHg, peripheral neuropathy, insulin - dependent estimate mean peak VO2 from mean 6-minute walking
diabetes, periperative anterior myocardial infarction, distance (6 MWD); Mean peak VO2 (ml/kg/min) =
and any orthopedic or neurological limitation that 4.948 + 0.023 x mean 6 MWD.
interfere with the rehabilitation program. The patients
Training procedures
were admitted to the rehabilitation center at the
Coronary Care Unit (C.C.U.) and Inpatient Cardiology All patients in the training group underwent
Department in El-Hussin University Hospital during training program, at 4 th day postoperative after
the preoperative period (one or two days before the assessment was done. The program consisted of two
operation), and 4 th day postoperative. They were daily sessions of 30-minute for two weeks (24 sessions).
randomly assigned to either training group or control The training program was conducted into steps
group by arrangement into numerical numbers from according to Paul et al. (2001)11.
1 to 50, then odd numbers were allocated as a training
group and the even numbers were allocated as a Step 1: (1.0: 1.5 Metabolic Equivalents) (MET)
control group. Patients assigned an informed consent (sitting).
and the study was approved by Ethical Committee of
A.M.: Active assisted to active range of motion to
El-Hussin University Hospital.
all extremities; active ankle; Active scapular; repetition
Initial evaluation procedures 3:5 times; deep breathing.
On admission to rehabilitation center, one or two P.M.: monitored ambulation 30:60 meters (assisted).
days, the referred reports, all previous preoperative
Step 2: (1.0: 1.5 MET) (sitting): repetition 3:5 times;
documents and investigations were revised in addition
deep breathing; ambulation 60 meters with assistance
to recording their personal and anthropometric data
(stress correct posture).
then the procedure of the operation that was be done
had been explained. Then the role of cardiac Step 3 (1.5: 2.0 MET) (standing): active upper limb
rehabilitation in preventing postoperative exercise and trunk bilateral (circumduction-
complications was explained. backwards); knee extension 5:10 repetition; ambulation
90 meters.
Preoperative assessment
Step 4 (1.5: 2 MET): increase repetition 5:10;
Six minute walking test according to ATS statement
monitored ambulation 130 meters.
20028, and Wu et al., 20039.
Step 5 (2: 2.5MET): increase to 15 repetition;
The test was symptom-limited, so patients who
ambulation 130: 260 meters, for 5: 10 min; Exercise
became symptomatic were told to stop walking and
center : walk to inpatient center ; strengthen exercise
restart when possible. The hallway length was marked
15 repetition; treadmill 5:10 min,leg stretching exercise
every three meters. The peak heart rate and the
(hamstring, calf); increase ambulation to 3 laps
distance walked during the test were recorded. Before
(130 m.).

Step 6 (2: 2.5MET): active range of motion to each heart rate, the main effect of time was significant; p
upper limb with one pound (= 0.450 kg) 15 repetitions; value was (0.0001). The time by group interaction was
ambulation up to 5 laps (600 meters) for 10: 15 min; significant; p value was (0.0001). The main effect of
treadmill 10: 15 min; up stairs 6: 12 with assistance. group was significant, p value was (0.0001); see Table
2, 3. Considering distance walked, the main effect of
Step 7 (2: 3 MET): active R.O.M. to each upper limb time was significant, p value was (0.0001).The time by
with one pound weight 15 repetition; ambulation 10:15 group interaction was significant, p value was (0.0001).
min; treadmill 20: 30 min; up stairs 14 with assistance. The main effect of group was significant, p value was
Step 8 (2: 3 MET): resisted with two pounds weight; (0.04); see Table 2, 3. Regarding peak oxygen
up stairs 16; ambulation 9 laps (1150 meters) consumption, the main effect of time was significant,
p value was (0.0001).The time by group interaction was
Step 9 (2: 3 MET): continue; ambulation 12 laps significant, p value was (0.0001).The main effect
(1550 meters); up stairs 18. of group was significant, p value was (0.04); see Table
2, 3.
Step 10 (2: 3 MET): continue with 3pounds; up stairs
up to 24; up to 14 laps (1675meters) Table 2. The main effect of time for different studied
variables within patients
The training intensity was adjusted according to Variable Group Statistical Pre 4th At the F P
value operative day end
85% of maximal heart rate12 reached during the 6- Training Mean 99.857 97.904 85.809 441.692 0.0001
Resting heart group SD 5.729 5.584 5.124
minute walking test, the heart rate was monitored by rate (b/min)
Control Mean 98.952 96.571 91.809
pulse oximeter. Patients in the control group continued group SD 5.132 4.388 4.589
Training Mean 114.952 112.095 91.857 1228.471 0.0001
to perform mild walking, calisthenics, and breathing Recovery heart group SD 2.085 2.586 4.028
exercises with coughing technique without adjustment rate (b/min)
Control Mean 116.00 114.952 107.476
group SD 1.843 1.745 2.088
for the exercise intensity for about 24 sessions (2 Training Mean 268.523 301.142 392.333
sessions daily for 2 weeks). Distance walked group SD 27.069 24.777 26.255 3851.110 0.0001
(meters) Control Mean 259.523 297.142 343.809
group SD 36.422 35.223 38.249
Data collection and statistical procedure
Training Mean 11.124 11.874 13.971
Peak VO2 ml/ group SD 0.622 0.810 0.603 3851.110 0.0001
Two ways mixed ANOVA was conducted to kg / minute
Control Mean 10.917 11.782 12.855
group SD 0.837 0.810 0.879
evaluate the effect of time and grouping and their
interaction. A level of P < 0.05 was considered Table 3. Statistical comparison between groups and the
indicative of statistical significance. time by group interaction
Variable Between both groups Interaction of time by group
F P F P
RESULTS Resting heart 0.683 0.413 59.699 0.0001
rate (b/min)
Table 1. The demographics and clinical Recovery heart 95.582 0.0001 9992.544 0.0001
characteristics of the sample rate (b/min)
Distance walked 4.458 0.041 204.435 0.0001
Training group Control group
(meters)
1. Number of Patients: 25 25 Peak VO2 4.458 0.041 204.435 0.0001
2. Age 50.68.6 507.5 (ml/kg/min)
3. BMI(kg/m2) 243 252
4. EF % 50 - 55% 51 - 56%
5. Tobacco use 23(92 %) 22 (88%) DISCUSSION
6. Hypertension 23(92 %) 22 (88%)
7. Cholesterol mg/dl 19530 19525 Mechanical injury to the autonomic nerve fibers
8. myocardial infarction (MI) number 15 14 during surgery might interfere with vagal cardiac
9. Time after MI in months 8.5 (4-31) 6.5 (3-24)
reflex. Moreover, bed-rest reconditioning may lower
10. Medications
- Antiplatelet 18 19 the parasympathetic tone in the early phase of cardiac
- Diuretics 15 15 rehabilitation, but the mechanism by which vagally
- Calcium antagonists 18 17
- - Blockers 4 3 mediated heart rate recovery is blunted in post-CABG
- Statin 13 12 remains unclear13.
- Vasodilators 4 3
Considering the resting heart rate, the main effect The results of the present study, concerning the
of time was significant; p value was (0.0001). The time effect of cardiac rehabilitation program on heart rate
by group interaction was significant; p value was recovery were in accordance with Sato et al. (2005)14
(0.0001). The main effect of group was not significant, who conducted a supervised cardiac rehabilitation
p value was (0.41); see Table 2, 3. Regarding recovery program on male patients at two weeks after CABG.
The patients were divided into; active group walking

> 5, 434 steps / day and less active group. The training clinical condition and the results of symptom-limited
program lasted for two weeks and patients who used exercise testing. The improvement seen in the control
-blockers were excluded. group of the present study was lower than that
observed in the study of Hirschhorn et al. (2008)21 who
It's generally accepted that structured exercise showed a change to about 44484 meters and 43198
training enhances the vagal contribution to the cardiac meters in walking and walking breathing exercise
autonomic control in patients with coronary artery groups who were trained in the inpatient phase after
disease15,16. CABG without adjustment for exercise intensity. This
The significant decrease in heart rate recovery in discrepancy may be related to the time of measurement
the first minute may be attributed to the release of as Hirschhorn et al. 21 measured 6 MW distance
inhibitory central command or afferent stimulation preoperative, at discharge and four weeks following
from baroreflex or chemoreflex functions 17. discharge.
The results of this study also go a head with The significant improvement observed in mean six-
Soleimani (2008)4 who supported an increase in HRR minute walking distance and mean peak VO2 may be
over one minute in patients who completed 24 sessions related to reduction of resting and recovery heart rate
of cardiac rehabilitation (phase2). The study indicated along with improvement of autonomic nervous system
that precutaneous coronary intervention patients balance 22, other mechanisms potentially involved in
achieved greater improvement in HRR by comparison functional capacity improvement may be related to
with CABG patients. correction of anemia, the reduction of chest pain and
of respiratory limitation usually appearing early after
Wu et al. (2006)18 also showed that the mean value surgery 19.
of HRR decline improved from 9.24.5 to 6.2 beats
per minute after cardiac rehabilitation among CABG REFERENCES
patient.
1. Botega F, Junior GC, Lima F and Arena R.
The results of the present study also were Cardiovascular behavior during rehabilitation
confirmed by the results gained by Soleimani. (2008)6 after coronary artery by pass grafting. Rev Bras
who investigated out patient cardiac rehabilitation Cir Cardiovascular. 2010; 25 (4): 527-533.
program impact on HRR after precutaneous 2. Soares PP, Morena AM, Cravo SL and Nobrega
transluminal angioplasty, the results showed a AC. Coronary artery by pass surgery and
reduction in HRR post training. longitudinal evaluation of the autonomic
cardiovascular function. Crit care.2005; 9(2):
The reduction of resting heart rate in the present 129-131.
study conceded with Wu et al. (2005)19 designed a 3. Vivek an anthan DP, Blackstone, EH, pothier CE
cardiac rehabilitation program according to 60-85% of and Lauer MS. Heart rate recovery after exercise
peak heart rate achieved in cardiopulmonary exercise is a predictor of mortality, independent of
test conducted at discharge and 3 months later for angiographic severity of coronary disease. J Am
CABG patients. Coll Cardiol. 2003; 42: 831-838.
4. Soleimani A, Alidoosti M, Salarifar M and
According to the reference values for distance Kassaian S. Effect of cardiac rehabilitation
walked in the 6-minute test soon after cardiac surgery program on heart rate recovery after
in male patients with ejection fraction more than 50% percutaneous coronary intervention and
and having no operatively 7 comorbidies, the patients coronary artery by pass grafting. Teh Univ Heart
included in the present study, had a lower functional Ctr. 2008a; 1: 11-16.
5. Shabani R, Gaeini AA, Nikoo MR and Nikbackt
capacity post.
H. Effect of cardiac rehabilitation program on
The significant increase observed in the functional exercise capacity in women undergoing coronary
capacity in the present study conceded with Fiorina et artery by pass graft in Hamadan, Iran. Int. J. Prev
al. (2007)20 showed an increase the walked distance Med. 2010; 1(4): 247-251.
measured after in-hospital cardiac rehabilitation 6. Soleimani A, Salarifar M, Kasaian SE and
Sadeghian S. Effect of completion of cardiac
program for 15 days. The rehabilitation program
rehabilitation on heart rate recovery. Asian
included training with treadmill, and/or bicycle
cardiovascular and Thoracic Annals.2008b; 16:
ergometer, walking, jogging, stair climbing and step
202-207.
aerobic. The intensity was established according to the

7. Opasich C, De-Feo S, Pinna GD and Furgi G. prognosis after myocardial infarction Circulation.
Distance walked in the 6-minute test soon after 2002; 106: 945-949.
cardiac surgery, towards an efficient use in the 16. Matsumoto M, Yamashita T, Fukuda E and Sagara
individual patient. Chest. 2004 ; 126-1796-1801. K . Relation between variability of ventricular
8. The American Thoracic Society. ATS statement: response intervals and exercise capacity in
guidelines for the six-minute walk test. Am J patients with non-valvular atrial fibrillation. Circ
Respir Crit Care Med. 2002; 166: 111-117. J. 2004; 68: 294-296.
9. Wu G, Sanderson B and Biltner V. The 6-minute 17. Toska K and Eriksen M . Peripheral
walk test: how important is the learning effect? vasoconstriction shortly after onset of moderate
Am Heart J. 2003; 146: 129-133. exercise in human. J Appl Physiol. 1994; 77: 1519-
10. Ross RM, Murthy JN, Wollak ID and Jackson AS. 1525.
The six-minute walk test accurately estimates 18. Wu SK, Lin YW, Chen CL and Tasi SW. Cardiac
mean peak oxygen up take. BMC pulmonary rehabilitation versus home exercise after coronary
medicine. 2011; 10: 1-9. artery by pass graft surgery: a comparison of
11. Paul S and Frank G. Cardiac Rehabilitation Phase heart rate recovery. Am J Phys Med Rehabil. 2006;
I. Paul S., Frank G., and Philip K. Cardiac 85: 711-717.
Rehabilitation Adult Fitness and Exercise testing. 19. Wu S, Luo H and Tsai S. The change of resting
2001 3rd ed. London. Williams and Wilkins. pp:- heart rate after cardiac rehabilitation in patients
297: 319. with coronary artery by pass graft surgery. 2005:
12. Legramante JM, Iellamo F, Massaro M and Sacco 43-49.
S. Effects of residential exercise training on heart 20. Fiorina C., Vizzardi E., Lorusso, R. and Maggio
rate recovery in coronary artery patients. Am J M. The6-min walking test early after cardiac
physiol Heart Circ physiol. 2007; 292: H510-H515. surgery. Reference value and the effects of
13. Niemela MJ, Airaksinen EJ, Tahvanainen KUO rehabilitation programme. European Journal of
and linnaluoto MK. Effect of coronary artery by Cardio-thoracic Surgery. 2007; 32: 724-729.
pass grafting on cardiac parasympathetic nervous 21. Hirschhorn AD, Richards D, Mungovan S and
system. Eur Heart J.1992; 13: 932-935. Morris NR. Supervised moderate intensity
14. Sato S, Makita S and Majima M. Additional exercise improves distance walked at hospital
physical activity during cardiac rehabilitation discharge following coronary artery by pass graft
leads to an improved heart rate recovery in male surgery. Heart, Lung Circ. 2008. 17 (2): 129-138.
patients after coronary artery by pass grafting. 22. Hautala AJ, Makikallio TH and Kiviniemi.
Circ J. 2005; 69: 69-71. Cardiovascular autonomic function correlates
15. La Rovere MT, Bersano C, Gnemmi M and with the response to aerobic training in healthy
Specchia G. Exercise-induced increase in sedentary subjects: Am J Physical Heart Circ
baroreflex sensitivity predicts improved Physiol. 2003; 285: H1747-1752.

Analysis of the Influence of Fear of Fall on the Score of

Berg Balance Scale among the Elderly Population
R. Sivakumar1, C.M. Radika2

1
Reader in Physiotherapy, 2Assistant Professor
Sri Ramachandra University, Porur, Chennai 116, India
ABSTRACT
Background: Fear of fall felt by the elderly population even in the absence of incidence of fall can
affect their mobility. It can also expected to affect the scoring of Berg Balance Scale. This study is done
to analyse this impact of fear of fall on score of Berg Balance Scale.
Method: 50 elderly individual in the age range of 65 to 74 years were recruited. Tinetti Fall Efficacy
scale was administered to quantify the fear of fall in them. Berg Balance Scale was administered.
Confidence to do the Berg Balance Scale was measured with Visual Analogue Scale. Counseling and
placebo exercise training was given to improve their ability to perform ADL and Berg Balance Scale.
Pre and Post counseling with training data was analysed. Correlation between scores of Tinetti Fall
Efficacy scale and Berg Balance Scale was identified.
Results: Higher level of correlation was found between Tinetti Fall Efficacy and Berg Balance Scale.
There was a significant change found the in the scores of both the scales with counseling and placebo
training.
Conclusion: Fear of fall has to be considered while measuring balance with Berg Balance Scale and
counseling prior to evaluation will improve the quality of the measurement.
Key words: Tinetti Fall Efficacy Scale, Fear of fall, Berg Balance Scale.
INTRODUCTION reports that, out of 1,103 individuals studied 19%

avoided activities due to fear of falling. Avoidance of
WHO defines elderly population as individual in activities will result in further decrease in lower
the age group above 65 years. Increase in age may lead extremity muscle strength. Women are more likely to
to increasing probability of degenerative changes in report fear of falling than man8. Fear of falling is
biological systems, which may lead to functional and considered to be an important factor which restricts
structural changes in the body mechanism. These the activities of daily living9-13. Chandler et al14 states
changes may be extremely profound and may result that with advancing age, a psychological symptom
in total disability. Advancing age is related with called fear of falling develop in elderly. This happens
decrease in lower extremity strength1-5. This results in even without an experience of fall. Chandler et al14
decrease in mobility and increase risk of fall among found that 38% of 306 community dwelling male aged
elderly. Lord et al6 states that quadriceps muscle 70 and above, experienced fear of fall without a history
strength was poorer in multiple fallers when compared of fall. Van Haasstregt JC et al15 found that depression
to non fallers. Individuals who experience fall, reduces was associated with severe fear of falling. This
their mobility. Fear of falling induced avoidance of depression can further decrease the mobility and result
activities among elderly individuals. Tinetti et al7 in further weakness. As fear of fall reported to have
negative impact on mobility of an individual, it may
Correspondence Address also have influence on any mobility related tests
R.Sivakumar performed on the individual. The score of the test may
MPT (Neurosciences) get altered because of the fear of fall impeding the
Sri Ramachandra University, Porur, movement, not due to presence of motor deficit.
Chennai 116, India
53 Shivkumar 7th june 11 (268-271).pmd 268 10/16/2012, 2:41 PM

Berg Balance scale is one such measure, which is scale (1-10), where 1 indicates 'very confident, no fear
commonly used to predicting falls. Muir SW and Berg of falling' and 10 'not confident at all, very afraid of
K16 did a prospective study to find out the use of Berg falling'. Subjects who had a score of 70 and greater than
Balance Scale among community dwelling older 70 were concluded to have Fear of falling. Eighty-three
people, and concluded that Berg Balance Scale has a individuals were screened and 50 who scored 70 and
good discriminative ability to predict multiple falls greater than 70 in Tinetti Fall Efficacy Scale were
among older people. This scale consist of fourteen selected for the study. The selected individuals were
functional task commonly performed in everyday life explained about the study and written informed
it is reported to be highly reliable and sensitive consent was obtained. Subjects were explained about
measure for balance. As fear of fall can affect motor the Berg Balance Scale. As it was felt that measuring
performance of an individual, it may also have impact the confidence of the individuals to score maximum
on scores of Berg Balance scale. But the impact of fear in Berg Balance Scale, will add clarity to the study, it
of falling on the scores of Berg Balance Scale has not was marked on Visual Analogue Scale. In Visual
been documented. This study was intended to analyze Analogue scale 1 indicated minimal confidence to
whether fear of fall will have an impact on the scores score maximum in Berg Balance Scale and 10 indicated
of Berg Balance Scale among elderly population. maximal confidence to score maximum in Berg Balance
Scale. Berg Balance Scale was administered and scored.
Tinetti et al17 have referred fear of falling as low As it was assumed that existence of a relationship
perceived self efficacy at avoiding falls during between presence of fear of fall and decrease in score
essential, non hazardous activities of daily living. Fear of Berg Balance Scale may even be a coincidence, it
of falling can be measured by Tinnetti Fall Efficacy was decided to decrease the fear of fall by an
scale. This scale consists of 10 items of activities of intervention and analyse the relationship again with
daily living. Individuals are instructed to score their scores of Berg Balance Scale. All the individuals were
confidence in doing the activity without falling on given a counseling to improve their confidence to do
a scale of 1 to 10, with 1 being very confident and their daily activities and reduce the fear fall. The
10 being not confident at all. This scale has good test researcher who did counseling was blinded from the
retest reliability and is useful in evaluating the scores of Fall Efficacy Scale and Berg Balance Scale to
independent contribution of fear of falling to functional avoid bias during counseling. All the subjects were
decline among elderly. A total score of 70 and greater given a set of exercises to improve their confidence.
than 70 indicates that the person has a fear of falling. Exercises were structured in such a way they that they
In this study influence of fear of falling on scores will not improve their performance in Berg Balance
of Berg Balance scale was studied. The fear of fall was Scale, but will give them only psychological well being.
quantified with Tinetti Fall Efficacy scale. The Exercise program consisted of four exercises, and
subjects were advised to repeat for 10 times per session.
The exercises were given for 5 days consecutively. All
METHODOLOGY
the subjects received one session of exercises per day,
Elderly women population in the age range of 65 under the supervision of the researcher. Subjects were
to 74 years, in old age home was screened for the insisted not to perform them in the absence of the
inclusion and exclusion criteria. Those who ambulate researcher. This instruction was repeated regularly to
without any assistive devices were included for avoid any influence of exercises on physical
screening. Cognitive function was screened with Mini performance in Berg Balance Score. The four exercises
Mental State Examination. One hundred and Two given were quadriceps contraction in high sitting, in
individuals were screened. All of them briefed about supine lying static quadriceps contraction, hip & knee
the need for the screening process. Three were flexion and hip abduction & adduction to neutral.
excluded as they scored 23 in their Mini Mental State Counseling was along with the exercise session on a
Examination and 15 had orthopaedic and neurological daily basis. On the fifth day the same examiner who
impairments which can compromise balance and one administered Visual Analogue Scale and Berg Balance
didn't agree for further screening. Finally 83 were Scale during initial evaluation did the evaluation.
selected for further screening with Tinetti Fall Efficacy
scale to grade their "Fear of Fall" or otherwise their RESULTS
confidence in doing their Activities of Daily living
independently. Fall Efficacy Scale consists of This study was done on 50 subjects and the result
10 components with a total score of 100. The original was analysed. The subjects comprise of only
Falls Efficacy Scale consists of 10 items with a 10-degree females.

Table I shows the correlation between Tinetti Fall and analyse the influence of fear of fall on their ability
Efficacy Scale (TFES) and Berg Balance Scale (BBS) for to perform Berg Balance Scale. The subjects were given
pre counseling values was calculated and table shows a set of placebo exercises under supervision for a
the correlation between Tinetti Fall Efficacy and Berg period of five days to decrease their fear of fall. It was
Balance Scale pre counselling values and the hypothesized that by the influence of supervised
correlation was significant. placebo exercise the fear of fall might decrease and
their functional abilities would improve.
Table 1. Pre counseling correlation
between TFES and BBS Subjects with the score of 70 and greater than 70 in
No of r value Level of Tinetti Fall Efficacy Scale were taken for the study. In
subject Significance
P<0.05 this study fifty subjects with the score greater than
Tinetti Fall 50 -.783 Significant 70 were included. Anne Shumway Cook in motor
Efficacy Scale control 2007, states that fear of fall increases with age.
Score
Berg Balance 50
It was noted that 32 out of 50 subjects were greater
Scale Score than 70 years of age.
Table II shows the correlation between Tinetti Fall Analysis of pre and post consoling values of Tinetti
Efficacy (TFES) and Berg Balance Scale (BBS) post Fall Efficacy Scale showed that there is a statistically
counselling values and the correlation was significant. significant difference between the values. There was a
decrease in values in post counseling period, denoting
Table 2. Post counseling correlation that there was a decrease in the fear of fall or increase
between TFES and BBS
in the confidence in doing the Activities of daily living.
N r value Level of
Significance
Correlating the pre-counseling score of Tinetti Fall
P<0.05 Efficacy Scale and Berg Balance Scale showed that they
Tinetti Fall 50 -.825 Significant are negatively related with r-value -.783. The
Efficacy Scale
Score relationship between Tinetti Fall Efficacy Scale and
Berg Balance 50 Berg Balance Scale post counseling session also shows
Scale Score higher value of r -.825. These data suggests that there
exist a relationship between the fear of fall and
Table I and II shows that the relationship between performance of Berg Balance Scale.
the fear of fall and scores of Berg Balance scale was
not due to coincidence. Individual subject level analysis revealed more
interesting findings. In this study 42 individuals as
The change in the fear of fall due to counseling was whole had decrease in scores of Tinetti Fall Efficacy
also measured and found that there was a significant Scale after counseling. This group forms 64% of the
decrease. Table III shows analysis for pre counseling population studied. In this 42 only 33 have shown
and post-counseling score of Tinetti Fall Efficacy Scale increase in the score of Berg Balance Scale. All these
(TFES) using Student's T test. The value is highly individuals had their Visual Analogue Scale score
significant. increased displaying their increase in the level of
Table 3. Comparison of Pre and post confidence to perform Berg Balance Scale. Seven
counseling values of TFES Subjects with decrease in Tinetti Fall Efficacy Scale
Mean Std. t test Level of score didn't show any changes in Berg Balance Score,
Deviation Significance
P<0.05
even though their Visual Analogue Scale score
TFES Pre 74.84 4.8 11.1 Significant recorded an increase in their confidence in six subjects.
counseling values
This controversy between the scores may be due to
TFES Post 70.26 5.6
counseling values the subjects' visualisation of functional activities stated
in Tinetti Fall Efficacy Scale and activities performed
The change in values of Visual Analogue scale was in Berg Balance Scale as different with respect to the
also anlysed for changes in the confidence to perform requirement of Balance. Hence even though they
the Berg Balance Scale. The change was highly thought they could perform the activities noted in the
significant with't' value 10.0. Tinetti Fall Efficacy Scale with ease with their
counseling, they did not feel the same level of
DISCUSSION
confidence with the Berg Balance Scale performance.
The aim of this study was to select Elderly subjects Seven subjects did not show any changes in Tinetti
with fear of fall without any previous history of fall Fall Efficacy Scale, Visual Analogue Scale and Berg

Balance Scale. This could be assumed as a result of factors associated with falls in an eldely fallers
insufficient counseling to those individuals. and elderly non-fallers. J Am Geriatr Soc 1991;
Dec; 39(12):1194-1200.
The fear of falling among the elderly has an 7. Tinetti ME, Mendes de Leon CF, Doucette JT,
influence on the mobility of the individual that in turn Baker DI. Fear of falling and fall-related efficacy
reduces the functional ability. As components in Berg in relationship to functioning among community-
Balance Scale replicates or mimics few postures and living elders. J Gerontol. 1994; May; 49(3): M
movements commonly noted in daily living, fear of 140-147.
fall may influence Berg Balance Scale scores. The 8. Vellas BJ, Wayne SJ, Romero LJ, Baumgartner RS,
results of this study suggest that there is a negative Garry PJ. Fear of falling and restriction of mobility
correlation between fear of fall and Berg Balance Scale. in elderly fallers. Age Ageing 1997; May; 26(3):
189-193.
It can be suggested that Berg Balance Scale scores may
9. Deshpande N, Metter EJ, Laurentani F,
vary even if the individual has fear of fall during
Bandinellis S, Guralnik J, Ferrucci L. Activity
movements or posture control without having any restriction induced by fear of falling and objective
physical impairment affecting the balance. This has to and subjective measures of physical function: a
be considered when the Berg Balance Scale is used to prospective cohort study. J Am Geriatr Sco 2008;
evaluate balance especially in elderly population. Prior Apr; 56(4): 615-620.
counseling about the testing, precautions provided or 10. Delbaere K, Crombez G, Vanderstraeten G,
environment that makes them feel safe against fall and Williams T, Cambier D. Fear related avoidance
risk of injury may alter the Berg Balance Scale scores. of activities, falls and physical frailty. A
prospective community based cohort study. Age
CONCLUSION Ageing. 2004; July; 33(4): 368-373.
11. Cumming RG, Salkeld G, Thomas M, Szonyi
The results suggest that there is a negative G. Prospective study of the impact of fear of
correlation between fear of fall that was present among falling on activities of daily livin, SF-36 scores,
elderly and Berg Balance Scale, when fear reduces and nursing home admission. J Gerontol A Biol
among elderly it may alter the scores of Berg Balance Scie Med Sci. 2000; May; 55(5): M299- 305.
12. Scheffer AC, Schuurmans MJ, van Dijk N, van
Scale.
der Hooft T, de Rooij SE. Fear of falling:
Proper counseling and instruction regarding the measurement strategy, prevalence, risk factors
Berg Balance Scale can positively influence the scores and consequences among older persons. Age and
of Berg Balance. Aging 2008; 37; 19-24.
13. C L Arfken, H W Lach, S J Birge, and J P Miller.
The prevalence and correlates of fear of falling in
REFERENCES elderly persons living in the community. Am J
1. Aniansson A, Hedberg M, Henning GB et al. Public Health. 1994 April; 84(4): 565-570.
Muscle morphology, enzymatic activity and 14. Chandler, Julie McClure, Duncan, Pamela W,
muscle strength in elderly men: A follow up Sanders, Linda, Studenski, Stephanie. The fear
study. Muscle Nerve 1986; 9; 585-591. of falling syndrome: Relationship to falls, physical
2. Larsson L, Grimby G, Karisson J. Muscle strength performance, and activities of daily living in frail
older person. Topics in Geriatric Rehabilitation.
and speed of movements in relation to age and
1996; March: Vol 11; Issue 3.
muscle morphology. J Appl Physiol 1979; 46;
15. Van Hasstregt JC, Zijlstra GA, van Rossum E, van
451-456.
Eijk JT, Kempen GI. Feelings of anxiety and
3. Cahalan TD, Johnson ME, Liu S et al. Quantitative
symptoms of depression in community living
measurements of hip strength in different age
older persons who avoid activity for fear of
groups. Clin Orthop 1989; 246; 136-145.
falling. Am J Geriatr Psychiatry. 2008 Mar; 16(3);
4. Winegard KJ, Hicks AL, Sale DG et al. A 12 year
186-193.
follow up study of ankle muscle function in older
16. Muir SW, Katherine Berg, Bert Chesworth and
adults.l J Gerontol A Biol Sci Med Sci 1996; 51A;
Mark Speechley. Use of Berg Balance Scale for
B202-B207. predicting multiple falls. Physical Therapy 2008
5. Vendervoort AA, McComas AJ. Contractile Vol. 88(4): 449-459.
changes in opposing muscles of the human ankle 17. Tinetti ME, Richman D, Powell L. Falls efficacy
joint with aging. J Appl Physiol 1986; 61; 361-367. as a measure of fear of falling. J Gerontol 1990
6. Lord SR, Clark RD, Webster TW. Physiological Nov; 45(6) : 239-243.

Impairment of Spinal Proprioception Following Stroke
Shruti S1, Alagumoorthi G2, Suresh Kumar3

1
Lotus Physiotherapy Clinic, Vazhudavoor Road, Kathirkamam, Puducherry
2,3
Lecturer, Department of Neurological Physiotherapy, Mother Theresa Post Graduate
& Research Institute of Health Sciences, Indira Nagar, Gorimedu, Puducherry
ABSTRACT
Objective: To objectively determine any impairment in Spinal Proprioception in individuals with

chronic stroke.
Methods: A two group, observational study was performed on 30 individuals with chronic stroke
(Age 48.92.5 years, post stroke interval in years 1.40.6), and 30 healthy controls. Spinal
Proprioception impairments, as determined by Trunk Reposition Error (TRE) was assessed by the
Spinal Reposition Sense Device
Results: The individuals with chronic stroke had a significantly higher trunk reposition error, more
than twice that of the healthy controls.
Conclusion: This is the first Indian study to report significant impairments in Spinal Proprioception
in individuals with chronic stroke. This finding can be used to expand interventional strategies post-
stroke, by considering the state of a client's proprioceptive system when developing a plan of care.
Key words: Proprioception, Spinal Reposition Sense, Trunk Reposition Error, Stroke
INTRODUCTION of the spine, as the muscle spindles present in the trunk

muscles function as kinesthetic sensors for spine
Brain stroke is the third largest cause of death and motion4. While trunk musculature provides some
disability in India after heart attack and cancer, stabilization to the spine, without adequate position
affecting 130 per 1,00,000 people every year.1 Stroke sense, the trunk cannot be stable. Trunk reposition
leads to a lot of impairments, such as motor and accuracy is found to be impaired in various
sensory paralysis, cognitive, perceptual, speech musculoskeletal and neurological conditions, and also
disorders, and many other systemic dysfunctions. It in geriatric individuals2,5,11. It has also been identified
is also a major cause of postural imbalance in terms of in people in the chronic phase of recovery post-stroke2,
static and dynamic control2. Individuals with strokes but more evidence is needed to backup this result, as
have been shown to exhibit problems with balance and there is only one study that has objectively
postural control, which can hamper their movements. documented errors of trunk position sense in
Stroke individuals with balance impairments take individuals poststroke. There is association of the loss
longer time than those without balance impairments of selective control in the trunk with problems of
to reach the same level of functional gain3. Disuse of breathing, speech, balance, gait, arm and hand
the trunk musculature, due to weakness, as seen in function2, but as most literature concerning motor
stroke, can impair tracking the position and velocity evaluation in stroke focuses on the upper and lower
extremity, there are many lacunae, leaving many areas
Correspondence Address less explored. One of such area is Trunk proprioception
Shruti S, in stroke. Thus in this study, which is the first Indian
Lotus Physiotherapy Clinic, study of its kind, we have attempted to fill the lacuna
Vazhudavoor Road, Kathirkamam, by exploring proprioceptive sense impairments in
Puducherry - 605009. individuals with chronic stroke.
Email id: shrutiphysio87@gmail.com
54 shruti 14th june 11 (272-276).pmd 272 10/16/2012, 2:41 PM

Proprioception describes those sensations DESIGN & METHODOLOGY

generated within the body which contribute to an
awareness of the relative orientation of the body parts, A two group, observational design was used.
both at rest and at motion. Better spine proprioception Samples were selected as per the selection criteria
leads to better spine control, which in turn reduces based on convenient sampling method. 30 individuals
effort level.4 Position sense is one of the dimensions of in the chronic phase of stroke were taken for the study.
proprioception that is classically assessed by the ability 30 age-matched non-neurologically impaired
to reproduce a preselected target position6. Position individuals used as controls.
sense testing of the spine, or components of the spine, Medically stable male individuals between the age
is less common and in some circumstances more group of 45 and 60 years were selected for the study.
difficult because of the multiple joints involved and As per the selection criteria, individuals with either
the inability to match a contralateral limb, thus relying right or left hemiplegia, with post stroke interval >6
heavily on memorizing the target position 7 . months <2 years; with NIHS Scale Score either 0 or 1
Impairments in trunk position sense is measured by in the selected 3 domains; and with the ability to sit
Trunk Reposition Error (TRE), which is defined as the independently on a bench, reach forward and down
difficulty to sense trunk position. Researchers have to the floor, and return to an upright sitting position
emphasized on the importance of a sensitive method with arms in front the body, hands clasped and eyes
for quantitative assessment of proprioception deficits, closed were included. As screened by the neurologist,
which would help clinicians identify patients in need individuals with strokes involving the parietal lobe,
of such treatment, and would facilitate monitoring of posterior limb of internal capsule and thalamus;
treatment efficiency in terms of increased accuracy and history of Balance Disorders prior to stroke; any co
reduced performance instability8. morbid neurological diseases, any clinical evidence of
Using a device which could be easily incorporated shoulder subluxation, chronic uncontrolled Diabetes
into the community setting is needed, in order to meet Mellitus, low back pain and any degenerative spinal
out the socioeconomic status of the Indian population. disorders were excluded from both groups. Female
Due to the inability to use most of the methods citing individuals could not be considered for the study,
greater cost, increased time and less ease of use, a owing to privacy reasons.
purpose effective clinical measurement tool for The study was performed in Physical Medicine and
proprioception10, the Spine Reposition Sense Device Rehabilitation Centre, Govt. of Puducherry, a Tertiary
for measurements within the sagittal plane which was Care Centre, following the Ethical guidelines.
developed by Clive Pai et al was considered. Trunk
Reposition sense in non-neurologically involved OUTCOME MEASURES
healthy individuals was evaluated by various
researchers, by the use of different methods, albeit the To measure the Proprioception of the trunk by TRE,
disagreement in literature about the ranges of the the Spinal Reposition Sense Device (SRSD) developed
Reposition Errors obtained, and it was found that the by Clive Pai et al, an objective outcome measure was
Spine Reposition Sense Device was a cost effective chosen.
clinical technique for sagittal trunk reposition sense
Spinal Reposition Sense Device (SRSD):
measurement10.
This device is a cost effective clinical technique for
Proprioception is highly emphasized in sports and sagittal trunk reposition sense measurement.10 It
musculoskeletal injuries11, but conversely there is lack consists of two meter sticks and a sliding mechanism.
of sufficient number of studies targeting spinal One meter stick is positioned vertically and the second
reposition sense in stroke. Trunk proprioception meter stick extends horizontally, perpendicular to the
receives only little attention, if at all measured, the vertical meter stick. Leveling the entire device ensures
objective values and their clinical implications are 90 angles, enabling the use of a trigonometric equation
not mentioned, thus lacking sufficient literature in measuring trunk orientation and reposition error.
backup. This lack of emphasis on trunk stability and The Interclass correlation coefficient of this device was
objective evaluation of reposition sense in stroke forms 0.82.
the need for this study, whereby the primary objective
of this study is to objectively determine any RESEARCH PROCEDURE
impairment in Spinal proprioception in individuals
The procedure of the study was thoroughly
with chronic stroke.
explained to the individuals selected for the study and

an informed written consent was obtained in the

individuals' vernacular language. For the assessment
of Spinal Proprioception, the procedure followed by
Clive Pai et al was used, with their permission. All the
individuals were tested by the same evaluator.
Individuals of both groups were instructed before

testing not to perform any unaccustomed strenuous
physical activity for 24 hours before testing and not to
eat or drink two hours prior to testing10, and the Fig. 1. Trunk Reposition Errors of the individuals of the Control
Group
cutaneous, visual and auditory inputs were
minimized.
During testing, the individuals were seated on the

Spinal Reposition Sense Device, adjusted to
standardize individual sitting positions, hips at 90
degrees, and feet flat on the floor. The individuals were
then palpated in sitting by the examiner and a line was
marked with a pen on the top of the T1 spinous process.
The initial test position of the individuals was upright
sitting with arms either in front the body with hands Fig. 1(b). Trunk Reposition Errors of the individuals of the Study
Group
clasped, or with arms folded across the chest. The
measurement procedure was standardized and
completed by the examiner. The X and Y coordinates
were recorded for the estimated 50% flexion1, and used
in a trigonometric calculation ? = Tan-1 X / Y to
determine the starting angle. This procedure was
performed once, as the initial trial, and was repeated
for 7 trials. Reposition error was calculated as the
difference between each trial's 50% angle position and
the initial trial. Mean absolute reposition error for each
individual was calculated as the average of the sum
of the reposition angle errors across trials. The
individuals were allowed to rest 10 seconds between
each trial. Fig. 2. Impairment in Spinal Proprioception Measured By Trunk
Reposition Error
The data obtained were documented and analyzed.
RESULTS
DATA ANALYSIS & RESULTS
Referring the baseline characteristics of the study
The outcome values obtained were tabulated in participants (Table 1), and the breakdown of the TRE
GraphPad Prism 5 for Windows Version 5.03 for values of individuals of both groups (Figure 1a,b), the
statistical analysis. The level of impairment of Spinal outcome TRE's were compared using independent t-
Proprioception was analyzed using the Independent test. The means (3.870.94, 1.520.63) and median
sample "t" test. quartiles (3.9, 1.5) of the TRE's of both the groups
differed significantly, with "t"- value 11.35 at P < 0.05.
Table 1. Baseline Characteristics of Group A
Thus, in analysis of the Impairment of Spinal
& Group B Individuals
Characteristics Group A Group B
proprioception, the individuals with chronic stroke of
(Healthy controls) (Stroke group) Group A had an increased difference in TRE (more than
Total Number of Participants 30 30 twice the value) when compared to the healthy control
Age (yrs.) 48.92.5 50.33.2 Group B. (Figure 2)
Post-Stroke Interval (yr.) 1.40.6
Side of Hemiparesis (Right : Left) 14:16 v
DISCUSSION
NIHS Score* (0-6) 0
Spinal Reposition Sense score 3.870.94 1.520.63
This is the first Indian study on objective
* The items of this scale that have been used in this study have been limited to Level of assessment of spinal proprioception, performed on
Consciousness (Commands and Questions) and Extinction and Inattention.
individuals with chronic stroke. It was found that the

individuals with chronic stroke had a significant central disruption of proprioception.

increased TRE when compared to the healthy controls.
The obtained mean values of TRE in individuals with The measurement of spinal reposition sense using
chronic stroke (3.870.94) were lower than with the the Spinal Reposition Sense Device was in the sagittal
TRE's reported in study performed by Susan Ryerson plane, since there is presence of double TRE in the
et al. (6.193.1) The TRE's obtained in the normal sagittal plane, when compared to other planes, as
controls (1.520.63), also were lower than the observed by Susan Ryerson et al (2008) and Goldberg
corresponding values reported by Susan Ryerson et et al (2005). Further research is needed to address the
al, (3.21.8) Peterson et al, (2.260.84) Goldberg et al, question whether regional assessment of spinal
(3.80.7) and ssel et al. (6.152.3) These variations position sense in one plane can functionally imply in
could be attributed to the morphological differences other planes. Also, correlating the obtained values of
in the individuals, as the studies were conducted in TRE with clinical measures of balance can find out the
different geographical locations. The TRE's of the critical value of the error which causes functional
individuals with right sided hemiplegia (3.651.5) did implications. Researching in this regard can also help
not significantly differ from that of the individuals with formulate an age and gender wise reference value
left sided hemiplegia, (4.090.9) thus implying no range for the TRE.
influence of the side of the hemiplegia on the trunk
proprioception. However, further studies are needed CONCLUSION
to confirm this observation. Also, the influence of
From this study it can be concluded that individuals
gender on spinal proprioception could not be
with chronic stroke had a significantly higher TRE,
considered, owing to privacy reasons females could
more than twice that of the healthy controls. Hence,
not be assessed.
proprioceptive assessment of the trunk must be made
In this study individuals with chronic motor stroke an integral part of evaluating stroke, in order to
devoid of any lesions directly affecting the sensory improve functional gain.
pathways were included, as diagnosed by the
neurologist. This was done so to eliminate the influence REFERENCES
of central sensory disruption on spinal reposition
1. World Health Organisation. Measurement in
sense, as there is evidence that ascending sensory
health. Statistics Tables 2009.
information can have a powerful influence on cortical
2. Ryerson S, Byl NN, Brown AD, Wong AR et al.
motor circuits and their descending pathways. Trunk Altered Trunk Position Sense and Its Relation to
proprioception in all individuals in the study group Balance Functions in People Post-Stroke. J Neurol
was supposedly impaired due to impairment in Phys Ther 2008; 32: 14-20.
processing of the trunk position sense input and the 3. Pyoria O, Era P, Talvitie U. Relationships
detection of position sense from spinal muscles and between standing balance and symmetry
joints during the active target movement. Disturbances measurements in patients following recent
in somatic sensation, especially in position sense or strokes (?3 weeks) or older strokes (?6 months).
proprioception may have detrimental functional Phys Ther. 2004; 84: 128 -136.
implications, consequent upon poorly controlled 4. Reeves P. N, Narendra K. S. Cholewicki J. Spine
posture and balance. Such disturbances may arise stability: Lessons from balancing a stick. Clin
following damage to the sensory pathways anywhere Biomech. 2011; 26(4): 325-330.
between the peripheral nerve endings and the 5. Franchignoni FP, Tesio L, Ricupero C, Martino
somatosensory association cortex of the parietal lobe.13 MT. Trunk control test as an early predictor of
Decreased input from position sense receptors as a stroke rehabilitation outcome. Stroke.1997 ; 28:
1382-1385.
result of trunk muscle weakness could be a
6. Lewis NG, Byblow DW. The effects of repetitive
contributing factor. Formation of accurate neural
proprioceptive stimulation on corticomotor
models of the spine system, which then use sensory
representation in intact and hemiplegic
signals to predict the state of the system, is aided by individuals Clinical Neurophysiology 2004; 115:
trunk muscles and their embedded sensory receptors. 765-773.
This generates feedback control signals to activate the 7. Allison T.G, Fukushima S. Estimating Three-
trunk muscles to stabilize the spine, delays of which Dimensional Spinal Repositioning Error: The
can impair spine control, particularly when the spine Impact of Range, Posture, and Number of Trials.
is in motion.2,5 Further studies can be performed to Spine 2003; 28: 2510-2516.
evaluate the impairment of Spinal proprioception on

8. Lonn J, Crenshaw AG, Djupsjobacka M et al. 17. Allum JHJ, Bloem BR, Carpenter MG et al.
Position sense testing: influence of starting Proprioceptive control of posture: a review of
position and type of displacement. Arch Phys new concepts. Gait and Posture 1998; 8: 214-242.
Med Rehabil. 2000; 81: 592-597. 18. Jones AL. Motor Illusions: What Do They Reveal
9. Vidoni ED. Proprioception is central to motor About Proprioception? Psychol Bulletin 1988;
learning: Different consequences of peripheral 103(1): 72-86.
versus central proprioceptive disruption to 19. Ashton-Miller JA, Wojtys EM, Hutson LJ et al.
sequence learning-Dissert. 2008. Can proprioception really be improved by
10. Petersen C, Zimmermann C, Cope S et al. A new Exercises? Knee Surg, Sports Traumatol, Arthrosc
measurement for spine reposition sense. 2001; 9:128-136.
J Neuroeng Rehabil 2008, 5(1): 9. 20. Lee AS, Cholewicki J, Reeves NP, Zazulak BT,
11. Eils E, Rosenbaum D. A multi-station Mysliwiec LW. Comparison of trunk
proprioceptive exercise program in patients with proprioception between patients with low back
ankle instability. Med. Sci. Sports Exerc. 2001; pain and healthy controls.
33(12): 1991-1998. 21. Lee M-J, Kilbreath SL, Refshauge KM. Movement
12. Goldberg A, Russell JW, Alexander NB. Standing detection at the ankle following stroke is poor.
Balance and Trunk Position Sense in Impaired Austr J Physiother. 2004; 51: 19-24.
Glucose Tolerance (IGT)-Related Peripheral 22. Preuss RA, Grenier SG, McGill SM. Postural
Neuropathy. J Neurol Sci. 2008; 270(1-2): 165-171. control of the lumbar spine in unstable sitting.
13. Welch DK. Improvement in proprioceptive acuity Arch Phys Med Rehabil. 2005; 86: 2309-2315.
with training-Dissert. 1998. 23. Riemann BL, Lephart MS. The Sensorimotor
14. Swinkels A, Dolan P. Spinal Position Sense Is System, Part I: The Physiologic Basis of
Independent of the Magnitude of Movement. Functional Joint Stability. J Athl Train. 2002; 37(1):
Spine 2000; 25: 98-105. 71-79.
15. ssell M, Sjlander P, Kershbaumer H et al. Are 24. Riemann BL, Lephart MS. The Sensorimotor
lumbar repositioning errors larger among System, Part II: The Role of Proprioception in
patients with chronic low back pain compared Motor Control and Functional Joint Stability.
with asymptomatic subjects? Arch Phys Med J Athl Train. 2002; 37(1): 71-79.
Rehabil 2006; 87: 1170-1176. 25. Vidoni DE, Boyd AL. Preserved motor learning
16. Dietz V, Quintern J, Sillem M. Stumbling reactions after stroke is related to the degree of
in man: Significance of Proprioceptive and Pre- proprioceptive deficit. Behavioral and Brain
Programmed Mechanisms. J Physiol. 1987; 386: Functions 2009, 5: 36.
149-163.

A Cost-effective Patient Designed Hand Splint

for Rehabilitation after Two-stage Flexor
Tendon Reconstruction
Muhammad Adil Abbas Khan1, Mark Gorman2, Arvind Mohan3, Zain A. Sobani4, Alastair Platt5
1,3
Plastic Surgery Trainee, University Hospital of North Staffordshire NHS Trust, Stoke-on-Trust, United Kingdom
2,5
Plastic Surgery Trainee, Castle Hill Hospital, Hull, United Kingdom
4
Medical Student, Aga Khan University Hospital, Karachi, Pakistan
ABSTRACT
Background : A number of splints have been described to aid in the rehabilitation after two-stage
flexor tendon reconstruction. We present an innovative splint design by a motivated patient to assist
in his own functional recovery in a cost-effective manner.
Case: A 45 year old male engineer underwent a traumatic motor bike injury to the volar aspect of his
left middle finger at the level of the distal interphalangeal (DIP) joint. He was found to have a segmental
loss of the distal segment of the flexor digitorum profundus (FDP) that prevented a primary repair.
He was planned for a two stage repair with physiotherapy. After consulting with the therapist, the
patient designed a device to aid himself with the flexion of the DIP, PIP and MCP joints of his affected
digit which he used during this period. His post operative recovery was remarkable with excellent
functional recovery scoring 95% of normal movement on the Strickland's Adjusted system.
Conclusion: In combination with a hand therapy regime, we recommend this innovative patient
designed splint as a simple and inexpensive alternative to existing splints for rehabilitation for two-
stage flexor tendon reconstructions.
Key words: Occupational Therapy; Flexor Tendon Reconstruction; Splint; FDP (flexor digitorum profundus);
FDS (flexor digitorum superficialis); PIP (proximal interphalangeal) Joint; DIP (distal interphalangeal) joint.
INTRODUCTION finger at the level of the distal interphalangeal (DIP)

joint and underwent a primary debridement of a
A number of splints have been described to aid in surgically contaminated wound. He was found to have
the rehabilitation after two-stage flexor tendon
a segmental loss of the distal segment of the flexor
reconstruction. We present an innovative splint design
digitorum profundus (FDP) that prevented a primary
by a motivated patient. The novel aspect is that in this
case the well informed patient came up with the idea repair. After consulting with the therapist, the patient
which was recognized by the clinical team and hand designed a device to aid himself with the flexion of
therapist who allowed the patient to assist in his own the DIP, PIP and MCP joints of his affected digit. He
functional recovery in a cost-effective manner. also underwent a standard protocol of digital exercises
supervised by hand therapists in the three months
CASE REPORT leading to his first stage flexor reconstruction with a
silicone rod. Postoperatively he remained compliant
A 45 year old male engineer underwent a traumatic with physiotherapy and continued wearing his splint.
motor bike injury to the volar aspect of his left middle Three months later at the time of his second stage
reconstruction, he was observed to have 90 degrees of
Muhammad Adil Abbas Khan flexion at the DIPJ and PIPJ of the affected digit.
Plastic Surgical Trainee
After the second stage reconstruction he was again
Address: 10 Harvey Lodge, Admiral Walk,
assessed by the hand therapist and a week later started
London W9 3TH, United Kingdom
wearing his designed splint again for another four
Phone: 0044 786 333 2517
weeks. His post operative recovery was remarkable
Email: adilaku@hotmail.com, adilkakar@yahoo.com
55 Sobani 19th may 11 (277-279).pmd 277 10/16/2012, 2:41 PM

with excellent functional recovery scoring 95% of started 2 - 3 days after surgery4. In the postoperative
normal movement on the Strickland's Adjusted system therapy after stage two of flexor reconstruction, there
[(PIP + DIP) flexion extension deficit 100/175 has been a steady trend toward early active
degrees]. mobilization1,5,6.
THE SPLINT - DESIGN AND APPLICATION
The splint designed by the patient consisted of a

Velcro hood constructed by stitching together two
Velcro straps (wire securing Velcro bought from an
electrical store). This hood covered the tip of the digit
and was secured to the wrist with elastic bands that
passed as adjustable straps through a slit on each side
of the hood. The elastic straps were secured distally
with knots allowing the elastic band length to be
adjusted (if it became loose secondary to
overstretching) by simply pulling the band distally
through the slits and securing the newly adjusted
length with a new knot. The distal segment of the band
could then be cut off enabling this design to be used
successfully in digits of all lengths with easy
adjustment.
The elastic straps chosen by the patient were soft

and the splint design allowed the fulcrum to rest of
the dorsum of the hand (just distal to the wrist joint)
(Figure 1) enabling passive assisted flexion of the digit
at both the DIPJ and PIPJ after each active extension
Fig. 1. Dorsal view of the worn splint
(Figure 2). Despite allowing full extension of the finger
against the elastic, there was still enough tension
remaining to provide sufficient traction when flexed.
There was no restriction imposed on the the volar
surface of the hand by the device. The elastic straps
despite not having a base did not dig into the wrist or
the finger webs and hence did not pose a risk for
neuropraxia or pressure. The splint was worn fulltime
by the patient prior to first stage reconstruction and in
the interim period between the first and second stages
(when it kept the PIP, DIP and MCP joints in flexion),
and also after a few days of the second stage of
reconstruction (when it allowed both passive flexion
as well as extension against some resistance).
It could also be easily removed and washed for

hygiene purposes and the total cost price of the Velcro
and elastic bands was described by the patient to be
0.40 pounds sterling (approximately US $ 0.65).
DISCUSSION
Prior to a two stage flexor reconstruction, it is wise

to start the patient on a range-of motion and scar
softening therapy program to attain maximum
preoperative passive range of motion1-3. After stage one Fig. 2. Lateral view of splint with flexed PIP, DIP and MCP joints
of flexor reconstruction, passive motion exercises are

There are several splint designs and splinting CONCLUSION

protocols including the Duran and the Kleinart rubber
traction, the Brooke Army palmer-bar modification, In combination with a hand therapy regime, we
the Mayo clinic synergistic wrist splint, Evan's short recommend this innovative patient designed splint as
arc motion, and the Strickland hinged wrist splint and a simple and inexpensive alternative to existing splints
active tenodesis. The splints can vary in design from for rehabilitation for two-stage flexor tendon
simple elastic straps around PIP and DIP joints, elastic reconstructions.
straps of various designs around the palm and distal
phalanx, flexion gloves with elastic traction or with ACKNOWLEDGEMENTS
an extra strap around the distal phalanx and palm. The patient has given consent to them being
Other alternatives include palm based dynamic finger presented as a case and we would like accredit
flexion splints or sticking hook-Velcro to the nail plate Mr. Ian Tomkins for the splint he has designed.
and attaching a loop or elastic from the palm to the
wrist.
REFERENCES
Most of these alternatives are complex in design 1. Mackin EJ, editor. Physical therapy and the staged
and have to be custom made by occupational therapists tendon graft: Preoperative and postoperative
and can have a substantial cost and time factor management. AAOS Symposium on Tendon
involved in the manufacturing process. Full details of Surgery in the Hand; 1975; St. Louis, CV: Mosby.
the treatment protocol, the rationale for why splints 2. Mackin EJ. Therapist's management of staged
are used and how the different existing designs address flexor tendon reconstruction. In: Hunter JM SL,
specific treatment objectives such as early protected Mackin EJ,, editor. Rehabilitation of the Hand.
mobilization are beyond the scope of this manuscript. 2nd ed. St. Louis, CV: Mosby; 1984.
3. Mackin EJ, Maiorano L. Postoperative therapy
The patient designed splint acted as a flexion strap following staged flexor tendon reconstruction. In:
which allowed him to regain flexion at the DIP and Hunter JM SL, Mackin EJ, editor. Rehabilitation
PIP joints. The fact that the patient had an excellent of the Hand. St. Louis, CV: Mosby; 1978.
outcome may not be enough evidence that this splint 4. Cannon NM, Strickland JW. Therapy following
is generally effective, but the splint designed by the flexor tendon surgery. Hand Clin. 1985 Feb; 1(1):
patient proved to be innovative, simple, inexpensive 147-165.
and fulfilled the requirements of therapy. The design 5. Hunter JM, Blackmore S, Callahan AD. Flexor
has since been used to help other patients with good tendon salvage using the Hunter tendon implant.
outcome. J Hand Ther 1989; 2: 107-113.
6. Stanley BG. Flexor tendon injuries: late solution.
Therapist's management. Hand Clin. 1986 Feb;
2(1): 139-147.

Comparative Study Between Auditory, Visual and

Combined EMG Biofeedback in Management of Patients
with Tension type Headache
Veena Bembalgi1, Karkal Ravishankar Naik2

1
Assistant Professor, KLES College of Physiotherapy, Hubli, 2Professor and Head,Department of Neurology,
KLE University's, Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
ABSTRACT
Background : Tension-type headache (TTH) is the commonest primary headache.Electromyography

(EMG) biofeedback (BF) is considered an effective therapy for tension-type headaches.Comparative
effects of auditory and visual EMG biofeedback have not been systematically studied in TTH.The
objective of the present study was to compare the effects of EMG BF with audio, visual and integrated
BF on headache and quality-of-life in subjects with TTH.
Methods: Subjects with TTH fulfilling the International Headache Society criteria were selected by
random sampling and allocated into EMG audio feedback (EMG-a),visual feedback (EMG-v) and
integrated audiovisual feedback (EMG-av) groups.They underwent EMG BF therapy for fifteen
sessions of thirty minutes each.The headache (pain) variables and SF-36(Quality of life) scores were
documented at baseline, one month and three months after commencement of EMG BF therapy.
Results: All groups showed significant improvements in all pain variables.Improvements were also
seen in the total,physical and mental scores of SF-36 scores in first and third month follow-up (p<0.05).
Inter-group analysis revealed significant differences between the three groups (p<0.05) with EMG
audio-visual BF showing more significant improvement in the pain variables.EMG-av BF group also
showed highest improvement in SF-36 scores at first and third month follow up.EMG audio group
showed significant improvement in the intensity parameter of pain variable at the third month
follow-up.
Conclusion: Auditory, visual and integrated auditory-visual EMG biofeedbacks are effective in
treatment of TTH with most benefit seen with combined feedback.
Key words: Tension Type Headache, EMG Biofeedback, Audio Biofeedback, Visual Biofeedback, SF-36.
INTRODUCTION headaches, electromyographic (EMG) BF has shown

maximum benefits4.
Tension type headache (TTH) is the most common
type of primary headaches 1. Biofeedback (BF), a Muscle hardness has been found to be increased in
process whereby information about usually the pericranial muscles of the patients with TTH5. It
unconscious biological activities is made available to has been widely accepted that increased pericranial
consciousness is an established treatment modality for muscle activity is of important for the development of
TTH2. BF treatments for pain emphasize the patients' TTH as reflected in the formerly used term muscle
active role in managing these conditions, thereby contraction headache6-8. EMG BF is directed at reducing
establishing improved coping with the psychological pericranial muscle activity and is the most frequently
used behavioral treatment option for TTH9. McCrory
and psychosocial consequences of pain. BF is virtually
et al reported medium-to-large average effects for
free of untoward side effects and if effective for EMG-BF in adults with TTH10. EMG BF units provide
preventive and abortive treatment of headaches would visual, auditory or both feedbacks. To our knowledge
obviously be preferable to the use of medication3. no study has been done so far to find out the
Though various forms of BF have been used in effectiveness of auditory, visual or integrated (audio-
migraine, tension type headaches and combined visual) EMG feedback in TTH patients.
56 veena 13th july 11 (280-284).pmd 280 10/16/2012, 2:41 PM

In a study, auditory EMG BF was used in TTH maintained for all groups to avoid any bias due to
patients and it was found that the subjects were not positioning. After preparing the forehead skin, surface
only able to maintain low frontalis EMG levels but also EMG electrodes were applied 2.5cm above the centre
managed to remain headache free during follow-up11. of each eyebrow6. All subjects received BF for duration
Similar studies utilizing only auditory BF have been of 30 minutes per session for 15 sessions with eyes
performed in both TTH and migraine patients6,12-14. open. The EMG BF was performed using EMG-IR
Visual EMG BF has been used less compared to Retrainer, Chattanooga group Inc, U.S.A.
auditory feedback15. In another study, TTH patients
received both visual and audio EMG feedback and The EMG-a group (n=10) received auditory BF with
found significant decrease in headache3. headphones. The pitch of the sound was directly
proportional to the relative muscle tension displayed
Though there is evidence pointing out the efficacy on the screen. The subjects were instructed to reduce
of BF in tension headache patients, it is not advocated the pitch and intensity of the sound.
very frequently in India which could due to the cost
of the equipment involved and hence the added cost The EMG-v group (n=10) received visual feedback
to the patient as well. Most BF equipment provide both in form of glowing bars and numerical display,which
visual and audio feedback, hence if the equipment increased or decreased depending on the muscle
could be designed to provide only the form of feedback tension in bilateral frontalis (right and left separately).
which is the most effective, it could automatically The auditory feedback was switched off for this group.
reduce the equipment cost as well as the cost to the The subjects were instructed to reduce the number of
patient making it more economical for both glowing bars or the numerical score.
practitioner as well as patient. The EMG-av group (n=10) received combined
No controlled trials have been done so far to auditory and visual feedback.
compare the efficacy of visual EMG feedback or After the end of 15 sessions the patients were
auditory EMG BF separately in tension type headache. instructed to relax similarly off sessions,whenever the
This study therefore was conducted to find out relative headache started. They were also instructed to avoid
efficacy of visual and auditory BF in isolation or taking any medication unless the headache was
combination in TTH subjects. unbearable. Complete data on medication usage before
and after therapy could not be obtained hence that data
MATERIAL AND METHODS was not analyzed in this study.
Subjects fulfilling the International Headache All subjects were given diaries in which they had
Society (IHS) criteria for TTH were recruited in the to note the pain variables at the end of every week.
study after obtaining informed voluntary consent. Both They were instructed to calculate frequency of
males and females were included in the study. Subjects headache as number of headache episodes per week,
were recruited from various neurology clinics and average duration as total hours of all episodes of
subjects referred by neurologists to our physiotherapy headache that week divided by the number of episodes
department for biofeedback therapy. Ethical clearance experienced in that week and intensity of headache as
was obtained from the institutional ethical committee. average of the visual analogue score (VAS) on a
A total of 30 TTH subjects were recruited by simple standard 10 point scale scored per headache that week.
random sampling method and were allocated to The average scores of the pain variables were recorded
various groups using the lottery method. at baseline, one month and three months after receiving
Demographic data on pain variables namely average BF.
duration, frequency and intensity of headache per
week were obtained. Quality-of-life score was obtained Statistical analysis was performed using the SPSS-
using the licensed SF-36 questionnaire at baseline, after 16 version.
one and three months of EMG BF therapy.
RESULTS
PROCEDURE
Thirty subjects were recruited in the study (females-
The subjects were explained the treatment 18, males-12). Of the thirty subjects, seven subjects
procedure in detail.The subjects were made to lie with dropped out of the study. Three subjects failed to report
head end slightly higher to visualize the visual display for the first month follow up [EMG-a(1), EMG-av(2)]
in the EMG-v group. The same position was and four for the third month follow up [EMG-a(2),

EMG-v(1), EMG-av(1)]. All subjects however Wilcoxon matched pairs test was used for analysis
completed the 15 sessions of therapy. Therefore at the of data obtained (pain variables and SF-36) for
end of one month the sample size was: EMG-a: n=9, comparison within the groups. A non-parametric test
EMG-v: n=10 and EMG-av: n=8 and at the end of three was considered since the sample size per group was
months,it was: EMG-a:n=7, EMG-v: n=9 and EMG- small. The analysis showed a highly significant
av:n=7. No analysis was carried out for the missed data reduction in all pain variables and SF-36 scores (p<0.05)
since it accounted for less than 20% of the sample size. after one and three months (Table 2), except in the
groups which received only audio and visual feedback
The three groups were matched relative to age and showing insignificant differences in average duration
pain variables and SF-36 total scores (Table 1). The inter and frequency in the first month follow up. All groups
group analysis revealed non- significant differences showed significant improvement in all variables at six
between the groups in all variables,therefore the months follow-up.
groups could be treated as homogeneous groups.
Kruskall Wallis test was used to compare the groups Table 2. Intra-group analysis (p-value)
for age and baseline parameters. using Wilcoxon matched pairs test
Variables Groups Baseline 1 month Baseline
vs 1month vs 3 months vs 3 months
Table 1. Baseline data of the subjects
Average duration EMG-a 0.006* 0.007* 0.005*
Sl. Demographic EMG-a EMG-v EMG-av P-value of headache/ week EMG-v 0.02* 0.01* 0.005*
No. variables (hrs) EMG-av 0.007* 0.007* 0.005*
1 Age 42.3 9.8 39.7 15.1 43.5 11 0.07 Average frequency of EMG-a 0.005* 0.2 0.005*
headache/ week EMG-v 0.04* 0.1 0.01*
2 Average duration 11.3 5 10.8 6 10.7 6 0.14 EMG-av 0.008* 0.008* 0.006*
of headache/week
Average intensity of EMG-a 0.01* 0.07 0.005*
3 Average frequency 5.4 1.6 5.2 1.5 4 1.5 0.13 headache/ week (VAS) EMG-v 0.05* 0.2 0.008*
of headache/week EMG-av 0.005* 0.044* 0.005*
4 Average intensity 5.7 2.1 5.2 1.5 4.3 1.3 0.15 SF-36 EMG-a 0.008* 0.03* 0.01*
of headache/week Total score EMG-v 0.008* 0.04* 0.007*
5 SF-36 baseline 42.0 10.0 45.0 10 43.0 11 0.65 EMG-av 0.008* 0.05* 0.008*
total scores SF-36 EMG-a 0.008* 0.031* 0.008*
Physical score EMG-v 0.047* 0.008* 0.008*
EMG-av 0.016* 0.008* 0.008*
Mean of SF-36 scores and pain variables in all
SF-36 EMG-a 0.008* 0.047* 0.008*
groups,at all end points in the study namely Mental score EMG-v 0.008* 0.016* 0.008*
EMG-av 0.008* 0.008* 0.008*
baseline,after one month and after months are depicted
*significant
in the figures 1 and 2.
Inter-group comparison was done using the
Bl-Baseline, 1m-after one month, 3m-after three months Kruskall Wallis test(Table 3). All parameters showed
significant differences in the intra group analysis.
Table 3. Inter-group analysis
EMG-a EMG-v EMG-av Kruskall
Wallis test
p value
Headache Baseline 11.3 5.5 10.8 6.6 10.7 6.7 0.14
Duration 1 month 6.8 4.3 6.5 4.7 5.8 3.7 0.002
3 months 2.6 1.6 2.9 3.0 2.1 2.4 0.001
Headache Baseline 5.4 1.6 5.2 1.5 4.0 1.5 0.13
Frequency 1 month 3.3 1.9 3.0 1.1 1.7 1.4 0.000
3 months 2.0 1.0 1.9 2.2 1.1 0.8 0.000
Fig. 1. Mean of SF-36 score in all groups Headache Baseline 5.7 2.1 5.2 1.5 4.3 1.3 0.15
Intensity 1 month 3.8 1.9 3.6 2.1 1.7 1.4 0.000
3 months 1.6 1.5 2.3 1.6 1.4 1.0 0.001
SF-36 total Baseline 42 10 45 10 43 11 0.65
Bl-Baseline,1m-after one month,3m-after three months 1 month 64 9 60 10 78 7 0.001
3 months 71 9 71 10 82 7 0.000
SF-36 Physical Baseline 41 10 43 7 44 10 0.33
1 month 61 8 53 11 77 9 0.001
3 months 69 9 68 8 82 8 0.000
SF-36 Mental Baseline 44 8 45 8 44 9 0.17
1 month 66 11 63 9 78 9 0.001
3 months 69 15 71 11 80 6 0.000
All pain variables showed a highly significant

difference between the groups after one month
(p<0.005). Analysis of average intensity of headache
Fig. 2. Mean of pain variables in all groups per week showed that EMG-av had the lowest mean
rank (EMG-a: 19, EMG-v:18, EMG-av: 9.5) indicating

that group EMG-av showed maximum benefit in the Pain variables were difficult to compute in our
first month as compared to other two groups, however study especially intensity, since it was variable through
at three month follow up EMG-a group had the lowest out the duration of headache. Hence to minimize the
mean rank as compared to other groups. bias the patients were instructed to note the intensity
at the peak of headache irrespective of intervention in
The variable average frequency of headache per the form of relaxation or medication. Number of
week had EMG-av scoring the lowest mean rank at headaches during the therapy was not analyzed,but
the first and third month follow up. there was a general trend of decrease in the frequency
Average duration of headache per week too of headaches during the BF sessions in all groups
showed EMG-av with the lowest rank as compared to irrespective of whether they received audio,visual or
the other groups at the first month and third month. integrated EMG BF. One confounder we noticed in the
study was the fluctuations in the auditory tone and
SF-36 total, physical and mental scores too showed visual bars on the display of the EMG equipment
the best improvement in EMG-av group at one month whenever the patient blinked causing a transient
and three month follow up with highest mean ranking increase in the audio tone and increase in number of
compared to the audio or visual BF group. bars which may have caused confusion and distraction
to the patient and therefore could have affected
DISCUSSION learning. The regional language (Kannada) version of
SF-36 QOL questionnaire was used for all subjects who
Learning is facilitated when auditory and visual knew the language.The English version was used for
information is provided simultaneously, which subjects who could not understand the regional
explains why audio-visual aids are an integral part of language to omit the bias created by translation of
learning.Likewise BF too is a learning process which Kannada into English.
therefore can be assumed to be facilitated by providing
audio and visual cues to the patients.In our study there The inter-group analysis showed that EMG-av
was significant improvement of headache variables group had better benefits as compared to other groups
and SF-36 sum and sub-scores in EMG-av group and intra-group analysis too showed that EMG-av
indicating that integrated feedback is more effective group had significant improvement over three months
than isolated feedback. indicating that retention of improvement is good too.
It was noted at several instances that inspite of specific
In a similar non-therapeutic study,audio,visual and instructions, some patients found it difficult in the
integrated (auditory plus visual) BF was given to initial sessions to concentrate on audio feedback in the
participants and task performance like putting peg in EMG-a group. They used to either scan the room or
a hole and electronic box assembly task was assessed looked distracted.This distraction may have affected
for task completion time, performance errors and our parameters too, since it would have affected the
subjective opinions. The results showed that integrated learning/ training which is provided by BF. On the
feedback offered better assembly task performance contrary EMG-av group had better concentration as
than either feedback used in isolation.16This study compared to other groups.Our brain processes visual
indicates that adequate learning and retention and associated audio information as a natural habit in
(memory) requires input from both auditory as well everyday life which is very essential for cognition,
as visual sources. hence providing both feedbacks could have made
information processing and modifying the biological
Another study similar to ours in terms of
processes (reducing frontalis activity) easier for the
methodology, in which EMG BF was used for
subjects. Moreover integrated feedback obviously
relaxation training.In this study the subjects were
gives additional information as compared to isolated
randomly assigned to four groups:1) group receiving
feedback therefore understanding of the information
EMG audio BF with eyes closed, 2) group receiving
is better and hence its modification too, which is the
EMG audio BF with eyes open, 3) group receiving EMG
main aim of BF therapy.
visual BF and4)control group which received no
feedback. It was reported that group which received The sample size in each group was small,hence
EMG audio BF with eyes closed showed better studies with larger sample sizes should be considered
decrease in frontalis muscle activity as compared to in future. Though the groups were matched relative
other groups. 17 However, integrated feedback was to age,pain variables and SF-36 scores (p<0.05), a better
not used in this study. homogeneity could have been achieved if the subjects

were matched according to their baseline frontalis 7. Boureau F, Luu M, Doubrere JF.Study of
quantitative EMG activity.Another limitation of the experimental pain measures and nociceptive
study was the study duration.The duration of study reflex in chronic pain patients and normal
too was small, considering the time factor involved in subjects. Pain, 1991; 44, 131-138.
our study, hence longer duration longitudinal studies 8. Scott DS, Lundeen TF.Myofascial pain involving
should be considered to study the efficacy of individual the masticatory muscles:an experimental model.
or integrated EMG BF and its retention of Pain, 1980; 8, 207-215.
9. Nestoriuc Y, Martin A,Rief W,Andrasik F.BF
improvement with time. Since this is the first study of
Treatment for Headache Disorders:A
this nature,similar studies would definitely be required
Comprehensive Efficacy Review. Appl
to confirm the efficacy of individual and integrated
Psychophysiol BF 2008; 33, 125-140.
BF procedures in TTH as well as other psycho-somatic 10. McCrory D, Penzien DB, Hasselblad V, Gray
disorders where BF has proven effective. R.Behavioral and physical treatments for tension-
type and cervicogenic headaches.De Moines, IA:
CONCLUSION Foundation for Chiropractic Education and
Research, 2001.
All forms of EMG biofeedback are effective in 11. Budzynski T, Stoyva J, Adler C & Mullaney
treatment of TTH. Integrated EMG biofeedback is most D.EMG BF and tension headache: A controlled
beneficial in reduction of headache and improving outcome study. Psychosomatic Medicine, 1973,
quality of life in subjects with TTH. 35, 484-496.
12. Cram JR.EMG BF and the Treatment of Tension
REFERENCES Headaches:A Systematic Analysis of Treatment
Components. Behavior Therapy, 1980; 11,
1. The International classification of headache 699-710.
disorders.Cepahalgia-An International journal of 13. Haynes SN,Griffin P,Mooney D and Parise
headache.2004, 2nd edition, Vol 24,supplement M.Electromyographic BF and Relaxation
1, 37-43. Instructions in the Treatment of Muscle
2. Rubin A. Biofeedback and binocular Contraction Headaches. Behavior therapy, 1975;
vision.Journal of behavioural optometry. 1992; 6, 672-678.
Vol 3; 4, 95-98. 14. Cohen MJ,Mc Arthur DL.Comparison of Four BF
3. Mullally JW,Hall K,Goldstein R.Efficacy of BF in Treatments for Migraine Headache:Physiological
the Treatment of Migraine and Tension Type and Headache Variables. Psychosomatic
Headaches. Pain Physician:November/ Medicine, 1980; Vol.42, No. 5; 462- 480.
December 2009: 12: 1005-1011. 15. Lake A,Rainey J and Papsdorf JD.BF and rational-
4. Fumal A, Scohnen J.Tension-type headache: emotive therapy in the management of migraine
current research and clinical management.Lancet headache. Journal of applied behavior analysis.
Neurology, 2008; 7: 70-83. 1979, 12: 1; 127-140.
5. Millea JP, Brodie JJ.Tension type headache: 16. Zhang Y,Fernando T,Xiao H,Travis A R.L.
American Family Physician. 2002, Vol.66, No 5, Evaluation of Auditory and Visual Feedback on
Sept 1, 797-803. Task Performance in a Virtual Assembly
6. Sturgis ET,Tollison CD and Adams HE. Environment.Presence, 2006; Vol 15, No 6,
Modification of combined migraine-muscle 613-626.
contraction headaches using BVP and EMG BF. 17. Alexander AB,French CA and Goodman NJ. A
Journal of applied behavior analysis, 1978; 11(2): Comparison of Auditory and Visual Feedback in
215-223. BF Assisted Muscular Relaxation Training.
Psychophysiology. 1975, 12: 119-123.

Effect of Manual Therapy Techniques on Knee

Proprioception in Patients with Osteo-arthritis of Knee
Singh Yuvraj Lalit1, Mhatre Bhavana Suhas2, Mehta Amita3

1
Lecturer, MGM School of Physiotherapy, Vashi, Navi Mumbai, 2Associate Professor,
3
Professor and Head, P.T School and Centre, Seth Dhurmal Bajaj Orthopaedic Centre,
Seth G.S.Medical College and KEM Hospital, Parel, Mumbai
ABSTRACT
A prospective clinical trial of 90 patients with osteoarthritis knee was carried out. Outcome measures
assessed were full weight bearing knee joint proprioception (mean proprioception error), pain on
visual analogue scale and physical function on WOMAC scale. Subjects were divided into 3 groups;
Group A received Maitland's mobilization technique and exercise program, Group B received
Mulligan's mobilization technique and exercise program and Group C received only exercise program.
The duration of treatment was 5 days which included 3 sessions on day1, day3 and day5. Outcome
measures were assessed pre and post treatment at the end of day 1 and day 5. The data obtained was
analyzed statistically and results were displayed graphically. The within group results showed
statistically significant reduction in mean proprioception error, pain on VAS and WOMAC score post
treatment of day 5. However, when between groups comparison was done no statistically significant
difference was noted.
Thus it was concluded that exercises alone are effective in improving full weight bearing knee joint
proprioception in patients with osteoarthritis knee. Manual therapy techniques did not have any
added benefits to those of exercise alone.
Key words: Knee Osteoarthritis, Manual Therapy, Proprioception.
INTRODUCTION attention is given to the role of altered knee

proprioception in these patients.
Osteoarthritis is defined as a degenerative joint
disease characterized by breakdown of articular Pai and Sharma in their study in patients with knee
cartilage. Osteoarthritis affects mainly the weight osteoarthritis1 concluded that proprioception declines
bearing joints of the body such as lumbar spine, with age and is further impaired in elderly patients
cervical spine, hip and knee joint. with knee OA. Poor proprioception contributes to
functional impairments in knee OA. Barrett noted that
Functional impairments associated with knee OA the patient's satisfaction was more closely correlated
are pain, restricted range of motion (ROM), reduced with their proprioception than with their clinical
muscle strength and endurance, altered gait and scores. He has demonstrated that limb function
altered knee proprioception. depends more on proprioceptive information than on
The rehabilitation for patients with knee OA strength2.
generally is focused on pain relief, restoration of ROM, Hence, there is a need to address this important
muscle strength and joint flexibility. However, little impairment when treating patients with OA knees.
Ufuk Sekir and Hasan Gur have show that using a

Correspondence Address proprioceptive exercise program it is possible to
Singh Yuvraj Lalit improve postural control, functional capacity, decrease
Lecturer perceived knee pain and improve both passive, active
MGM School of Physiotherapy, and weight bearing joint position sense in patients with
Sector 30, Plot No.46, Vashi, Navi Mumbai
bilateral knee osteoarthritis8.
yuvraj555@hotmail.com
57 Yuvraj 6th june 11 (285-290).pmd 285 10/16/2012, 2:41 PM

Wyke et al in 1973 showed that manual therapy Visual Analogue Scale(VAS)

techniques improve joint propriocetive inputs. WOMAC scale
Thus there is literature describing how ageing and Procedure:

osteoarthritis reduces knee proprioception3-7. Studies 1. Proprioception was tested as follows:
indicate that this knee proprioception is of utmost Weight bearing position sense: The protocol for
importance for lower limb function. Exercises alone testing knee joint position sense in full weight
have been shown to improve knee proprioception and bearing position is a modification of that reported
thus the functional capacity in patients with knee by Bullock and Saxton (12). The test was performed
OA 8,9 .Maitland's and Mulligan's mobilization at 30 degrees of knee flexion. Rotation axis of a
techniques have been shown to be effective in reducing
standard Goniometer was placed on lateral surface
patient's pain, improve range of motion and thus
of the affected knee joint when subjects remained
finally the quality of life10,11. However, there is paucity
of literature assessing the effects of these manual standing. The knee was fully extended i.e. 0 degrees
therapy techniques on knee proprioception in patients at the starting position and was moved randomly
with osteoarthritis knee. to the allocated target angles of 30 degrees of knee
flexion. This was maintained for 5 sec. Subjects then
This study therefore aims to study the effect of returned the knee to the start position and after a
manual therapy techniques - Maitland's and 5sec. rest attempted to reproduce the previously
Mulligan's mobilization techniques, on knee attained target angles. The outcome measure used
proprioception in patients with osteoarthritis knee and for the reposition test is an error score calculated
then to compare these with effects of exercise alone.
as the absolute difference between the target and
the replicated angle (in degrees).
Starting position End position
The study was prospective clinical trial. Ethics (at allocated target angle of 30 deg.)
committee approval was obtained from the

institution's ethical committee before commencement
of the study. There were ninety participants with
diagnosis of knee osteoarthritis who were referred to
Physical Therapy OPD of KEM hospital, Mumbai
between the period from March 2008 to May 2009 and
were willing to participate in this study.
Fig. 1. Testing of full weight bearing knee proprioception
Inclusion criteria:
According to American college of Rheumatology, 2. Pain assessment :
Inclusion criteria for OA knees: 0_________________________________10

Crepitus on active joint motion (No pain) (Worst pain)
Morning stiffness<30 mins
Bony enlargement of knee on examination A 0 to 10 visual analogue scale (VAS 10 cm) was
No palpable warmth used to find the intensity of pain13.
Age > 40 years
3. WOMAC scale was used to assess functional status
Any 3 of above mentioned criteria should be of the patient14,15.
present along with knee pain.
90 subjects were then divided into 3 groups.
Patients with pain on VAS < 5 on weight bearing
were taken for the study. INTERVENTIONS
Patients with any history of trauma to knees, Group A: 30 patients of this group received
ligament injuries or neurological impairments were Maitland's mobilization techniques16, 17 for the affected
excluded from the study. knee joint in addition to exercise program.
Materials used: Tibio-femoral anterior and posterior glides and

Standard Universal Goniometer patellofemoral superior-inferior and medio-lateral
Velcro straps glides were given.

Grade of mobilization: Grade 2 and 3. Group C: This group received only the exercise
program. Exercise program consisted of the following:
2a) Tibiofemoral posterior glide
1. Multiple angle isometrics
2. Terminal arc knee extension (Fig 4)
3. Mini squats (Fig 5)
4. Partial lunges (Fig 6)
5. One-leg balances (Fig 7)
6. Cross-body leg swings (Fig 8)
Repetitions: 10 repetitions per session
3 sessions per day.
2b) Tibiofemoral anterior glide
Fig. 4. Terminal arc knee extension
2c) Patellofemoral mobilzation
Fig. 2. Maitland's mobilization
Group B: 30 patients of this group received

Fig. 5. Mini squats
Mulligan's mobilization techniques for the affected
knee joint in addition to exercise program.
Technique: The therapist flexed up the knee just

short of the painful limitation. Now the therapist
grasped the lower leg and internally rotated the tibia
on femur. Maintaining this patient was asked to flex
further and overpressure was applied17, 18.
Dosage: 3 sets of 3 repetitions each.

Starting position End position (with tibia in internal Fig. 6. Partial lunges
rotation)
Fig. 3. Mulligan's Mobilization with movement

Fig. 7. One leg balance

In this study pre-test score of pain on VAS at

baseline was 3.93 in Group A, 3.77 among Group B
and 4.17 among Group C which were same and
difference was not statistically significant. Post test
scores after treatment on Day1 showed that pain on
VAS had a significant fall in all groups i.e., 0.83 (21.1%)
in Group A, 1.23 (32.6%) among Group B and 0.57
(13.7%) in Group C. Between group comparison
Fig. 8. Cross body leg swings showed that the reduction was more in Group A and
Group B, but the difference between the three groups
FINDINGS was not found to be statistically significant. Post test
scores after treatment on Day5 showed that pain on
Age of the subjects in this study was between 40-
VAS had a significant fall of 3.00 (76.2%) in Group A,
70 years with mean age of 54.67 years among Group
3.07 (81.4%) in Group B and 2.47 (59.2%) in Group C.
A, 51.67 years among Group B and 51.90 years in
Between group comparison showed that the fall was
Group C which were comparable and difference was
less in Group C, but the difference between the three
not statistically significant. 50.0 - 53.3 % of total cases
groups was not found to be statistically significant.
were males in all three groups.
Table 2. Comparison of changes in mean pain
Mean proprioception error at baseline was 7.79 on VAS between groups
among Group A, 6.36 among Group B and 6.67 in Group A Group B Group C P value
Group C which were same and difference was not Pre Day1 3.930.98 3.771.22 4.170.70 #NS
statistically significant. Post test score after treatment Post Day1 3.101.09 2.531.41 3.600.89 -
on Day 1 showed that mean proprioception error had Post Day 5 0.931.05 0.930.98 1.701.21 -
Mean Change *0.831.18 *1.231.98 *0.570.63 #NS
a significant fall in all groups i.e. 2.93 (37.6%) in Group Pre - Post: Day 1
A,1.90 ( 29.9%) among Group B and 2.12 (31.8%) in Mean Change *3.001.31 *3.071.28 *2.471.07 #NS
Day1 pre- Day5 Post
Group C. Post test scores after treatment on Day 5
* By Wilcoxon Rank Test P<0.05 Significant
showed that mean proprioception error had a # By ANOVA (Kruskal Walli's) P >0.05 Not Significant
significant fall of 3.51(45.1%) in Group A, 3.35 (52.7%)
among Group B and 3.26 (48.9% ) in Group C. Between The mean WOMAC score was 25.33 among Group
group comparison showed that difference between the A, 23.43 among Group B and 27.03 in Group C; which
three groups was not found to be statistically were same and difference was not statistically
significant post treatment day1 and also post treatment significant. Post test scores after treatment on Day 5
day 5. showed that mean WOMAC score had a significant
fall in all groups i.e. 11.87 (46.9%) in Group A, 11.97
Table 1. Comparison of changes in mean (51.1%) among Group B and 14.37 (53.2%) in Group C
proprioception error score between groups respectively from basal. Difference between the three
Group A Group B Group C P value groups was not found to be statistically significant.
Pre 7.792.82 6.363.04 6.673.37 #NS
Post 4.851.87 4.461.87 4.551.35 - Table 3. Comparison of changes in mean
Day 5 4.282.07 3.011.47 3.421.38 - WOMAC score between groups
Mean Change Day *2.933.09 *1.903.37 *2.123.37 #NS
1Pre - Day1Post Group A Group B Group C P value
Mean Change Day *3.512.49 *3.352.40 *3.262.41 #NS Day 1 25.339.26 23.439.43 27.037.08 #NS
1pre- Day 5post Day 5 13.475.51 11.475.34 12.674.65 _
* By Wilcoxon Rank Test P<0.05 Significant Mean Change *11.876.96 *11.9710.93 *14.375.55 #NS
# By ANOVA (Kruskal Walli's) P >0.05 Not Significant Day 1- Day 5
* By Wilcoxon Rank Test P<0.05 Significant
# By ANOVA (Kruskal Walli's) P >0.05 Not Significant
The result of this study showed that the mean

proprioception error showed a significant fall in all
the groups. These changes in mean proprioception
error were considered statistically not significant when
compared between groups. This implies both groups
A and B showed similar improvements to Group C.
Chart. 1. Comparison of changes in mean proprioception error
score between groups. This is in accordance with study of Ufuk Sekir and
Hasan Gur (10) who showed that exercise program

alone was able to improve knee joint proprioception indicated by a reduction in mean proprioception error
in patients with knee OA. in full weight bearing position in patients with knee
osteoarthritis. This in turn would lead to improvement
Improvements seen with respect to proprioception in lower limb functions.
in all the 3 groups could be attributed to common
therapeutic effects of exercises. 4 of this set of exercises
CONCLUSION
which were primarily closed chain kinematic exercise
had certain common therapeutic effects namely: Exercises alone are effective in improving full
1. Muscular contraction weight bearing knee joint proprioception in patients
2. Neurophysiologic effects: Stimulation of type I, II with osteoarthritis knee. Manual therapy techniques
and III receptors. do not have any added benefits to those of exercises
3. Neural adaptation: Using functional Closed chain alone.
kinetic activities enhanced nervous system's ability Conflict of Interest
to recruit groups of muscles to work together.
Neural pathways are created that closely replicate We, Singh Y, Mhatre B and Mehta A state that there
functional demand. is no conflict of interests with other people or
4. Stimulation of muscle spindles and GTOs thus organizations about our work.
contributing to proprioception19.
ACKNOWLEDGEMENTS
With respect to pain on Visual Analogue Scale, all
We are heartily thankful to the staff of PT School
the 3 groups showed statistically significant reduction
and Centre, KEM hospital, who supported us from the
after 5 days of treatment with no statistically significant
preliminary stages of the project.
difference when compared between the groups.
However, here both the manual therapy groups
REFERENCES
Maitland's and Mulligan's showed better results (76.2%
and 81.4% reduction in pain on VAS) compared to only 1. Pai YC, Rymer WZ, Chang RW, Sharma L. Effect
exercise group (59.2% reduction). of age and osteoarthritis on knee proprioception.
Arthritis Rheum. 1997; 40: 2260-2265.
Maitland's mobilization techniques stimulated a 2. Barret DS: Proprioception and function after
diphasic response from mechanoreceptors in joint anterior cruciate ligament reconstruction. J Bone
capsule that was stretched. This consists of an initial and joint surgery 73B: 833-837, 1991.
brief burst of impulses from type II receptors that 3. Harrison AL. The influence of pathology, pain,
melted into a prolonged type I receptor activity. These balance, and self-efficacy on function in women
transmissions modulated transmissions from type IV with osteoarthritis of the knee. Phys Ther. 2004;
nociceptors through the "gateway" synapses in the 84: 822-831.
basal spinal nucleus up into the brain.20,21 4. Hewitt BA, Refshauge KM, Kilbreath SL.
Kinesthesia at the knee: the effect of osteoarthritis
The improvement in Mulligan's group could be and bandage application. Arthritis Rheum. 2002;
attributed to the rationale behind Mulligan's 47: 479-483.
techniques which is that mobilization with movement 5. Marks R. Further evidence of impaired position
sedates an agitated, facilitated nervous system, sense in knee osteoarthritis. Physiother Res Int.
particularly the dorsal horn by bombarding it with 1996; 1: 127-136.
painless normality it has been patterned to receive. 6. Sturnieks DL, Tiedemann A, Chapman K, et al.
Physiological risk factors for falls in older people
Physical function improved as indicated by with lower limb arthritis. J Rheumatol. 2004; 31:
reduction in WOMAC scores. The reduction was 46.9, 2272-2279.
51.1 and 53.2 % in Maitland's, Mulligan's and exercise 7. Andrew Guccione, Marian Minor, Arthritis. IN:
only group. The difference between the groups was Susan B O'Sullivan, Physical Rehabilitation:
not significant. Improvement in physical function can Assessment and treatment, 4th edition. New
be attributed to a combination of reduced pain and Delhi: Jaypee Brothers; 2001. p. 679-714.
improved knee joint proprioception. 8. Ufuk Sekir and Hakan Gr. A multi-station
proprioceptive exercise program in patients with
Clinical application: A well designed exercise bilateral knee osteoarthrosis:Functional
program inclusive of close chain kinematic exercises capacity,pain and sensorimotor function. A
is effective in improving knee proprioception as randomized controlled trial:. Journal of Sports
Science and Medicine (2005) 4, 590-603.

9. Hassan, B.S., Mockett, S. and Doherty, M. (2001) osteoarthritis index in Asians with osteoarthritis
Static postural sway, proprioception, and in Singapore. Osteoarthritis cartilage, 2001: 9(5),
maximal voluntary quadriceps contraction in p. 440-446.
patients with knee osteoarthritis and normal 15. Bellamy N, Buchanan WW, Goldsmith GH:
control subjects.Annals of the Rheumatic Validation study of WOMAC: A health status
Diseases 60, 612-618. instrument for measuring clinically important
10. Gail D Deyle, Stephen C Allison, Robert L patients relevant,outcomes to anti-rheumatic
Matekel, Michael G Ryder, John M Stang, David drug therapy in patients with osteoarthritis of hip
D Gohdes, Jeremy P Hutton, Nancy E Henderson and knee. J Rheumatology.1998; 15, p. 1833-1840.
and Matthew B Garber, Physical therapy 16. Maitland GD: Peripheral Manipulation, 3rd
Treatment Effectiveness for Osteoarthritis of the edition, Butterworth Heinemann 1997 p. 238-249.
Knee: A Randomized Comparison of Supervised 17. Kisner C,Colby LA: Therapeutic exercises.
Clinical Exercise and Manual Therapy Foundation and techniques. 4th edition. Jaypee
Procedures Versus a Home Exercise Program. brothers 2002. p. 246-249.
Phys Ther Vol. 85, No. 12, December 2005, 18. Mulligan BR: Manual Therapy. NAGS, SNAGS,
pp. 1301-1317. MWM etc. 5th edition. p.120.
11. Evgeniya Dimitrova : Efficacy of mobilizations 19. Susan Lefever-Button: Closed kinetic chain
with movement in patients with knee training IN: Hall C,Brody LT: Therapeutic
osteoarthritis. Sport Medicine Journal" No. 16 - exercise: Moving toward function,Lippincott
2008. Williams and Wilkins. p. 254-255.
12. Bullock-Saxton, J.E., Wong, W.J. and Hogan, 20. Tierney D: The efficacy of physiotherapy: A
N: The influence of age on weight-bearing joint literature review with reference to the Maitland
reposition sense of the knee. Experimental Brain and Mulligan paradigms in mobilization of a
Research 136, 400-406. joint. 2003.
13. Husskisson EC. Measurement of pain. The Lancet 21. Wyke BD: Articular neurology and manipulative
197. therapy. IN: Maitland GD: Aspects of
14. Thumboo J, Chew LJ, Soh CH: Validation of the Manipulative therapy 2nd edition. Churchill
Western Ontario and McMaster University Livingstone 1985. p. 72-80.

Call for Papers / Article Submission

Indian Journal of Physiotherapy and Occupational Therapy has commenced publication since 2006. IJPOT will
he published four times in a year.
Purpose & Scope: IJPOT is a multidisciplinary refereed journal devoted to disseminating rigorous research
on all aspects of the physiotherapy and occupational therapy to enhance learning. The journal seeks to be a
and cognition, education, and technology, with a view to improving practice and achieving real-world impact in
technology enhanced learning.
The journal encourages research from theoretical perspectives, research reports of evidence based practice
as well as praxis research work that focuses on the interface between theory and practice and how each can
support the other. In addition, the journal strongly encourages reports of research carried out within or involving
Invitation to submit papers: A general invitation is extended to authors to submit journal papers for publication
in IJPOT.
The following guidelines should be noted:
The article must be send by E-mail in word only as attachment. Hard copy need not be send.
The article should be accompanied by a declaration from all authors that it is an original work and has not been
sent to an other journal for publication.
As a policy matter, journal encourages articles regarding new concepts and new information.
Article should have a Title
Names of authors
Abstract
Key words
Introduction or back ground
Material and Methods
Findings
Conclusion
Acknowledgements
References in Vancouver style.

Please quote references in text by superscripting
Indian Journal of Physiotherapy & Occupational Therapy

Dr Archna Sharma, Editor IJPOT
First Floor, Punjab National Bank Building
Main Dadri Road, Bhangel, Noida - 201 304, Uttar Pradesh
Tel: 0120-4222020, 09971888542

CALL FOR SUBSCRIPTIONS
About the Journal

Print-ISSN: 0973-5666 Electronic - ISSN: 0973-5674, Frequency: Quarterly (4 issues per volume).
An essential journal for all Physiotherapists & Occupational therapists provides professionals with a forum
in which to discuss todays challenges-identifying the philosophical and conceptural foundations of the practice;
sharing innovative evaluation and treatment techniques; learning about and assimilating new methodologies
developing in related professions; and communicating information about new practice settings. The journal serves
and reports that are directly relevant to practice. The journal is internationally indexed and is also covered by
Index Copernicus (Poland).
Subscription Information
Journal Title Pricing of Journals
IJPOT Print Only Print+Online Online Only
Indian INR 6000 INR 8000 INR 4500
Foreign USD 400 USD 500 USD 300
Note for Subscribers

Advance payment required by Cheque / Draft in the name of Indian Journal of Physiotherapy and
Occupational Therapy payable at New Delhi
Concellation not allowed except for duplicate payment.
Claim must be made within six months from issue date.
A free copy can be forwarded on request.
SEND REMITTANCE TO:

Archna Sharma, Executive Editor, IJPOT
Indian Journal of Physiotherapy and Occupational Therapy

First Floor, Punjab National Bank Building
Main Dadri Road, Bhangel, NOIDA - 201 304, UTTAR PRADESH
Mobile: 09971888542

View publication stats

Effectiveness of Physiotherapy For The Handwriting Problem of School Going Children PDF

Enviado por

Dados do documento

Título original

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

Effectiveness of Physiotherapy For The Handwriting Problem of School Going Children PDF

Enviado por

Direitos autorais:

Formatos disponíveis

See

Effectiveness of Physiotherapy for the

Article July 2012

Chandan Kumar Poonam Mehta

SEE PROFILE SEE PROFILE

Ageing and Pain View project

The user has requested enhancement of the downloaded file.

Indian Journal of Physiotherapy and

2. Role of Aerobic and Resistive Exercises in Postmenopausal Women .................................................................................. 07

3. Quality of Life, Disablement, Comorbidity and Socio-Demographics of Stroke ............................................................... 13

6. The Effectiveness of Iontophoresis Over Conventional Therapy in Relieving Pain, ......................................................... 28

9. Effect of Posterior Tibial Nerve Stimulation and Trospium Hydrochloride in .................................................................. 42

Content Final.pmd 1 10/16/2012, 2:42 PM

16. Efficacy of Knee Osteo-arthritis Outcome Score (KOOS) in Measuring .............................................................................. 79

18. A Randomised Controlled Trial of Stimulation of Triceps as an Adjunct to ...................................................................... 88

20. Effects of Three Weeks Plyometrics on Sprint Velocity ......................................................................................................... 98

23. An Analysis of Memory Retrieval and Performance of Physiotherapy ............................................................................ 111

Content Final.pmd 2 10/16/2012, 2:42 PM

34. Effect of Sensory-Specific Balance Training in Elderly ......................................................................................................... 168

35. A Comparitive Study of Early Intervention Programme vs Home .................................................................................... 173

43. Epidemiology of Cerebral Palsy in Jalandhar ........................................................................................................................ 219

Content Final.pmd 3 10/16/2012, 2:42 PM

50. Physiotherapy-supervised Mobilization and Exercise Following ...................................................................................... 254

54. Impairment of Spinal Proprioception Following Stroke ...................................................................................................... 272

Content Final.pmd 4 10/16/2012, 2:42 PM

Phansalkar Archana A1, Iyer Saraswati2

INTRODUCTION have a significant impact on the lives of the patient.

1. aarchna phansalkar 6th aug 11 (1-6).pmd 1 10/16/2012, 2:40 PM

A biological basis explained is:

The first major theory about biological etiology of

INTELLIGENCE Fatigue is described as a lack of energy, sense of

1. aarchna phansalkar 6th aug 11 (1-6).pmd 2 10/16/2012, 2:40 PM

4. Mini mental status(MMSE) The above table shows negative correlation

Exclusion Criteria: A negative correlation between HOEN&YAHR and

eg;Parkinsons plus syndrome. BDE 30 25.37+ 9.02 -0.56 3.56 <0.01

All the subjects could answer the questions on all 3

Samples Mean SD r t P Each question of the FSS was evaluated to find

1. aarchna phansalkar 6th aug 11 (1-6).pmd 3 10/16/2012, 2:40 PM

DISCUSSION The dysfunction of reward -oriented systems

1. aarchna phansalkar 6th aug 11 (1-6).pmd 4 10/16/2012, 2:40 PM

Mitochondria are intracellular powerhouses and Psy 1974; (37); 27-31).

1. aarchna phansalkar 6th aug 11 (1-6).pmd 5 10/16/2012, 2:40 PM

1. aarchna phansalkar 6th aug 11 (1-6).pmd 6 10/16/2012, 2:40 PM

Role of Aerobic and Resistive Exercises in Postmenopausal

Abha Sharma1, Heena Sahi2

Study Design: Experimental

Key Words: Menopause Rating Scale, Aerobic Exercises, Resistive Exercises.

INTRODUCTION previously it was thought to provide and because large

2. Abha sharma 19th may 11 (7-12).pmd 7 10/16/2012, 2:40 PM

women and in the present study we compare the TREATMENT PROTOCOL

SAMPLE 20 subjects(n=20) included in the study. Week 1 and 2 20minutes 15minutes

2. Abha sharma 19th may 11 (7-12).pmd 8 10/16/2012, 2:40 PM

Strengthening of elbow flexion both sides. Week Set/exercise Repetitions/ exercise

Table 1.1 Details of Subjects

Table 1.2 Mean (SD) of MRS, BMI, Weight

2. Abha sharma 19th may 11 (7-12).pmd 9 10/16/2012, 2:40 PM

Table 1.4 Independent Samples Test (Between Groups)

Table 1.5 Paired T- Test

postmenopausal women using MRS (except for sexual

Our study shows that both exercise regimes

2. Abha sharma 19th may 11 (7-12).pmd 10 10/16/2012, 2:40 PM

2. Abha sharma 19th may 11 (7-12).pmd 11 10/16/2012, 2:40 PM

12. Kisner/Colby, Therapeutic exercise foundations Between Menopausal Status, Hormone