Você está na página 1de 301


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


0 304

3 authors, including:

Chandan Kumar Poonam Mehta

School of Allied Health Sciences, Greater Noi University of Otago


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.


Indian Journal of Physiotherapy and

Occupational Therapy
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


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

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


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

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

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


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

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

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


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:


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.

Fig. 1.
According to this, an abnormality in the functioning
of the receptors leads to depression.

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.
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)

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

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
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
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
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
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

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

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

4 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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.

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

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 5

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-
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
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

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

6 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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).

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

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 7

Role of Aerobic and Resistive Exercises in Postmenopausal


Abha Sharma1, Heena Sahi2

1 2
Asst. Professor, Student, Physiotherapy, Banarsidas Chandiwala Institute of Physiotherapy, Chandiwala Estate, Maa
Anand Mai Marg, Kalkaji, New Delhi


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

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

8 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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.

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

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 9

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
 Pull up, bending at elbow.
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)

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

10 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

Table 1.4 Independent Samples Test (Between Groups)

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

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

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

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 11

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
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.

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

12 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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

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

Quality of Life, Disablement, Comorbidity and Socio-
Demographics of Stroke Survivors in South-Western

Aderonke O. Akinpelu1, Caleb A. Gbiri2, Fatai A. Maruf3

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.


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.

3. Adenoke nigeria 7 th jne 11 (13-18).pmd 13 10/16/2012, 2:40 PM

14 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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.

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

3. Adenoke nigeria 7 th jne 11 (13-18).pmd 14 10/16/2012, 2:40 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 15

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
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

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

3. Adenoke nigeria 7 th jne 11 (13-18).pmd 15 10/16/2012, 2:40 PM

16 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

Table 3. Age Group, Highest Educational Attainment, and Occupational Comparison of Quality of Life of Stroke
Variable PH PSH SR EV
<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

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 =

Table 4. Comparison of Quality of Life Scores of Stroke Survivors across Levels of Motor Disability and Co-morbidity.
Variable PH PSH SR EV
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

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

3. Adenoke nigeria 7 th jne 11 (13-18).pmd 16 10/16/2012, 2:40 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 17

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
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.
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
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.

3. Adenoke nigeria 7 th jne 11 (13-18).pmd 17 10/16/2012, 2:40 PM

18 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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

3. Adenoke nigeria 7 th jne 11 (13-18).pmd 18 10/16/2012, 2:40 PM

Efficacy of Mesh Glove Sensory Stimulation on Spasticity
Control in Hemiplegic C.P.

Ahmed M. Azzam
Department of Physiotherapy for Developmental Disturbance and Pediatric Surgery, Faculty of Physical Therapy,
Cairo University , Giza, Egypt.


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 feed- back and lack of its representation in

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

20 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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

4. Ahmad Azam egypt 12th april 12 (19-23).pmd20 10/16/2012, 2:40 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 21

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

4. Ahmad Azam egypt 12th april 12 (19-23).pmd21 10/16/2012, 2:40 PM

22 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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 neuro- physiological 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

4. Ahmad Azam egypt 12th april 12 (19-23).pmd22 10/16/2012, 2:40 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 23

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
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 feed- back 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.

4. Ahmad Azam egypt 12th april 12 (19-23).pmd23 10/16/2012, 2:40 PM

24 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

Rehabilitation of a Patient with Post Traumatic Triple

Nerve Palsy of the Upper Limb

Anil Mathew
Associate Professor, Dept. of Orthopaedics & Hand Surgery


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
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
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

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 25

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)

5. anil mathew 21st sept 11 (24-27).pmd 25 10/16/2012, 2:40 PM

26 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

(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.

5. anil mathew 21st sept 11 (24-27).pmd 26 10/16/2012, 2:40 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 27


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;
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.

5. anil mathew 21st sept 11 (24-27).pmd 27 10/16/2012, 2:40 PM

28 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

The Effectiveness of Iontophoresis Over Conventional

Therapy in Relieving Pain, Improving Rom and Functional
Skills in Adhesive Capsulitis

Anila Paul1, Nizar2, Thresiamma VT3

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.


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

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 29

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

6. Anila Paul 19th april 11 (28-32).pmd 29 10/16/2012, 2:40 PM

30 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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

6. Anila Paul 19th april 11 (28-32).pmd 30 10/16/2012, 2:40 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 31

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
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

6. Anila Paul 19th april 11 (28-32).pmd 31 10/16/2012, 2:40 PM

32 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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,
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
Santoianni, Topical delivery of active principles:
The field of dermatological research.
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.

6. Anila Paul 19th april 11 (28-32).pmd 32 10/16/2012, 2:40 PM

Comparison of Dynamic Balance Between Flat Feet and
Normal Individuals Using Star Excursion Balance Test

Ajit Dabholkar1, Ankita Shah2, Sujata Yardi3

Associate Professor, 2BPTh, 3Professor & Director, Pad. Dr. D.Y. Patil College of
Physiotherapy Nerul, Navi Mumbai.


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
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

34 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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

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

7 ankita shah 28th sept 11 (33-37).pmd 34 10/16/2012, 2:40 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 35

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
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

7 ankita shah 28th sept 11 (33-37).pmd 35 10/16/2012, 2:40 PM

36 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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

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
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

7 ankita shah 28th sept 11 (33-37).pmd 36 10/16/2012, 2:40 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 37

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

7 ankita shah 28th sept 11 (33-37).pmd 37 10/16/2012, 2:40 PM

38 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

Evaluation of 6 Minute Walk test Parameters in Normal

Indian Pediatrics age Group between 6-11yrs

Jinal Chitroda1, Anuprita Thakur2, Sujata Yardi3

Dept. of Physiotherapy, MPT, 2Assoc. Prof, 3Prof & Director


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

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
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

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 39

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
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

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.

8. Anuprita 16th july 11 (38-41).pmd 39 10/16/2012, 2:40 PM

40 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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

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

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
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

8. Anuprita 16th july 11 (38-41).pmd 40 10/16/2012, 2:40 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 41

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.
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;
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.


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

8. Anuprita 16th july 11 (38-41).pmd 41 10/16/2012, 2:40 PM

42 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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
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


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

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

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 43

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

44 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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.
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,
placing the ground electrode on the ipsilateral
extremity. Electrical stimulation (Medtronic Key Point
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
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
Type of incontinence 11/5 13/4
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

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 45

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
Volume at first desire 126.5 120.0 205.0* 210.0* 205.5* 157.0* A 151.0* 149.5* B,C
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
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.
Comparison of Post-T (week 18) and Post-T (week 12): P< 0.05.
Comparison of Post-T (week 24) and Post-T (week 12): P<0.05.
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).
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

46 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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

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
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

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 47

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

48 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

Pulse Rate Response to Footwear in Rehabilitation Phase

of Coronary Artery Bypass Graft Surgery (CABG) Patients
A Clinical Trial Study

Shaily Razdan1, Aparna Sarkar2

Research Scholar Department of Research, Singhania University, Jjunjhunu, Rajasthan,
Asst. Proffessor, AIPT K-Block, Amity University, Uttar Pradesh


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. therapeutic strategy against diseases known to cause

10. Aparna Sarkar 15th june 12 (48-52).pmd 48 10/16/2012, 2:40 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 49

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

10. Aparna Sarkar 15th june 12 (48-52).pmd 49 10/16/2012, 2:40 PM

50 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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.
12. Von Tscharner V, Goepfert B, Nigg BM. . Changes
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

10. Aparna Sarkar 15th june 12 (48-52).pmd 50 10/16/2012, 2:40 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 51

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

10. Aparna Sarkar 15th june 12 (48-52).pmd 51 10/16/2012, 2:40 PM

52 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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.

10. Aparna Sarkar 15th june 12 (48-52).pmd 52 10/16/2012, 2:40 PM

Effect of Passive Pelvic Fixation on Non-Specific
lumbopelvic Pain: A Case Report

Apeksha A1, Khatri SM2

Postgraduate student, College of Physiotherapy, Pravara Institute of Medical Sciences,
Loni, Maharashtra State, 2Professor & Principal


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
Correspondence Address
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

54 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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,

11. apeksha 3rd june 11 (53-56).pmd 54 10/16/2012, 2:40 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 55

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.


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

Fig. 3. Graph showing Immediate Pain Relief After PPF REFERENCES

1. http://www.medhelp.org/tags/health_page/
Introduction?hp_id=190 (accessed on 27th March,
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

11. apeksha 3rd june 11 (53-56).pmd 55 10/16/2012, 2:40 PM

56 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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.

11. apeksha 3rd june 11 (53-56).pmd 56 10/16/2012, 2:40 PM

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


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

58 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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

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
Sign Rank
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.

12. Archna gore 11th july 11 (57-61).pmd 58 10/16/2012, 2:40 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 59

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
significant after task A & B in ECFI condition. 2. Eyes closed firm surface Somatosensory and Vision and cognition
3. Eyes open foam surface Vision and vestibular Somatosensory and
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
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 &

12. Archna gore 11th july 11 (57-61).pmd 59 10/16/2012, 2:40 PM

60 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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
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,

12. Archna gore 11th july 11 (57-61).pmd 60 10/16/2012, 2:40 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 61

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.

12. Archna gore 11th july 11 (57-61).pmd 61 10/16/2012, 2:40 PM

62 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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

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


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

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

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 63

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.

13. arju 22nd sept 11 (62-67).pmd 63 10/16/2012, 2:40 PM

64 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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
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.
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.


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.

13. arju 22nd sept 11 (62-67).pmd 64 10/16/2012, 2:40 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 65

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
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.

13. arju 22nd sept 11 (62-67).pmd 65 10/16/2012, 2:40 PM

66 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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

13. arju 22nd sept 11 (62-67).pmd 66 10/16/2012, 2:40 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 67

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.

13. arju 22nd sept 11 (62-67).pmd 67 10/16/2012, 2:40 PM

68 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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


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

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 69

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
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.

14. B anandha priya 22nd 11 (68-74).pmd 69 10/16/2012, 2:40 PM

70 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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.


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
1. Practicing compensatory techniques for decreased
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.

14. B anandha priya 22nd 11 (68-74).pmd 70 10/16/2012, 2:40 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 71

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

14. B anandha priya 22nd 11 (68-74).pmd 71 10/16/2012, 2:40 PM

72 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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.

14. B anandha priya 22nd 11 (68-74).pmd 72 10/16/2012, 2:40 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 73

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:

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.

14. B anandha priya 22nd 11 (68-74).pmd 73 10/16/2012, 2:40 PM

74 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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.

14. B anandha priya 22nd 11 (68-74).pmd 74 10/16/2012, 2:40 PM

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

MPT 2 Year (Pediatrics), 2Associate Professor, 3Principal and Professor, Gian Sagar College of Physiotherapy,

Assistant Professor, Gian Sagar Medical College and Hospital, Ram Nagar, Rajpura, Dist.


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

76 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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

15. bhanu thapar 24th june 11 (75-78).pmd 76 10/16/2012, 2:40 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 77

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


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,

15. bhanu thapar 24th june 11 (75-78).pmd 77 10/16/2012, 2:40 PM

78 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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.

15. bhanu thapar 24th june 11 (75-78).pmd 78 10/16/2012, 2:40 PM

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


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

80 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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
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

16. Bindya Sharma 18th Feb 12 (79-81).pmd 80 10/16/2012, 2:40 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 81


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
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.

16. Bindya Sharma 18th Feb 12 (79-81).pmd 81 10/16/2012, 2:41 PM

82 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

Reliability and Concurrent Validity of Dynamic Rotator

Stability Test A Cross Sectional Study

Binoy Mathew K V1, Charu Eapen2, P.Senthil Kumar3

Clinical Instructor cum Lecturer, College of Physiotherapy, Medical Trust Institute of Medical Sciences, Kochi, Kerala,
Associate Professor, Kasturba Medical College Hospital, Mangalore, Karnataka


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

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 83

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,


Fig. 1.

17. binoy mathew 19th nov 10 (82-87).pmd 83 10/16/2012, 2:41 PM

84 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3


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

17. binoy mathew 19th nov 10 (82-87).pmd 84 10/16/2012, 2:41 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 85

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
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
during DRST .137 .320* .170 .280 .061 .450*

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
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.

17. binoy mathew 19th nov 10 (82-87).pmd 85 10/16/2012, 2:41 PM

86 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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.

17. binoy mathew 19th nov 10 (82-87).pmd 86 10/16/2012, 2:41 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 87

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.

17. binoy mathew 19th nov 10 (82-87).pmd 87 10/16/2012, 2:41 PM

88 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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

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


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

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 89

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

18. Archna gore 26th july 11.doc (88-92).pmd 89 10/16/2012, 2:41 PM

90 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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
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.

18. Archna gore 26th july 11.doc (88-92).pmd 90 10/16/2012, 2:41 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 91

Table 3. Mean difference (%) of outcome measures between Conventional and Experimental groups pre and post
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

18. Archna gore 26th july 11.doc (88-92).pmd 91 10/16/2012, 2:41 PM

92 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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

18. Archna gore 26th july 11.doc (88-92).pmd 92 10/16/2012, 2:41 PM

The Effect of Task Oriented Training on Hand Functions in
Stroke Patients- A Randomized Control Trial

Chandan Kumar1, Ruchika Goyal2,

(PT) Assistant Professor M. M. Institute of Physiotherapy & Rehabilitation Mullana, Ambala,
M.P.T (Neurology-Student) M. M. Institute of Physiotherapy and Rehabilitation, Mullana, Ambala


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.


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

94 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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
Upper limb dysfunction in stroke is characterized
by paresis, loss of manual dexterity, and movement
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
TASK ORIENTED TRAINING 3. Any neurological pain or disorder limiting the
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.

19 chandan kumar 14th april 12 (93-97).pmd 94 10/16/2012, 2:41 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 95

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
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
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,

19 chandan kumar 14th april 12 (93-97).pmd 95 10/16/2012, 2:41 PM

96 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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.

19 chandan kumar 14th april 12 (93-97).pmd 96 10/16/2012, 2:41 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 97

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.

19 chandan kumar 14th april 12 (93-97).pmd 97 10/16/2012, 2:41 PM

98 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

Effects of Three Weeks Plyometrics on Sprint Velocity

Jagdeep Kaur Dhamija1, Jaspreet Singh Vij2, Rajesh Gautam3

Asst. Prof., Department of Physiotherapy, Lyallpur Khalsa College, Jalandhar (Punjab) India
Professor and Coordinator, Department of Physiotherapy, LPU, Phagwara (Punjab)
Asst. Prof., Department of Physiotherapy, Lyallpur Khalsa College, Jalandhar (Punjab) India


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

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 99

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
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
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

20 Jagdeep Dhamija 24th sept (98-100).pmd 99 10/16/2012, 2:41 PM

100 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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
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

20 Jagdeep Dhamija 24th sept (98-100).pmd 100 10/16/2012, 2:41 PM

Perception about Stroke amongst Rural Population in

Swati Limaye1, Deepak Anap2, Dhiraj Shete3

BPT College of Physiotherapy, Pravara Institute of Medical Sciences, Loni (Maharashtra),
MPT Associate Professor, 2MPT (CBR) Lecturer, Asst. Professor


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

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

102 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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
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
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%

21 Deepak anap 18th jan 12 (101-105).pmd 102 10/16/2012, 2:41 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 103

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.
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

21 Deepak anap 18th jan 12 (101-105).pmd 103 10/16/2012, 2:41 PM

104 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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.
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
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

21 Deepak anap 18th jan 12 (101-105).pmd 104 10/16/2012, 2:41 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 105

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.

21 Deepak anap 18th jan 12 (101-105).pmd 105 10/16/2012, 2:41 PM

106 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

To Study and Compare the Effect of Laptop Computers

with Desktop Computers on Working Posture and
Self-Reported Musculoskeletal Symptoms

Aditi Biswas1, Dheeraj Lamba2

Incharge, Physiotherapy IAHSET, Government Medical College, Haldwani


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

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 107


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
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.


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.

22 Dheeraj lamba 29th july 11 (106-110).pmd 107 10/16/2012, 2:41 PM

108 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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.

22 Dheeraj lamba 29th july 11 (106-110).pmd 108 10/16/2012, 2:41 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 109

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
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
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.

22 Dheeraj lamba 29th july 11 (106-110).pmd 109 10/16/2012, 2:41 PM

110 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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

22 Dheeraj lamba 29th july 11 (106-110).pmd 110 10/16/2012, 2:41 PM

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


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
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

112 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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
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.
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.
Postural neck pain 5 5 10
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
exercises for each of the three conditions. When he
Postural neck pain 5 5 10
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.

23 dhiraj shete 2nd jan 12 (111-116).pmd 112 10/16/2012, 2:41 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 113

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.


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.

23 dhiraj shete 2nd jan 12 (111-116).pmd 113 10/16/2012, 2:41 PM

114 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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

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


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

Demonstration by Model Method.


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,
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.

23 dhiraj shete 2nd jan 12 (111-116).pmd 114 10/16/2012, 2:41 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 115

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,
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
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.

23 dhiraj shete 2nd jan 12 (111-116).pmd 115 10/16/2012, 2:41 PM

116 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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.

23 dhiraj shete 2nd jan 12 (111-116).pmd 116 10/16/2012, 2:41 PM

Effectiveness of Physiotherapy for the Handwriting
Problem of School Going Children

Chandan Kumar1, Poonam Mehta2, Sobika Rao3

Neurology-Assistant Prof, 2Paediatrics- Assistant Prof, 3 MPT Student
M.M Institute of Physiotherapy and Rehabilitation, Mullana, Ambala


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

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

118 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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
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.
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

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:

24 chandan kumar 29th aug 11 (117-121).pmd 118 10/16/2012, 2:41 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 119

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
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

24 chandan kumar 29th aug 11 (117-121).pmd 119 10/16/2012, 2:41 PM

120 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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
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

24 chandan kumar 29th aug 11 (117-121).pmd 120 10/16/2012, 2:41 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 121

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.

24 chandan kumar 29th aug 11 (117-121).pmd 121 10/16/2012, 2:41 PM

122 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

Effect of Kinesio Tape in the Treatment of

Antenatal Carpal Tunnel Syndrome

Soheir M. El Kosery1, Fayiz F. Elshamy1, Hamid A. Atta Allah2

Department of Physical Therapy for Obstetrics and Gynecology, Faculty of Physical Therapy, Cairo University, Egypt
Department of Orthopedic Surgery, Faculty of Medicine (Girls), Al Azhar University, Egypt


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

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 123

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:

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

25 Fayez egypt 14th april 12 (122-126).pmd 123 10/16/2012, 2:41 PM

124 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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.

25 Fayez egypt 14th april 12 (122-126).pmd 124 10/16/2012, 2:41 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 125

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
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.

25 Fayez egypt 14th april 12 (122-126).pmd 125 10/16/2012, 2:41 PM

126 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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.

25 Fayez egypt 14th april 12 (122-126).pmd 126 10/16/2012, 2:41 PM

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

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.


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

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
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

128 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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
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
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.

26. Hanan Egypt (127-131).pmd 128 10/16/2012, 2:41 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 129


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

26. Hanan Egypt (127-131).pmd 129 10/16/2012, 2:41 PM

130 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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

(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.

26. Hanan Egypt (127-131).pmd 130 10/16/2012, 2:41 PM

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 131

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,

26. Hanan Egypt (127-131).pmd 131 10/16/2012, 2:41 PM

132 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

Efficacy of Active Release Technique in Tennis Elbow A

Randomized Control Trial

Harneet K M1, Khatri SM2

Postgraduate student, 2Professor & Principal College of Physiotherapy,
Pravara Institute of Medical Sciences, Loni- 413 736, Maharashtra state


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

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

Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3 133

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.


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).


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

27. Harneet 7th oct 11 (132-135).pmd 133 10/16/2012, 2:41 PM

134 Indian Journal of Physiotherapy & Occupational Therapy Letter. July-Sept., 2012, Vol. 6, No. 3

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

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 interve