Indian Journal of

Physiotherapy and Occupational Therapy An International Journal

ISSN P - 0973-5666ISSN E - 0973-5674

Volume 4 Number 2 April - June 2010

website: www.ijpot.com

Contentswww.ijpot.com

April - June 2010Volume 4, Number 2

Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2 I

1 Cumulative musculoskeletal disorders related to computer products use in Arabic children andadolescentsAfaf A.M. Shaheen, Samia A. Abdel Rahman

6 Effect of trunk control retraining in hemiparetic patients with postural disturbancesKumar A.

10 Efficacy of ischaemic compression technique in combination with strain counterstrain technique inmanaging upper trapezius myofascial trigger point painAmir Iqbal, Sohrab. A. Khan, Mohd. Miraj

16 Perception of effort and exhaustion in trained athletes – a validation of the psychobiological modelof exercise toleranceAmrith Pakkala, N.Veeranna

18 Effect of mechanical traction on neck pain and disability in patients with cervical radiculopathySanduja A.

22 Treatment of calcifying tendinitis of Gluteus medius and Gluteus minimus by Acetic acidIontophoresis – A case studyDeepak B. Anap, S.G. Gandge, Nitin J. Wagh

25 Effect of knee support brace and lateral wedge in sole on isokinetic peak torque in osteoarthritis ofthe knee–a randomized clinical trialGirija P., Eapen C., Zulfeequer, Kamath S.

29 Self motivation: Does it influence performance of motor function in post stroke individuals?Talhatu K. Hamza-t, Omobolanle A. Adebisi-Akinbile

32 Comparison of muscle energy technique and positional release therapy in acute low back pain – RCTNaik Prashant P., Heggannavar Anand, Khatri Subhash M.

37 Anterior cruciate ligament injury rehabilitation – An overview of reviewsBinu S. Das, Narasimman S.

40 Effect of sitting balance training under varied sensory input on balance and quality of life in strokepatientsIbrahimi N., Tufel S., Singh H., Maurya M.

46 Effect of single session of prolonged muscle stretch on spastic plantarflexors of children withquadriplegic and diplegic spastic cerebral palsyPreet Kamal Kaur

51 Influence of high-heels on few mechanical factors of lower extremity and lumbar lordosis amongcollege going femalesManishtha Bhan, Rahul Singh Parihar, P. Dhakshinamoorthy

55 Autism–Help for parentsRyan J. Smith

61 Comparison of Real-time Ultrasound Imaging and Pressure Biofeedback training for performingAbdominal Drawing-in Maneuver in low back painBajaj S., K. Chitra, S. Shallu

66 Effect of dominant hand training on intermanual transfer to sub dominant hand in patients withcerebral tumorsD. Satheesh, Ajay Sharma

71 Effect of ankle position on isometric quadriceps strengthening in osteoarthritis of knee jointKatyal Shveta, Nishat Quddas, Zubia Vequar

76 Craniocervical flexors endurance training: Treatment approach for cervical spondylosisShweta Gupta, Shallu Sharma, Chitra Kataria

82 Attitude of physiotherapy students towards communication skills and effects of an interactivelecture - A randomized controlled trialVaishali, Sailakshmi Ganeshan, C.V. Raghuveer

85 A cross sectional study of skeletal deformities in post menopausal women in urban and rural areasVeena Bembalgi

89 Comparative Analysis of Knee-laxity measurements by a left-hand- and a right-hand-dominantphysiotherapist in patients with Anterior Cruciates ligament injuries and healthy control groupVikas Trivedi, Vaibhav Agarwal

Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2

INDIAN JOURNAL OF PHYSIOTHERAPY ANDOCCUPATIONAL THERAPY

EditorDr. Archna Sharma

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Abstract

Background and Aim of the Study

Cumulative trauma disorder is physical injury resultingfrom the cumulative effects of repetitive stressfulmovements or postures. In recent years, there has been anincreasing concern over the association between interactivemedia, such as computers and video games and reports ofaches and pains in users. Computers are being used bychildren in the school and home environment morefrequently and there is little sign that this will reduce. Theaim of this study was to examine issues related to Arabicchildren/adolescents computer products use and upperphysical discomforts.

Methods

A cross-sectional study was conducted on 200 childrenand adolescents ranged in age from 7 to 16 years. Theywere selected from both sexes of equal number. Astructured 21-item Arabic questionnaire was used for datagathering. Questionnaire items included frequency andduration of use, type of computer products/ games and inputdevice used, presence of physical discomfort and parentalconcern related to the child's computer use. Results: Manychildren and adolescents experienced physical discomfortsattributed to computer use ranging from neck pain (42%) tobackache (30%). Some computer activities such as playingvideo arcade games and a joystick were significantlypredictive of physical discomfort using logistic multipleregression. Independent t-test showed that girls were morelikely to complain from neck pain (P=0.000). Many parentsused a computer as reward/punishment for the children(65%) and some of them (32%) reported difficulty gettingtheir children off the computer.

Conclusion

The computer products used in this study wereassociated with self-reported physical discomforts. Resultssuggested a need for multiyear longitudinal surveys.

Keywords

Cumulative musculoskeletal disorders, Computer products,Children, Adolescents.

Introduction

An increasing exposure of the younger generation tomedia is a worldwide phenomenon. Information technology

(IT) use by children is rapidly growing as children embraceIT activities as part of their normal daily life in education,leisure and communication, at both school and homeenvironments. Research on the ergonomics of IT use bychildren has begun to investigate the potential effects of ITuse on a child’s health, satisfaction and productivity. Severalstudies have suggested children with high usage of IT maybe at greater risk of the development of musculoskeletalproblems1.

Cumulative trauma disorder (CTD) is physical injuryresulting from the cumulative effects of repetitive stressfulmovements or postures. Areas commonly involved are thehand, wrist, shoulder, and neck, resulting in disorders suchas carpal tunnel syndrome and neck tension syndrome2.

Not only have adults increased their computer use overthe years, but children are also spending more time e-mailing, playing video games, and word processing3. TheLongitudinal Study of American Youth found that in 1990,only one in fifty children used a computer for ten hours ormore outside of class for the entire year4.

Although use levels are not the same as for adultcomputer users who are at risk of work-related upperextremity problems, children’s overall burden of computerand electronic device use is notable. Combined media useestimates approach a working day, with combined keyboardand game use accounting for up to three hours. Newertechnologies such as text-messaging phones may add tothe load5.

In 2000, the Kaiser Family Foundation reported that ninepercent of all children use a computer for more than an houra day. Children are using computers more than ever, andthere is a strong correlation between increased computeruse, improper computer posture, and musculoskeletal pain,such as back, neck, and shoulder pain, in children ages 7-176.

Many studies have reported that the discomfortassociated with computer use may be the result ofinadequate workstation set-ups that do not meet students’postural needs1,6,7. There are limited studies on the effectsof computer use on a child’s physical well being. Someresearchers suggested that children are at an even greaterrisk than adults because computers and peripherals aredesigned for adults’ larger proportions8.

Childhood's back, neck, and shoulder pain have beensuggested to be a predictor of adult's back, neck, andshoulder pain. Therefore, the risk factors associated withcomputer use causing these discomforts; need to beaddressed at a young age in order to preventmusculoskeletal discomfort or injuries in adulthood6.

Studies conducted in elementary and middle schoolshave reported that children do experience musculoskeletaldiscomfort similar to those of adults during computer use6.

1Afaf A.M. Shaheen / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2

Cumulative musculoskeletal disorders related to computerproducts use in Arabic children and adolescentsAfaf A.M. Shaheen1, Samia A. Abdel Rahman2

1Departments of Basic Sciences, 2Physical Therapy for Disturbances of Growth and Development in Children and its Surgery,Faculty of Physical Therapy, Cairo University, Egypt

Two studies have shown that the use of electronic gamesand computers by children and adolescents can beassociated with pain, pain syndromes and repetitive straininjuries (RSI) of the musculoskeletal system7,9. Morerecently, three cases of tendonitis and/or cutaneous lesionsassociated with computer and video game use have alsobeen described in children and adolescents10,11,12.

Generally, none of the studies on children andadolescents to date have adequately examined usagehabits, prevalence of symptoms or specific causal models ofupper extremity musculos-keletal disorders and computerproducts use among Arabic school children andadolescents. In effort to better understand the potential CTDrisk for Arabic children and adolescents, a questionnairewas administered to a sample of students to ascertainpatterns of use, self-reported physical discomfort, andbehavior changes. The principal hypothesis thequestionnaire examined was increased computer use andcomputer-related games exposure was related to higherself-reported upper body physical discomfort.

Subjects and Methods

SubjectsA cross-sectional study was conducted during the period

from October to February 2010. Two hundred children/adolescents were recruited from 2 public primary and 2intermediate schools in Riyadh, Kingdom of Saudi Arabia.Children had equal number of boys and girls with ageranged from 7 to 16 years old. Children/ adolescents wereexcluded if they had any past histories of musculoskeletaltrauma and/or other diseases affecting their musculoskeletalsystem.

QuestionnaireAccording to Burke and Peper13, a structured 22-item

questionnaire that included 16 items for the interviewedchild and 5 items for child's/ adolescent's parents wastranslated (forward and back ward) into Arabic and modifiedto include only 21-items, 16 items for the children and 5items for their patents. Validity and reliability ofquestionnaire were tested. The main out-come variablesincluded 6 dichotomous (present/ absent) CTD-relatedphysical complaints: wrist discomfort, neck discomfort,headache, eye strain and fatigue. The main predictorvariables included items from 4 relevant areas: (a) somaticfactors (age, gender, glasses, and level of activity); (b)psychological factors (depression, social withdrawal,hyperactivity and aggression); (c) environmental factors(time using computer alone and parental control of access);and (d) behavioral factors (input devices, nature of use andduration of use).

ProceduresBefore collecting data, the volunteers were familiarized

with the questionnaire and instructed in data collectionprocedures. The questionnaire was described as aninstrument to assess children and adolescents/familycomputing habits. Ethical approval was obtained fromschools authority. Children’s parents were informed of allaspects of the study and were given their consents.

Statistical analysisStatistical analysis was carried out using the statistical

package for social sciences (SPSS) version 10.1. All of thestatistical tests were two-tailed, and the 5% level of

significance was adopted (p≤0.05). In the description of thevariables, the parameters determined were mean, standarddeviation, range and percentiles. Independent t-test wasused to compare the difference between boys and girlsregarding to computer activities and self- reported physicaldiscomfort. Independent t-test was also used to comparephysical discomfort in boys and girls according to the level(moderate and high) of computer use. Logistic regression(backward stepwise) was used to consider the bestpredictors of physical complaints based on differentsomatic, psychological, behavioral and environmentalfactors.

Results

The questions were completed fully by 200schoolchildren/adolescents, their mean age was10.85±1.65. The following analysis was based on theiranswers. Students reported using computer products for anaverage 3.79±1.29 year, range (0-7) years. The averageweekly use of computer products was 7.77±3.69 hours,range (1-19 hours).

Using computer productsMost of the students had computer available for use at

home (98%), followed by friends' home (31%) and school(19%). In addition the students reported using computer fore-mail (66.50%), chat (46.50%), surfing (68.50%),educational games (74%) and non-educational games(76%). There was no significant difference between boysand girls regarding all the computer activities (p>0.05). Inaddition to playing games on computer, students alsoreported whether they played home video games such asNintendo (22 %) and video arcade games (37%) and handheld games such as game boy (56%). On the other hand, t-test referred no significant differences between boys andgirls regarding using videogames, home videogames andhand held games (p>0.05) (Table 1).

Students played games either alone, with others liveplayers or with other net work players. Sixty seven percentreported that they played alone at times, (36%) played withothers while (19%) played networked players. The mostcommon input device used by children was the mouse(80%) followed by keyboard (40%) and joysticks (5%).

Self-reported physical complaintsStudents reported on physical complain they believed to

be related to computer products use. On average, 29.5% ofstudents reported back discomfort and 41.5% reported neckdiscomfort. Independent t-test showed that girls were morelikely to complain from neck pain (p=0.000) (Table 2).

2 Afaf A.M. Shaheen / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2

Table 1: Percent of using each computer activity, comparison by gender

Computer Activities Percent Boys Girls t-value Two-tailedof using Mean ± SD Mean ± SD Significance

eachactivity

E-mail 66.50 0.61±0.49 0.72±0.45 1.651 0.10Chat 46.50 0.42±0.49 0.51±0.50 1.275 0.204Surfing 68.50 0.67±0.47 0.70±0.46 0.455 0.650Educational games 74.00 0.69±0.46 0.79±0.41 1.615 0.108Non-educational games 76.00 0.77±0.42 0.75±0.44 -0.330 0.742Videogames 37.00 1.60±0.49 1.64±0.52 0.557 0.578Home videogames 22.00 1.79±0.43 1.71±0.49 -1.21 0.227Hand held games 56.00 1.41±0.49 1.45±0.52 0.558 0.568

SD: Standard deviation.

Physical discomforts were analyzed in relation to hoursof computer use throughout the week. According to the levelof computer products use, the students were placed intoone of two levels - moderate and high use - thencomparisons for the presence of physical discomforts weremade between the two levels. Significance differences werefound for head (p=0.024), neck (p= 0.000), wrist (p= 0.001)and back (p= 0.033) (Figure 1).

Physical complaints related to multiple predictors

Logistic regression was used to consider the bestpredictors of physical complaints based on differentsomatic, psychological, behavioral and environmentalfactors according to Burke and Peper13, the specificpredictors selected were (a) somatic factors (glasses), (b)psychological factors (depression, social withdrawal,hyperac-tivity, aggression), (c) behavioral factors (inputdevices such as mouse, keyboard and joystick), gamedevice choices such as home computer videogames,handheld games), and the duration of use) and (d)environmental factors including time using computer alone,parental control of access). The predictors of physicaldiscomforts were shown in Table (3).

Parent's observationsParents commented on several issues related to their

children's computer products use. Sixty nine percentimposed limits on computer use. About 34% of parents usedsoft ware to control internet use and 32% had difficultygetting their children off the computer. On other hand, 65%of parents used a computer as reward/punishment for theirchildren.Psychological factors reported by parents

Parents also reported on psychological factors believedto be related to computer products use. Parents reportedincreased aggression 39%, less interest in outdoors andless physical activities 37%, hyperactivity 24.5%, socialwithdrawal 15.5% and depression 9.5%. There were nosignificant differences by gender except for aggression

(p=0.03) with boys being more aggressive than girls aftercomputer product use (Table 4).

LimitationsAs in any study, there are limitations and for this study,

one major limitation was the use of self-report survey. Theresults were also limited to four public schools in one city.Risk factors for musculoskeletal disorders may revealfurther if the study is performed on larger sample torepresent children and adolescents.

Discussion

There was a high rate of computer products use by bothsexes, with students reporting an average of 7.77 hours ofuse per week. Most of the students (about 98%) hadcomputers at home, and most of the time in use was spentin playing games alone (about 67%). Physical complaintsperceived to be related to computer use were common,ranging from 30% reporting backache to 42% for neckdiscomfort. These results are supported by Harris andStraker14 who found that 60% of a sample of 271 students,aged 10–17 years, reported discomfort with using theirlaptop computers. The results are also supported by thework done by Jacobs and Baker7 who reported that morethan 40% of the participants reported that they haveexperienced computer-related musculoskeletal discomfort/pain. In a survey of 382 high school students, 28% reportedhand discomfort after using the computer, 40% reportedneck/back pain and 41% reported general body pain15.

3Afaf A.M. Shaheen / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2

Table 2: Percent of students who reported computer-related discomfort, bygender

Physical Percent Boys Girls t-value Two-tailedlocations reporting Mean ± SD Mean ± SD Significanceor discomfortSymptoms by location

Head 33.50 0.31±0.46 0.36±0.48 0.75 0.456Neck 41.50 0.28±0.45 0.55±0.50 4.01 0.000Eye 37.50 0.32±0.47 0.43±0.49 1.61 0.109Wrist 30.50 0.30±0.46 0.31±0.46 0.15 0.879Back 29.50 0.25±0.44 0.34±0.48 1.39 0.164Fatigue 31.00 0.28±0.45 0.34±0.48 0.92 0.361

SD: Standard deviation.

Fig. 1: Means of physical discomforts between levels of weekly computeruse.

Table 3: Significant predictors of each physical complain via logisticregression

Physical Predictors Probability βComplains

Eye glasses 0.035 0.404Headache Joystick 0.016 5.798

Weekly use 0.024 1.013Neck Weekly use 0.000 1.277discomfortEyestrain No significant predictors

Weekly use 0.000 1.226Depression, sadness, moodiness 0.029 0.088

Wrist Play video arcade game 0.050 0.470discomfort Less interest in outdoor or physical activity 0.017 2.726

Hyper, restless, fidgety 0.005 3.404Irritability, easily angered, aggressive 0.050 2.230Play home videogame 0.016 0.412Years of using computer 0.014 1.421

Backache Play game boy 0.042 0.502Weekly use 0.001 1.180Irritability, easily angered, aggressive 0.037 2.216Less interest in outdoor or physical activity 0.010 2.658Play video arcade game 0.001 4.377Mouse 0.004 0.302Weekly use 0.005 1.143

Fatigue Keyboard 0.011 2.325Play game boy 0.018 0.421Play alone 0.026 2.394Less interest in outdoor or physical activity 0.041 2.107

Table 4: Percent of parents reporting perceived psychological changes inchildren

Psychological Percent Boys Girls t-value Two-tailedChanges Mean ± SD Mean ± SD Significance

Aggression 39.00 0.47±0.50 0.32±0.47 -2.185 0.03Depression 09.50 0.90±0.29 0.10±0.30 -0.240 0.81Hyperactivity 24.50 0.25±0.44 0.24±0.43 -0.164 0.87Social withdrawal 15.50 0.16±0.37 0.15±0.36 -0.194 0.85Less physical activity 37.00 0.37±0.48 0.37±0.49 0.000 1.00

SD: Standard deviation.

Jones and Orr15 further concluded that since high schoolstudents are establishing their lifestyle activities andpatterns, the increased computer use at a younger age mayincrease the prevalence and trauma associated withcomputer use as students become older. Students are atrisks for repetitive strain injuries because of studentbehavior, laboratory arrangements, a lack of emphasis onposture in the curriculum and the attitudes/perceptions offaculty and administrators16.

There were no significant differences in reportedcomplaints by gender except for neck discomfort as theresults showed that the girls were more likely to complainfrom neck discomfort. Significant differences were found forlevels of usage, with higher use related to more reporteddiscomforts. This is consistent with previous research,where gender was also found to be a significant factor17,18,19.Noack-Cooper et al.,20 stated that the students in their studyreported experiencing frequent musculoskeletal discomfortspecifically associated with the activity of using computers.Female students in the study reported a higher frequencyof discomfort associated with using a computer than themale participants. They also reported that the neck region tobe the most common site of frequent discomfort. This alsoagrees with other studies who found more discomfort infemales21,22,23,24.

The results of this study disagree with a study done byZapata et al.,25 who stated that despite the frequent use ofcomputer and video games among the adolescents whoparticipated in the study; this use was not associated withthe presence of pain and musculoskeletal pain syndromes.

Most of parents used the computer asreward/punishment for their children. They reported difficultyin getting their children off the computer products. Parentsalso perceived an increase in various psychologicalphenomena, including aggression, less physical activity andhyperactivity. The parents reported that boys were moreaggressive than girls after computer product use. Thesereports come in agreement with a study done by kraut etal.,26 who reported that the computer use was related toincreases in depression and social isolation and a reductionin psychological well-being. Also, television viewing and useof computer games are significant aspects of theincreasingly sedentary life-style of adolescent andcontribute to the epidemic in adolescent obesity27,28.

Logistic regression predicting physical discomforts froma variety of variables found fatigue to have the largestnumber of significant predictors followed by wrist discomfortand backache. These findings agree with those of Kroemeret al.,2 who found hand and wrist pain to be the mostcommonly associated CTD symptoms of computer use. Thebest predictor of fatigue in the present study was playingvideo arcade games (p=0.001).

The psychological factors – depression, less interest inoutdoor or physical activity, depression – were significantlyin three of the six physical complaints. Interestingly, all ofthem were significant predictors of wrist discomfort. Otherresearchers have similarly found significant relationshipbetween computer use and changes in psychological well-being14, and between psychological factors and CTDsymptoms29,30, 31. In a multivariate analysis of a studyperformed by Burke and Peper13, an association was foundbetween pain/discomfort in the wrist and the use of nonpedagogic electronic games, games involving the use of a

joystick and also with psychosocial factors, such asdepression, aggressiveness and social isolation.

Conclusion

A great deal of further research is necessary tounderstand how computer products are influencing thehealth of Arabic children/ adolescents. This study was justa preliminary examination of many questions about childrenand computer use. Without controls in this area, we may beraising children/adolescents who are more prone tomusculoskeletal disorders because they have had a longerexposure period to computer use and also, have no ideahow to protect themselves through the use of ergonomicallycorrect computer workstations. Efforts to reduce exposuresto risk factors associated with musculoskeletal discomfortshould not only include the workforce, but those that arebeginning to use computers, including children inelementary schools, middle schools and high schools.Healthy interactive media strategies may be vital topreventing/reducing the incidence of discomfort similar tothose of adults during computer use.

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29. Barmmer C. Review of current knowledge –musculoskeletal problems. In: Berlinuet L, BertheletteD, eds. Work with display units 89. Amsterdam: ElsevierScience Publishers: 1990; pp. 113-120.

30. Moon SD, Sauter SL. Beyond biomechanics:psychosocial aspects of musculoskeletal disorders inoffice work. London: Taybr & Francis: 1996.

31. Lundberg U, Dohns IE, Melin B, Sandsjo L, PalmerudG, Kadefors R, et al. Psychological stress responses,muscle tension and neck and shoulder pain amongsupermarket cashiers. J Occup Health Psychol. 1999;4: 245-255.

Afaf A.M. Shaheen / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2 5

Effect of trunk control retraining in hemiparetic patients withpostural disturbancesKumar A.

Lecturer, Department of Physiotherapy, Guru Jambheshwar University, Hisar, Haryana

Abstract

Background

Postural disorders are frequent in victims of hemiplegiaand limit or delay the recovery of gait and functionalindependence. This makes postural control a priority in poststroke rehabilitation.

Objective

To find out the effectiveness of Trunk Control Retrainingin Hemiparetic patients with postural disturbances and alsoto find out any probable relationship between posturaldisturbance and side of paresis.

Design

One group pre-test post-test quasi experimental design.

Setting

Tagore Hospital and Research Centre, Jalandhar.

Population & sampling

15 hemiparetic subjects of both sexes in age group of40-65 years and of either side affection were selected byconvenient sampling method (right and left hemi.) andassigned in a single group.

Intervention

Trunk control retraining therapy for duration of 30 mineveryday for 4 times a week and for a total of 4 weeksduration. i.e. total 16 sessions was administered with triviallymade Bon Saint Come device.

Main outcome measure

Patients were assessed before commencement andafter the completion of 16th treatment session by a fixedbattery of tests namely sitting equilibrium index and uprightequilibrium index and then postural graphs were taken withthe help of trivially made swaymeter.

Results and conclusions

Trunk Control Retraining has significant effect inimproving the postural disturbances in right hemipareticpatients but there is no statistically significant effect on Lefthemiparetic patients.

Introduction

Postural steadiness is the dynamics of the posturalcontrol system associated with maintaining balance duringquiet standing. The control of posture requires a complexinteraction of Neural and Musculoskeletal systems. Neuralcomponents essential to postural control include (a) Motorprocesses, which include organizing muscles throughoutthe body into neuromuscular synergies; (b) Sensory/perceptual processes involving organization and integrationof visual, vestibular, and somatosensory systems; and (c)higher level processes essential for mapping sensation toaction and ensuring anticipatory and adaptive aspects ofpostural control. On the other hand, musculoskeletalcomponents include such things as joint range of motion,spinal flexibility, muscle properties and biomechanicalrelationships among linked body segments1.

Postural disturbances are frequent in victims ofhemiparesis and limits or delay the recovery of functionalindependence and gait. This makes postural control apriority in post stroke rehabilitation2. In patients withhemiparesis, the unrestricted and unguided repetitions ofthe motor task may reinforce compensatory movements3.After stroke, the ability to control balance in the sitting andstanding positions is a fundamental skill of motor behaviorfor achieving autonomy in everyday activities. The posturalperformance of patients soon after a stroke has been foundto be closely correlated with long-term functionalimprovement. Because it may help in establishing theseverity and prognosis of a stroke, the early assessment ofbalance in stroke survivors is an important part of the clinicalexamination4. Analysis of balance relies either on clinicalscales or on instrumentation. The advantage of the formeris mainly related to the need to assess balance in eachpatient with a stroke, irrespective of the severity ofimpairment. The advantage of the latter is mainly related tothe fact that in some conditions, the use of newbiotechnology is helpful for understanding the diseases5.

In patients with the recent hemiparesis, trunk movementcontrol is an indispensable basic motor ability for executionof many functional tasks. Trunk is recruited beforerecruitment of arm joints such that the trunk begins movingbefore the beginning of the hand movement and cancontinue moving even after the hand has stopped at thetarget6.

There is no consensus as to the method of rehabilitatingpostural control in hemiparetic patients, but variousapproaches which are probably complementary appearpromising. These measures include a neuromuscularapproach7, biofeedback training8 and cognitivemanagement9. Sensory manipulations including vestibularcaloric stimulation and transcutaneous neurostimulation

Kumar A. / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 26

have been shown to improve posture in hemiplegic patients,probably by modifying their egocentric reference frame10.Recently promising results in rehabilitation of hemiplegicpatients for whom retraining control over voluntary trunkmovement was coupled with execution of exploratory taskby using a device conceived by Bon Saint Come. Thismethod was initially applied with success in unilateralneglect11.

Material and method

Population and Sampling15 hemiparetic subjects of both sexes in age group of

40-65 years and of either side affection were selected byconvenient sampling method (right and left hemi.) andassigned in a single group.

Criteria for Sample selectionPatients were included in the study with following

Inclusion Criteria:• Hemiparesis caused by single supratentorial ischemic

or hemorrhagic stroke.• Duration should not be more than 1 month.• Static imbalance of the trunk resulting from the stroke

as measured by sitting and upright equilibrium indexes.i.e. only grade 1 and 2.A criterion for Exclusion of the patients was:

• Multi/Infratentorial cerebral lesions (confirmed byCT/MRI findings).

• Severe deficits of execution of functions (cognitivedysfunctions like Aparaxia or agnosia etc).

• Visual or auditory deficits found during detailedNeurological assessment of the patient.

• Deterioration of state of general health that might alterpostural performances.

• Any prediagnosed movement disorder e.g. Parkinsonism,chorea, and athetosis.

Instrumentation and tools used

1. Indexes to measure postural control namely• Sitting equilibrium index.• Upright equilibrium index.

2. Postural Sway Assessment tool for measuring posturaldisturbances mainly in forward and sideway reachingactivity i.e. Swaymeter.

3. Trivially made Bon Saint Come Device for treatmentpurpose.

4. Graph Sheets having millimeters markings.

5. Ball Pen to record the spontaneous movements of thebody at waist level.

6. Table on which graphs were plotted.

Technique of data collection

Swaymeter that measures spontaneous displacementsof the body at waist level (in between ASIS and GT level)was used to take postural graphs. The device consisted ofa 40cm long rod with a vertically mounted pen at its end.One rod was attached to subjects by a firm belt that extendsposteriorly. As subject attempt to stand as still as possible,the pen records the sway of subjects on a sheet of millimetergraph paper fastened to the top of an adjustable heighttable. Testing was performed with the eyes open. Total pre-treatment sway (number of millimeter squares traversed bythe pen) in the 30 second periods was recorded for the testson the day of assessment. Patients were guarded all thetimes by the therapist and one helper during the wholeprocedure.

Trivially made Bon Saint Come device was used for thetreatment purpose. Device has 2 parts that areinterconnected by straps: a trunk orthosis and one pointer.A custom molded trunk orthosis having chin supportanteriorly and one posterior vertical support that hold a 150cm horizontal pole projecting over subject’s head which isdesignated as the pointer was used.

Procedure used

During the initial session, a history, subjective andobjective examination and thorough neurological evaluationwere performed. Fifteen patients with hemiparesis rangingfrom 40-65 yrs of age, of both sexes and of either affectedside were included in this study. Their demographic profileand detailed medical history were collected throughindividual interviewing and from medical records. A signedconsent was taken from each of the patient. Sitting and

Fig. 1: Trivially made Swaymeter

Fig. 2: Trivially made Bon Saint Come Device

Table 1: Comparison of Mean for Anteroposterior (AP) & Mediolateral Sway(ML) at Pre Vs Post intervals within whole group:

Mean SDPre AP 21.06 5.22Post AP 17.66 5.15

Pre Vs Post (t value) 2.74P Value <0.016Pre ML 7.66 1.23Post ML 9.13 2.16

Pre Vs Post (t Value) -2.621P Value <0.020

Kumar A. / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2 7

upright equilibrium index scores were taken first and thenwere included in the study. Their postural graphs were takenwith trivially made swaymeter on the same day i.e.assessment day.

Subject’s positioning and stabilization

Position of the patient for Trunk Control Retrainingprotocol was sitting on a stool placed beyond the arm’slength. Each patient received Trunk Control Retrainingtherapy in which he was instructed to perform the exercisesof touching the wall with the pointer by controlling the trunkmovements. All the exercises were performed in sittingposition only. During the whole procedure, the patients wereguarded by therapist and one helper all the times to avoidany fall or other injury to the patient.

Data analysis and interpretation

Pre-test and Post-test values were obtained before andafter Trunk Control Retraining program. Changes in posturalcontrol were assessed using Anteroposterior (AP) andMediolateral (ML) sways. Mean, SD and’t’ test values wereused to find out the statistically significant difference.

Total No. of subjects = 15No. of males = 8 No of females = 7Right hemiparetics = 11 Left Hemiparetics = 4

Results and discussion

This was a one group pre-test post-test quasiexperimental study which finds out the effect of TrunkControl Retraining in hemiparetic patients with posturaldisturbances. The hypothesis that the trunk controlretraining is significantly effective in patients with posturaldisturbances can be fully accepted on the basis of findingsin this study as the P value for Anteropoaterior andMediolateral sway was less than 0.016 and 0.02 whichrevels the statistical significance of the study.

But when we compare the effect of this trunk controlretraining between right and left hemiparetic patients, whichwas the second objective of this study, then it is found thatit is effective only in right hemiparetic patient as the P<0.05.The same hypothesis cannot be fully accepted for lefthemiparetic patients on the basis of statistical findings(p>0.05).

It appears from the results of the present study, that righthemiparetic group had similar improvement in terms ofAnteroposterior and mediolateral sways; however we coulddetect no significant difference in left hemiparetic patientsin terms of same anteroposterior and mediolateral sways.

Fig. 3: Postural graphs taken from patients with Swaymeter

Fig. 4: Patient receiving Trunk Control Retraining Therapy

Fig. 5: Showing comparison of Mean for AP and ML sways within wholegroup.

Table 2: Comparison of Mean for Anteroposterior (AP) & Mediolateral Sway(ML) at Pre Vs Post interval within Right Hemiparetic group:

Mean SD Pre AP 19.72 3.74Post AP 16.00 3.49

(Pre Vs Post) ‘t’ Value 2.23P Value <0.05Pre ML 7.54 0.93Post ML 9.27 2.10

(Pre Vs Post) ‘t’ Value -2.72P Value <0.05

Table 3: Comparison of Mean for Anteroposterior (AP) & Mediolateral Sway(ML) at Pre Vs Post interval within Left Hemiparetic group:

Mean SD Pre AP 24.75 7.50Post AP 22.25 6.70

(Pre Vs Post) ‘t’ Value 2.61P Value <0.05Pre ML 8.00 2.00Post ML 8.75 2.62

(Pre Vs Post) ‘t’ Value -0.60P Value >0.05

21.06

17.66

7.669.13

0

5

10

15

20

25

sway excursion

(Cms)

Comparison of Mean for Anteroposterior (AP) & Mediolateral Sway

(ML) at Pre Vs Post intervals within whole group

Series1 21.06 17.66 7.66 9.13

Pre AP Post AP Pre ML Post ML

Kumar A. / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 28

Fig. 6: Showing comparison of Mean for AP and ML sways within the group. Fig. 7: Showing comparison of Mean for AP and ML sways within the group

This is the first study in its type which shows thedifference in the pattern of recovery in Right and Lefthemiparetic populations.

Hemiparetic patients show a larger sway area and alateral displacement of the center of pressure toward theside of the lesion compared to normal subjects.Furthermore, left hemiparetic patient shows greater swayarea and lateral displacement compared to right hemipareticpatients9.

Displacements of Center of pressure is much more inleft or right hemiparetic patients than the normal ambulatorysubjects. The affected hemisphere and the disturbedcerebral networks likely produce different postural deficitsin right and left hemiparetic patients. Left hemiparetics havemore low frequency center of pressure movement from sideto side and from back to back than the patients with righthemiparesis12.

Motor cortex, cerebellum, and basal ganglia are involvedin voluntary control of posture and learning different posturaltasks. However, these structures play different roles inpostural control and learning: basal ganglia are mainlyinvolved in learning a general strategy of CP control whilethe function of the motor cortex chiefly concerns learning aspecific CP trajectory. The cerebellum is involved in bothkinds of learning13.

It was examined by some researchers that theanteroposterior and mediolateral components of balanceduring quite stance. They noted that with mediolateral swaythe loading and unloading of right and left side look likemirror images, with the weight unloaded from one side beingtaken up by the other. In addition, mediolateral movementsthat occur during quite stance shows a descendingresponse organization, with head movement occurring first,followed by hip movements (20 msec latency) and thenankle movements (40 msec latency). Head movementsoccur in the direction opposite to those at the hip andankle14.

As these postural disturbances are very frequent inhemiparetic patients, so Trunk control retraining therapy canbe considered as an adjunct to physical therapy protocols.Additional studies are required to quantitate clinical effectsand dose responsiveness. The deficiency of clinicalresearch on Bon Saint Come has resulted in controversyregarding their implementation for patient with posturaldisturbances more in mediolateral direction.

19.72

16

7.549.27

0

5

10

15

20

sway excursion

(Cms)

Comparison of Mean for Anteroposterior(AP) and Mediolateral Sway

(ML) at Pre Vs Post interval within Right Hemipareticgroup

Series1 19.72 16 7.54 9.27

Pre AP Post AP Pre ML Post ML

24.7522.25

8 8.75

0

5

10

15

20

25

sway excursion

(Cms)

Comparison of Mean for Anteroposterior(AP) & Mediolateral Sway(ML)

at Pre Vs Post interval within Left Hemiparetic group

Series1 24.75 22.25 8 8.75

Pre AP Post AP Pre ML Post ML

References

1. Shumway-cook A, Woollacott M. motor control theoryand practical application. Williams and Wilkins,Baltimore 1995.

2. Wade DT, Wood VA, Hewer RL. Recovery after stroke:the first three months. J Neurol Neurosurg Psychiatry,1985; 48:7-13.

3. Cirstea MC, Ptito A, Levin MF: Arm reachingimprovement with short term practice based on theseverity of the motor deficits in stroke. Exp Brain Res.2003; 152:476-488.

4. Feigin L, Sharon B, Czaczkes B, Rosin AJ. Sittingequilibrium 2 weeks after a stroke can predict thewalking ability after 6 months. Gerontology. 1996;42:348 –353.

5. Jongbloed L. Prediction of function after stroke: a criticalreview. Stroke.1986; 17:765–766.

6. Kaminski TR, Bock C, Gentile AM. The coordinationbetween trunk and arm movements. Exp brain Res,1995; 106:457-466.

7. Bobath B. Adult hemiplegia: evaluation and treatment.London: Heinemann; 1974.

8. Winstein C, Gardner ER, McNeal DR, Barto PS,Nicholson DE. Standing balance training: effect onbalance and locomotion in hemiparetic adults. ArchPhys Med Rehabil 1989; 70:755-62.

9. Rode G, Tiliket C, Charlopain P, Boisson D. Posturalasymmetry reduction by vestibular caloric stimulation inleft hemiparetic patients. Scand J Rehabil Med 1998; 30:9-14.

10. Magnusson M, Johansson K, Johansson BB. Sensorystimulation promotes normalization in postural controlafter stroke. Stroke 1994;25:1176-1180.

11. Wiart L, Bon saint come A, Debelleix X, Petit H, JosephPA, Mazaux JM, et al. unilateral neglect syndromerehabilitation by trunk rotation and scanning training.Arch Phys Med Rehabil 1997; 78:424-9.

12. Peurala SH, Könönen P, Pitkänen K, Sivenius J, TarkkaIM Postural instability in patients with chronic stroke.Restor Neurol Neurosci. 2007; 25(2):101-8.

13. Ioffe ME, Ustinova KI, Chernikova LA, Kulikov MA.Supervised learning of postural tasks in patients withpost stroke hemiparesis, Parkinson's disease orcerebellar ataxia, Exp Brain Res. 2006 Jan; 168(3):384-94. Epub 2005 Sep 21.

14. Winter DA, Prince F, Steriou P, Powell C. Medial-lateraland anterior-posterior motor responses associated withcenter of pressure changes in quite standing.Neurosciences Res Commun 1993; 12:141-148.

Kumar A. / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2 9

Efficacy of ischaemic compression technique in combinationwith strain counterstrain technique in managing upper trapeziusmyofascial trigger point painAmir Iqbal*, Sohrab. A. Khan**, Mohd. Miraj***

*Research Student, **Lecture, Hamdard University, ***Director, Institute of Health and Management Studies, New Delhi

Abstract

Objective

To establish the best possible long term effective choiceof treatment program for deactivating MTrPs by using thecombination of ischaemic compression technique withstrain-counterstrain technique.

Design

Pretest-Posttest control group design.

Setting

Outpatient physiotherapy department, Northern RailwayCentral Hospital, New Delhi.

Patients

Fourty five subjects (only male) with Myofascial TriggerPoints Pain. Subjects were randomly placed into threegroups: Experimental group A (n=15), Experimental group B(n=15) and a control group C (n=15).

Intervention

The experimental group A received ischaemiccompression technique in combination with strain-counterstrain technique and experimental group B receivedischaemic compression technique alone whereas controlgroup received conventional treatment only.

Main Outcome Measures: Pain pressure threshold wasassessed with the pressure threshold meter (PTM). Painand functional status of the patients were measured by avisual analogue scale (VAS) and the Neck Disability Indexscores respectively.

Results

Within group analysis revealed significant improvementin pain pressure threshold, functional status and reductionin pain intensity in all groups. Between group analysisrevealed significant difference between group A, group Band group C. Further post hoc analysis revealed significantdifference between group A and B, group A and C andgroup B and C for all variables even after one week of followup after the termination of intervention.

Conclusion

The combination of ischaemic compression techniquewith strain-counterstrain has been shown to produce greater

improvement in pain pressure threshold on pressurethreshold meter, function status on neck disability indexscores and reduction in pain intensity on visual analoguescores even after one week of the termination ofintervention. This shows the long term effectiveness ofcombination of two manual techniques. This study mayprovide a rationale for the clinical use of these two manualtechniques in deactivating the myofascial trigger points pain.

Key words

Myofascial trigger points pain, Upper trapezius musclepain, Pain pressure threshold, Pressure threshold meter,Ischaemic compression technique, Strain-counterstraintechnique.

About 23 million persons, or 10 percent of the U.S.population, have one or more chronic disorders of themusculoskeletal system1. Musculoskeletal disorders are themain cause of disability in the working-age population andare among the leading causes of disability in other agegroups2. Myofascial pain syndrome is a common painfulmuscle disorder caused by myofascial trigger points3. Thismust be differentiated from fibromyalgia syndrome, whichinvolves multiple tender spots or tender points3. The spotsare painful on compression and can produce referred pain,referred tenderness, motor dysfunction, and autonomicphenomena4.

Trigger points are classified as being active or latent,depending on their clinical characteristics5. An active triggerpoint causes pain at rest. It is tender to palpation with areferred pain pattern that is similar to the patient’s paincomplaint6. This referred pain is felt not at the site of thetrigger-point origin, but remote from it. The pain is oftendescribed as spreading or radiating7. Referred pain is animportant characteristic of a trigger point. It differentiates atrigger point from a tender point, which is associated withpain at the site of palpation only8.

Fig. 1: Application of Ischaemic compression technique on upper trapeziusmyofascial trigger point.

Amir Iqbal / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 210

A latent trigger point does not cause spontaneous pain,but may restrict movement or cause muscle weakness6. Thepatient presenting with muscle restrictions or weakness maybecome aware of pain originating from a latent trigger pointonly when pressure is applied directly over the point9.

There are several proposed histopathologicmechanisms to account for the development of triggerpoints and subsequent pain patterns, but scientific evidenceis lacking. Many researchers agree that acute trauma orrepetitive micro trauma may lead to the development of atrigger point. Lack of exercise, prolonged poor posture,vitamin deficiencies, sleep disturbances, and joint problemsmay all predispose to the development of micro trauma5.Occupational or recreational activities that producerepetitive stress on a specific muscle or muscle groupcommonly cause chronic stress in muscle fibers, leading totrigger points. Predisposing activities include holding atelephone receiver between the ear and shoulder to freearms; prolonged bending over a table; sitting in chairs withpoor back support, improper height of arm rests or none atall; and moving boxes using improper body mechanics11.Often, the muscles used to maintain body posture areaffected, namely the muscles in the neck, shoulders, andpelvic girdle, including the upper trapezius, scalene,sternocleidomastoid, levator scapulae, and quadratuslumborum12. In the head and neck region, myofascial painsyndrome with trigger points can manifest as tensionheadache, tinnitus, temporomandibular joint pain, eyesymptoms, and torticollis13.

Palpation of a hypersensitive bundle or nodule of musclefiber is the physical finding most often associated with atrigger point10. The palpation will elicit pain over the palpatedmuscle and/or cause radiation of pain toward the zone ofreference in addition to a twitch response. The commonlyencountered locations of trigger points and their painreference zones are consistent8. No laboratory test orimaging technique has been established for diagnosingtrigger points9. However, the use of ultrasonography,

electromyography, thermography, and muscle biopsy hasbeen studied.

There are many treatments approach are available inphysical therapy to deactivate the MTrPs12 such asIschaemic compression technique, spry and stretchtechnique, Strain -Counter strain technique, Trigger pointpressure release technique, Ultrasound deep heat therapy,Thermo Therapy, Laser Therapy, Needling Therapies,Transverse Friction massage, Post isometric relaxation(MET), Electrical muscle stimulator, Stretching etc.

MTrPs can be deactivated by temporarily occluding theirblood supply and causing a reactive increase in bloodsupply, effectively flushing out the muscle of inflammatoryexudates and pain metabolites, breaking down scar tissue,and reducing muscle tone. The muscle is nourished by theextra flow-through of blood, nerve endings are desensitized,and scar tissue is broken down so that the muscle fibers canmove better.

Essentially, Ischaemic compression technique involvesapplying sustained pressure to the trigger points withsufficient force and for long enough to slow down the bloodsupply and force the tension out of the muscle. Strain-Counterstrain (S-CS) is a gentle, indirect manipulativetechnique for the treatment for the treatment of somaticdysfunction. It is one of several treatment approaches wherepositioning of the body is used to evoke a therapeutic effect.These approaches have been categorize and “positionalrelease” and include “functional technique” and “facilitatedpositional release”.

Travell12 discussed Strain Counterstrain in relation to thetreatment of trigger points and suggested that most of thetender points listed in Jone’s original books (Jones 1981)are closely related to attachment trigger points’ site. This ishowever, not universally true. In most of the cases majority,of Jone’s tender points are demonstrately the same entitiesas Simon and Travell’s trigger points. Moreover, Simon andTravell suggested that a therapeutic approach whicheffectively deactivates tender points should beneficiallyinfluence the other trigger points also. Therefore, LeonChaitow(13) suggested that clinical evidence also support

Fig. 2: Application of Strain-counterstrain technique on upper trapeziusmyofascial trigger point.

Table 1: Between group post hoc Bonferroni analysis for PPT

PPT 0 PPT 1 PPT 3 PPT 5 PPT 6‘p’ ‘p’ ‘p’ ‘p’ ‘p’

Group A Vs Group B 1.000 0.119 .000 .000 .000Group B Vs Group C 1.000 .396 .006 .000 .000Group A Vs Group C 1.000 .002 .000 .000 .000

Table 2: Between group post hoc Bonferroni analysis for VAS

VAS0 VAS1 VAS3 VAS5 VAS6‘p’ ‘p’ ‘p’ ‘p’ ‘p’

Group A Vs Group B 1.000 .061 .000 .027 .000Group B Vs Group C 1.000 .781 .001 .000 .000Group A Vs Group C 1.000 .003 .000 .000 .000

Fig. 3: Subject performing stretching maneuver to upper trapezius muscle.

Amir Iqbal / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2 11

this supposition, especially when the positional releasemethod is combined with other approaches such asischaemic compression, MET, etc. which have good trackrecord in trigger point deactivation.

Although ischemic compression technique used invarious studies has been proven to be effective in themanagement of trigger points, but only short-term effectshave been established with this manual technique. Also noresearch till date has been attempted to reveal thecombined effectiveness of ischemic compression techniquewith any other manual technique for the complete resolutionof trigger points. Therefore the study has designed toestablish the best possible long term effective choice oftreatment program for deactivating MTrPs by using thecombination of ischaemic compression technique withstrain-counterstrain technique. Aim and Objective of thestudy was to find out the efficacy of ischemic compressiontechnique in combination with strain – counterstraintechnique in managing upper trapezius myofascial triggerpoint.

Experimental hypothesis

Ischaemic compression technique in combination withStrain-counterstrain technique is more effective thanischaemic compression technique alone in managingrelieving upper trapezius myofascial trigger point pain.

Null hypothesis

Ischaemic compression technique in combination withStrain-counterstrain technique is as effective as ischaemiccompression technique alone.

The Purpose of the study to establish the best possiblelong term effective choice of treatment program fordeactivating MTrPs by using the combination of ischaemiccompression technique with strain-counterstrain technique.

Materials and methods

Total 45 male subjects those met the inclusion criteriaand found to have clinically active palpable myofascialtrigger point pain (MTrPs) in unilateral upper trapeziusmuscles were recruited from the northern Railway CentralHospital (NRCH), Connaught Place, New Delhi andpresented with the proposal of the study. Subjects were

invited to participate in the study and informed consent wastaken from them.

Inclusion criteria was limited to male only having age 19-38 years, maximum 3-5 active MTrPs which when palpatedreplicated their chief complaints in the upper trapeziusmuscle (unilateral), subjects didn’t receive any treatment fortheir trigger points before one month prior to the study.Patients were excluded when they had diagnosed case offibromyalgia syndrome according to American college ofRheumatology (Wolf et al 1990). Presented active MTrPs inbilateral Upper Trapezius Muscles, history of whiplashinjury, History of cervical spine surgery, diagnosis of cervicalradiculopathy or myelopathy determined by the primaryhealth care physician, had undergone myofascial paintherapy within the past one month before the study,exhibited inadequate co-operation. Sample of conveniencewas used for the selection of the subject. Pretest – Posttestcontrol group design was used in the study. There werethree groups each containing 15 subjects.

A Thermoregulatory Hydrocolator machine was used inthis study. Thermostat knob was fixed at 750C to achievethe therapeutic range of warmthness for hot packs.Standardized hot pack was used in this study. Hot packtemperature was maintained at the 750C, wrapped with 2towels to keep the temperature for comfortable warmth andapplied for 20 minutes over the shoulder as to cover theupper trapezius muscle in supine lying position. Pressurethreshold meter (PTM), standardized tape measure,treatment plinth (Couch) and washable marker wareused.Outcome measures were pain pressure threshold(PPT), visual analogue scale (VAS) and Neck DisabilityIndex Scores (NDI). Manual techniques applied wereischaemic compression technique and strain–counterstraintechnique.

Procedure

The pressure threshold meter (“WAGNER FORCE DIALFDK 20” was used in this study, It was used to assess thepain pressure sensitivity of myofascial trigger point pain as

Table 3: Between group post hoc Bonferroni analysis for NDI

Variables NDI0 NDI5 NDI6‘p’ ‘p’ ‘p’

Group A Vs Group B 1.000 0.007 .001Group B Vs Group C 1.000 .002 .003Group A Vs Group C 1.000 .000 .000

Fig. 4: Between group comparison of VAS

Fig. 5: Between group comparison of NDI

Fig. 6: Between group comparison of PPT

Amir Iqbal/Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 212

suggested by Fischer.17 The trigger point with lowestpressure pain threshold value was designated the primarytrigger point. Subjects were advised that they would feelsome pressure over the trigger points and that they shouldindicate when the sensation changed from one of pressureto one of pain by saying ‘there’ / ‘yes’. Three consecutivemeasurements were obtained by the same assessor andthe mean was considered in further analysis. At least 1minute elapsed between the 2 consecutive measurements,as suggested by Fischer.17 After the pre-treatment data ofthe PPT, a second application of 2.5 kg/cm2 of pressurewas applied by the physiotherapist. Subjects were told torate their pain on the VAS, assessing local pain evoked bythe application of that amount of pressure. A functionalquestionnaire “Neck Disability Index (NDI)” was provided tothe subjects to assess their functional limitations due tomyofascial trigger points pain. The subjects were instructedto take the closest choice to the one which indicated the truesubjective assessment of the subject disability for thatparticular item. The scores for each item were added andfinal score was calculated for analysis. After pre-treatmentmeasurements, subjects were divided randomly into twogroups, using a “Chit Method”: All the three groups receivedHot Packs and Active Stretching Under the supervision ofPhysiotherapist followed by Group A was treated withischemic compression technique along with straincounterstrain technique, and group B was treated only withischemic compression technique and group C was nottreated with any of the manual techniques rather thanconventional treatment. The appropriate technique wasapplied by physiotherapist. Post-intervention measurementswere taken 2 minutes after the application of the techniqueby Physiotherapist in the same way as in the preinterventionmeasurements. For the ischemic compression technique,the patient was in supine position with the cervical spine inopposite lateral flexion to the treating part so that the uppertrapezius muscle fibers was kept in a lengthen position (107)(fig 3.3). The Physiotherapist applied gradually increasingpressure to the MTrP until the subject perceived firstnoticeable pain. At that moment, the pressure wasmaintained until the discomfort and/or pain eased by around50%, perceived by the own patient, at which time pressurewas increased until discomfort appeared again. Thisprocess was maintained for 90 seconds. For strain counter-strain technique, the part (upper trapezius muscle) wasexposed and the subject was in supine position with thecervical spine in neutral position. The Physiotherapistlocated the active MTrPs in the Upper Trapezius muscleusing “pincer palpation” method. A mechanical PressureThreshold Meter was used to find out the most active triggerpoint among all MTrPs. Once located, the Physiotherapistapplied gradually increasing pressure to the MTrP until thesensation of pressure became one of pressure to one ofpain. Followed by subject was then passively placed in aposition that reduced the tension under the palpating fingersand caused a subjective reduction of pain by around 75%.In the present study, the position that reduced pain wasusually ipsi-lateral side-flexion of the cervical spine inaddition to a slightly contra lateral cervical rotation i.e. 5–80. The subject upper extremity was previously passivelypositioned in 900 of abduction. That position wasmaintained for 90seconds. Finally, the subject was slowlypassively placed in a neutral position (13). For Active

Stretching (self stretching), Subject was seated on a fullback supported chair without arm rest.

Protocol

Prior to participation each subject were required to readand sign an informed consent form. The entire subject whohad met the inclusion and exclusion criteria was assignedrandomly via chit method to any of the three groups.Pressure Pain Threshold (PPT), and Visual Analogue Scale(VAS) scores were taken pre-intervention and after 2 min. ofpost-intervention at day 1, day 3 and day 5 and one week offollow up after the termination of intervention. Neck DisabilityIndex (NDI) score assessment were taken but limited to preintervention at day 1 , post intervention at day 5 day andone week of follow up after the termination of intervention.All the three groups received the treatment on threealternate days for one week. Experimental group A receivedHot Packs at 750C for 20 minutes and Active Stretchingexercises (Slow, 5 repetition per session, 10 seconds holdand 10 seconds relaxation between two repetition) followedby ischemic compression (90 seconds) followed by straincounterstrain technique (90 seconds Hold in “position ofease”). Experimental group B received all the exercises ofgroup A except Strain Counterstrain technique only. Controlgroup C received all the exercises of group A except StrainCounterstrain and Ischemic compression technique only.

Statistical analysis was done using SPSS 15.0 Software.Repeated measure ANOVA was used for within groupanalysis and one way ANOVA was used for between groupanalysis for all the variables. These outcomes measureswere pain pressure threshold, pain intensity and neckdisability index scores.

Results of statistical analysis of pain intensity (PI), PainPressure Threshold (PPT) and Neck Disability Index Scoresare described below

Within group: All the three group showed the significantimprovement for all variables at day 1 postintervention andfinal day 5 postintervention when compared with theirrespective baseline. Only group C showed insignificantimprovement after one week of follow up when comparedwith their baseline value.

Between group analysis revealed significant differencebetween group A, group B and group C. Further post hocanalysis revealed significant difference between group Aand B, group A and C and group B and C for all variableseven after one week of follow up after the termination ofintervention. Further details are given in following tables:

Discussion of the results

The study was designed to find out the efficacy ofischemic compression technique in addition to strain-counterstrain in managing upper trapezius myofascialtrigger point pain. The inter group comparison of the studyreveal that trigger point sensitivity was significantly reducedwhen ischemic compression was combined with strain-counterstrain technique than Ischaemic compression alone.

The results of this study can be discussed with theprevious studies done by Hong et al., 1993; Hanten et al2000; Freyer and Hodgson, 2005; (Jones, 1981; Chaitow,2001). The results obtained by these authors are similar tothose obtained in this present study for ischemic

Amir Iqbal/Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2 13

compression and strain counterstrain techniques in themanagement of myofascial trigger point pain.

Hong et al. (1993) concluded that the best results indecreasing pain from MTrPs were obtained with deep softtissue compression techniques when compared toconventional massage.

In another study by Hanten et al. (2000), theeffectiveness of a home program involving ischemiccompression followed by sustained stretching over activeMTrPs was examined. The results of their study clearlyrevealed that the combination of these techniques was moreeffective in reducing tenderness from MTrPs.

Fryer and Hodgson (2005) have concluded that theischemic compression technique was better than shammyofascial technique in reducing tenderness on latentMTrPs in the upper trapezius muscle.

The above studies explained that ischemic compressiontechnique may bring analgesia and increase pressure painthreshold by following mechanism.

Pain relief from pressure treatment may result fromreactive hyperemia in the MTrP region, or a spinal reflexmechanism for the relief of muscle spasm21.

Local pressure may equalize the length of sarcomeres inthe involved MTrP and consequently decrease pain18.

Deep pressure could offer effective stretching andmobilization of the taut bands20.

Fryer and Hodgson (2005,) who recently demonstratedthat decreased local MTrPs tenderness was due to achange in tissue sensitivity rather than any unintentionalrelease of pressure by the practitioner12.

The ischemic compression technique can also beexplained by the concept of the “barrier release” proposedby Lewit (1991) in which the therapist gradually appliespressure to the MTrP until a definitive increase in resistanceis perceived, i.e. the barrier, which is usually perceived asnot being painful by the subject21.

Hence it can be concluded that ischemic compressiontechniques might be helpful in reducing pain, increasingpain pressure threshold and in turn improving functionalstatus in subjects with myofascial trigger points.

The mechanism relief of pain and increased painpressure threshold by Strain-Counterstrain technique is alsothought to achieve its benefits by means of an automaticresetting of muscle spindles which would help to dictate thelength and tone into the affected tissues13. Finally, there isemerging evidence supporting the activation of descendinginhibitory pathways with the application of manualinterventions (Ferna´ndez-de-las-Pen˜as et al., 2007; Skybaet al., 2003). Hence, different mechanisms would probablyact at the same time.

The improvement in the control group is attributed to theeffects caused by stretching and hot packs. Stretching ofthe affected muscle is believed to be an integral part oftrigger point therapy. Lewit and Simons demonstrated that“muscle lengthening” utilizing post-isometric relaxationappears to be effective in reducing trigger point sensitivityand pain intensity, without the use of vapocoolant spray22.Jaeger and Reeves, who reported the effectiveness of sprayand stretch in decreasing pain intensity and increasingpressure pain threshold, indicated that vapocoolant spraycould not produce anesthesia in the subcutaneous tissuesor muscle because of the depth of the tissue.They sugg-

ested, therefore, that it is the stretch that resulted in thedecrease in trigger point sensitivity, not the spray. Theirstudy supports the idea that muscle lengthening is theprocess that provides pain relief19. Travell and Simons alsoargued that the mechanism of relief in spray and stretch isthe stretch. They hypothesized that decreasing MTrPs painutilizing spray and stretch is due to the elongation of themuscle to its full normal length12. Moist heat tend to relaxthe underlying muscles and to diminish the tension on theTrPs, thereby reducing referred pain and local tenderness topressure12. The patient’s passive or active stretch exercisesat home are more effective performed during or immediatelyafter the application of moist heat12.

Since, the group A received all the techniques such asischemic compression, strain-counterstrain, so the highergain in pain relief and increase pain pressure threshold maybe attributed to the above mechanism explained andsupported by different previous studies12,13,18,19,20,21,22.

Clinical relevance to the practice is that it is highlyeffective in deactivating the MTrPs within a very short spanof period, cost effective as well as non invasive therapy,requires minimum time to get relieve without causing muchpain. Its long term effects will establish this combinationtechnique as a complete choice of treatment to deactivatethe MTrPs. Future research is required to support thehypothesis of pain relief by quantifiable histochemicalanalysis.Further research is required to clearly define thetherapeutic mechanism of pressure treatment. There is alsono agreement as to the amount of pressure that it isnecessary to apply during a pressure technique. Therefore,further studies are required to clearly define the quantifiedamount of pressure that is necessary to apply to a MTrP toobtain clinical improvement. The result of the study showedthat application of Ischaemic compression technique alongwith Strain Counterstrain technique is the most beneficial,result oriented method in managing upper trapeziusmyofascial trigger point pain, though the Ischaemiccompression technique and Active stretching exerciseshave also found to be effective. The dependent variable wasfound to be improved in all the three groups, maximum beenseen in experimental group A.

Therefore this study is concluded by rejecting the “NullHypothesis” that “Ischemic Ischaemic compressiontechnique in combination with Strain-Counterstraintechnique is as effective as ischaemic compressiontechnique alone” and accepting the ExperimentalHypothesis that “Ischaemic compression technique incombination with Strain-counterstrain technique is moreeffective than Ischaemic compression technique alone inmanaging upper trapezius myofascial trigger point pain.This study was limited to small sample size, only malesubjects as it was cultural suitable to expose the treatmentarea, lack of definitive amount of pressure to deactivateMTrPs and limited to railways employees only.

Acknowledgment

I am very very thankful to research review board JamiaHamdard, Internal guide Dr. Sohrab A, Khan, External guideDr. Mohammad Miraj, participant of the study and my familyfor their valuable suggestions and constant supportthroughout of this study.

Amir Iqbal / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 214

References

1. Imamura ST, Fischer AA, Imamura M, Teixeira MJ,Tchia Yeng Lin, Kaziyama HS, et al. Pain managementusing myofascial approach when other treatment failed.Phys Med Rehabil Clin North Am 1997; 8:179-96.

2. Cole TM, Edgerton VR. Musculoskeletal disorders.In:Cole TM, Edgerton VR, eds. Report of the Task Forceon Medical Rehabilitation Research: June 28-29, 1990,Hunt Valley Inn, Hunt Valley, Md.Bethesda: NationalInstitutes of Health, 1990:61-70.

3. Hong CZ, Hsueh TC. Difference in pain relief aftertrigger point injections in myofascial pain patients withand without fibromyalgia. Arch Phys Med Rehabil 1996;77:1161-6.

4. Simons DG, Travell JG, Simons LS. Travell & Simons’Myofascial pain and dysfunction: the trigger pointmanual. 2d ed. Baltimore: Williams & Wilkins, 1999:5.

5. Han SC, Harrison P. Myofascial pain syndrome andtrigger-point management. Reg Anesth 1997;22:89-101.

6. Ling FW, Slocumb JC. Use of trigger point injections inchronic pelvic pain. Obstet Gynecol Clin North Am1993;20:809-15.

7. Mense S, Schmit RF. Muscle pain: which receptors areresponsible for the transmission of noxious stimuli? In:Rose FC, ed. Physiological aspects of clinicalneurology. Oxford: Blackwell Scientific Publications,1977:265-78.

8. Hopwood MB, Abram SE. Factors associated withfailure of trigger point injections. Clin J Pain 1994;10:227-34.

9. Fricton JR, Kroening R, Haley D, Siegert R. Myofascialpain syndrome of the head and neck: a review of clinicalcharacteristics of 164 patients. Oral Surg Oral Med OralPathol 1985;60:615-23.

10. Simons DG, Travell JG, Simons LS. Travell & Simons’Myofascial pain and dysfunction: the trigger pointmanual. 2d ed. Baltimore: Williams & Wilkins, 1999:94-173.

11. Rachlin ES. Trigger points. In: Rachlin ES, ed.Myofascial pain and fibromyalgia: trigger pointmanagement. St. Louis: Mosby, 1994:145-57.

12. Simons DG, Travell JG, Simons LS. Travell & Simons’

Myofascial pain and dysfunction: the trigger pointmanual. 2d ed. Baltimore: Williams & Wilkins, 1999:11-93.

13. Sola AE, Bonica JJ. Myofascial pain syndromes.In:Bonica JJ, ed. The management of pain. 2d ed.Philadelphia: Lea & Febiger, 1990:352-67.

14. Hou, C.R., Tsai, L.C., Cheng, K.F., Chung, K.C., Hong,C.Z., 2002. Immediate effects of various physicaltherapeutic modalities on cervical myofascial pain andtrigger-point sensitivity. Archives of Physical andMedical Rehabilitation 82, 1406– 414.

15. Meseguer A.A, Ferna´ndez-de-las-Pen˜as C, Navarro-Poza J L, Rodrı´guez-Blanco C, Bosca´ Gandia J.J.Immediate effects of the strain/counterstrain techniquein local pain evoked by tender points in the uppertrapezius muscle; Clinical Chiropractic: 2006 vol. 9,112—118.

16. Jensen, M.P., Turbner, J.A., Romano, J.M., Fisher,L.D., 1999. Comparative reliability and validity ofchronic pain intensity measures. Pain 83, 157–162.

17. Fischer, A., pressure algometry over normal muscle,standard values, validity and reproducibility of pressurethreshold, pain 1987, 30; 115-126.

18. Simons, D., Hong, C.-Z., Simons, L., 2002. Endplatepotentials are common to mid fiber myofascial triggerpoints. American Journal of Physical Medicine andRehabilitation 81, 212–222.

19. Jaeger, B., Reeves, J.L., 1986. Quantification ofchanges in myofascial trigger point sensitivity with thepressure algometer following passive stretch. Pain 27,203–210.

20. Hou, C.R., Tsai, L.C., Cheng, K.F., Chung, K.C., Hong,C.Z., 2002. Immediate effects of various physicaltherapeutic modalities on cervical myofascial pain andtrigger-point sensitivity. Archives of Physical andMedical Rehabilitation 82, 1406–1414.

21. Lewit, K., 1991. Manipulative Therapy in Rehabilitationof the Locomotor System, second ed. ButterworthHeinemann, Oxford.

22. Lewit D, Simons DG. Myofascial pain: relief by post-isometric relaxation. Arch Phys Med Rehabil. 1984;65:452– 456.

Amir Iqbal / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2 15

Perception of effort and exhaustion in trained athletes – avalidation of the psychobiological model of exercise toleranceAmrith Pakkala*, N.Veeranna**

*MD, Associate Professor, Dept. of Physiology, PES Institute of Medical Sciences & Research, Kuppam 517 425, AP**Ex-Professor, Deptt. of Physiology, Karnataka Substitute of Medical Sciences, Hubli

Abstract

The point of maximum perception of effort andexhaustion in exercise is believed to be based on twomodels of exercise tolerance- the muscle fatigue model andthe psychobiological model. The muscle fatigue modelproposes that high intensity aerobic exercise stops at thepoint commonly called exhaustion because fatiguedsubjects cannot continue to generate the required poweroutput despite maximal voluntary effort. Exhaustion is aform of task disengagement rather than task failureaccording to the psychobiological model of exercisetolerance based on motivational intensity theory. This studyaims to further the validity of the psychobiological model ofexercise tolerance by studying the effect of motivationalpractices on the point of fatigue.

The results are suggestive of improvement in exercisetolerance after motivational practices bringing out the neuralcorrelates in point of fatigue.

Key words

Work achievability, Point of fatigue, Behaviouralpractices, Motivational practices.

Introdution

The muscle fatigue model of exercise toleranceassumes that exhaustion during high intensity aerobicexercise occurs because fatigued subjects are no longerable to generate the power output required by the taskdespite their maximal effort1. According to thepsychobiological model of exercise tolerance2 based onmotivational intensivity theory3,4 exhaustion is a form of taskdisengagement rather than task failure. Time to exhaustionto a large extent depends on state of mind resulting fromoccupational exposure to physiological and emotional stresswhich manifests through a combination of negativeattitudes. The psychobiological model of exercise tolerancecan explain the negative effect of experimental locomotormuscle fatigue on time to exhaustion5.

This study aims to further the validity of thepsychobiological model of exercise tolerance by studyingthe effect of motivational practices on the point of fatigue.

Material and methods

The present study was conducted in the Dept. ofphysiology, Karnataka Medical College, Hubli on a group of10 young adult male professional long distance runners tobring out the role of motivation practices on time toexhaustion and point of fatigue. All the subjects whoparticipated in the study gave informed consent. Detailed

procedure of the non-invasive investigation was explainedto them. They were subjected to detailed clinicalexamination to rule out the presence of any underlyingdiseases.Inclusion criteria for the study group:1. Healthy young adult males.2. Aged between 18-25 years.3. Long distance runners, 1500m & 5000m

Exclusion criteria for study group:1. Participation in competitive sports or any other regular

exercise program.2. Smoking.3. Clinical evidence of anemia, obesity, involvement of

cardio respiratory system or any illness.

Participants visited the laboratory on two differentoccasions with a minimum of 48hr between visits. All visitswere completed within a period of two weeks.Environmental conditions in the lab were kept between 19and 23 deg Celsius for temperature and 46 and 60% forhumidity.

During the first visit, subjects performed a incrementalexercise test until exhaustion on a motorized treadmill.Subjects were instructed to run on the treadmill as fast andas hard as possible for the entire duration of the test.

During the second visit subjects performed the test asabove but in order to instill a sense of competition and as amotivation a rank with all individual times to exhaustion wascirculated before the study from the previous visit.

The details of the anthropometric data of the group isshown in table no. 1

The following parameters were recorded on the studygroup after a maximal exercise testing and thecorresponding values were compared before and after thefirst and second visit. Statistical analysis was done by usingpaired t-test.i) Duration of work achievability[min]ii) Distance [km]iii) Work Done[kg m]iv) Power[kg m/s]

Results

Table 1: Anthropometric data of the study group (mean ±SD).

No. of Age Height Weight BMI Body surfaceCases (yrs) (cm) (kg) (kg/m2) area (m2)

10 22.2 ± 2.62 168 ± 7.50 61.46 ± 5.60 21.02 ± 2.46 1.81 ± 0.07

Table 2: Comparison of Exercise data before & after motivation session

Mean ± SD First Visit Second Visit p- value InferenceTime[min] 4.31 ± 0.42 4.72 ± 0.99 <0.05 S

Distance[km] 0.56 ± 0.14 0.81 ± 0.16 <0.001 VHSWork Done [kg m] 4245 ± 1056 5690 ± 1345 <0.001 VHS

Power[kg m/s] 974 ± 162 1207 ± 139 <0.001 VHS

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Discussion

On analysis of results, it is found that there is nostatistically significant difference in the duration of exercisebut there is a very highly significant difference [p<0.001] asfar as distance travelled, work done and peak powerachieved is concerned. All these parameters are found tobe higher in the second visit after the motivation by showingprevious rank of performance.

Most of the result on sustenance of aerobic exercise isbased on the assumption that, in highly motivated subjects,the tolerable duration of aerobic exercise is limited bycentral and/or peripheral muscle fatigue. It is assumed thataerobic exercise stops at the point commonly calledexhaustion because fatigued subjects are no longer able togenerate the power output required by the task despite theirmaximal voluntary effort.

Exercise tolerance is not only determined bycardiovascular, respiratory, metabolic and neuromuscularmechanisms of muscle fatigue but by psychological factorswhich are not well understood. The psychobiological modelof exercise tolerance2 views exhaustion as a form of taskdisengagement rather than task failure. Various studies lendsupport to the view that perception of effort and potentialmotivation are the key determinants of exercise tolerance.

The stress factors in a person range from personal tojob related to organizational.

Highest stressors included excessive workload,increasing overhead, departmental budget deficits, tenureand promotion, disputes with the dean, and loss of keyfaculty. Personal-professional life imbalance was identifiedas an important risk factor for emotional exhaustion.Withdrawal, irritability, and family disagreements are earlywarning indicators of burnout and emotional exhaustion6. Allthese result in progressive emotional exhaustion andbehavioural symptoms of de-motivation. De-motivationadversely affect performance of an individual in the shortrun and may bring down the productivity levels in the healthinstitution. The older adage that drive depends on anadequate level of stress is no longer held true. The signs ofstress all have an additive and accumulative effect. Taskperformance tends to drop.

The signs of stress lead to the typical burn out in theform of chronic exhaustion, a cynical attitude to work, lackof commitment, irritability and mental depression.Psychosomatic complaints are common in advancedstages.

This study is in line with the conclusion of similar ones7

that a psycho stimulant and the presence of a competitorhad a significant effect on work achievability. The results aresuggestive of improvement in exercise tolerance aftermotivational practices bringing out the neural correlates inpoint of fatigue and further the validity of thepsychobiological model of exercise tolerance.

References

1. Noakes TD, St Clair Gibson A (2004) Logical limitationsto the “catastrophe” models of fatigue during exercise inhumans. Br J Sports Med 38(5):648–649

2. Marcora SM, Bosio A, de Morree HM (2008) Locomotormuscle fatigue increases cardiorespiratory responsesand reduces performance during intense cyclingexercise independently from metabolic stress. Am JPhysiol Regul Integr Comp Physiol 294(3):R874–R883

3. Brehm JW, Self EA (1989) The intensity of motivation.Annu Rev Psychol 40:109–131

4. Wright RA (2008) ReWning the prediction of eVort:Brehm’s distinction between potential motivation andmotivation intensity. Soc Pers Psychol Compass2(2):682–701

5. Gagnon P, Saey D, Vivodtzev I, Laviolette L, MainguyV, Milot J, Provencher S, Maltais F (2009) Impact ofpreinduced quadriceps fatigue on exercise response inchronic obstructive pulmonary disease and healthysubjects. J Appl Physiol 107(3):832–840

6. Saleh KJ, Quick JC, Sime WE, Novicoff WM, EinhornTA. Recognizing and preventing burnout amongorthopaedic leaders. Clin Orthop Relat Res 2008 Nov22 [E pub ahead of print]

7. Jacobs I, Bell DG (2004) EVects of acute modaWnilingestion on exercise time to exhaustion. Med SciSports Exerc 36(6):1078–1082

Amrith Pakkala / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2 17

Effect of mechanical traction on neck pain and disability inpatients with cervical radiculopathySanduja A.

Department of Physiotherapy, Guru Jambheshwar University of Science & Technology, Hisar, Haryana

Abstract

Background

Neck pain and cervical radiculopathy is a very commonproblem in general population and in musculoskeletalpractice, accounting for 15% of all soft tissue problems.Twenty-six percent to 71% of the adult populationexperiences an episode of neck pain or stiffness in theirlifetime. Neck pain is more common in females than inmales, with rates reported as high as 77.8 percent. It has acostly impact on society because of visits to healthcareproviders, sick leave, disability and loss of productivity.

Method

A total of 20 patients (11 female & 9 male) with neck painparticipated in this prospective comparative study and weredivided into Control (group A) & Experimental (group B) byconvenient sampling. Neck pain and disability weremeasured with Visual Analogue Scale (VAS) & NeckDisability Index (NDI). These variables were assessed at0th, 8th and 16th session.

Results

Multivariable stepwise One way ANOVA and‘t’ testshowed that NDI score for group A and group B consistentlyreduced at 0th, 8th and 16th session but VAS score forgroup A notoriously changed. It finally reduced at 16thsession after a short span of increase at 8th session. Ingroup B, it showed consistent decrease at regular interval.

Conclusion

The findings of this study provide strong evidences thatneck pain is directly related with disability. The results implythat mechanical cervical traction is useful physiotherapeuticadjunct for reducing neck pain and ultimately neck disability.

Key words

Radiculopathy, Traction, Neck Disability, Pain.

Introduction

Cervical radiculopathy may be a result of mechanicalpressure on the nerve root exerted by disk protrusion orspondylotic spurring or a combination associated with aninflammatory component1. It has a costly impact on societybecause of visits to healthcare providers, sick leave,disability and loss of productivity. Some patients do notrecover and with time develop a chronic cervical pain

condition that also may involve pain in the shoulder andarm, being most pronounced on one side.

The presence of degenerative changes including diskdisease does not necessarily indicate a causal relationship2.Most individuals with radiographic signs of cervicalspondylosis and disk disease do not exhibit any symptoms3.Such changes therefore can only be regarded as a possiblepredisposing factor for the development of pain.

Factors associated with increased risk including heavymanual labor requiring the lifting of more than 25 pounds,smoking, and driving or operating vibrating equipment.Other, less frequent causes include tumors of the spine, anexpanding cervical synovial cyst, synovial chondromatosisin the cervical facet joints, giant cell arteries of cervicalradicular vessel, and spinal infections4.

Radiculopathy caused by a significant nerve rootcompression should be expected to produce weakness inthe muscle innervated by the involved nerve root5. Theseventh (C7; 60%) 6 and sixth (C6; 25%) cervical nerveroots are the most commonly affected7.

Motor or sensory loss may not always indicate the truelevel of pathology because of overlap or intersegmentalconnection of cervical roots or due to anastomoses betweenperipheral nerves8. Sometimes, the patients are not awareof any motor weakness9.

There are many controversies as to the choice oftreatment. The treatments that patients receive for the neckpain are varied, as the perception of the benefits of thesetreatments10. There is not enough study evaluatingcommonly used treatment strategies for patients with neckpain11. Different modalities of physiotherapy are oftenapplied in the acute as well as the chronic phase6,9. Thecomponents of usual physiotherapy treatment given in theliterature include electrotherapy, ultrasound, heat therapy(hot packs, ice), exercises, and manual therapy10,9. Manyauthors advocate a soft or semi-rigid collar, while somesuggest early mobilization as being most important for therelief of neck pain.

Fig. 1: Wall mounted cervical traction

Sanduja A. / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 218

Mechanical traction is often used as part of acomprehensive program in outpatient rehabilitation. Thevalue of this treatment has often been questioned becausestudies of its usefulness have generally been inconclusive12.It involves a traction force applied to the neck by amechanical system which can be applied intermittently orcontinuously. Traction has also been reported to decreasepain by providing muscle relaxation, stimulation ofmechanoreceptors, and inhibition of reflex muscleguarding13.

Material and methods

20 patients with radiating neck pain to either side fromlast 6 weeks, of both sexes in age group of 20-50 years inDepartment of Physiotherapy were divided into control(group A) and experimental (group B) by convenientsampling method. Patients were included in the study if theymet the following criteria:a) Neck pain radiating to either side from last 6 weeks.b) Age between 20-50 years of either sex.c) Grade 1 & 2 of cervical disc protrusion.d) Pre diagnosed degenerative disorder of cervical spine.

e.g. Cervical spondylosis.

Exclusion Criteria were:a) Patient above age of 50 years.b) Whiplash traumatic injuries.c) Severe deficits of execution of functions(cognitive

disorders)d) Progressive deterioration of state of general health.e) Cervical spine surgeries and spinal tumors.

Instrumentation and tools

a) Visual analogue scale (VAS) for measuring intensity ofpain.

b) Neck disability index (NDI) for measuring neck disability.c) Wall mounted traction unit.d) Cervical Hydro collateral packs.

Procedure

During the initial session, history, subjective andobjective examination and thorough neurological evaluationwere performed. 20 patients with radiating neck pain ofeither sex were divided into 2 groups viz.

Group A and group B by convenient sampling method.There demographic profile and detailed medical historywere collected through individual interviewing. A signedconsent was taken from each of the patient. There VASscores as well as NDI scores were taken on the day ofassessment i.e. day 0.

Subject PositioningPosition of the patient for mechanical cervical traction

was sitting on a stool with pillow on thighs and underforearms.

For cervical hydro collateral pack, the position of patientwas supine lying with pillow under the head.

Fig. 2: Hydro collateral pack

Fig. 3: Patient doing Neck Isometric

Fig. 4: Patient receiving ICT

Fig. 4.1: Showing the comparison of mean values of neck disability index(NDI) at 0th, 8th and 16th session.

Sanduja A. / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2 19

For neck isometric exercises, the position of the patientwas high sitting.

Group A (Control)Patients in this group were given Conventional

Physiotherapy which included hydro collateral packs, Neckisometric exercises and Ergonomic advices. The neckisometrics were given as per the standard isometricexercises. The duration of treatment was 40 minutes.

Group B (Experimental)Group B received mechanical traction in addition with

conventional physiotherapy. The weight for traction was10% of the total body weight of patient and duration ofmechanical cervical traction was 15 min.

Frequency of the treatment sessionDuration of the treatment protocol was of 40 minutes

every day for four times a week and for a total of four weeksi.e. sixteen sessions.

Data analysis & interpretation

The data obtained from 20 patients with cervicalradiculopathy participated in neck pain and disabilitytreatment program was analyzed with one way ANOVA andt-test. There were 11 females and 9 males in the wholepopulation. The whole population was divided into twogroups A and B having 10 patients each.

Results

Eleven female and 9 male patients with age group of 20-50 years were included in the study. The patients weredivided into two groups, viz. Group A (Control group) and

group B (Experimental group), each having 10 patients. Nopatients were performing regular exercises. The mean pre-treatment NDI and VAS pain scores for group A was38.60±11.15 and 5.00±1.15, respectively and for group Bwas 39.20±10.29 and 4.90±0.99 respectively. Whereas thepost-treatment values of NDI and VAS for group A were34.00±11.96 and4.50±1.35 respectively and for group Bwere 30.00±10.04 and 3.20±0.63 respectively.

In group A i.e. control group where only conventionalphysiotherapy was given, showed marked reduction indisability but no effect on pain. At the end of whole treatmentprogram, the p value was less than 0.05 for NDI, whereasthe intensity of pain was notoriously changing over thewhole period. In beginning, p value for VAS was more than0.05 which became less than 0.05 at the end of completionof 16th session. But when we compared the effect on Painintensity for whole of the group over stipulated treatmentprogram, there we found no statistically significant resultsas the p value was more than 0.05.

In group B i.e. experimental group receiving mechanicalcervical traction in addition to conventional physiotherapyshowed statistically significant improvements in VAS andNDI scores. This means that both the concerned domains ofstudy i.e. pain and disability showed marked improvementin experimental group (p< 0.05).

Discussion

These results are in accordance with the work of MoffettJAK, Jackson DA, Richmond S et al (2005). Moffett JAK etal in their study showed statistically significant improvementin neck range of motion in patients receiving continuoustraction.

Goldie and Landquist (1970) reported the results of arandomized controlled trial in 73 neck and arm pain patientswho were placed into one of the three groups: traction,isometric exercises, instruction. There was slightimprovement in the first two groups, with patient report,physician report, and ranges of motion used as outcomemeasures14.

Disease or injury to the cervical structures is thought toresult in muscle spasm of this supporting neck musculaturewhich may cause further pain. The cervical traction isapplied in an effort to stretch the involved cervical structuresto relieve spasm and pain. Investigators have hypothesizedmany causes for muscle spasm including (1) decreasedcirculation to the muscle fibers with ischemia and build up ofwaste products15. (2) Muscle tearing16. (3) Irritation ofsinuvertebral nerve serving injured ligaments or jointcapsules17. (4) Accumulation of irritating by-products ofinflammation16. (5) Over stretching and hyper-sensitivity ofmuscle spindles16. (6) Reflex firing of anterior horn cells inresponse to noxious stimuli.

Hunt CC, (1952) hypothesized an autogenic inhibitoryrole for the muscle spindle. The group II afferents werethought to be activated when the muscle was placed inlengthened position.

Jackson R (1978) and De Lacerda have suggested thatrhythmic intermittent traction reduces pain by improvingcirculation or by preventing and reducing adhesions andcontractures of the cervical structures. Traction stimulatesthe large afferent fibers of muscles and joints thatpresynaptically inhibit pain fiber transmission at the spinalcord level.

Fig. 4.2: Showing the comparison of mean values of Visual Analogue Scale(VAS) at 0th, 8th and 16th session.

Table 1: Comparison of mean value for NDI at 0, 8th and 16th session withinGroup A and Group B (Paired t test):

Comparison Group A Group Bt value P value t value P value

0 Vs 8th session 2.34 P < 0.05 6.70 P < 0.050 Vs 16th session 4.64 P < 0.05 5.23 P < 0.05

8th Vs 16th session 3.49 P < 0.05 2.74 P < 0.05

Table 2: Comparison of mean value for VAS at 0th, 8th and 16th sessionwithin Group A and Group B (Paired t test)

Comparison Group A Group Bt value P value t value P value

0th Vs 8th session -1.80 P > 0.05 3.67 P < 0.050th Vs 16th session 1.86 P > 0.05 6.53 P < 0.058th Vs 16th session 2.86 P < 0.05 4.71 P < 0.05

Sanduja A. / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 220

References

1. Ahlgren BD, Gar® n SR. Cervical radiculopathy.Orthopedic Clinics of North America 1996; 27: 253±263.

2. Matsumoto M, Fujimura Y, Sukuki N, Toyama Y, ShigaH. MRI of cervical intervertebral discs in asymptomaticsubjects. Journal of Bone and Joint Surgery 1998; 80:19± 24

3. Schellhas K, Smith M, Gundry C, Pollei S. Cervicaldiscogenic pain. Prospective correlation of magneticresonance imaging and discography in asymptomaticsubjects and pain suOEers. Spine 1996; 21: 300± 312.

4. Shelerud RA, Paynter KS. Rarer causes ofradiculopathy: spinal tumors, infections, and otherunusual causes. Phys Med Rehabil Clin N Am. Aug2002; 13(3):645-96. [Medline]

5. Garvey TA, Eismont F (1991) Diagnosis and treatmentof cervical radiculopathy and myelopathy. Orthop Rev20: 595-603

6. Radhakrishnan K, Litchy WJ, O'Fallon WM, Kurland LT.Epidemiology of cervical radiculopathy. A population-based study from Rochester, Minnesota, 1976 through1990. Brain. Apr 1994; 117(pt 2):325-35. [Medline]

7. Bogduk N, Twomey LT. Clinical Anatomy of the LumbarSpine. 2nd ed. Edinburgh, UK: Churchill LivingstoneInc; 1991.

8. Benini A (1987) Clinical features of cervical rootcompression C5-C8 and their variations.Neuroorthopedics 4: 74-88

9. Fager CA (1993) Identification and management ofradiculopathy. Neuro Surg Clin N Am 4: 1-12

10. Moffett JAK, Jackson DA, Richmond S et al (2005)

Randomized trial of a brief physiotherapy interventioncompared with usual physiotherapy for neck painpatients: outcomes and patients’ preference. BMJ330:75–81

11. Jellman G, Öberg B (2002) a randomized clinical trialcomparing general exercise, McKenzie treatment and acontrol group in patients with neck pain. J Rehabil Med34:183–190

12. Gross AR, Aker P, Goldsmith C, Peloso P.Conservative management of mechanical neckdisorders. A systematic overview and metaanalysis.The Online Journal of Current Clinical Trials 1996;30(5): doc no 200

13. Olivero WC, Dulebohn SC (2002) Results of haltercervical traction for the treatment of cervicalradiculopathy: retrospective review of 81 patients.Neurosurg Focus 12(2):1–3

14. Goldie I, Landquist A (1970) Evaluation of the effectsof different forms of physiotherapy in cervical pain.Scand J Rehabil Med 2–3:117

15. Gross AR, Aker P, Goldsmith C, Peloso P.Conservative management of mechanical neckdisorders. a systematic overview and metaanalysis.The Online Journal of Current Clinical Trials 1996;30(5): doc no 200

16. Peeters GGM, Verhagen AP, deBie RA, OostendorpRAB. The efficacy of conservative treatment in patientswith whiplash injury. Spine 2001; 26: E64_/E73

17. Kjellman GV, Skargren EI, Oberg BE. A critical analysisof randomized clinical trials on neck pain and treatmentefficacy. A review of the literature. Scand J Rehabil Med1999; 31: 139 _/152.

Sanduja A. / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2 21

Treatment of calcifying tendinitis of Gluteus medius and Gluteusminimus by Acetic acid Iontophoresis – A case studyDeepak B. Anap1, S.G. Gandge2, Nitin J. Wagh3

1Senior Lecturer, College of Physiotherapy, PIMS, 2HOD Dept. of Radiology, Pravara Medical Trust, Loni, 3College ofPhysiotherapy, PIMS, Loni

Introduction

Painful periarticular calcification is most commonly seenwithin the rotator cuff of the shoulder, although it maydevelop around the wrist, elbow, hip, knee, foot and rarelyin the neck . The deposits may be located within the tendonor in the soft tissues adjacent to the tendon or ligament nearits attachment to the bone. There is an acute inflammatoryreaction, with pain, exquisite tenderness, local swelling andredness. Misdiagnosis is common and leads to delay intreatment and recovery1-2.

Calcifying tendinitis of gluteus medius and minimus israrely seen condition with incidence of 0.5-1%. Goldenbergand Leventhal (1936) found calcified deposits near thegreater trochanter in 5.4%.

The etiopathogeny of calcifying tendinitis remainshypothetical. However, it has repeatedly been shown thathydroxy-apatite crystals3 are the main component of thecalcification after the occurrence of fibrocartilage within thetendon4. Degenerative tendons that have ruptured containsmore calcium deposits, but it is not always in the form ofcalcium phosphate. The increase calcium deposits is dueto degenerative calcification5 In contrast, the calcium intendons with radiographically visible calcifications is in theform of crystalline hydorxy-apatite. The clinicalpolymorphism of this condition is common6 and pain ispresent along with the functional impairment, it is customaryto treat these symptoms with anti-inflammatory drugs (orallyor injection), analgesics and if necessary, variousphysiotherapy treatment such as acetic acid iontophoresis7

and ultrasound therapy8. Other treatment alternatives arepercutaneous needle aspiration of calcium deposits byusing using ultrasonography guidance9. Extracorporealapproach with shockwave therapy10 and more rarely,surgery11. Iontophoresis is the introduction of topicallyapplied, physiologically active ions through the epidermisusing continuous direct current.

The clinical uses of acetic acid iontopheresis intreatment of patients with calcium deposits was firstdescribed in 1955 by Psaki and Carrol, and again in 1977 byKahn13.

Iontophoresis would appear to be an alternativetreatment to injection for introduction of the acetic acid16.

The physiologic basis for this approach rests on thepassage of ionisable substances through the skin—mainlyhair follicle and sweat gland canals17—through the polareffect of direct (galvanic) current, which thus triggers themigration of the ionized molecules placed under the samepolarity electrode toward the opposite polarity electrode18.In this way, acetic acid, which is an inorganic anion, isapplied under the cathode (negative electrode) and willmigrate toward the anode (positive electrode) whilesubmitted to galvanic current. Because the calcification

consists mostly of hydroxyapatite crystals, which is insolublein water but soluble in acidic pH, it is reasonable to expecta regression of the calcification. In the context of adversereactions or intolerance to anti-inflammatory agents, aceticacid iontophoresis, because of its noninvasive character,remains a frequently used treatment for calcifying tendinitisof the shoulder19.

Purpose of our study was to access the clinical andradiological effect of acetic acid iontophoresis in treatmentof calcific tendinitis of gluteus medius and minimus.

Case report

History

A 49 year male came with complaints of pain in left hipsince 6 months with inability to lie down on left side. He wastaking pain killers for same problem since six months but hefound no relief. Then he came to physiotherapy.

Pain history

Site: Over left hipOnset: InsidiousDuration: 6 monthsQuality: Dull AchingQuantity: (VAS Score)0--------------------6-----------------10Aggravating factors: Lying on the left side, prolongedsitting.Relieving Factors: Supine, lying on the right side, standing.

Examination

Patient was examined thoroughly by therapist.• Point tenderness (grade-2) on left range of motion for

abduction adduction and rotation was slightly reducedas compared to normal side.

• Resisted isometric for gluteus medius and gluteusminimus was weak and painful.

• End feel for left hip adduction was empty and forflexion/extension/rotation was absent.

Special test for left hipo Ober’s test positive.o Thomas test negative.o Faber Patrick test negative.

• So we suspected pathology in gluteus medius andgluteus minimus.

Investigations• X ray and USG investigation were advised under

orthopaedic opinion.• X-ray reveled a 15x10mm calcific deposits at the

Deepak B. Anap / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 222

insertion of gluteus medius and gluteus minimus. • USG confirmed x-ray findings

Pre Treatment X Ray

Treatment

Therapist discussed the treatment plan withorthopaedician, surgeon and patient.

In an attempt to decrease the size and possibleprogression of the calcium formation acetic acidIonotophoresis was chosen to supplement orthopaedicsurgeons prescription of analgesic tablet (tab Ultracet) andrelaxyl gel.

The patient was treated with acetic acid Iontophoresis inaccordance with sharps protocol for 3 weeks.

Technique3ml of a 2% acetic acid solution using a distilled water

dilution medium was introduced into the active drugelectrode.

The drug electrode [negative electrode (black-active)] ofPhyaction- Guidance-E was covered with cotton which canhold the solution and release slowly.

The treatment area of the electrode was approximately48 cm2 in diameter. Using an Phyaction-Guidance-E(Uniphy), the patient was treated with 4 mA of direct currentfor 20 mins for a total of 80mA.min, in accordance withsharp protocol.

Electrode position: Both electrodes sites were thoroughlycleaned with spirit and active (negative) drug electrode wasplaced over the site of calcific tendinitis. (Greater trochanter)on left side. Other electrode (positive-inactive) was placed8-10 cms distal to the active electrode. This treatment wasfollowed by treatment of tendinitis with protocol of

TendinitisTime-10min, Dynamic-CP, MF-frequency-50HRz, DF-

frequency-100HRz, MF-15, DF- 15On Phyaction-Guidance –E (Uniphy)

Exercises: Exercises like gluteus medius and gluteusminimus strengthening using thera tube and stretching(manual & self). The treatment was administered regularly5 days per week for 3 weeks. X-ray was repeated after 10days.

At the conclusion radiograph revealed mass to be 6mmin width and 4mm in length. After 2 weeks, pain in hip wasreduced to greater extent and X-Ray showed considerablereduction in calcific mass 3mm in width and 2mm in length.

At the end of third week resisted isometrics contractionfor gluteus medius and minimus was strong and painless.The calcific mass reduced almost to 1/4th of its original sizeand previously painful activities were found painless. Patientregained painless, full ROM of hip abduction and adductionand was able to resume daily activities. These results re -presented 95% decrease of mass.

Ergonomic advice:Patient was instructed to avoid anypainful activity like cross legged sitting and sleeping onaffected side, prolonged sitting on examination chair for 2weeks.

Post treatment x ray

Discussion

The exact mechanisms of the origin and of resorption ofthe calcium deposits are not clearly understood21.

Treatment using acetic acid Iontophoresis had beenpreviously indicated in treating conditions such as myositisossificans, calcific bursitis and calcifying tendinitis22-23.

The rationale of treatment was primarily to aim atincreasing the solubility of calcium deposits in tendons ofsoft tissues22-23 to encourage the removal of excess calciumions from injury site into the blood stream.

The acetate ion found in acetic acid is negative inpolarity and has been cited as effective in reducing the sizeof calcium deposits through the absorption of calcium. Theprocess by which iontophoresis occurs relies much more onthe laws of passive diffusion14. It has been postulated thatthe acetate radical replaces the carbonate radical in theinsoluble calcium carbonate deposits, forming a moresoluble calcium acetate, as the following equationdemonstrate15.

CaCo3 + 2 H (C2 H3O2) = Ca (C2H3O2)2 + H2O+ CO2

Japour et.al described in details the theoretical biom-echanical process where the use of acetic acidIontophoresis converts insoluble calcium carbonate inchronically inflamed tissue to calcium acetate, which isblood soluble22. After resorption of the calcium, the tendonprobably regains its original architecture by thesynthesis ofnew matrix, so that no functional impairment remains21.

Pain related with calcific tendinitis may be reduced by(Protocol Phyaction-Guidance–E) by pain gate mechanism24.

Stretching Exercises for gluteus medius and minimusmay have improved extensibility of muscle thereby increa-sing the ROM of hip joint.

Strengthening Exercises help to maintain the strength ofGluteus medius and minimums throughout the pathologicalprocess21.

Deepak B. Anap / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2 23

Conclusion

Calcific Tendinitis of Gluteus medius and minimus isuncommon pathology little research has been completed inthis area of treatment.

Following completion of this programme 95% reductionin the size of calcifying mass was demonstrated byradiographic evidence. Further studies are needed tosupport the use of acetic acid Iontophoresis for bothtreatment and possible use as prevention of calcifyingtendinitis.

Controlled studies with acetic acid Iontophoresis andcalcific tendinitis are necessary to establish the cause effectrelationship additional research, including single subjectdesign should be implemented to document the efficacy ofthis procedure.

Acknowledgement

Special thanks to Dr.S.A.Rairikar, Pricipal, COPT, Ourstudents and Friends.

References

1. Jozsa L, Balint B J, Reffy A. Calcifying tendinopathy.Arch Orthop Trauma Surg 1980; 97: 305-7.

2. Kannus P, Jozsa L. Histopathological changespreceding spontaneous rupture of a tendon. Jf BoneJoint Surg Am 1991; 73: 1507-25.

3. Gartner J, Simons B. Analysis of calcific deposits incalcifying tendinitis. Clin Orthop 1990;May(254):111-20.

4. Uhthoff H, Sarkar K, Maynard JA. Calcifying tendinitis:a new concept of its pathogenesis. Clin Orthop1976;Jul-Aug (118) : 164-8.

5. Anthony H Woodword “Calcifying Tendinitis” E -Medicine article October 23rd 2007.

6. Noe¨l E, Brantus JF, Nove-Josserand L, Liotard JP,Warch G. Les calcifications de la coiffe des rotateurs.Evolution naturelle. In: Simon L, editor. Actualite´s enre´e´ducation fonctionnelle et re´adaptation. Paris:Masson e´d; 1995. p 118-27.

7. Psaki C, Carroll J. Acetic acid ionisation, a study todetermine the absorptive effects upon calcifiedtendinitis of the shoulder. Phys Ther 1955;35:84-7.

8. Ebenbichler GR, Erdogmus CB, Resch KL, et al.Ultrasound therapy for calcific tendinitis of the shoulder.N Engl J Med 1999;340:1533-8.

9. Aina R, Cardinal E, Bureau NJ, Aubin B, Brassard P.Calcific shoulder tendinitis: treatment with modified US-guided fine-needle technique. Radiology 2001; 221:455-61.

10. Wang CJ, Ko JY, Chen HS. Treatment of calcifyingtendinitis of the shoulder with shock wave therapy. ClinOrthop 2001; Jun(387):83-9.

11. Ark JW, Flock TJ, Flatow EL, Bigliani LU. Arthroscopictreatment of calcific tendinitis of the shoulder.Arthroscopy 192;8: 183-8.

12. Cummings J, Iontophoresis. In: Nelson RM,Currier DP,eds. Clinical Electrotherapy. EastNorwalk, Conn:Appleton & Iange; 1987:231.

13. Kahn J. Acetic acid iontophoresis for calciumdeposits:suggestion from the field. Phys Ther. 1977;57:65&6.

14. Prentice, WE (2002). Therapeutic Modalities forPhysical Therapists (2nd edition). McGraw-Hill: NewYork.

15. Kahn J. Principles and Practice of Electro- 16.Philadelphia, Pa: FA Davis Co;

16. Antao NA. Myositis of the hip in a profes- sound therapyin calcific bursitis: case report. 1986:160. professionalsoccer.

17. Sloan J, Soltani K. Iontophoresis in dermatology. Areview. J Am Acad Dermatol 1986;15:671-84.

18. Puttermans FJM, Massart DL, Gilles F, Lievens PC,Jonckeer MH. Iontophoresis: mechanism of action bypotentiometry and x-ray fluorescence. Arch Phys MedRehabil 1982;63:176-80.

19. Kahn J. Acetic acid iontophoresis for calcium deposits.Phys Ther 1977;57:658-60.

20. Bosworth BM. Calcium deposits in the shoulder andsubacromial bursitis: a survey of 12,122 cases. J AmMed Assoc 1941;116: 2477–82.

21. JS Sarkar. FS Haddad. SV Crean. P.Brooks. from ListerHospital. Stevenage. England. “acute caccific tendintisof the rectus femoris”(journal–Bone Joint Surgery)Br1996, 78-B, 814-6.

22. ICCA, 2007, 51(3)23. Clayton’s Electrotherpy 9th edition24. Therapeutic exercises by Colby kisner.

Deepak B. Anap / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 224

Effect of knee support brace and lateral wedge in sole onisokinetic peak torque in osteoarthritis of the knee–a randomizedclinical trialGirija P.1, Eapen C.2, Zulfeequer3, Kamath S.4

1-3Department of Physiotherapy, 4Department of Orthopedics, 1-4Kasturba Medical College, Mangalore, Manipal University, India

Abstract

Purpose of the study

To investigate and to compare the effect of knee supportbrace and lateral wedge insole on isokinetic concentric peaktorque of quadriceps and hamstrings muscle, pain andfunctional status in osteoarthritis (OA) of knee.

Methods and measures

28 subjects with unilateral or bilateral medialcompartment osteoarthritis of the knee were randomlyallocated into two groups, knee support brace group andlateral wedge insole group. The patients wore theirrespective orthosis 8 hours per day for 4 weeks. Theoutcomes were isokinetic concentric peak torque ofquadriceps and hamstrings, pain and functional status(WOMAC), pre and post intervention.

Results

Both the knee support brace and lateral wedge insoleimproved the isokinetic concentric peak torque of bothquadriceps, hamstrings muscles, functional status andreduced pain.

Conclusion

Both the orthosis were found to be equally effective inimproving the isokinetic concentric peak torque ofquadriceps and hamstrings, reducing pain and functionalstatus.

Key words

Medial compartment osteoarthritis, isokinetic peaktorque, knee brace, lateral wedge insole.

Introduction

Osteoarthritis (OA) is a chronic, localised joint diseaseaffecting approximately one-third of adults, with the diseaseprevalence increasing with advancing age1. It forms aconsiderable burden for society because of its chroniccourse and high costs of intervention2. It is particularlydisabling when the knee joints are affected, because it limitsthe ability to walk, to rise from chair, and to use stairs3. Itaffects most commonly the medial compartment of the kneeand leads to varus deformity4.

The primary compliants of these patients are pain,stiffness, instability and loss of function5. Patients with OAknee have weak lower-extremity muscles, particularly

quadriceps muscle group3. The assessment of muscleperformance in research and in clinical practice is commonlyemployed by isokinetic dynamometer6. The main theoreticaladvantage of isokinetic contraction studies concerns theangular velocity constancy throughout the range of motion,which provides accuracy and reproductivity when comparedwith others7. The nonpharmacological treatment forosteoarthritis of the knee include patient education, weightloss, thermal modalities, orthotic inserts, knee braces, andphysiotherapy8. Two orthotic devices that have beencommonly used for the treatment of medial compartmentalosteoarthritis are lateral wedge insole and knee braces4.Lateral wedge insole alters the mechanical alignment of thelower leg by enhancing a valgus correction of thecalcaneus9. The mechanical axis of the lower limbapproaches a more upright position, with decreased loadingon the medial compartment of the knee joint and the tensileforce on the lateral side10. Knee brace improves the functionby reducing the patient’s symptoms which can beaccomplished by reducing the biomechanical load on theaffected compartment of the knee11 After wearing a brace,there was increase in the isokinetic quadriceps musclestrength in osteoarthritis patients12. A study found increasein dynamic stability and immediate pain relief when wearinga combined lateral wedge insole and functional knee bracein medial compartment knee OA13. No study could beretrived to compare the effect of knee support brace andlateral wedge insole on isokinetic peak torque of quadricepsand hamstrings muscle, pain and functional status. So theaim of our study was to find out and to compare the effectof knee support brace and lateral wedge insole on isokineticconcentric peak torque of quadriceps and hamstringsmuscles, pain and functional status in medial compartmentknee osteoarthritis patients.

Materials and methods

The study was conducted in a multi speciality teachinghospital, out patient physiotherapy department afterapproval from the institutional ethical committee. Inclusion

Fig. 1: BTe primus isokinetic dynamometer

Girija P. / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2 25

criteria were patients with age between 40 to 75 years,either gender and with medial compartment(unilateral/bilateral) knee osteoarthritis. Patients withpatellofemoral osteoarthritis, rheumatoid arthritis,inflammatory joint diseases, hip and ankle osteoarthritis,bone infections, recent fractures in lower extremity, anylower limb surgeries and neurological diseases wereexcluded from the study. The purpose of this study wasexplained to the participant and informed consent wasobtained. Patients who fulfilled the inclusion criteriademographic data was taken and baseline measurement ofwere taken. Pain severity was evaluated using a VisualAnalogue Scale (VAS) during rest and activity using a 10cm line. The functional status of participants was assessedwith Western Ontario and McMaster Arthritis Index(WOMAC).

Isokinetic Peak Torque Measurement: BTe Primus RSisokinetic dynamometer machine was used to measure theisokinetic concentric peak torque of quadriceps andhamstrings. Patients were positioned as shown in figure 1.A trial of the testing was given to all the patients forfamiliarization and 1 minute rest was given between the trialand testing. The test was performed in 30°/sec which wasfound to be comfortable for the subjects and tolerated bythe elderly. 14 During the test, the subjects continuouslypushed the lever arm of the isokinetic device up and downas forcefully as possible, through the whole range of motionand it was repeated three times. Patients were thenassigned into group A and group B using blockrandomization. Patients in group A were given a kneesupport brace and patients in group B were given a lateralwedge insole. The patients were instructed to wear thebrace and lateral wedge insole 8 hours per day, as it wasfound to be the optimal duration15, for 4 weeks and to comefor follow up after 4 weeks. Outcome measures were takenafter 4 weeks. Data was analysed with wilcoxon signedranks test which was used to detect the differences inoutcome variables pre post within the groups and mannwhitney test was used to find out the differences in outcomevariables between the groups.

Results

Baseline characteristicsThe knee support brace group (Group A) consisted of

14 patients with a mean age of 52.07± 10.788 years andlateral wedge insole group (Group B) consisted of 14patients with a mean age of 52.71± 7.650 years. There were

8 females and 6 males in group A and 11 females and 3males in group B (p = 0.418). The age, gender and baselinemeasurements of isokinetic concentric peak torque ofquadriceps and hamstrings, pain and functional status(Table 1.1) were comparable and there was no significantdifference between the groups.

Isokinetic concentric peak torque

QuadricepsThere was statistically significant increase in the

isokinetic concentric peak torque of quadriceps in kneesupport brace group and lateral wedge insole group afterthe intervention (Table 2.1). There was no statisticallysignificant difference in pre post difference when comparedbetween the groups (Table 2.2)

HamstringsThere was statistically significant increase in isokinetic

concentric peak torque of hamstrings in knee support bracegroup between the pre and post measurements. There wasno statistically significant difference in lateral wedge insolegroup between the pre post measurements (Table 3.1).There was no statistically significant difference in pre postdifference when compared between the groups (Table 3.2)

Visual Analogue Scale (VAS)There was statistically significant reduction in VAS

during rest and activity after the intervention difference inboth the groups (Table 4.1).There were no statistically

Table 1.1: Pre values of outcome variables of both the groups

Group Mean± SD t value p valueRest VAS Pre Knee support brace 5.21±1.369 .324 .748

NSLateral wedge insole 5.07±0.917

Activity VAS Pre Knee support brace 7.36±1.216 -.982 .338NS

Lateral wedge insole 7.71±0.611WOMAC Pre Knee support brace 43.50±7.133 .112 .912

NSLateral wedge insole 43.14±9.550

Hamstrings Peak Knee support brace 98.293±46.4688 -.574 .566Torque Pre NS

Lateral wedge insole 92.364±67.6007Quadriceps Peak Knee support brace 130.36±93.483 -.230 .818

Torque Pre NSLateral wedge insole 114.56±95.471

Table 2.1: Pre – post isokinetic concentric peak torque of quadriceps for boththe groups

Group Mean±SD Wilcoxon p valueSignedRanksTest

Z valueKnee support Quadriceps pre 130.36±93.483 2.17 0.030

brace Quadriceps post 195.71±109.196 SigLateral wedge Quadriceps pre 114. 56±95.471 2.67 0.003

insole Quadriceps post 185.51±76.022 HS

Table 2.2: Inter group comparison of isokinetic concentric peak torque ofquadriceps.

Group Mean±SD Mann- P valueWhitney

U Z valueQuadriceps(pre Knee support 65.35±105.728 0.14 0.890

– post) diff braceLateral wedge 70.94±67.089 NS

insole

Table 3.1: Pre – post isokinetic concentric peak torque of hamstrings of bothgroups

Group Mean± SD Wilcoxon p valueSignedRanksTest

Z valueKnee support brace Hamstrings pre 98.293±46.46888 2.37 0.019

Hamstrings post 135.186±67.3328 sigLateral wedge insole Hamstrings pre 92.364±67.607 1.73 0.084

Hamstrings post 126.343±36.2267 NS

Table 3.2: Inter group comparison of isokinetic concentric peak torque ofhamstrings.

Group Mean±SD Mann- p valueWhitney UZ value

Hamstrings Knee support brace 36.893±54.0976 0.23 0.818(pre – post) diff Lateral wedge insole 33.979±58.7494 NS

Girija P. / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 226

significant difference in pre post difference when comparedbetween the groups (Table 4.2)WOMAC Scale

There was high statistical significance in WOMACscores in both the groups improved (Table 5.1). There wasno statistically significant difference when comparedbetween the groups (Table 5.2)

Discussion

Lateral wedge insoleNumerous studies10,16,17,18,19,20,21 were done with lateral

wedge insole which studied their effect on pain, functionalstatus, gait analysis and radiographic changes in knee OA.There was increase in the subtalar valgus moment whichcaused lateral shift of the centre of pressure which in turnreduced the knee varus moment which reduced the loadover the medial compartment20. These biomechanicalchanges caused a reduction in knee pain. In this study alsothese biomechanical changes might have caused reductionin pain. The lateral wedge changes the alignment of thelower extremity by statically aligning the knee in moreupright position by shifting position of the calcaneus intovalgus relative to the tibia10. These biomechanical changesmight have increased the muscle efficiency which wasshown by increase in isokinetic concentric peak torque ofquadriceps with lateral wedge insole. This is probably thefirst study which has shown the effect of lateral wedge insoleon isokinetic peak torque of quadriceps in knee OA. Therewas improvement in the functional status (WOMAC) withlateral wedge insole this is in consistent with other studiesdone19 which may have improved because of the reductionin pain. In our study we used elevation of 8mm in the lateralwedge insole which was found to be comfortable andeffective in correcting the calcaneus valgus9.

Knee support brace

Previous studies have shown that the unloader brace isreasonably comfortable, but it was more common for thepatients to wear the brace for specific activities rather thanfor the entire day. This may limit the usefulness of the bracefor people who work4. Sleeve is comfortable, can be wornfor extended periods and is relatively less costly but has tobe replaced as it looses its elasticity4. The knee support

brace used in our study was affordable by the patient andwas worn for atleast 8 hours per day as per the giveninstructions. It is rigid and does not have the disadvantageof losing elasticity. Moreover it is easily available in differentsizes. Previous studies showed that when a brace is wornfor the treatment of medial compartment osteoarthritis of theknee, pain relief may be the result of reduced musclecontractions, mediated by the brace mechanically stabilizingthe knee22. In our study the brace may have improved thejoint stability. So the patient may find it more comfortable indoing daily activities. Reduction in pain may reduce pain-induced reflex inhibition of the quadriceps. Quadricepsinhibition was demonstrated in approximately one third ofsubjects with knee OA.23 So in our study the reduction ofpain might have reduced the reflex inhibition of thequadriceps and thus improving the peak torque of thequadriceps muscle. Earlier study demonstrated thatproprioception alone may account for subjectiveimprovements in knee OA patients4. In our study bracingmay have improved the proprioceptive feedback andprovided additional input to the patients sensory system.This might have given the patient improved ability toperceive and react to forces inside and outside of patientsbody and acts as stabilizers, providing physical support aswell as a sense of security during activities of daily living likewalking, stair climbing. This may be the cause for thepatients overall functional status to improve with theWOMAC scale. Few limitations in our study: There was no control group.The sample size was small.

Further studies should be done with a control group toattribute the changes to brace or orthosis and with a largersample size.

Conclusion

Lateral wedge insole group showed significant increasein isokinetic concentric peak torque of quadriceps. Kneesupport brace group showed significant increase inisokinetic concentric peak torque of both hamstrings andquadriceps. Both the groups were effective in reduction ofpain and improvement of functional.

References

1. Bennell K, Bowles KA, Payne C, Cicuttini F, OsborneR, Harris A, Hinman R. Effects of laterally wedged

Table 4.1: Pre – post VAS scores in both groups

Group VAS Mean ± SD Wilcoxon p valueSigned

Ranks TestZ value

Knee support Rest VAS pre 5.21 ± 1.369 3.37 0.001brace Rest VAS post 3.21 ±1.188 HS

Activity VAS pre 7.36 ±1.216 3.25 0.001Activity VAS post 5.07 ± 1.141 HS

Lateral wedge Rest VAS pre 5.07 ± 0.917 3.33 0.001Insole Rest VAS post 3.07 ± 1.072 HS

Activity VAS pre 7.71 ± 0.611 3.34 0.001Activity VAS post 5.36 ± 0.633

Table 4.2: Inter group comparison of VAS scores

VAS Group Mean ± SD Mann- p valueWhitney UZ value

Rest VAS diff Knee support brace 2.00±0.679 0.20 0.844(pre-post) Lateral wedge insole 2.00±0.961 NS

Activity VAS diff Knee support brace 2.29±1.139 0.30 0.767(pre – post) Lateral wedge insole 2.36±0.842 NS

Table 5.1: Pre – post WOMAC scale of both groups

Group WOMAC Mean±SD Wilcoxon p valueSignedRanksTest

Z valueKnee support WOMAC pre 43.50±7.133 3.30 0.001

brace WOMAC post 26.93±6.754 HSLateral wedge WOMAC pre 43.14±9.550 3.30 0.001

insole WOMAC post 28.64±7.996 HS

Table 5.2: Inter group comparison of WOMAC scale

Group Mean± SD Mann- p valueWhitney U

Z valueWOMAC Knee support 16.57±15.00 0.53 0.595

(pre –post) diff braceLateral wedge 14.50±15.50 NS

insole

Girija P. / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2 27

insoles on symptoms and disease progression inmedial knee osteoarthritis: a protocol for a randomized,double blinded, placebo controlled trial. BMCMusculoskelet Disord 2007;8:96.

2. Brouwer RW, Jakma TSC, Verhagen AP, Verhaar JAN,Bierma-Zeinstra SMA. Braces and orthosis fortreatment for osteoarthritis of the knee (Review).Cochrane Database of Systemic Reviews 2005;1:1-14

3. Giir H, Cakin N. Muscle Mass, Isokinetic Torque, andFunctional Capacity in Women with Osteoarthritis of theKnee. Arch Phys Med Rehabil 2003;84:1534-41.

4. Kirkley. A, Webster-Bogaert. S, Litchfield R, AmendolaA, Macdonald S, Mccalden R, Fowler P. The effect ofbracing on varus gonarthrosis. J Bone Joint surg1999;81-A(4):539-47.

5. Emrani A , Bagheri H, Hadian MR, Ameli MJ, ROlyaeiG, Talebian S. Isokinetic Strength and FunctionalStatus in Knee Osteoarthritis. J Phys Ther Sci2006;83:107-14.

6. Sole G, Hamren J, Milosavljevic S, Nicholson H,Sullivan J. Test-Retest Reliability of Isokinetic KneeExtension and Flexion. Arch Phys Med Rehabil 2007May;88:626-30.

7. Neder JA, Nery LE, Shinzato GT, Andrade MS, PeresC, Silva AC. Reference Values for Concentric KneeIsokinetic Strength and Power in Nonathletic Men andWomen from 20 to 80 Years Old. J Orthop Sports PhysTher 1999;29(2):116-26.

8. Milne A.D, Evans N.A, Stanish W.D. NonoperativeManagement of Knee Osteoarthritis Diagnosis,behavior modification, and pharmacologic options.WOMEN’S HEALTH in primary care 2003;3(12):841-46.

9. Toda Y, Tsukimura N, Kato A. The Effects of DifferentElevations of Laterally Wedge Insoles with SubtalarStrapping on Medial Compartment Osteoarthritis of theKnee. Arch Phys Med Rehabil 2003;85:673-77.

10. Maillefert JF, Hurdy C, Baron G, Kieffert P, BourgeoisP, Lechevalier D, Coutaux A, Dougados M. Laterallyelevated wedged insoles in the treatment of medialknee osteoarthritis: a prospective randomizedcontrolled study. Osteoarthritis and Cartilage2001;9:738-45.

11. Kelly K. Footwear alterations and bracing as treatmentsfor knee osteoarthritis. Curr Opin Rheumatol2005;17:653-56.

12. Richards JD, Sanchez BJ, Jones RK, Darke N,Livingstone BN. A comparison of knee braces during

walking for the treatment of osteoarthritis of the medialcompartment of the knee. J Bone Joint surg (Br)2005;87(7):937-39.

13. Hsieh CJ, Kuo FL, Yang SW, Hsieh LF. Effect ofFunctional Knee Brace and Lateral Wedge Insole inManagement of Patients with Osteoarthritic Knee.Journal of Biomechanics 2007;40, suppl 449

14. Matsuno H, Kadowaki KM, Tsuji H. Generation ІІ KneeBracing for Severe Medial Compartment Osteoarthritisof the Knee. Arch Phys Med Rehabil 1997;78:745-49.

15. Toda Y, Tsukimura N, Segal N. An optimal duration ofdaily wear for an insole with subtalar strapping inpatients with varus deformity osteoarthritis of the knee.Osteoarthritis and cartilage 2005;13:353-60

16. Mehta J, Mulgaonkar KP. Effect of laterally raisedfootwear on bilateral medial compartment kneeosteoarthritis and its biomechanical analysis –Acomparative study. IJOT December 2004 –March2005; XXXVI (3):51-5

17. Kaihana W, Akai M, Yamasaki N, Tamasaki T,Nakazawa K. Changes of joint moments in the gait ofnormal subjects wearing a lateral wedge insoles. ArchPhys Med Rehabil 2004;83:273-78.

18. Shimada S, Kobayashi S, Wada M, Uchida K, Sasaki S,Kawahara H et al. Effects of Disease Severity onResponse to Lateral Wedge Insole for MedialCompartment Knee Osteoarthritis. Arch Phys MedRehabil 2006;87:1436-41.

19. Fang MA, Taylor CE, Nouvong A, Masih S, Kao KC,Perell KL. Effects of footwear on Medial compartmentknee osteoarthritis. JRRD 2006;43:427- 34

20. Kakihana W, Akai M, Nakazawa K, Naito K, Torii S.Inconsistent knee varus moment reduction caused by alateral wedge insole in knee osteoarthritis. Am J PhysMed Rehabil 2007;86:446 – 54.

21. Toda Y, Segal N, Kato A, Yamamoto S, Irie M. Effectsof a Novel Insole on the Subtalar Joint of Patients withMedial Compartment Osteoarthritis of the Knee. JRheumatol 2001;28:2705-10.

22. Ramsey DK, Briem K, Axe MJ, Mackler LS.A.Mechanical Theory for the Effectiveness of Bracingfor Medial Compartment Osteoarthritis of the Knee. JBone Joint Surg Am 2007;89:2398-407.

23. Hassan BS, Doherty SA, Mockett S and Doherty M.Effect of pain reduction on postural sway,proprioception, and quadriceps strength in subjects withknee osteoarthritis. Ann Rheum Dis 2002;61:422-28.

Girija P. / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 228

Self motivation: Does it influence performance of motor functionin post stroke individuals?Talhatu K. Hamza t, Omobolanle A. Adebisi-Akinbile

Department of Physiotherapy College of Medicine (UCH), University of Ibadan, Nigeria

Abstract

Objective

Recovery of motor function after stroke could beinfluenced by biological, environmental and psychologicalfactors. This ex-post-facto research assessed theassociation between self-motivation and motor functionamong chronic stroke survivors. Association between self-motivation and each of age, gender, stroke laterality andtime since onset of stroke was also investigated.

Methods

Thirty (20 males and 10 females) individuals who havesuffered a first-ever stroke (mean age 59.30 ± 13.81years),22 of whom had right hemiplegia, were consecutivelyrecruited from among stroke survivors receivingphysiotherapy on out-patient basis at a tertiary health facilityin Nigeria. Stroke laterality, age, gender and time sinceonset of stroke were documented. Self–motivation andmotor function were assessed using Self-MotivationInventory (SMI) and Modified Motor Assessment Scale(MMAS) respectively. Data were analysed using Spearmanrank order correlation and Mann-Whitney U statistics at 0.05alpha.

Results

Association between motor function and self motivation(rho= 0.14; p = 0.45) was not statistically significant. Similartrend was observed between self motivation and each ofage (rho= -0.21; p=0.26); time since onset of stroke (rho =0.16; p = 0.33). There was a negative but non-significantassociation between age and motor function (rho = -0.26; p=0.44). Both SMI and MMAS scores were not significantlydifferent between males and females; as well as betweenright and left hemiplegic patients.

Conclusion

Self–motivation did not influence motor functionperformance. Similarly age, stroke laterality, gender andtime since onset of stroke are not associated with selfmotivation of stroke survivors. These findings imply that selfmotivation may not be influencing motor performance afterstroke.

Key words

Stroke, Self-motivation; Motor function

Introduction

Stroke is regarded as an important cause of deathworldwide with an estimated 5.7 million people dying fromthe disease in 2005 out of which 87% were said to be in low-income and middle income countries1. Whereascomprehensive stroke surveillance data for Africa arelacking, the available information show that age-standardised mortality, case fatality and prevalence ofdisabling stroke in Africa are similar to or higher than thosemeasures in most high income regions of the world2. Theseriousness of the impact of this disease on individuals andsocieties is underscored by its being a leading cause ofdisability in the victim, with about 40% of stroke survivorsliving with some degrees of functional impairment3.Sequelae of stroke include perceptual, cognitive, sensoryand communication dysfunctions. The patient who hassuffered a stroke may therefore present in thephysiotherapist’s clinic with a unique complexity of physical,psychological and social challenges4. A patient who hassuffered a stroke undergoes rehabilitation to aid recovery.Rehabilitation post stroke is described as a process in whichthe patient and the health care system, through interactionand negotiation, try to reach agreement about activities tobe emphasized and goals to be pursued5.

Stroke recovery is a life-long process filled withachievements and setbacks 6 and is significantly influencedby clinical and demographic characteristics of patients, withearly rehabilitation having a likely role to play7. Post strokerecovery also depends on the patient’s ability to learn, familysupport, quality and intensity of therapy as well as patient’smotivation8. Dobkin9 had also noted that one of the majorfactors affecting rehabilitation outcome is the level ofmotivation of the patient towards his/her recovery.

Researchers have explored the attitudes and beliefs ofstroke patients undergoing rehabilitation and who wereidentified by professionals as having either “high” or “low”motivation for rehabilitation10. The effect of environmentalfactors in stroke rehabilitation has also been examined11. Inview of possible interaction among sociocultural factors,psychological profile and recovery of function after stroke, itbecomes necessary to study association betweenpsychological factors such as self-motivation and recoveryof motor function among stroke survivors in different socio-cultural settings. This ex-post facto research study wascarried out to assess the association between selfmotivation and motor function performance some Nigerianstroke survivors. Self motivation and motor function werealso correlated with each of age, gender, stroke lateralityand time since onset of stroke.

Talhatu K. Hamza t / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2 29

Methods

ParticipantsThirty individuals comprising 20 males and 10 females

who have suffered a first-ever stroke, 22 of whom had lefthemispheric stroke and referred for physiotherapy at atertiary health facility (University College Hospital) in Ibadan,Nigeria were consecutively recruited into the study over a4-month period. They satisfied eligibility criteria of living intheir respective community post hospital discharge andbeing able to communicate and give informed consent.Those with cognitive dysfunction assessed using mini-mental state instrument and those with history or incidenceof psychological dysfunctions such as depression that couldaffect motivation were excluded. The participants represent42.0% of post-stroke individuals seen at the Physiotherapyclinic over the 4-month period.

ProcedureThe study was approved by the Joint Institutional Ethics

Committee of the University of Ibadan/University CollegeHospital, Ibadan, Nigeria. The procedure for the study wasexplained to all willing patients before obtaining theirinformed consent. Information such as age, gender, timesince onset of stroke and stroke laterality were obtainedfrom the patients and documented. Self-motivation andmotor function ability were assessed using the Self-Motivation Inventory (SMI) and the Modified MotorAssessment Scale (MMAS) respectively.

The MMAS is a 8-item descriptive assessment of motorrecovery for patients who have suffered a stroke12. The 8items are assigned a score from zero to six (zero means notpossible, and 6 means most difficult) relating to upperextremity motor recovery, balance and function. Themaximum point obtainable on the items is 48. The 8 itemsare (i) supine to side lying (ii) supine to sitting over the sideof the bed (iii) balanced sitting (iv) sitting to standing (v)walking (vi) upper arm function (vii) hand movement and(viii) advanced hand activities. The MMAS had been usedby Hamzat et al13 to assess motor function ability amongstroke survivors.

The SMI is a valid, reliable and easy-to-administermeasure of self-motivation. It comprises 40 phrases of 19positively keyed items and 21 negatively keyed items with40 to 200 score range14. There are 5 possible responses toeach of the questions in the SMI from which therespondents are expected to choose the option that suitthem most. The total self-motivation score was computedbased on these responses and recorded for eachparticipant.

One assessor each administered the MMAS and SMI onall participants to avoid assessor’s bias. The two assessorswere blinded to the outcome of the study.

Data analyses

Data obtained were analysed using the SPSS version10.0 package. Association between self-motivation scoresand each of motor function scores, age and time since onsetof stroke was established using Spearman rank ordercorrelation coefficient (rho). Mann-Whitney U- statistic wasused to compare self-motivation and motor function scorebetween male and female as well as between those with leftand right hemispheric stroke at p ≤ 0.05.

Results

The mean age of the participants is 59.30 ± 13.81 yearsand the mean time interval between onset of stroke and timeof the study is 5.50 ± 3.46 months. Correlation analysisshowed no statistically significant association between self-motivation inventory score (SMI) and modified motorassessment scale – MMAS (rho = 0.14; p = 0.45). Resultsalso showed no statistically significant association betweenSMI and time since onset of stroke (rho = 0.16; p = 0.33);and age (rho = -0.21; p = 0.26). Results of Mann-Whitney Ustatistical analysis comparing participants by gender andstroke laterality showed no statistically significant differencein SMI scores between males and females (U=41.5; p=0.54)and between right and left hemiplegic stroke survivors(U=52.5; p=0.09).

Discussion

Investigating clinical and personal factors that mayinfluence outcomes of stroke could help cliniciansunderstand how their intervention after stroke could beaffected by those factors. Self motivation, an example ofsuch personal factors, encompasses a person’s desire toactivate or persist with a particular behaviour15. It is apersonal attribute of a patient that may relate to how well hecooperates with the attending physiotherapist and theinformal caregivers, complies with his physiotherapyschedule, and how well disposed he might be to setting andattaining goals in the course of his rehabilitation. Motorfunction is an important construct used to monitor clinicalimprovement after stroke. In this study, the degree and typeof association between a patient’s factor (self-motivation)and motor function was assessed among stroke survivors.This represents the first attempt in literature to establishsuch association among Nigerian stroke survivors.

Results showed no statistically significant associationbetween self-motivation and motor function ability amongthe stroke survivors sampled. This suggests that how well ornot a patient is self-motivated after a stroke may notnecessarily influence his motor function ability within the first6 months post stroke. A caution that needs to be exercisedin interpreting this finding is that both constructs (self-motivation and motor function) were assessed on aone-time basis rather than how each could have influencedthe other in the course of intervention programme andrecovery over a specified period of time. Nonetheless, thetrend observed in this study is in agreement with thesubmission of Maclean et al16 that self-motivation has nosignificant relationship with motor function. Those authorsobserved inconsistencies in what rehabilitationprofessionals identified as “motivate” and “unmotivated”behaviour and thus concluded that their findings justified theremoval of the term “motivation” from the lexicon of physical

Table 1: Correlation between self motivation inventory scores and each ofmotor function, age and time since onset of stroke (N=30).

SMI MM ASRho p-level rho p-level

MMAS 0.14 0.45Age 0.30 0.10 -0.21 0.26Time Since Onset of Stroke 0.16 0.38 0.33 0.07

Key:SMI=Self Motivation InventoryMMAS=Modified Motor Assessment Scale

Talhatu K. Hamza t / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 230

rehabilitation. The World Health Organisation17 had alsoreported that other factors that affect motor functionrecovery after stroke are status of cognition and highermental function, side of stroke affectation, depression, andsocial status such as occupation, level of education and rolein the family.

Results obtained showed non statistically significantdifference in self-motivation scores between male andfemale participants. Age was also found not to besignificantly associated with self motivation. This implies thatself-motivation status of a patient is not gender inclined andthat age may not be a determining factor in how well self-motivated or not a stroke survivor will be. An earlier study byMerkle et al14 to assess effect of age on self-motivation andthe study by King et al15 to determine relationship betweenpatient’s age and gender, and self-motivation found nosignificant association between age and self-motivation afterstroke. It is pertinent to note that in the study of King et al15,self-motivation was assessed using self-motivationinventory which is the same instrument used in the presentstudy. This shows that irrespective of socio-cultural milieu ofpost stroke individuals, their personal factor of selfmotivation may not influnce their ability to perform a motorfunction. Conversely, Oldridge and Stoedefalke17 hadreported that patients’ self – motivation varied with age andgender. However, this variance of Oldridge andStoedefalke17 report and this present study can be ascribedto the fact that the former studied patients on cardiacrehabilitation programme, while male and female strokesurvivors who were receiving physiotherapy as part of theirrehabilitation programme took part in this study.

A negative but non – statistically significant associationobserved between age and motor function is similar to thetrend reported by Kugler et al.18 No difference was observedin motor function between males and females suggestingthat gender has no significant effect on this construct.Hamzat and Okesola19 had observed that female stroketook a longer time than their male counterparts to achieveindependent walking, a component of motor performance.Each of self motivation and motor function was found tohave no statistically significant correlation with period sinceonset of stroke. Conversely though, Adegoke andAkinkoye20 had reported a statistically significant correlationbetween motor function and period since stroke. Evidencefrom this study showed that stroke laterality have noinfluence on both motor function and self-motivation.Results of statistical analysis showed no significantdifference in the mean scores between the male and femalestroke survivors.

It was concluded that self motivation does not influenceability to perform motor function among stroke survivors.Age, stroke laterality, gender are not significantly associatedwith self motivation and motor function after stroke. There isstill a need to longitudinally explore how self motivation maydetermine recovery of motor function after stroke.

References

1. Strong K, Mathers C, Bonita R. Preventing stroke:saving lives around the world The Lancet Neurology2007;6(2): 182-187

2. Mensah GA (2008): Epidemiology of stroke and highblood pressure in Africa. Heart 2008 Jun;94(6):697-705

3. Young J, Forster A. Review of stroke rehabilitation.BMJ. 2007; 334: 86-90.

4. Durward BJ, Baer G, Wade J. Stroke. In Strokes M(2000). Neurological Physiotherapy 2nd edition,Philadelphia, Mosby 2002; 75-90.

5. Bendz M. Rules of relevance after a stroke. Soc SciMed. 2000; 51: 713-723.

6. Venketasubramanian N, Ang YH, Chan BPL, Chan P,BH Bridging the gap between primary and specialistcare – An Integrative Model for Stroke Ann Acad MedSingapore 2008;37:118-27

7. Paolucci S, Antonucci S, Grasso MG, Morelli D, TroisiE, Coiro P, Bragoni M. Early versus delayed inpatientstroke rehabilitation: A matched comparison conductedin Italy. Arch Phys Med Rehabil 2000; 81(6): 695-700

8. Teasell RW, Foley NC, Bhogal SK, Speechley MR. AnEvidence-Based Review of Stroke Rehabilitation.Topics in Stroke Rehabilitation. 2004; 10(1): 29-58.

9. Dobkin MD. Rehabilitation after stroke. New EnglandJournal of Medicine. 2005; 352 (16): 1677-1684.

10. Maclean N, Pound P, Wolf C, Rudd A. Qualitativeanalysis of stroke patient’s motivation for rehabilitation.BMJ. 2000; 321: 1051-1054.

11. Holmquist L, Von Koch L. Environmental factors instroke rehabilitation. BMJ. 2001; 322:1501-1502.

12. Loewen SC, Anderson BA. Reliability of Modified MotorAssessment Scale and the Barthel Index. Phys Ther1988; 68: 1077-1081.

13. Hamzat TK, Olaleye OA, Adeniyi AF, Awolola OE.Standing asymmetry and functional ability in relation togait parameters in hemiparetic stroke patients. SaudiJournal of Disability and Rehabilitation 2006; 12(1,2): 1-5.

14. Merkle LA, Jackson AS, Zhang JJ, Dishman RK. Re-examining the construct validity of the Self-MotivatingInventory. International Sports Journal. 2002; 6(2): 48-59.

15. King KM, Humen DP, Smith HR, Phan CL, Teo KK.Psychosocial components of cardiac recovery andrehabilitation attendance. Heart 2001; 85: 290-294.

16. World Health Organization. Task Force on Stroke andother Cerebrovascular Disorders: Recommendationson stroke prevention, diagnosis and therapy. Stroke.1989; 20(10): 1407-1431.

17. Oldridge NB, Stoedefalke KG. Compliance andmotivation in cardiac exercise programme. Clin SportsMed. 1984; 3(2): 443-454

18. Kugler C, Altenhoner T, Lochner P, Ferbert A. and forthe Hessian Stroke Data Bank Study Group ASH. Doesage influence early recovery from ischemic stroke? Astudy from the Hessian Stroke Data Bank. J Neurol2003;250(6): 678-681.

19. Hamzat TK, Okesola YA. Some clinical andpsychological determinants of independent walkingattainment by post-stroke patients. African Journal ofNeurological Sciences. 2006; 25:1.

20. Adegoke BOA, Akinkoye OO. The relationshipsbetween gender, motor function, period since strokeand asymmetry of lower limb weight distribution post-stroke. South African Journal of Physiotherapy 2003;59 (3): 15-19.

Talhatu K. Hamza t / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2 31

Comparison of muscle energy technique and positional releasetherapy in acute low back pain – RCTNaik Prashant P.*, Heggannavar Anand**, Khatri Subhash M***

*Post Graduate Student, **Lecturer, ***Professor & HOD, K.L.E.S, J.N. Medical College, Belgaum, Karnataka, India

Abstract

Purpose of studyThe objective was to study the effectiveness of Muscle

energy technique and Positional release therapy in AcuteLow Back Ache on pain and disability.

Material and methods

60 participants with acute low back pain were randomlyassigned to Group A (HMP+MET) and Group B(HMP+PRT) during the study period of April 2008 to January2009. The outcome measures were visual analogue scale(VAS), lumbar extension ROM by Schobers method, anddisability level in terms of MODQ. Pre and post sessionintervention values of outcome measures were noted on 1stand 8th day of intervention.

Results

The participants treated within groups showed astatistically significant decrease in pain, increase in amountof lumbar extension ROM, and decrease in disability levelas per MODQ with p<0.0001, but there was no statisticallysignificant difference when compared between groups indecreasing pain (p= 0.1611) increase in amount of lumbarextension ROM (p=0.4642), and decrease in disability levelas per MODQ (P=0.3303) after 8 days of intervention.

Conclusion

Both MET and PRT along with HMP for acute low backpain showed improvement following 8 days of treatment asper significant decrease in pain (VAS), amount of lumbarextension ROM, and disability level as per MODQ and canbe used as an effective treatment regime in participants withacute low back pain.

Key words

Low back pain; MET; PRT; Manual therapy; HMP.

Introduction

Low back pain is the largest cause of sick leave and halfof the population will have experienced a significant incidentof low back pain by age of 301. In India its incidence hasbeen reported to be 23.09%. Acute low back pain is usuallythe result of various causes2, such as posturalabnormalities, muscle dysfunction (imbalances, shorteningor weakening of muscle), overuse, instability, and articulardysfunction in the lower back, injury or accident, most oftenroad vehicle accidents. It has been reported that 37% of

health care costs associated with low back pain are directresult of physical therapy service1,3. 85-90% of all episodesof low back pain are non specific in nature4.

The treatment of patients with back pain can beextremely interesting and rewarding. However, somepatients with low back pain can be difficult to treat and careof these patients is quite often challenging5. People whoreport LBP often have reduced spinal motion6-8. Whenmotion is limited, spinal extension is more restricted thanflexion7-9. Reduced spinal extension can be result of pain orstiffness and can be classified as being either general (totalspine) or segmental (one vertebral level)6-8,10,11. The functionand co-ordination of the muscles that stabalize the lumbarspine, especially the back extensor muscles are oftenimpaired in patients with low back pain12. Sorensen foundthat good endurance of back extensor muscles in menappeared to protect them from low back pain13. Erectorspinae strain and fatigue is one of the causes of back pain14.

In general, positional release therapy and muscle energytechniques are the forms of manual therapy that are used inan effort to reduce pain and improve range of motion.Positional release therapy (PRT) is a method of total bodyvaluation and treatment using tender points and a positionof comfort to relieve the associated dysfunction19. Thetender point is used as a guide and the position of comfortis maintained. This position of minimal discomfort is usuallya position where the muscle is at its shortest length. Theposition is held for 90 seconds and the joint is slowly andpassively returned to the neutral position. This prolongedshortening of the muscle causes shortening of both theintrafusal (muscle spindle) and extrafusal fibers15,16. Thesechanges in turn result in a significant increase in functionrange of motion and a decrease in pain. Muscle energytechnique (MET) is an active technique in which isometriccontraction with 30% of effort is utilized to treat patient’spain. Greenman2 defined Muscle energy technique as amanual medical treatment procedure controlled direction, atvarying levels of intensity against a distinctly executedcounter force applied by the operator. The goal is toincrease joint mobilization and lengthen contracted muscles.Because no thrusting is done, this procedure has a very lowlikelihood of producing complications and can be usedwhere high velocity low amplitude is contraindicated17.

Methodology

Source of DataData was collected from physiotherapy OPD of KLES

Dr. Prabhakar Kore Hospital and MRC, KLES AyurvedHospital and Research center, Belgaum during the studyperiod of April 2008 to January 2009.

Naik Prashant P. / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 232

Study DesignThe study design used for this research was randomized

clinical trial. For this R.C.T ethical clearance was obtainedfrom the institutional ethical committee, JNMC, Belgaumbefore commencement of the study

Study sampleThe study sample consisted of both male and female

participants referred to the physiotherapy outpatientdepartment with clinical diagnosis of acute low back ache.There were 60 participants with clinical diagnosis of nonspecific acute low back ache.

Inclusion criteria1. Non specific low back pain.2. Symptoms less than 3 weeks.3. Low back pain without radiation to buttock, thigh or leg.4. Age 20 – 65 yrs.

Exclusion criteria1. History of spinal surgery2. Motor weakness3. Altered sensation such as paraesthesia, numbness,

hyperaesthesia, anaesthesia4. Altered deep tendon reflexes5. Subjects receiving muscle relaxants.

ProcedureParticipants who reported to KLES Dr. Prabhakar Kore

Hospital and MRC, KLES Ayurved Hospital and Researchcenter, Belgaum with non specific low back ache withduration of less than 3 weeks were screened for theireligibility depending on inclusion and exclusion criteria toparticipate in this study. After finding their suitability, theywere requested to participate in the study. Then they wererequested to give informed consent. After obtaining their

consent, demographic data and other specific data such asinitial MODQ, VAS and ROM was measured. After this initialevaluation, they were randomly allocated to one of the twostudy groups viz A and BGroup A: The study participant was made to lie prone onthe couch comfortably. Hot moist pack was kept on theparticipant’s lumbar region for a period of 10 minutes(Photograph 1). After receiving hot moist pack therapy for 10minutes, muscle energy technique for erecter spinae wasperformed on the participant for 10 hold with 20 secondsrelaxation for 9 times i.e. total of 270 seconds in followingway:

The participant sits with back to therapist on treatmentcouch, legs hanging over side and hands clasped behindthe neck. The therapist places knee on the couch close tothe participant, at the side towards which side bending androtation will be introduced (Photograph 2). The therapistpasses a hand in front of participant’s axilla on the side towhich the participant is to be rotated, across the front ofparticipant’s neck, to rest on the shoulder opposite.

The participant is drawn into flexion, side bending androtation over the therapist’s knee (Photograph 2). Thetherapist’s free hand monitors the area of tightness andensures that the various forces localise at the point ofmaximum contraction/tension. When the participant hasbeen taken to a comfortable limit of flexion, is asked to looktowards the direction from which rotation has been made,whilst holding the breath for 7 to 10 seconds, or to do thiswhile also introducing a very slight degree of effort towardsrotating back to upright position, against firm resistance fromthe therapist.

The patient is then asked to release the breath,completely relax and to look towards the direction in which

Table 1: VAS Score

Group Pre session Post sessionMean SD Mean SD

Group A 6.62 1.41 1.9 0.73Group B 6.94 1.48 1.7 0.76

Graph 1:

Graph 2:

0

2

4

6

8

Pre Post

MEAN VAS

MET

PRT

Table 2: Active Lumbar ROM

Pre session (cms) Post session (cms)Group Active Active

Mean SD Mean SDGroup A 3.3 0.61 4.27 0.39Group B 3.3 0.56 4.34 0.26

0

2

4

6

Pre Post

Active ROM Lumbar

extension

MET

PRT

Naik Prashant P. / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2 33

side bending/ rotation is being introduced (i.e. towards theresistance barrier). The therapist waits for the participant’ssecond full exhalation and then takes the participant furtherin all the direction of restriction, towards new barrier, notthrough it18.Group B: After giving HMP positional release therapy forerecter spinae for 90 seconds with 3 repetitions i.e. total of270 seconds was given in following way:

The participant is prone with trunk laterally flexedtowards the tender side. The therapist stands on the side ofthe tender point (Photograph 3). The therapist places his orher knee on the table and rests the participants affected legon the therapist’s thigh. The participant’s hip is extendedand adducted, and slight rotation is used to fine tune19.

VAS score and lumbar range of motion (extension) weremeasured pre and immediately post intervention.

All the participants received the selected treatment 8sessions over a period of 8 days. After 8days of intervention,post treatment outcome measures were recorded and datathus obtained was used for statistical analysis.

Duration of the symptoms and the side affected wasnoted and initial evaluation of the pain profile was doneusing Visual Analogue Scale (VAS).The pain was recordedby 10 cm horizontal visual analogue scale (VAS), theparticipants were asked to mark their intensity of pain on a10 cm long line in the data collection sheet with numbers 0to 10 where 0 symbolized no pain, and 10 was severe pain.Active range of lumbar extension was measured with theparticipant standing on the floor, a pen was used to markthe midpoint between the posterior superior iliac spines(PSIS). Then tape measure was used to identify and marktwo points that is 10 cm superior to the PSIS, and 5 cminferior to the PSIS. Distance between the superior and

inferior marks was measured as the participant extendedthe spine as far as possible. Modified Oswestry Low BackPain Disability Questionnaire (MODQ) scoring was done byasking the participants to mark their ability to perform eachof the 10 activities in the data collection sheet.

Results

The result of this study was analysed in terms ofdecrease in pain, increase in amount of lumbar extensionROM, and decrease in disability level as per MODQ.

Statistical analysis

Statistical analysis was done by the statistical packageof social science (SPSS) version13. Statistical measuressuch as unpaired ‘t’ tests and paired ‘t’ tests were used toanalyze the data. The results were concluded to bestatistically significant with p< 0.05. Paired ‘t’ tests wereused to compare the differences of scores on day 1 and day8th within a single group. Unpaired ‘t’ tests were used tocompare differences between the two groups, MET groupand the PRT group.

Demographic profile

Each group had 30 participants each. The mean age ofthe participants in Group A was 31.60 years ±13.82 yearsand the mean age of the participants in Group B was 34.80years ±13.42 years. The difference in mean age of twogroups was not statistically significant (‘t’=0.910, DF=58, p=0.3666). The gender ratio of Group A was 19:11 (19 malesand 11 females) and Group B was 21:9 (21 males and 9females) and this was not statistically significant (χ2=0.075,DF=1, p=0.7842). Therefore both the groups are matchedwith respect to age and gender. The mean duration of theparticipants in Group A was 10.63 days ± 6.06 days and themean duration of the participants in Group B was 9.90 days± 4.84 days. The difference in mean duration of two groupswas not statistically significant (p= 0.6064).

Clinical parameters

The participants treated within groups showed astatistically significant decrease in pain, increase in amountof lumbar extension ROM, and decrease in disability levelas per MODQ with p<0.0001,

In the Group A, the mean VAS score on 1st daypresession was 6.52cms which was reduced to a 1.9cmson post session i.e. on the 8th day and in Group B, it wasreduced from 6.94cms to a mean of 1.7cms on the postsession i.e. on 8th day. Unpaired ‘t’ test p values were0.2613 and 0.1611 respectively which was statistically notsignificant.

In the Group A, the mean active lumbar extension ROMon 1st day pre session was 3.30cms which was increasedto 4.27cms on post session i.e. on the 8th day. In Group B,from 3.30cms it increased to a mean of 4.34cms on postsession i.e. on the 8th day.

Unpaired ‘t’ test p values 0.9825 and 0.4642 respectivelywhich was statistically not significant

In the Group A, the mean MODQ score on 1st day presession was 23% which was reduced 10% on post sessioni.e. on the 8th day. In Group B, it was reduced from 30% to

Table 3:

Group Pre session (%) Post session (%)Mean SD Mean SD

Group A 23 9 10 4Group B 30 14 11 6

Graph 1:

0

10

20

30

Pre Post

MEAN MODQ %

MET

PRT

Naik Prashant P. / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 234

a mean of 11% on the post session i.e. on 8th day. Unpaired‘t’ test p value was 0.3303 which was statistically notsignificant.

Discussion

This randomized clinical trial consisted 8 sessions ofintervention following which both the groups (MET and PRT)showed that there was no statistically significant differencebetween each other and were equally effective in reducingpain in VAS, an increase in lumbar range of extension, anddecrease in disability level as per MODQ.

Reduction in the pain intensity was significant in both thegroups i.e. MET and PRT. Pain relief could have occurreddue to decrease in the intrafusal and extrafusal fiberdisparity and reset of the inappropriate proprioceptiveactivity. Korr has provided a conceptual model how differentmanipulative technique like isometrics and stretching maybe effective in treatment of somatic dysfunction20.

Erector spinae strain is one of the cause of back pain10.The application of MET and PRT must have facilitated in theresolution of inflammation and spasm of the erecter spinaemuscle due to its effects similar to the soft tissue techniquessuch as stretching of soft tissue in affected area, moving offluids out of inflamed area reflexly relaxing or tonifyingmuscle21.

There was statistically significant improvement in activeand passive lumbar extension range of motion with in thegroups on last day of treatment, but there was no statisticaldifference when compared between the two groups.

Schenk et al performed a RCT to determine the effectiveness of MET in increasing lumbar extension in symptomaticindividuals and found that there was increase in ROM inexperimental group. The study results on the present studyare also coinciding with the study results of Schenk et al.1 Acase study was done on the effect of Rib Cage Rigidity onLow Back Pain in which the patient received treatment withIntegrative Manual Therapy in the form of positional releasetherapy after treatment was completed, the patientpresented with decreased pain and increased ranges ofmotion22.

In the present study Schobers method (Modified) wasused to evaluate the lumbar extension range of motion. It isa valid and reliable method as many studies have beendone in which Schobers method was used for evaluation ofrange of motion23.

In this study MODQ was used to evaluate functionaldisability. A study done on A Comparison of a ModifiedOswestry Low Back Pain Disability Questionnaire and theQuebec Back Pain Disability Scale by Fritz and Irrgangconcluded that the MODQ demonstrated superiormeasurement properties compared with the QUE24.

Limitation

1. Small sample size2. Study was confined to acute low back pain of non

specific and non traumatic conditions.3. Duration of the study was short.4. There was no control group.

Conclusion

This randomized clinical trial which was performed on

60 subjects consisting of males and females with a complainof acute low back pain with interventions in the form of hotmoist pack + muscle energy technique and hot moist pack+ positional release therapy showed that, both the treatmentinterventions can be useful in alleviating the acute low backpain in terms of pain, increase in active and passive lumbarextension range of motion, and reduce the ModifiedOswestry Low Back Pain Disability Questionnaire score.

References

1. Capt. Eric Wilson, Otto Payton, Lisa Donegan-Shoaf,Katherine Dec: Muscle energy technique in patientswith low back pain: A pilot clinical trial JOSPT.2003:33(9):502-510

2. Sharma SC, Singh R, Sharma AK, Mittal R: Incidenceof low back pain in workage adults in rural North India.Medical journal of India.2003:57:4: 145-147

3. Jouhua A. Cleland et al: The use of lumbar spinemanipulation technique by physical therapists inpatients who satisfy clinical prediction rule: a caseseries. JOSPT.2006:36:4

4. George E. Ehrlich: Bulletin of the World HealthOrganization; Special Theme –Bone and Joint Decade2000 –2010; 2003; 81:671-676

5. White AH, Anderson R. "The challenge of conservativecare." In: White AH, Anderson R. Conservative Care ofLow Back Pain. Baltimore: Williams & Wilkins,1991:427-434.

6. McGregor A, Anderson L, Gedroyc W. the assessmentof intersegmental motion and pelvic tilt oarsmen. MedSci Sports Exerc. 2002;34:1143-1149

7. Burton Ak, Battie MC, Gibbions L, et al. Lumbar discdegeneration and saggital flexibility. J Spinal Disorder.1996;9:418-424.

8. Latimer J, Lee M, Adams R, Moran CM. Aninvestigation of relationship low back pain and lumbarposteroanterior stiffness. J Manipulative PhysicalTher.1996; 19: 587-591

9. Troup JD, Foreman TK, Baxter CE, Brown D. 1987Volvo award in clinical sciences: the perception of backpain and role of psychophysical tests of lifting capacity.Spine. 1987; 12:645-657

10. Melllin G. Decreased joint and spinal mobilityassociated with low back pain in young adults. J SpinalDisord. 1990; 3:238-243

11. Pearcy M, Portek I, Shepherd J. the effect of low backache on lumbar spine movements measured by threedimensional X-ray analysis. Spine. 1985; 10:150-153

12. Julie Moreland, Elspeth Fiinoh et al: Interater reliabilityof Six tests of Trunk Muscle Function and Endurance.J OrthopSportsPhys Ther.1997;26(4):200-208.

13. Jorgensen K, Nicolaisen et al: Trunk ExtensorEndurance Determination and Relation to Low BackTrouble. J Orthop Sports Phys Ther 1987; 30: 259-267.

14. http://www.faqs.org/abstracts/Business/Effects-of-ated-posture-on-erector-spinae-EMG

15. Kerry J.D’Ambrogio, George B. Roth.Positional releasetherapy Assessment & Treatment of MusculoskeletalDysfunction. Mosby publication: Philadelphia: 1997:20-25

16. DiGiovanna EL, Martinke DJ, Dowling DJ. Introductionto osteopathic medicine. An Osteopathic Approach toDiagnosis and Treatment. Philadelphia: JB Lippincott;1991:1-31.

Naik Prashant P. / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2 35

17. Heilig D. The 1984 Thomas L. Northup memorialaddress: osteopathic manipulative care in preventivemedicine. J Am Osteopath Assoc. 1986;86:645651.

18. Leon Chaitow, Judith Walker Delany. Clinicalapplication of neuromuscular techniques. Vol 2.London: Elsevier Health Science. 2000

19. Leon Chaitow, Ed Wilson, Dylan Morrissey, John M.McPartland. Positional Release Techniques. 2 Edi.London: Elsevier Health Sciences, 2002

20. Korr IM: The neural basis of the osteopathic lesionJAOA 1947; 47:191-198

21. John V. Basmajian, Rich Nyberg: Rational Manual

Therapies. Manipulation, Spinal Motion, and SoftTissue Mobilization: Williams & Wilkins : University ofMichigan: 1993: 301-313

22. http://www.centerimt.com/ejournal/articles/ej00037.htm23. Sjolie, Astrid N, Ljunggren et al: The Significance of

High Lumbar Mobility and Low Lumbar Strength forCurrent and Future Low Back Pain In Adolescents.Spine. 2001;26(23):2629-2636

24. Fritz and Irrgang: A Comparison of a Modified OswestryLow Back Pain Disability Questionnaire and theQuebec Back Pain Disability Scale. Physical Therapy.2001;81(2):776-7

Naik Prashant P. / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 236

Anterior cruciate ligament injury rehabilitation – An overview ofreviewsBinu S. Das*, Narasimman S.**

*Physiotherapist, **Associate Professor and Head, Department of Physiotherapy, Father Muller Medical College, Mangalore,Karnataka, India

Abstract

Back ground

Anterior Cruciate ligament injuries are commonestamong the soft tissue injuries around knee. Rehabilitationfollowing ACL injuries always has been a challenging onefor the physiotherapists. Literature reviews are consideredas potential source of knowledge.

Methods & results

A structured review was conducted to find out theefficacy of various protocols of ACL injury rehabilitation invarious electronic databases. Three reviews with differentqualities were retrieved.

Conclusion

This paper gives an overview of three reviews about theAnterior Cruciate Ligament injury rehabilitation. This isstrengthening the knowledge in ACL injury rehabilitation andguides towards the future research in ACL injuryRehabilitation

Key words

ACL Injury, Rehabilitation, Physiotherapy, Exercises

Abbreviations

ACL – Anterior Cruciate LigamentOKC- Open Kinematic ChainCKC- Closed Kinematic ChainCPM- Continuous Passive Movement

Introduction

The anterior cruciate ligament is the commonestligament that is injured in the knee1,2. The prevalence rate ofACL injury increases during sports activities3. Though theincidence of ACL injury was not documented in India, out of80,000 ACL tears which occur during various sportsactivities in United States 50,000 require surgical correction,remaining can be managed effectively by conservativemethods4. The patients can be selected for surgery on thebasis of their age, associated ligament and meniscalinjuries, functional and sporting demands on the knee, thepatient’s motivation level and the ability to participate in arehabilitation programme.

Kevin5. Colleagues stressed the importance of welldesigned rehabilitation protocols with a strong scientificrationale in the successful management of ACL injury. The

major goals of rehabilitation programmes are to strengthenthe knee joint muscles and to improve the joint mobilitythrough various exercises to achieve the maximal pre-injurystatus. From the late1980’s a good number of studies havebeen published regarding ACL injury rehabilitation and theprotocols are evolving in nature6,7,8. In the current era ofevidence based practice, the therapist should be aware ofthe recent trends and research evidence. The mainobjective of this review is to search for the availableresources pertaining to ACL injury rehabilitation. Reviewsare considered to be reasonable sources of knowledge.

Method

A structured literature search was performed inelectronic database like PUBMED, Ovid and Pedro by usingthe key words ACL Injury, rehabilitation and review. Thesearch was restricted to English language. Boolean logicwas used to combine, expand and restrict the search.

Results

While performing literature reviews regarding ACLrehabilitation three different reviews were retrieved, out ofwhich one is a systematic review. Overview of these reviewsis given below.

The systematic review as mentioned in the title ‘Asystematic review of evidence for anterior cruciate ligamentrehabilitation: how much and what type’ by Risberg M A,Lwek M and Mackler I S was published in Physical therapyin sports9. One other study which met the inclusion criteriawas by Joana Kevist10 from Linkoping University, Sweden.This study which was published in Sports Medicine with thetitle ‘Rehabilitation following anterior cruciate ligament injury:current recommendation for sports participation’ One otherreview by Beynnon B D11, and colleagues with the title ‘Thescience of anterior cruciate ligament rehabilitation’published in Clinical Orthopaedics and related research,was also included in the final review.

The study by Risberg et al9 reviewed 33 RCTs whichincreased the validity of that study. Moreover as mentionedabove, it is a systematic review. Beynnon11 et al reviewed 12RCTs while the numbers of RCTs were not mentioned byJoanna Kvist10.

Advantages of the reviews

In the study by Risberg et al9, evidence for effectiverehabilitation has been assessed based on RCTs on sixdifferent aspects.w Rehabilitation protocolsw Home vs. supervised rehabilitationw CKC vs. OKC

Binu S. Das / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2 37

w Neuromuscular electrical stimulation for quadricepsstrengthening

w Neuromuscular trainingw Specific exercises used.

Methodological quality for each topic in the study isexplained. Moreover quality of the included RCTs areappraised and further research directions were given in thatstudy.

The study by Joana Kvist10 is a sports oriented reviewand current recommendations for sports participation wereexplained. Other than the general factors social andpsychological aspects were also considered in this study.

Importance was given to the biomechanical aspects byBeynnon et al11. The authors reviewed retrospective,observational, prospective and randomized studiesregarding ACL rehabilitation.

GraftAccording to Risberg et al strenuous exercises are not

advised immediately after surgery because of concernsabout graft healing. Aggressive rehabilitation programmeswill not affect the graft (no published RCT’s evaluateaggressive vs. non – aggressive rehabilitation programmefollowing ACL reconstruction)

Kvist10 suggested that initially following ACLreconstruction, the graft undergoes necrosis andrevascularisation. Biomechanical studies in animals haveshown the load to failure and stiffness of a new ligament tobe less than 25 % of normal, 7-12 months post operatively.An increase in anterior tibial translation related to femur iscorrelated to weakened structural properties in graft.

Beynnon et al11 discussed more pertaining to grafts inrelation to other authors, they noticed that iliotibial autograft’s ultimate failure load was 23 – 40 % of normalstiffness was 45%. Patellar tendon auto graft’s anteroposterior laxity was 156 – 269 % of normal side after oneyear. A large proportion of original tendon survives and ACLgraft healing in humans may not undergo the samecomplete necrosis stage that is reported in animals.

Increased anterior laxity due to excess graft strain duringhealing leads to permanent elongation which eventuallyleads to failure and stiffness of the bone patella tendon bonegraft which is 90 % of normal 8 months post operatively.

Open Kinematic Chain exercise vs. Closed KinematicChain exercise

The suggestions related to the selection of open andclosed kinematic chain exercises were the following.

Risberg9 et al noticed that belief exists that CKC is betterthan OKC. Increased laxity in the joint due to OKC is notwell supported by quality studies. The authors explainedthat in order to minimize the strain on ACL during quadsstrengthening, the knee should be in less than 60º of flexionin CKC and greater than 40º in OKC. Kvist and Beynnon etal10,11 concluded that CKC is better than OKC, but no validproof was given through those reviews. Beynnon et al10

observed that CKC put less strain on the graft and less/nearnormal laxity while OKC give more strain on the graft.

Weight bearingAll the reviews supported immediate weight bearing.

Risberg stated that immediate weight bearing showedreduced anterior knee pain. Both Kvist and Beynnon10,11

observed no difference in laxity between immediate weightbearing and non-weight bearing. Beynnon10 also observedless patellofemoral pain following immediate weight bearing.

CPM and other ROM exercisesWhile Beynnon et al concluded that immediate use of

CPM does not lead to any laxity or lower limb girthdifference; other authors did not mentioned about CPM.Early post operative ROM is advised by Kvist as it willeliminate the deleterious effects of immobilization on graftstiffness and ultimately knee strength.

Neuromuscular trainingAll the reviews explained about the importance of

neuromuscular training.Risberg, through the review noticed that evidence on

neuromuscular training was limited but the incidence of ACLinjury was much less in athletes who participated inproprioceptive training. Beynnon gave more importance toneuromuscular training to prevent ACL injury and followinginjury.

Psychological factorWhile both risberg et al and beynnon et al did not

considered about psychological factors leading to the injuryand following injury, Kvist explained properly about theimportance of this factor. The author concluded thatpsychological hindrance such as fear of re-injury persistsfollowing the initial injury. Also significant correlation wasnoticed between fear of re-injury as a reason to return topre-injury activity level. Athletes perceived injury as a reasonto stop competitive sports and to give more importance totheir social and family life.

Discussion

A Systematic review analyzed the evidences in sixdifferent aspects of ACL rehabilitation. Immediate weightbearing following ACL reconstruction was recommended bythe authors. OKC exercises are recommended in order toimprove the quadriceps strength within the range of 40 – 90degrees of knee flexion along with CKC up to 60 degrees(Riseberg et al, 2004). Kvist (2004) explained the factorswhich influence a safe return to sports along with therehabilitation protocols and the importance of thepsychological aspects of the athlete as well. Beynnon andcolleagues also stated that CKC along with OKC showspositive outcomes in terms of quadriceps strength.

Though these reviews explain the importance of earlyrehabilitation following ACL reconstruction, a lot ofcontroversies still exist regarding the protocol selection. Ithas been observe red that the authors focused on somespecific areas instead of considering the entire rehabilitativeaspects. Gregory and colleagues 8 suggested criteria basedprogression protocol for the return to sport following ACLreconstruction. They proposed an algorithm for ACLrehabilitation based on several literatures. Along with theroutine protocol proprioceptive training should also beconsidered to maximize the outcome and return to normalactivities.

Conclusion

The recent trends in rehabilitation after ACL injury andreconstruction are leading towards accelerated programmeswith early return to functional activities or sports. Anteriortranslation of the tibia may lead to graft elongations, but welldesigned RCTs are needed to find out about the effects ofaggressive vs. non-aggressive rehabilitation protocols on

Binu S. Das / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 238

graft healing. One should consider OKC as well as CKCexercises during the rehabilitation. If both are incorporatedthe results seem to be better. However, further research isrequired in this regard. Immediate weight bearing should beconsidered in all the ACL rehabilitations. There is insufficientevidence for using CPM in ACL rehabilitation. More qualitystudies are required to explore this. Psychological factorsalong with cultural variations should also be taken intoaccount while designing rehabilitation protocols. Welldesigned studies in an Indian set up should be consideredto strengthen knowledge in this regard. These three reviewsprovide insight into the ACL rehabilitation. Further highquality systematic reviews are needed to prepareguidelines.

Acknowledgements

The authors extend their sincere gratitude to themanagement and the library staff of Father Muller Charitableinstitute, Mangalore.

Reference

1. Dehaven KE. 1980. Diagnosis of acute knee injurieswith hemarthrosis. Am J Sports Med. 8:9-14

2. Eva Ageberg. 2002. Consequences of a ligament injuryon neuromuscular function And relevance torehabilitation – using the anterior cruciate ligament-injured knee as model. J Electromyography andkinesiology. 12: 205-212.

3. McNair PJ, Marshal RN, Matheson JA. 1990. Importantfeatures associated with Acute anterior cruciateligament injury. NZ Med J. 103: 537 -539.

4. Griffin LY, Agel J, Albohm MJ, et al. 2000. Noncontactanterior cruciate ligament Injuries: risk factors andprevention strategies. J Am Acad Orthop surg. 8:141- 150.

5. Kevin EW, Michael MR, Todd RH. 2003. Recentadvances in the rehabilitation of isolated and combinedanterior cruciate ligament injuries. Orthop Clin N Am 34:107 – 137.

6. Blackburn TA. 1985. Rehabilitation of anterior cruciateligament injuries. Orthop Clinics N Am, 16: 240- 69.

7. Brewster CE, Moyens DR, Jobe FR. 1983. Rehabili-tation for Anterior Cruciate Reconstruction. J orthopsport Phys ther; 5: 121 – 6.

8. Gregory DM, Mark VP, Kevin RF, Carmen EQ, TimothyEH. 2006. Rehabilitation After Anterior CruciateLigament Reconstruction: Criteria – Based ProgressionThrough the return – to- sport phase. J orthop sportPhys ther. 36:385-99.

9. Risberg M A, Lwek M, Mackler I S. 2004.A systematicreview of evidence for anterior cruciate ligamentrehabilitation: how much and what type. Physicaltherapy in sports 5, 125-145

10. Joanna Kvist. 2004. Rehabilitation following anteriorcruciate ligament injury: Current recommendation forsports participation, Sports Medicine: Vol 34, 269-280.

11. Beynnon B D, Johnson R J, Fleming B C. 2002. Thescience of anterior cruciate ligament rehabilitationClinical Orthopedics and related research, 402: 9-20

Binu S. Das / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2 39

Effect of sitting balance training under varied sensory input onbalance and quality of life in stroke patientsIbrahimi N.*, Tufel S.**, Singh H.***, Maurya M.****

*PG Student, **Teaching Assistant Jamia Hamdard, ***Physiotherapist, AIIMS, ****Neurophysiotherapy HOD AIIMS, New Delhi

Abstract

Background

Balance is the most common problem occurs in strokepatients. Most of the work done in balance training isfocused on giving balance training once the standingposition is achieved. It is also seen that task related balancetraining with altered sensory input is better than task relatedtraining without altered sensory input. So this study isdirected toward giving balance training in sitting positionunder varied sensory for improving balance and quality oflife in stroke patients.

Methods

30 subjects of stroke were selected and randomized intoan experimental and control group. The experimental groupparticipated in sitting balance training under varied sensoryinput and control group were given sitting balance trainingwithout varied sensory input. Performance of training weremeasured before and after sitting balance training usingberg balance scale, stroke specific quality of lifequestionnaire and sitting and sit to stand component ofmotor assessment scale.

Results

After training both experimental and control groupimproved significantly in balance and quality of life but moresignificant improvement was seen in experimental group.

Conclusion

Balance training can be started early in rehabilitationprogram once sitting is achieved with altered sensory inputfor improving balance and quality of life.

Key words

Balance, varied sensory input, sitting balance training.

Introduction

The WHO, defines Stroke as rapidly developed clinicalsign of a focal disturbance of cerebral function of presumedvascular origin and of more than 24 hours duration,included within this definition are most cases of cerebralinfarction, cerebral hemorrhage and subarachnoidhemorrhage but deliberately excluded are those cases inwhich recovery occurs within 24 hrs.1

In India, during the last decade the age adjustedprevalence rate of stroke was between 250-350/100,000.

Hypertension was the most important risk factor2. Common impairments after stroke are impaired motor

function, sensory, perceptual deficits, impaired balance,cognitive limitations, aphasia and depression. The recoveryof independence following stroke is a complex processrequiring the reacquisition of many skills. Since controllingthe body’s position in space is essential part of functionalskills, restoration of balance is a critical part of the recoveryof ability after stroke3. Sensory systems involved inmaintance of balance are visual, vestibular andsomatosensory. The somatosensory system provides theCNS with position and motion information about the bodywith reference to supporting surfaces also somatosensoryinputs throughout the body report information about therelationship of body segment to one another and hencemaintaining balance3.

The main cause of balance disturbance after stroke isthe central nervous system lesion, which affects informationprocessing and integration of sensory input as well as theeffector pathways. Impairment in balance after strokeoccurs due to muscular weakness, abnormal muscle tonewith stiffening of joints, shortening of muscle with loss ofrange of motion, distorted proprioception and impairment ofvestibular mechanism. It has been demonstrated that strokepatient have abnormal and delayed postural response inlower extremity in standing displacement.

Few studies have addressed participation restrictions instroke survivors using the international classification offunction, disability and health frame work. Most studiesdealing with the social impact of stroke have focused onquality of life of survivors , and have shown that restrictionin participation4,5 and depression6 following stroke aredetrimental for life quality , while social support can enhancethis quality.

The treatment available for above mentionedimpairments include physiotherapy in stroke rehabilitationwhich includes a variety of movement therapy approaches.Some Method like Proproiception NeuromuscularFacilitation, Rood, Brunnstrom, Bobath and recent motorrelearning programme are commonly used.

A recent study revels that regular exercise with selfinitiated training seemed to enhance HRQOL whichoccurred due to change in motor function, balance andwalking capacity and independence in activities of dailyliving7.

Methods used for retraining balance includes exploringlimits of stability through low frequency weight shifting,symmetrical weight bearing, shifting the weight more ontoaffected extremity. Dual task training in standing and forceplatform biofeedback are also used8. Postural perturbationsare used for training which may include sit or stand onmovable surface there by stimulating adjustments throughdisplacement of base of support.

Ibrahimi N. / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 240

It is also seen that when patients were givenmultisensorial approach based on higher intensity ofbalance tasks and exercise during visual deprivationshowed significant improvement in balance and walkingparameters, although it was not superior to NDT – basedtherapy that used a general approach for sensory motorreahablitation9.

Also, when task oriented exercise program, assisted bysensory manipulation was found to be more effective atimproving the standing balance of stroke subjects thanconventional task oriented program in standing position foreight weeks10.

All these balance training methods mentioned above arein standing position which carries high risk of fall duringtraining session as the patient might not be able to sustainthe position and perform balance exercises. In a studyconducted by Dean and Shephard there was a peculiarfinding of carryover of reaching activities in sitting positionto improved performance in standing activities as they statethat there exits biomechanical similarities between reachingin sitting and pre extension phase of standing11. They alsostated that individuals after stroke are slower and do notload affected foot or activate muscle of affected legsufficiently when reaching beyond arm’s length in sitting butwhen trained, they were able to increase load taken throughthe affected foot and increased the consistency of activationof muscle in affected leg12.

As still no consensus on the effective protocol forbalance training is there and for most of time duringrehabilitation programme, activities in standing are notinitiated early in the course of programme but as has beenstated earlier that carryover of training is there so instead ofdelaying standing balance training one strategy might be touse training in sitting activities for improving standingbalance.

So by combining the above stated findings this studywas intended to see the effect of training in sitting positionunder varied sensory input for two weeks on balance andquality of life so that training can be started early inrehabilitation program.

As rehabilitation aims to provide patients and theirsupporters with the knowledge, skills and support tomaintain their autonomy, minimize disability and maximizethe level of participation of individual, the same may be truefor Stroke patients. The present work was useful as itaccelerates the training of one the most important functionalposition required in daily life which is standing. Also high riskof falls which occurs during training balance in standing canbe minimized as this study was intended for trainingstanding balance in sitting position.

Methods

Subjects

A total of 30 subjects were selected for study on thebasis of inclusion and exclusion criteria from All IndiaInstitute of Medical Sciences (AIIMS), NeurophysiotherapyDepartment. There were two groups A experimental orgroup B control, each consisting of 15 subjects and wereassigned to either group through randomization. Informedconsent was signed.

Inclusion criteria• Cerebrovascular accident• 45 yrs and above• Onset of stroke less than 3 months• Both sexes, male and female• MAS sitting score of 313

• Requires many attempts to stand unsupported for30secs

• No visual deficits• No sensory deficits• Ability to understand instruction• Ability to reach with intact arm distance equivalent to

140% of arm’s length12

Exclusion Criteria• Any problems which would interfere the ability to perform

seated reaching task• Any cognitive deficits• Any other neurological deficits such as multiple

sclerosis, Parkinson’s disease etc• Any musculoskeletal abnormality such as fracture,

osteoarthritis, ligament injury in lower extremity etc.• Patient who was on any other balance training protocol.Design ---Pre test – Post test Experimental Group Design.Procedure----

The diagnosis, age, gender and duration of onset ofstroke were obtained from patient’s interviews and medicalchart. All those who met inclusion criteria were randomlyassigned into either group A (experimental group) –received sitting balance training under varied sensory inputor in Group B (control group)-received sitting balancetraining without varied sensory input. A detailed assessmentof every subject was done by me. On the day of initialassessment a pre score of Berg balance scale and Strokespecific quality of life questionnaire and MAS sitting andMAS sit to stand were taken for all the selected subjects andagain a post score for both the scales were collected at theend of training session which was at two weeks.

Graph No.1: Within group comparison of BBS

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pre

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Ibrahimi N. / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2 41

InstrumentationBerg balance scale14 Stroke specific quality of life

questionnaire15,16, MAS sitting and sit to stand17, Air filledpillows, Standardized stool for each patient, Measuringtape, Adhesive tape

ProtocolGroup A (experimental group) – received sitting balance

training under varied sensory inputIn this group all selected subjects underwent sitting

balance training protocol under varied sensory input for twoweeks. For training in sitting a stool without backrest wasselected for each subject and the height of stool wasstandardized for each subject. It was adjusted to 100% oflower leg length which was measured from lateral knee jointline to the floor with subject standing barefoot. Also themeasurement of arm length was done, which was measuredfrom tip of acromium process to the tip of middle finger ininches.

Then the stool was placed at a distance of 140% of armlength and line was marked with the help of adhesive tapeon wall at 140% of arm length at shoulder level and thesubject was asked to sit on stool. Varied sensory input wasprovided to the subject in form of air filled pillows below thebuttock as well as feet. The amount of air filled was keptconstant during the entire training period. This air filled pillowprovided the instability on which sitting balance trainingprotocol was followed.

In training protocol all subjects were asked to touch themarked line on wall in three directions forward, 45 degreestowards unaffected side and 45 degrees across the body

towards affected side using unaffected hand Subjects wereasked to perform all these reaching activities. Each sessionlasted for 20 to 30 minutes, which consisted of five sessionsper week for two weeks and each session consisted of 20repetition X 5 times in each session in each direction.

The experimental group also received conventionalphysiotherapy for stroke which included strengthing andstretching exercise for upper and lower limb. It was in formof 1-3 sets of 10-15 repetitions in each session.

Group B (control group)-received sitting balance trainingwithout varied sensory input

In this group all selected subjects underwent sittingbalance training protocol only without any sensory input fortwo weeks. A stool without backrest was selected for eachsubject. The height of stool was standardized for eachsubject. For this group also, it was adjusted to 100% oflower leg length which was measured from lateral knee jointline to the floor with subject standing barefoot. Also themeasurement of arm length was done, which was measuredfrom tip of acromium process to the tip of middle finger ininches.

Then the stool was placed at a distance of 140% of armlength and line was marked with the help of adhesive tapeon wall at 140% of arm length which was at shoulder leveland the subject was asked to sit on stool.

In contrast to experimental group no instability wasprovided. There protocol consisted of the marked line onwall in three directions forward, 45 degrees towardsunaffected side and 45 degrees across the body towardsaffected side using unaffected hand.

Each session lasted for 20 to 30 minutes, whichconsisted of five sessions per week for two weeks and eachsession consisted of 20 repetition X 5 times in each sessionin each direction.

Graph No. 2: Within group comparison of SSQOL

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post

Graph No. 3: Within group comparison of MAS sitting

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Graph No. 4: Within group comparison of MAS sit to stand

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Ibrahimi N. / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 242

The control group also received conventionalphysiotherapy for stroke which included strengthing andstretching exercise for upper and lower limb. It was in formof 1-3 sets of 10-15 repetitions in each session.

Data analysis: analysis was done using SPSS software15, Wilcoxan signed rank test was used for withingroupanalysis and Mann whitney U test for between groupanalysis.the level of significance was set at p< .05

Results

Within Group AnalysisWithin group analysis was done using wilcoxan signed

ranks test and results of within group analysis of BBS showsthat there is a significant difference statistically with group A( p value < .001) and group B (p< .001). Which means thatthere was significant improvement of balance in bothgroups.

Within group analysis of SSQOL also shows significantdifference both statistically with group A (P< .001) and groupB(p<.001), which means that there was significantimprovement in quality of life of both the groups.

Another variable that was used in study was balancesitting of motor assessment scale which also showedsignificant difference in within group analysis with group A(p<.000) and group B (p<.000) suggesting significantimprovement in both the groups

Also sit to stand component of motor assessment scalewas used, within group analysis of it also showed significantdifference with group A (p<.000) and group B (p<.000)

The above stated segments suggest that there was astatistically significant improvement in balance and quality oflife in both the groups

Between Group AnalysisMann -whitney test was used for between group analysis

and following result was obtained.During intergroup analysis post BBS score were found to

be statistically significant (p < .001), also it is seen that therewas no significant difference in pre BBS scores suggestinggroups were homogenous.

It is also seen that between group analysis of SSQOLshowed statistically significance (p<.000), also it was foundthat there was no significant difference in pre SSQOLsuggesting that groups were homogenous.

When between group analysis of post MAS sitting wasdone through mann- whitney test also showed statisticallysignificant (p<.000), where as pre values of MAS sittingwere non significant suggesting homogeneity of groups.

MAS sit to stand was also analyzed for between groupdifferences. Results of which suggest that they also showedstatistical significance (p<.000). Pre score of MAS sit tostand was non significant

The results of between group analysis suggest that therewas more improvement in group A (sitting balance trainingwith varied sensory input) than group B (sitting balancetraining without varied sensory input) in balance and qualityof life.

Discussion

The purpose of study was to find the effectiveness ofvaried sensory input on balance and quality of life in strokepatients. The main findings of the study are improvedbalance, and quality of life in both the groups, whereas moreimprovement in experimental group where varied sensoryinput was used. Therefore, the results clearly proves theexperimental hypothesis that sitting balance training undervaried sensory input is more effective in improving balanceand quality of life in stroke patients.

Improvement in balance and motor performance in bothgroups, this might have occurred because of the below

Graph No. 5: Between group comparison of BBS

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group B

Graph No. 6: Between group comparison of SSQOL

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160

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group B

Graph No. 7: Between group comparison of MAS sitting

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group B

Graph No. 8: Between group comparison of MAS sit to stand

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Ibrahimi N. / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2 43

mentioned reasons as present study was directed towardstask related training where protocol was given in sittingposition and subject was supposed to reach 140% armlength which resulted in weight bearing of lower extremity.There were also biomechanical similarities betweenreaching in sitting and pre extension phase of standing up.Hence the training protocol carried over to standing ability12.

Dietrich’s et al suggested that post stroke brain plasticitywhich includes synaptogenesis, change of function in preexisting synapses, cortical reorganization18, unmasking oflatent network representations as well as other adaptiveprocesses such as excitatory metabolic stress, animbalance in activating and inhibiting transmission leadingto salient hyperexcitabilty19. It is seen that cerebral cortexundergoes significant and functional structural plasticity forat least several weeks to months following injury. Adaptivechanges have been demonstrated in the intact tissuesurrounding the lesion, as well as in other cortical motorareas remote from the site of injury20. all these changes arestimulated by activity18, Rehabilitation interventions maymodulate mechanisms of neurofunctional plasticity andinfluence the natural course after stroke19. Task specific andrepeated exercises appear to be a key factor in promotingsynaptogenesis21 Intensive task specific practice withimpaired limb has a modulatory effect on the inevitablecortical plasticity20 Task specific and repetitive exerciseappears to be key factor in prompting synaptogenesis andare central elements in rehabilitation21.

Earlier study done by Bayounk et al10 proved that taskrelated training with altered sensory input is better thantask related training without altered sensory input forimproving balance in stroke subjects. The present study wasdirected towards giving training in sitting position undervaried sensory input for improving balance and quality oflife.

More improvement in experimental group might havebeen due to somatosensory manipulation which couldenhance multisensory interactions. This might have resultedfrom sensory training which may have improved the sensorymotor integration of postural stability of stroke patients10.

One possible mechanism of this improvement is thatstroke subject are able to select reliable information forpostural control more efficiently following multisensorytraining10. Bonen et al22 stated that balance is improvedmore after rehabilitation with visual deprivation than freevision after stroke. These findings suggest that subjectsimproved their integration of somatosensory and vestibularinput and that the program enabled them to use thepertinent input (somatosensory, vestibular. Visual) and tobecome less reliant on visual input22. He also suggested thatpostural imbalance might be due to more to a higher levelinability to select reliable sensory input than to elementarysensory impairment22. So, when subjects were giveninstability in form of air filled pillows below the buttock andfeet there was lack of accurate somatosensory information.In this condition the pertinent sensory input for posturalstability might came from vestibular and visual system10. So,it can be stated that compensatory mechanism can occurand can be improved with proper sensory training afterstroke patients10.

As suggested earlier that improvement in balance mightbe because of enhanced intersensory interactions andsensorimotor integration in central nervous system23. The

neural basis of intersensory interaction for postural controlis not yet fully understood23. An interaction among visual,vestibular and somatosensory system could occur whereverconvergence of sensory input may be found. Sensoryconvergence has been found at many levels of centralnervous system, including vestibular nuclei, the thalamus,cerebellum and cerebrum.sensory convergence occurs inthe vestibular nuclei and intersensory interactions results inthe modulation of neuron activity and subsequentadjustment of muscle activities related to postural control23.

An interaction among sensory systems also occurs athigher levels in the central nervous system. It is stated thatdirect visual and vestibular sensory interactions appear tooccur within the cerebral cortices.Hu and Wollacott23

suggested that complex sensory training can result inenhanced integrative ability of higher brain centers. Thestudies have demonstrated that higher brain centers retainplasticity at molecular level and that practice can induce themodulation of neuronal activity in cerebellum.

In present study improvement occurred in balance whichmust have caused improvement in mobility and self careand hence might have improved quality of life.

Aprile et al7 has shown that rehabilitation in patient withchronic stroke lessens disability and improves physical andsocial functions and hence quality of life can be improved.. Langhanmner et al24 has also seen that regular exercisehave an effect on motor function, balance, walking capacityand independence in activities of daily living which haveeffect on enhanced quality of life.

Conclusion

Sitting balance training under varied sensory input ismore effective for improving balance and quality of life thansitting balance training without varied sensory input in strokepatients.

References

1. Patricia AD, Cash textbook of neurology forphysiotherapist 4th edition, Japee brothers medicalpublishers 1993

2. Banerjee TK, Das SK, Epidemiology of stroke in India.Neurology Asia 2006; 11: 1-4

3. Shumway –Cook A, Woollacott MH, Motor controltheory and practical applications 2nd edition, LippincottWilliams and wilkins 2001

4. Kauhamen ML, Korpelianen JT, Hiltumen P, NeiemienP, Sotaniemi KA. Domains and determinants of qualityof life after stroke caused by brain infaction. Archivesof physical medicine and rehabilitation 2000; 81: 1541-1546

5. Robinson-smith G, Johnston MV. Self care efficacy,quality of life and depression after stroke. Archives ofphysical medicine and rehabilitation 2000; 81:460-464

6. Astrom M, Asplund K, Astrom T. Psychosocial functionand life satisfaction after stroke. Stroke 1992; 23 :527-531

7. Langhammer B , Stanghelle JK, Landmark B. Exerciseand health related quality of life during first yearfollowing stroke. A randomized control trail. Brain injury2008; 22(2) : 135-45

8. Barclay –Goddard R, Poluha W, Stevenson T et.al.Cochrane database systematic review 2004; 18(4) :CD004129

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9. Yelnik AP, Le Breton F, Colle FM et al. Rehabilitation ofbalance after stroke with multisensorial training, a singleblind randomized control study. Neurorehabilitationneural repair 2008; 22(5) : 468-476

10. Bayouk JF, Boucher JP, Leroux A. Balance trainingfollowing stoke: effect of task oriented exercise with andwithout altered sensory input. International journalrehabilitation research 2006; 29(1) : 51-59

11. Catherine M Dean, Elizabeth F Channon and Jillian MHall, Sitting training early after stroke improves sittingbalance and quality and carries over to standing up butnot to walking. Australian J. of physiotherapy 2007; 53:97-102

12. Catherine M Dean, Roberta B Shephard, Task relatedtraining improve performance of seated reaching taskafter stroke. Stroke 1997; 28: 722-728

13. Janet H. Carr, Robert B. Shepard, Denise Lymne,Investigation of new motor assessment scale for strokepatients. Physical therapy 1985; 65: 175-179

14. Mao HF, Hsueh IP et al, Analysis of comparison ofpsychometric property of three balance measure forstroke patients . Stroke 2002; 33: 1022-1027

15. Williams LS, Weinberger M, et al, Development ofstroke specific quality of life scale. Stroke 1999; 30:1362-1369.

16. Williams LS, Validation of the stroke specific quality oflife scale: Test of reliability and validity of the Danishversion. Clinical rehabilitation 2007; 21: 620-627

17. Janet H. Carr, Robert B. Shepard, Denise Lymne,

Investigation of new motor assessment scale for strokepatients. Physical therapy 1985; 65: 175-179

18. Dietrichs E et al, Brain plasticity after stroke-implications for post stroke rehabilitation. Tidsskr norlaegeforen 2007; 127(9): 1228-1231

19. Kreisel SH, Hennerici MG, Pathophysiology of strokerehabilitation: the natural course of clinical recovery,use dependent plasticity and rehabilitation outcome.Cerebrovascular disease 2007; 23(4): 243-255

20. Nudo RJ, Friel KM, cortical plasticity after stroke:Implication for rehabilitation. Rev neurology (paris)1999; 155(9): 713-717

21. O dell, MW Lincc, Harrison V, Stroke rehabilitation:Strategies to enhance motor recovery. Annu Rev Med2008; 17

22. Isabella V Bonen, Alian P Yelnik, et al, Reliance onvisual information after stroke. Part II: Effectiveness ofa balance rehabilitation program with visual cuedeprivation after stroke: A randomized controlled trail.Archives of physical medicine and rehabilitation 2004;85: 274-278

23. Ming Hsia Hu, Woollacott MH, multisensory training ofstanding balance in older adults I postural stability andone leg stance balance. Journal of gerontology1994;49: M52-M61

24. Aprile at al, Effects of rehabilitation on quality of life inpatient with chronic stroke. Brain injury 2008; 22(6):451-456

Ibrahimi N. / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2 45

Effect of single session of prolonged muscle stretch on spasticplantarflexors of children with quadriplegic and diplegic spasticcerebral palsyPreet Kamal Kaur*

*Lecturer, Department of Physiotherapy, Prakash Institute of Physiotherapy, Rehabilitation & Allied Medical Sciences,Greater Noida, U.P., IndiaAbstract

The control of spasticity is often a significant problem inthe management of patients with cerebral palsy whichhinders in achieving functional goals and mobility. ThePurpose of this study is to evaluate the effect of prolongedmuscle stretch on ankle plantar flexors spasticity. Twentypatients suffering from diplegia and quadriplegia spasticCerebral Palsy was enrolled which were divided into twogroups. One group received prolonged muscle stretch of theplantar-flexors of the ankle in the standing position on tilttable with ankle dorsiflexed and second group receivedConventional Physiotherapy for 45 minutes per session perday for 5 days a week for 2 weeks. The followingevaluations were done before and after treatment. Spastichypertonia was assessed by the Modified Ashworth Scale(MAS; range, 1-3). The Result indicated no significantreduction in MAS score for ankle plantar flexors spasticity(p>0.05). These results suggested that there is no effect ofthe prolonged muscle stretch in reducing spasticity inpatients with spastic cerebral palsy.

Keywords

Spasticity, Tilt Table, PMS, Passive Exercises

Introduction

Cerebral Palsy is the heterogenous group of persistentdisorder of movement and posture caused by nonprogressive defects or lesions of immature brain. Cerebralpalsy is not a disease, rather a category of disabilityincluding patients with one kind of problem, chronic nonprogressive disorders of movement or posture of early onset(Aneja. S, 2004).

The incidence of cerebral palsy in developed world is 2-2.5 per 1000 live births. The diagnosis of cerebral palsy isclinical but selected investigation may be required forascertaining the cause (Aneja. S, 2004).According to thetopographical distribution, Spastic Cerebral palsy may befurther categorized into monoplegia, quadriplegia, diplegiaand hemiplegia. In an analysis of 1000 cases of CP fromIndia, it was found that spastic quadriplegia constituted61% of cases followed by diplegia 22% (SinghiPratibha D,2004). Periventricular atrophy is a bilateral lesion thought tobe responsible for most cases of preterm spastic diplegia, ithas also seen reported as an asymmetrical or unilaterallesion or with bilateral lesions expressing only unilateralclinical symptoms (Wiklund et.al, 1991). Quadriplegia hasbeen associated with brainstem and basal nuclei damagein addition to cortical and subcortical lesion (Wilson et al,1982).CP is a condition with multiple causes leading todamage within the CNS. Although the causes are notcompletely understood certain prenatal, perinatal, postnatalfactors are associated with C.P (Torfs et al, 1990), CP in

developing countries is most often attributed to birthasphyxia and birth trauma. Birth Asphyxia is still a leadingcause of CP in India. A consensus statement issued byInternational Cerebral Palsy Task Force suggested a set ofcriteria which should be present to pinpoint intrapartumhypoxia as cause of Cerebral Palsy. The essential criteriasuggested were evidence of metabolic acidosis inintrapartum or very early neonatal blood samples, earlyonset of moderate to severe neonatal encephalopathy ininfants greater than 34 weeks gestation and Cerebral Palsyof spastic quadriplegic type (Mac Lennan et al, 1999).

Factors pointing to antenatal origin of Cerebral Palsy aremicrocephaly at birth, history of preterm birth, pressure ofmalformation history of Cerebral Palsy in Sibling, severeintrauterine growth retardation, early imaging evidence oflong standing neurological diseases like ventriculomegaly(Mac Lennan, 1999).

Associated problems of CP is impaired control andcoordination of voluntary muscles which is accompanied bycognitive delays or learning disabilities in 50-75% of childrenand by disorders of speech (25%), auditory impairments(25%), seizure disorders (25-35%) or abnormalities of vision(40-50%) (Batshaw and Perret 1992).Ankle plantar flexioncontractures are common problem in CP due to spasticity.Physical therapy specially when started early in life, ishelpful in promoting normal motor development andpreventing deformity and contractures (SinghiPratibha D,2004). Passive Stretching techniques have also been usedfor many years in management of spasticity. The use ofslow prolonged and sustain stretch of hypertonic muscleshas been advocated for inhibition of hypertonic muscles(Harres. F. A, 1978) and when applied over a long period forthe reduction of muscle contractures (Tardieu C et al, 1982).One method that has been used for many years to reducespasticity is passive ROM exercises. Passive ROMexercises are interventions that are used for contractures ofany severity and all limitations of joint passive ROM (Winter2005). Physical therapists intervene with the person withspasticity to improve joint motion, strength and endurancethrough a variety of techniques. One technique used by theclinician is range of motion. Range of motion is used toincrease the movement at a specific joint and must be donewith slow, sustained pressure to achieve improved jointmotion in the muscle with increased tone or spasticity.

Methods

The random sampling method has been used. 20subjects both male and female were included in the study.Their demographic profile and detailed medical history wascollected through interviewing parents or caretaker and fromprevious medical records following Inclusion criteria: a. Age: 3-8 yearsb. Children with Spastic Quadriplegia and Diplegia.c. Spasticity grade 1 to 3 according to MAS

Preet Kamal Kaur / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 246

Exclusion criteria werea. Children with spastic hemiplegia, monoplegia.b. Subjects with limb length discrepancy.c. Those subjects having foot edema, foot bony

deformities.d. Subjects with any surgical treatment of T.A.e. Children suffering from any medical disorders like

seizuresThe written informed consent before making there

child/ward participate in the study was taken from Parent orcaretaker. Before initiation of the study, institutional reviewboard approval was obtained. The Spasticity was assessed

on MAS on First and last day of intervention (Bohannan andSmith 1987)

Treatment Protocol

When these tests had all been completed, Patients weredivided by random sampling method into two groups A andB .GroupA subjects were positioned on a tilt-table.

adequate support (Fig. 1). The ankle joints were placedat maximal dorsiflexion. For each patient depending upontheir ROM. According to previous studies (Odeen andKnutsson, 1981; Tremblayet al., 1990), the duration of thetreatment time was set at 30minutes. While Group Breceived Conventional Physiotherapy (Passive Exercises).All the tests performed before treatment was performedwere repeated immediately after treatment and again 45minutes after treatment.

Data analysis

For data analysis, the differences in muscle tone (MAS)of the Triceps Surae between Quadriplegics and Diplegicswas analyzed using Paired t- Test to measure the changesbetween the different times before and after treatment werecompared by means of repeated measures analysis ofvariance at a significance level of 5%. It means thesignificance (Probability-P) was selected as 0.05. Also thecomparison between the male and female group was doneThe calculated t- value was compared with tabulated t-value(2.262) to find out whether there was any significantdifference between pre test and post test values. SPSSsoftware was used for analysis.

Results

Discussion

In present study there was no significant difference inmuscle tone on Modified Ashworth scale score of left pre

Table 1: Demographic profile of Subjects

Variables Group A Group BMale 3 5

Female 7 5M/F ratio 3:7 1:1

Age/years 5.8 6.1(mean)

Quadriplegics 4 6Diplegics 6 4Q/D Ratio 2:3 3:2

Fig. 1: Comparison of Quadriplegic between Group A and Group B

0

0.5

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MAS_lt_pre

MAS_lt_pos

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MAS_rt_pos

Table 2: Comparison of Quadriplegic patients between Group A and GroupB (Fig 1):

Group A Group BMean SD SE Mean SD SE t

MAS_left_pre 2.2500 0.95743 0.47871 1.1667 0.40825 0.16667 2.508*MAS_left_post 2.2500 0.95743 0.47871 1.1667 0.40825 0.16667 2.508*MAS_right_pre 2.2500 0.95743 0.47871 1.3333 0.51640 0.21082 1.988MAS_right_post 2.2500 0.95743 0.47871 1.3333 0.51640 0.21082 1.988

*Significant at p≤0.5

Fig. 2: Comparison of Diplegic Patients between Group A and Group B

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Table 3: Comparison of Diplegic patients between Group A and Group B(Fig. 2)

Group A Group BMean SD SE Mean SD SE t

MAS_left_pre 1.1667 0.40825 0.16667 2.0000 1.15470 0.57735 -1.661MAS_left_post 1.1667 0.40825 0.16667 2.0000 1.15470 0.57735 -1.661MAS_right_pre 1.6667 0.81650 0.33333 1.5000 0.57735 0.28868 0.351MAS_right_post 1.6667 0.81650 0.33333 1.5000 0.57735 0.28868 0.351

*Significant at p≤0.5

Fig. 3: Comparison of Males between Group A and Group B

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Preet Kamal Kaur / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2 47

and right pre MAS score, left post and right post MAS scoreafter 45 minutes of prolonged muscle stretch in group A and45 minutes of conventional therapy in Group B. There is nosignificant difference seen between the MAS score ofdiplegics and Quadriplegics.Although this scale is of tenused in clinics, Tsai et al (2001) revealed that it could notreflect any neurophysiological changes in spastic muscle.However there is some evidence to suggest that passivestretching can reduce spasticity in children with cerebralpalsy as those studies showing favorable outcome afterprolonged muscle stretch were mainly of higher levels ofevidence and more rigorous methodology. The effect sizewas fairly small and it was difficult to judge that whether itwas clinically significant (Tamis pin et al, 2006). In presentstudy no significant difference between the males andfemales were also seen.

The increase in extensibility of a shortened muscle bystretching is due to the responses of the soft tissue towardsstretch. The muscle shows mechanical response to stretchwhich results in increase of extensibility when a muscle isstretched mechanically or held in a lengthened position forseveral weeks. Sarcomeres are added in series. When noncontractile connective tissue are stretched with low intensity,prolonged stretch force, plastic deformation occurs andlength of tissue increase (Kisner 1996). F.Tremblay(1990)who suggested that prolonged muscle stretch for 30minutes can cause changes in the mechanical properties ofintrafusal muscle fibres and in the sensitivity of receptorterminals which will modify reflex responses followingchanges in muscle length (either active or passive).

Conclusion

It can be concluded that prolonged muscle stretch andConventional therapy showed no statistically significantimprovement in the level of spasticity showing that bothtreatment techniques have no effect on spasticity.

Limitations

1. Small number of subjects.2. Duration of study was small.3. Area of population was small so can’t be generalized.4. Use of various feet wears and home activity was not

controlled.

References

1. Aneja.S. Symposium on Cerebral Palsy, Indian Journalof Pediatrics, 2004, 71(7): 627-634.

2. Akbayrak Turkan, Armutlu Kadriye, Gunel.K. Mintaze,Guley Nurlu. Assessment of the short term effect ofantispastic positioning on spasticity, PediatricsInternational, 2005 Aug 47: (4)440-445.

3. Bem Marsha, Chees Shane, Deniss Sophie,GlinskyJoanne, Goelhi Gerlinde, Harvey Lisa. Does 12 weeksof regular standing prevent loss of ankle mobility andbone mineral density in people with recent spinal cordinjuries?, Australian Journal of Physiotherapy,2005,51:251.

4. Bem Marsha, Chees Shane, Deniss Sophie,GlinskyJoanne, Goelhi Gerlinde, Harvey Lisa. Little clinicaleffect on ankle ROM and bone density from tilt tablestanding in patients with spinal cord injuries,NewZealand Journal of Physiotherapy, 2006 March34(1):36-37.

5. Berger Wiltrud. Cerebral Palsy: aspects ofpathophysiology and principles of therapy, NeuroRehabilitation, 1998, 10:257-265.

6. Bohannon.W. Richard, Smith.B.Melissa. InterraterReliability of a Modified Ashworth Scale of musclespasticity, Physical Therapy, 1987, 67(2):206-207.

7. Brunnstrom.E.Janice. Clinical Considerations inCerebral Palsy and Spasticity, Journal of ChildNeurology, 2001, 16(4):10-15.

8. Cadenhead.L.Sherry, McEwen.R.Irene, Thompson.M.David. Effect of Passive Range of Motion Exerciseson Lower extremity Goniometric measurements ofadults with cerebral palsy:A Single Subject Design,Physical Therapy, 2002, 82(7):658-669.

9. Campbell.S, Linden.W.Darl, Palisano.J.Robert.Cerebral Palsy, Physical Therapy for Children, 2006,Ch-21:625-664, Saunders Elsevier.

10. Campbell.A.G.M, McIntosch.Neil. Disorders ofMovement, Textbook of Pediatrics, 1998, 738-760,Churchill Livingstone.

11. Chan.Michael, Dyke. Paula, Pin. Tamis. Theeffectiveness of passive stretching in children withCerebral Palsy, Developmental Medicine and ChildNeurology, 2006, 48:855-862.

12. Clopton Nancy, Featherston , Grigsby, Jami, Jennifer,Jessica, Melvin,Tandy. Interrater and IntraraterReliability of the Modified Ashworth Scale in Childrenwith Hypertonia, Pediatric Physical Therapy, 2005,17(4):268-274.

Table 4: Comparison of Males between Group A and Group B (Fig 3)

Group A Group BMean SD SE Mean SD SE t

MAS_left_pre 1.7143 0.95119 0.35952 1.8000 1.09545 0.48990 -0.145MAS_left_post 1.7143 0.95119 0.35952 1.8000 1.09545 0.48990 -0.145MAS_right_pre 2.0000 0.81650 0.30861 1.2000 0.44721 0.20000 1.972MAS_right_post 2.0000 0.81650 0.30861 1.2000 0.44721 0.20000 1.972

* Significant at p≤0.5

Table 5: Comparison of Females between Group A and Group B (Fig: 4)

Group A Group BMean SD SE Mean SD SE t

MAS_left_pre 1.3333 0.57735 0.33333 1.4000 0.54772 0.24495 -0.164MAS_left_post 1.3333 0.57735 0.33333 1.4000 0.54772 0.24495 -0.164MAS_right_pre 1.6667 1.15470 .66667 1.6000 0.54772 0.24495 0.114MAS_right_post 1.6667 1.15470 .66667 1.6000 0.54772 0.24495 0.114

Fig. 4: Comparison of Females between Group A and Group B

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8

Group A Group B

MAS_lt_pre

MAS_lt_pos

MAS_rt_pr

MAS_rt_pos

3-D Column 5

Preet Kamal Kaur / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 248

13. C.L.Richards, F.Dumas, F.Malouin. Effects of a singlesession of prolonged plantarflexor stretch on muscleactivations during gait in spastic cerebral palsy,Schand.J.Rehabilatation Med, 1991,23(2):103-11

14. Czell David, Rupp Rudiger, Reinhard Schreier, StephenEberhard, Volker Dietz. Influence of passive legmovements on blood circulation on the tilt table inhealthy adults, Journal of NeuroEngineering andRehabilitation, 2004, 1(4): 1173-1186.

15. Dain.P.LaRoche, Declan.A.J. Effects of stretching onpassive muscle tension and response to eccentricexercises, The American Journal of Sports Medicine,2006 June 34(6): 1000-1007.

16. Danial Herman, Johnson, Julie, May, Ryan, Vogel.Quantifying Weight Bearing by children with CerebralPalsy while in Passive Standers, Pediatric PhysicalTherapy, 2007, 19(4):283-287.

17. Edward Susans. Abnormal tone and movement as aresult of neurological impairnment, NeurologicalPhysiotherapy, 2nd ed, 1996, Ch-5:89-153, ChurchillLivingstone.

18. Eng.J.Janice, Levin.M.Stephen, Grant Huston, JoyBremner. Use of prolonged standing for Individuals withspinal cord injuries, Physical Therapy, 2001 Aug81(8):1392-1398.

19. Engsber.R.Jack, Ross.A.Sandy, Park.Sung Tae.Changes in ankle spasticity and strength followingselective dorsal rhizotomy and physical therapy forspastic cerebral palsy, Journal of Neurosurgery, 1999,91:727-732.

20. E.Witvrouw, N.Mahieu, P.Roosen, P.McNair. The roleof stretching in tendon injuries, British Journal of SportsMedicine, 2006 Apr 41:224-226.

21. Flett.P.J. Rehabilitation of spasticity and relatedproblems in childhood Cerebral Palsy, Journal ofPediatrics and Child Health, 2003, 39(1):6-14.

22. Fuchs.H.Robert, Meidnar.A.James, Stuberg.A.Wayne.Reliability of Goniometric Measurements of Childrenwith Cerebral Palsy, Developmental Medicine and ChildNeurology, 1998, 30:657-666.

23. Goldstien.M.Edward. Spasticity Management:AnOverview, Journal of Child Neurology, 2001, 16(1):16-23.

24. Harris SR, Krukowski L, Smith LH. Goniometricreliability for a child with spastic quadriplegia, Journalof Peadiatrics Orthopaedics, 1985, 74:348-351.

25. Harvey.A.Lisa, Jack.Crosbie, Julia.Batty, MPuphlth,Paulter.Simone. A Randomized Trial Assessing theeffects of 4 weeks of daily stretching on ankle mobilityin patients with spinal cord injuries, Arch PhysicalMedicine Rehabilitation, 2001, 81(10):1340-1347.

26. Helsel.Patty, Graveline Chantal, McGee Jennifer.Physical Management of Spasticity, Journal of ChildNeurology, 2001 Jan 16(1):25-29.

27. Jane.Styer.Acevedo. Physical Therapy for the child withCerebral Palsy, Pediatric Physical Therapy, 1994, Ch-4:90-134, J.B.Lippincot.

28. Jonck.T.Leen, Lysens.R, Schacke.S, Witvrow.E.Intertester and Intratester reliability of the standardgoniometer and the Cybex edi 320 for active andPassive shoulder range of motion in normals andpatients, Proceeding of first conference of the ISG.

29. Kaplon.E.Paul, Lois Richards, Wayne.Rodens,W.Goldschmidt. Reduction of Hypercalciuria in

Tetraplegia after Weight bearing and StrengthningExercises, Paraplegia, 19981, 19:289-293.

30. Kuen Horng Tsai, Chun-Yu Yeh, Hui Yi Chang, Jia JinChen. Effects of a single session of Prolonged musclestretch on spastic muscle of stroke patients,Proc.Natl.Sci.Council.ROC(B), 2001, 25(2):76-81.

31. Kunkel.F.Charles, Martinez. Sylvia, Roberts.Susan,Scremin.Erika.M.A. Arch Physical MedicineRehabilitation, 1993, 74:73-78.

32. Magnusson.P.S, Moller.Bojsen.E, P.Aagard,Simonsen.E. A Biomechanical Evaluation of Cyclic andStatic stretch in human skeletal muscle, InternationalJournal of Sports Medicine, 1998, 19:310-316.

33. McNair.J.Peter, Nadric Bressel. BiomechanicalLaboratory, Utah State University, Logan, U.S.A, Theeffect of Prolonged Static and Cyclic stretching on anklejoint Stiffness in humans with spasticity,ebressel@coe.usa.edu.

34. Moseley.M.Anne. The effect of casting combined withstretching on passive ankle dorsiflexion in adults withtraumatic head injuries, Physical Therapy, 1997,77(3):240-247.

35. Muynck.De.Martine, Nele Nelenathalie, Nele.Smith,Veerle Stevens, Witvrouw. Effect of Static and BallisticStretching on the Muscle Tendon Properties, Medicineand Science in Sports and Exercises, 2007 Mar39(3):494-501.

36. Norkin.Cynthia, White.D.Joyce. Measurement of JointMotion:A guide to Goniometry, 1998, 2nd ed.

37. Odeen.I. Reduction of muscular hypertonus by longterm muscle stretch, Scand Journal of Rehabilitationand Medicine, 1981, 13:93-99.

38. Odeen.I. Evaluation of the effects of muscle stretch andweight load in patients with spastic paraplegia, ScandJournal of Rehabilitation and Medicine, 1981, 13:117-121.

39. Radford.J.A, R,Buchbinder. Does stretching increaseankle dorsiflexion range of motion? A systemic review,British Journal of Sports and Medicine, 2007,40(10):870-875.

40. Rattlife.T.Katherine. Cerebral Palsy, Clinical PediatricPhysical Therapy, 1998, Ch-7:163-217, Mosby.

41. Roberta.B.Shephard. Cerebral Palsy andDevelopmental Delay, Physiotherapy in Pediatrics, 2nded, 1975, Ch-1:66-139, William Heinemann MannMedical Books Limited.

42. Satkunam.L.Lalith. Rehabilitation Medicine:3,Management of adult spasticity, Journal of CanadianMedical Association, 2003 Nov 169(11).

43. Scholtes.AB.Vanessa. Clinical Assessment ofSpasticity in children with Cerebral palsy: A criticalreview of available instruments, Development Medicineand Child Neurology, 2006, 48:64-73.

44. Singhi.Pratibha.D. Cerebral Palsy Management, IndianJournal of Pediatrics, 2004, 71(7): 635-639.

45. Selles.W.Ruud, Sun.G.Chung, Zhang.Li.Qun.Feedback Controlled and Programmed Stretching ofthe ankle plantarflexors and dorsiflexors in Stroke:Effects of a 4-week Intervention Program, Arch PhyicalMedicine Rehabilitation, 2005 Sep: 86(9).

46. Stubberg.A.Wayne. Considerations related to weightBearing Programs in Children with DevelopmentalDisabilities, Physical Therapy, 1992, 72(1):35-39.

47. Tremblay.F. Effects of Prolonged muscle stretch on

Preet Kamal Kaur / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2 49

PUBLIC NOTICE

Please take notice that some people or entities are misrepresenting that the Physiotherapist cannot prefix as “Dr.” are attempting to mislead the public at large whereas the Physiotherapy is system of therapy/medicine which involves evaluating, diagnosing, and treating a range of diseases, disorders, and disabilities by using physical means. Some unauthorized persons are misleading & creating an impression in the minds of general public that we Physiotherapist are involved in prescribing the drugs whereas the same is very untrue and against our ethics and methods of treatment.In the interest of the public at large we hereby notify that:1. This public notice has been issued on behalf of the Indian Association of Physiotherapists in the

interest of Public at large & had no intention to breach any law prevailing in India.2. Every clinical health care professional writes Dr. before their name as a matter of tradition and convention

and no one is allowed to write Dr. before their name if he or she is not having Ph.D. or M.D. as a matter of right. It is relevant to mention here that we prefix “Dr.” & suffix (P.T.) after the name as per the resolution and we also write physiotherapist clearly. In fact we are the only professionals in Health Profession who are using Suffix (Physiotherapist) after the name.

3. Physiotherapists are giving treatment by physical means and they never prescribe any drugs.4. Physiotherapy is a totally drugless therapy and a established profession having 4 and half years to 10

years of education in the prescribed course and clinical skills.5. Physiotherapist is a totally established profession in India & all developed countries like U.S.A., U.K.,

Canada etc and important component of health care delivery system.6. I.M.A. & MCI is having no statutory power to regulate physiotherapy profession in India, hence no right to

publish wrong information about physiotherapy as a whole.7. By this notice I.A.P gives stern warning to all to refrain from defaming physiotherapy and physiotherapists

in unauthorized way.

For and on behalf of

Indian Association of Physiotherapist, SD/-DR. SANJIV KUMAR JHA (P.T.)

General Secretary, I.A.P.

Published on (Saturday) March 28, 2010 in Times of India.

Delhi Edition on Page No. 15; Mumbai Edition on Page No. 25; Kolkata Edition Page No.09; Bangalore Edition Page No.14; Chennai Edition Page No. 08; Pune Edition Page No. 07; Hyderabad Edition Page No. 13; Ahmadabad Edition Page No. 11; Lucknow Edition Page No. 06; Jaipur Edition Page No.04.

Influence of high-heels on few mechanical factors of lowerextremity and lumbar lordosis among college going femalesManishtha Bhan, Rahul Singh Parihar, P. Dhakshinamoorthy

SBS PG Institute, Balawala, Dehradun, Uttarakhand

Introduction

The wearing of high-heeled shoes is a prime example ofwomen inviting foot problems. Most women admit highheels make their feet hurt, but they tolerate the discomfortin order to look taller, stylish and more professional.Unfortunately, the highly fashionable footwear isoverwhelmingly counterbalanced by a greater number ofharmful effects produced by them17. The foot is the integralmechanical part of lower extremity necessary for smoothand stable gait. During bare foot standing over 60% ofweight is distributed in the rear foot, 8% in the mid foot and28% in the forefoot. Footwear with elevated heels increaseforefoot pressure compared with standing barefoot6. An 8.3cm heel increased peak pressure by 7.5%. Due to use ofhigh heels footwear energy expenditure of normal workingof musculoskeletal system is increased and the bodybalance is decreased. Just three inches raise the body’scenter of gravity from its normal second sacral vertebrallevel to its new fifth lumbar vertebral level. As a result therewould be more chances of injury and dislocations of thelower extremities besides an increased spinal columncurve1. High-heeled footwear forces the meta-tarsalphalangeal (MTP) joint to go into acute dorsiflexion, whichinterfere with the foot’s ability to dissipate the groundreaction force generated by the heel strike. Usually, thecompensatory change for increased heel-height occurs atankle and knee rather than hip and lumbar spine. High heelsincrease the pressure on the inside of the knee by 26%.When wearing high-heeled footwear, the foot is held indownward position i.e. plantar flexion as person walks. Tomaintain balance, high heeled footwear cause the calfmuscle to bulge and foot goes in plantar flexion, knee inslight flexion, hip in flexion, which result in anterior tilting andproduce or increase the curve of lumbar spine17.

Rein Schmidt et al. (1995) stated that footwear designcould influence the kinetics and/or kinematics of lowerextremities during walking, running or in other activities.With the use of high heels line of gravity passes closer tolateral malleolus by 6 mm12. High heels produce plantarflexion at foot, the initial flexed knee posture, in addition topreventing the feeling of falling and also allow time foradjustments in posterior calf muscle activity.

During standing high heels cause 6.7 degree of kneeflexion in 62% of cases, whereas medium heels cause 5.2degree of flexion in 50% of cases where as low heels cause2.9 degree of hyperextension in 65% of cases. With high-heel footwear foot is held in downward position as personwalks16 out as they normally would. When lower extremityis bearing weight this keeps the knee and low back insomewhat flexed position, which prevents the muscle tocross the backside of these joint to stretch part of closed

kinematics chain range limitation at ankle joint it may causesrestriction in the knee joint flexion or extension5.

Lateur et.al. (1991) reported that the greatestcompensation is at the ankle and knee and high heelsdecreased the lumbar lordosis.16 Magee (2002) concludedthat exaggeration of normal lumbar lordosis curve is due towearing high heel shoes for prolonged period3. Kendall et.al(1993) stated that without minimizing the importance ofproper foot position that establishes the base of support, theposition of pelvis is the key to good or faulty posturalalignment8.

Previous studies demonstrated the postural changesrelated to line of gravity and center of mass position inrelation to bare foot verses high heels. To our knowledge,however, no one has reported on the effect on the softtissue extensibility in some specific muscles like hamstringsand iliopsoas and their correlation with the lumbar lordosisspecifically in high heel subjects.

The purpose of our study was to determine is there anyeffect on the soft tissue extensibility and there relation withlumbar lordosis in subjects with high heels as compared tolow heels.

Methodology

This study was conducted at Physiotherapy Departmentof Sardar Bhaghwan Singh Postgraduate Institute ofBiomedical Science and Research, Balawala, Dehradun.Sixty female subjects between 18 and 26 years age weredivided in two groups (30 subjects in each group) accordingto their inclusion and exclusion criteria via criteria fixedsampling. The subjects in group A were using footwear withheel height greater than or equal to 2 inches while thesubjects in group B used footwear with heels less than 2inches, for a period of more than 1 year with 4-5 days in aweek and 4-5 hours in a day.

After getting consent form filled from each subjectobservations were recorded.Exclusion criteria: The subjects with• Pathology of hip, knee, low back and foot.• Recent history of fracture.• Use of block heels or platforms.• Unwillingness to continue the study.• Any kind of infection or systemic disorders.• Active life style or on regular fitness programmer were

excluded from the scope of this study

VariablesThe subjects were classified on the basis of heel height

of the footwear as high-heeled footwear versus low-heeledfootwear. The measurements were made on Lumbarlordosis, Iliopsoas, Hamstrings and Gastrocnemius.

Manishtha Bhan / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2 51

InstrumentationAll range of motion (ROM) measurements were obtained

using a universal goniometer. Straps were used to stabilizethe part. Measuring scale was used to measure the distanceand the flexible ruler made of aluminum sheet placed onfoam was used to measure the body curves.

Protocol

Females with high heels/low heels footwear

¯

Measurements for Lumbar lordosis

¯

Measurements for extensibility of Iliopsoas

¯

Measurements for extensibility of Hamstrings

¯

Measurements for extensibility of Gastrocnemius

For lumbar lordosis measurement (Figure 1) flexibleruler was used. This method has good inter-rater reliability(ICC = 0.89) and intra-rater reliability (r = 0.84). In thisprocedure flexible ruler is placed between L-1 and S-2 andtwo twist ties are marked at the same level of the skin. Thenthe ruler is pressed firmly onto the spine. This curve of theruler, representing the lumbar curve, is traced onto thepaper for further analysis. For determining the degree oflumbar curvature was used. A line (L) connecting twopoints on the curve representing L-1 and S-2 was drawn anda perpendicular line (H) representing the height of lumbarcurve bisected the line L. The length of each line wasdetermined in millimeters and the values inserted into theformula20,21. = 4tan (2H/L)

All the subjects who met the criteria for inclusion in thestudy were measured for flexibility of the dominant side. Hipflexor tightness in the limb measured with the modifiedThomas test20 using the following procedure. The subjectsinstructed to sit as close to edge of the table as possible.Subjects hold the opposite knee to their chest with theirhands and then asked to roll backward slowly on the table.

While holding this position one lower limb released, allowingthe hip to extend towards the table while resting theipsilateral arm on the contra lateral knee. The leg and kneeof the limb being measured were unsupported while thesubject maintained a posterior pelvic tilt and ensure that thelumbar spine was flat, preventing the limb from abducting.Hip range of motion measured 2 times and average valuewas calculated. Measure the distance between plinth andlower end of thigh as tightness of iliopsoas20. Reliability ofthis test for inter-rater (ICC) it is 0.96 and intra-rater r = 0.84.

Measurements of knee extension range of motion i.e. forhamstrings extensibility made with the subjects lying supinewith the opposite i.e. the non-dominant lower extremityextended and stabilize along with pelvis. The dominantlower extremity flexed at hip and knee at 90 degree. Thegreater trochanter, lateral epicondyle of the femur andlateral malleolus marked and served as landmarks duringmeasurements as outline by Norkin and White. In addition,asked the subject to extend the knee actively, then readingtaken. Interrater and intrarater reliabilities are 0.99 and 0.89respectively20.

For the Gastrocnemius extensibility, a standard tapeused to ensure that the subjects positioned prone on thetesting table with their lateral malleolus 9 inches beyond thetable edge. All subjects wear shorts and secured to the tablewith waist and knee straps. The stationary arm ofgoniometer along the line made at axis of fibula by using themark on the fibular head and lateral malleolus. Theunmovable arm of goniometer placed parallel to the lateralborder of the foot by using the marks on the base and headof 5th metatarsal. The axis of goniometer then felt on thelateral border of the foot. The zero position of thedorsiflexion defined as the 90-degree angle between thelong axis of the fibula and the lateral border of foot. Allmeasurements recorded immediately as the subjectsachieved maximum active dorsiflexion. This procedure wasused by many researchers for several studies, withreference to study done by Wessling et.al32.

Fig. 1: Measurements of Lumbar Lordosis

Table 1: Average age, weight and height of two groups of subjects studied.

Group No. of subjects Age in years Weight in Kgs. Height in cm.A 30 21.6+2.08 51.50+5.53 155.2+3.86B 30 21.26+2.01 51.67+3.10 160.73+4.82

Graphical presentation of the dataCOMPARISON OF VARIABLES BETWEEN GROUP A & B

0

10

20

30

40

50

60

70

HAMSTRING ILIOPSOSAS GASTROCNEMIUS LUMBAR LORDOSIS

VARIABLES

GROUP A

GROUP B

Table 2: Extensibility of various parameters investigated in Group A and B

Group Hamstring (o) Iliopsoas (cm) Gastrocnemius(o) Lumbar lordosis(o)A 34.6+6.27 5.59+3.20 9.66+2.15 45.56+10.40B 50.63+7.48 2.29+2.14 15.33+2.25 43.74+11.03

Results S S S NSS= significant (P<0.05) NS= non-significant (P>0.05)

Table 3: Correlation of lumbar lordosis with extensibility of muscles.

Variables Group A (r) Group B (r)Lumbar lordosis v/s Hamstrings +0.08 +0.06Lumbar lordosis v/s Iliopsoas -0.08 -0.30

Lumbar lordosis v/s Gastrocnemius +0.05 +0.05

Manishtha Bhan / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 252

Data analysis

The data was analyzed by using independent t-testbetween groups A and group B for variables and seewhether high heeled footwear produce any significant effecton extensibility of hamstrings, iliopsoas and Gastrocnemiusand on lumbar lordosis. The significance level used was atprobability 0.05. Correlations of lumbar lordosis with othermeasurements were estimated.

Results

The mean age, weight and height of subjects of group Aand group B are given in table 1. The averages forextensibility of variables investigated and comparisonamong the two groups are given in Table 2 and thecorrelation of Lumbar lordosis with extensibility of musclesin the two groups are given in Table 3.

Comparison of variables between group A and group BIndependent t-test performed for comparing the

extensibility of hamstrings, iliopsoas, and gastrocnemiusshowed significant (P<0.05) and nonsignificant (P>0.05) forlumbar lordosis. Mean value for hamstring for group A andB is 34.6+6.27 and 50.6+7.48 respectively. Mean value foriliopsoas extensibility for group A and B is 5.59+3.20 and2.99+2.14 respectively. Mean value of gastrocnemiusextensibility for group A and B is 9.66+2.15 and 15.36+2.25respectively. Mean value for lumbar lordosis for group A andB is 45.56+10.40 and 43.47+11.03 respectively. (Refer table2)

Correlation of lumbar lordosis with other variablesKarl Pearson correlation test was used to find correlation

between the variables with in the groups. Hamstrings andgastrocnemius showed the positive correlation with thelumbar lordosis in both the groups. The values of coefficient(r) were +0.08 and +0.05, respectively in-group A. And thevalues for group B were +0.06 and +0.05, respectively.Whereas, iliopsoas showed negative correlation with lumbarlordosis in both the groups, and the values of coefficient (r)was –0.08 and –0.30, respectively. (Refer table 3)

Discussion

The results showed that as the height of heel increasesthe extensibility of the muscles reduces. The heel height didnot affect the lumbar lordosis significantly but lumbarlordosis showed positive correlation with the gastrocnemiusand hamstring and negative correlation with the iliopsoastightness.

As per Tom Bendix et.al (1984) with the increase in theheel height distance between LOG and malleolus isdecreases. The distance between toes and LOG remainsalmost constant result in increase plantar flexion at ankleduring walking and standing. When heel lifts are introduced,the muscle fiber length shortens and results in tightness ofgastrocnemius13. Kisner and Colby (1996) stated that if amuscle is immobile for a period, it loses its flexibility andassumes the shortened position in which it has been held4.

Snow and William (1994), anchor planter flexion causesknee flexion in standing position, which results in hip flexiondue to alteration in centre of mass and line of gravity.Whereas, the pelvis entrench move posterior towardsstationary line of gravity. When ankle goes in planter flexion

this causes flexion at knee, which results in shortness ofhamstrings muscle and restricts the full knee extension16.Kendall and McCreary’s personal observation suggestrestriction of knee extension when the flexed shortness ofhamstrings does not cause a posterior pelvic tilt and lumbarflattening of the lumbar spine often seen in subjects whohave hamstrings shortness8.

According to Opilla et al. in 1988; the location of the lineof gravity of the body with respect to anatomical landmarkwith high heels caused lumbar flattening rather than anincreases in lordosis15.

However in present lumbar lordosis showed nosignificant effect due to use of high heels. This may becausethe subjects of the present study were young females25.

David and Magee (1996) stated that soft tissue showearly changes due to any faulty posture as compared tobony tissue2. In addition J. de Lateur et al. (1991) concludedthat the greatest compensation is at the ankle and knee butthere is no compensation on the lumbar sine due to use ofhigh heels16.

In this study lumbar lordosis showed positive correlationwith gastrocnemius and hamstrings but iliopsoas showednegative correlation. Lower abdominal muscle length andshorter erector spine muscles length are also associatedsignificantly.8 however these muscles were not included inthis study. Alteration in muscle length of these muscles mayalso have effect on lumbar lordosis.

Because of the tightness of hamstrings muscle andgastrocnemius pelvis roll back thus decreases the lumbarlordosis from the standpoint of the action of musclesattached to the anterior spines and the symphysis pubis;opposing groups of muscles have an equal mechanicaladvantage in a straight line of pull. In neutral position of thepelvis there is normal anterior curve in the low back, inanterior tilt, a lordosis and in posterior tilt a flat back.

In this study only females between 18 and 26 years andno males were taken hence effects of high heels on malesare not known. Effect on elderly patients is also unknown.We were unable to describe the long-term effects on bodytissues due to high heels usages.

In future studies, researchers should investigate thechanges in other muscle length and endurance.Researchers should also find out whether these results arereversible or not and if reversible, then up to what limit.

Conclusion

The results of our study support that use of high heelshave adverse effect they decrease the joint’s range ofmotion by reducing the extensibility of some muscles. Theycan also produce effect on bony tissue also if wear itcontinuously for many days. Further work is necessary todetermine if muscle length alteration produce back pain,knee or foot pain or there these may be due to some otherreasons.

References

1. Kent K. Wu (1990), Foot Orthosis: Principles andClinical Application, 1st ed, 49-90

2. David J. Magee (1996), Athletic Injuries AndRehabilitation, 1st ed, 750-754

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4. Kisner and Colby(1996), Therapeutic ExerciseFoundation And Techniques, 3rd ed, 18-19

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17. www.personalhealthzone.com(2006), ‘wearing highheels-effect on body’

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standing and sitting in two types of chair: relationshipof hamstrings and hip flexor muscle length’ Phys.Therapy. Journal, Vol-70, 611-618

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motion : a guide to goniometry,: F A Davis, 2nd ed, 35-4632. Wessling et.al (1987), ‘effect of static stretch verses

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Manishtha Bhan / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 254

Autism–Help for parentsRyan J. Smith

Clinical Coordinator, Nuclear Medicine Institute, University of Findlay, 1000 North Main Street, Findlay, OH 45840, UnitedStates of American

Abstract

The word “autism” is becoming a common word in oursociety. Though much effort has been put into researchingthis condition, more work must be done in order to fullyunderstand this disability. Debate remains as to the causes,and what can be done by way of treatment. As this debatecontinues within the medical community, those whom thiscondition affects the most; autistic children and theirparents, continue to face day-to-day obstacles. A few ofthese obstacles include managing behavioral abnormalities,delayed socialization and speech, obtaining an accuratediagnosis and planning for treatments typically not coveredby insurance. Parents are often left overwhelmed, confusedand financially strapped, while their children struggle toexpress themselves and find their identity. How can all ofthis be managed and handled appropriately?

Introduction

Imagine a world in which your own child could not speakto you. Imagine a world where your child’s primary means ofcommunication involved screaming, hand flapping, tempertantrums, and other attention seeking behavior. Imagine achild like this who also suffers from other medical conditions,such as leaky-gut (a condition where yeast infection eatsaway at the intestinal lining causing severe internal andrectal bleeding), metal toxicity, severe food allergies,eczema, as well as other ailments. This is the reality thatmany parents are living each day in the fight against autism.The Centers for Disease Control now estimates that 1 in 150children have or are being diagnosed with autism (2009).These numbers are shocking, and seem to be growingannually as more research on the condition is beingperformed. What is causing this explosion of cases? Whatcan be done to treat these conditions? And lastly, how doparents not only cope with this horrible disease, but affordincredibly expensive, yet necessary treatment that causesso many families to choose between their home and theirchild’s treatment?

What is Autism?

The National Autistic Society defines autism as, “alifelong developmental disability that affects the way aperson communicates and relates to people around them”(2008). As more about autism is being discovered, themedical community has begun to diagnose a shockinglyhigh number of cases. Some even call it an epidemic. Aspectrum disorder, commonly referred to as AutismSpectrum Disorder (ASD), it affects individuals in a widerange of severities. Those diagnosed on the high functioningside of the spectrum may eventually lead a normal life given

the proper intervention. A child on the high functioning endof the autism spectrum may be diagnosed with a conditionknown as Asperger’s syndrome. Asperger’s syndrome is ahigh functioning form of autism differentiated only by thechild’s ability to speak and communicate at a more typicallevel. Still, many of the common symptoms associated withASD are still apparent. However, those on the lowfunctioning side of the spectrum may be required to havefull time care throughout their entire life. Regardless of theindividual’s severity level, three features are common in allautism cases. According to the Child Development Media,these three characteristics are: qualitative impairments insocial interaction; qualitative impairments in communication,both verbal and non-verbal; and restrictive repetitivestereotyped behaviors (2008). As noted, these traits can bedisplayed in a variety of severities on the autism spectrum,but everyone with autism struggles to find their identity. TheNational Autistic Society once quoted an (anonymous)autistic person with the following statement:

Reality to an autistic person is a confusing, interactingmass of events, people, places, sounds and sights. Thereseems to be no clear boundaries, order or meaning toanything. A large part of my life is spent just trying to workout the pattern behind everything (2008).

This truly expresses what it is like for so many who sufferwith this disability.

Originally discovered in 1943, this condition has onlyrecently been taken seriously by the medical community.Today, there still remains a great deal to be understood.Some interesting statistics about autism are listed onautisminfo.com. Included in the statistics is that:• Autism occurs in 1 in every 500 births and in a rate of 5

boys to every girl. • Autism currently affects over 400,000 people in the U.S.• Autism is the third most common developmental

disability following mental retardation and cerebral palsy.• Autism is more common than multiple sclerosis, cystic

fibrosis or childhood cancer.• Autism receives as little as 5% of the research funding

as other less common diseases.• Without any governmental standards, the annual per-

person allocation for persons with autism isapproximately $35; compared to other chronic diseases:multiple sclerosis $158, diabetes $424, breast cancer$600, and AIDS $1,000.

• Currently there is no medical detection or cure for autism(2002).The overwhelming majority of diagnoses occur in young

children usually by the age of three. However, some arediagnosed even earlier in life. Typically, parents will begin tonotice unusual behaviors or development delays whichultimately lead to the diagnosis. Though there is no knowncause of this disease, there are a variety of behavioral

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indications related to it. These behaviors, as noted by theAutism Society of America, include but are not limited to thefollowing:• Insistence on sameness; resistance to change. • Difficulty in expressing needs; using gestures or pointing

instead of words.• Repeating words or phrases in place of normal,

responsive language.• Laughing (and/or crying) for no apparent reason;

showing distress for reasons not apparent to others.• Preference to being alone; aloof manner, difficulty in

mixing with others; not wanting to cuddle or be cuddled.• Tantrums.• Showing little or no eye contact.• Sustained odd play, spinning objects.• Obsessive attachment to objects.• Apparent over-sensitivity or under-sensitivity to pain.• No real fears of danger.• Noticeable physical over-activity or extreme under-

activity.• Uneven gross/fine motor skills, need for sensory

stimulation (tiptoeing, rocking, smearing, hand flapping,etc.).

• Non-responsive to verbal cues or teaching methods;acts as if deaf, although hearing tests are in normalrange (2008).

The Big Debate: Causation

One of the most controversial topics surrounding theautism debate is related to its cause. What exactly causesautism? No one at this point is completely certain. However,some studies have shown a link to genetic andenvironmental factors. The website autism.about.comexplains that there may be a link between childhoodvaccines and autism; particularly vaccines protectingagainst diphtheria, tetanus, pertussis, hepatitis B, andinfluenza; containing a mercury-based preservative calledthimerosal. Because of this potential link, thimerosal is nolonger used in any childhood vaccines in the United States,with the exception of some flu vaccines (Church, 2009).Genetics has certainly shown to play a role. Studies haveshown that parents who come from families with autisticmembers are more likely to have autistic children. Churchexplains that studies are underway to collect DNA samplesfrom hundreds of families in which more than one familymember is diagnosed with autism, in order to more clearlyunderstand the link between genetics and autism (2009).Other causes may include atypical brain development andfood allergies…which will be discussed later.

It is important for parents to understand that theirparenting practices have no impact on the onset of autism.Society has made parents better aware of more sociallyacceptable parenting techniques then those of pastgenerations; where positive reinforcement and time outstake the place of stern lecturing and spanking. Often times,parents may feel guilt over less socially acceptableparenting practices utilized in days past, and wonder if thismay have triggered autism in their child. Additionally,parents of picky eaters worry about malnutrition and otherlong term health effects associated with poor diet. The lackof understanding about autism has led to unnecessary fear,guilt, and counterproductive behavior; often times delaying

necessary treatment and recovery. The about.com:autismwebsite specifically states that autism is not likely causedby malnutrition or bad parenting (2008). Clearunderstanding of this is crucial, so that parents can takecontrol of the situation and begin to move forward.

One of the most outspoken individuals in the fightagainst autism may come as a surprise to many people. Theformer model and actress, Jenny McCarthy has made it hermission to educate as many people as possible of thecauses, symptoms and treatments for autism. This journeybegan in 2005, when her son Evan suffered a violentseizure due to a high fever caused from his infantvaccinations. A perfectly healthy child prior to hisvaccinations, Evan eventually suffered from a wide rangeof health problems related to the high number ofvaccinations administered before his immune system wasdeveloped enough to process them effectively. It is believedthat this overwhelming of his immune system from thevaccinations triggered his autism. This had led her to beginthe fight against autism. Her main message is that autism isnot simply related to genetics, but due to the combination ofenvironmental factors along with genetic disposition whichtogether can trigger the disease. Many doctors known asDAN! ® (Defeat Autism Now) and scientists agree with thisthought about the effects of environmental factors.McCarthy quotes Dr. Francis Collins, Director of theNational Human Genome Research Institute, NationalInstitutes of Health, in her book ‘Mother Warriors – A Nationof Parents Healing Autism Against All Odds’ as saying “Allillnesses have some hereditary contribution. Genetics loadsthe gun and environment pulls the trigger” (McCarthy,2008). How powerful that statement has become in the livesof many parents of autistic children. This environmentalfactor has been a huge area of research in the fight againstautism, as we shall soon discuss.

McCarthy’s (2008) point about how the environmentalfactors play a role in triggering autism, are explained in thefollowing manner.

If a child is born with an infection that no one can seeand we vaccinate them while their immune system cannotsufficiently fight the toxins or viruses being injected, thatchild is going to get into trouble. The same holds true whenyou take your kid to get their shots and the doctor says hecan’t immunize because the child is sick. He or she wouldsay (that) because the immune system is under attack orfighting something else and (therefore) can’t handle theshot. So can we please assume that some children are bornwith an infection or yeast overload or maybe a mitochondrialissue and can’t handle the first shot they are given in thehospital? Can’t we assume that some kids could be bornperfectly healthy but vaccines can damage themitochondria, which could then trigger autism? Can weassume that some kids are more vulnerable to toxicoverloads than are others? Can we assume that somechildren can’t handle ALL thirty-six shots? (52).

Treatment: Another Debate

Another controversial issue revolves around treatmentfor autism. There is no known cure for autism, but there area variety of treatments which have shown to be quite helpfulin reducing the severity and symptoms associated it. Themajor controversy lies within the medical community itself.

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Most pediatricians are members of the American Academyof Pediatrics (AAP). Guidelines must be followed in orderfor these physicians to remain in good standing. A separategroup of physicians (as noted above) also exists, known asDAN! ® physicians. They specialize in alternative medicaltreatment for autism. Both group’s philosophies will bediscussed.

First, the AAP physicians’ philosophy is that autismcannot be prevented, so treatments should follow the moretraditional approach; occupational therapy, speech therapy,and early intervention. Though Autism cannot be cured withthese treatments (or any other); they certainly can have amajor impact on improving the child’s social and behavioraldevelopments. Church notes that diagnosis is made throughuse of visual screening using a variety of tools (including butnot limited to):• Autism Diagnosis Interview.• Autism Diagnostic Observation Schedule.• Childhood Autism Rating Scale.• Childhood Behavior Checklist.• Vinlind Adaptive Behavior Scale.• Childhood Asperger Syndrome Test (2009).

Using these tools, physicians can determine if Autism ispresent, and if so, to what degree. Once a clear diagnosishas been made, then plans for appropriate intervention canbe made. The treatment will be unique to the patient. Inother words, each child will have a specific plan designed tomeet his/her needs. This type of early intervention has beenmedically proven to improve outcomes in children with ASD,so long as the diagnosis is found early and parents arecommitted to proper treatment.

The DAN! ® physicians’ stance on autism is one whichclaims that autism is treatable using their alternative medicalapproach. They happen to boast several success stories. Itis important to remember that recovery does not mean cure,but does indicate an improvement in the individual’s overallhealth, behavioral mannerisms and communication abilities.As stated on the Defeat Autism Now! website, the DAN! ®physicians hold an annual conference to provide informationleading to medical treatment and metabolic support therebyreducing physical pain and roadblocks in children withautism, so that many are newly able to communicate andlearn (2009). Also listed on this website is the DAN! ®protocol. Included in this protocol are the followingalternative treatments:• Nutritional supplements, including certain prescribed

vitamins, minerals, amino acids, and essential fattyacids.

• Gluten (wheat, barley, rye, and possibly oats) free andCasein free (milk, ice cream, yogurt, and other dairy)diets.

• Testing for hidden food allergies, and avoidance ofallergenic foods.

• Treatment of intestinal bacterial/yeast overgrowth (withpro-biotics, supplements and other non-pharmaceuticalmedications).

• Detoxification of heavy metals through chelation…apotentially hazardous medical procedure (2009).

A brief explanation of both chelation therapy andGluten/Casein free diets is as follows; both of which areareas of debate and controversy among the medicalcommunity. Church notes that chelation treatment consistsof removing mercury (and other toxins) from the body. It is

used by some parents of children with autism in the hopethat it will cure the child of autism (2009). Mercury is a toxinpresent in many things that can affect brain development.Chelation treatment can take on several formats: sublingualspray, topical ointment, vaccine, etc. Theoretically, thisshould remove many of the toxins in the body absorbedfrom food preservatives, pesticides, cleaning products, etc.The concern, however, with chelation treatment is that it notonly removes mercury and other toxins from the body, butwill also remove important vitamins and minerals which areneeded for growth and development. The AAP claims thatthere is no connection between chelation therapy andautism, calling it unnecessarily dangerous, while the DAN!® physicians have noted several improvements in patientswho have undergone this treatment.

The other controversial treatment is known as theGluten/Casein Free diet. Gluten is a sugar component foundin many wheat products which may cause problems withdigestion. Some autistic children have other health issuesincluding a condition known as “leaky-gut”. This is a veryserious infection in the bowls which can cause extremepain, difficulty digesting food, rectal bleeding and pusbuildup in the digestive organs which can spread to otherparts of the body. Gluten Free diets have been studied bythe DAN! ® physicians who claim to have had muchsuccess. The AAP physicians on the other hand, see nobenefit to this diet, and are concerned about poor nutritionthat may arise from it.

The Casein diet aimed at reducing autism symptomsalso raises concern among some physicians. Churchexplains that,

Casein is a protein found in milk and dairy products. InJanuary, 2008 the National Institutes of Health (NIH)cautioned against the treatment, in particular because boyswith autism have an increased risk of reduced bone densitythat would be exacerbated by a dairy-free diet. The NIH,instead suggests the hiring of a dietician and addition ofvitamin supplements such as vitamin D and calcium (2009).

The DAN! ® physicians, however, have had numerouscases where children with autism have made considerableprogress while on these diets. In McCarthy’s book, ‘MotherWarriors’, numerous success stories are laid out in detail ofhow the DAN! ® protocol has treated and even “cured”many children suffering from ASD. The following is a truestory of a little boy named Branson, as explained by hismother Coral in McCarthy’s (2008) book.

My son, Branson, was perfectly fine until I took him tothe doctor. They gave him his shots on the day after his firstbirthday. At fifteen months, the slide into hell began. He losthis speech, his ability to point or imitate. He lost his senseof balance, his eye contact, and all of his pain receptors. Helost most of his muscle tone and then, tragically, he losthimself. He had diarrhea for six months straight and wouldscratch himself all over until he bled. His behavior becamewild and he no longer would return in response to his ownname. The diagnosis for my only child: regressive autism.Upon visiting a DAN! ® doctor, Branson began the gluten-free, casein-free diet that day. He does not eat any wheat,milk, sugar, soy, eggs, and most fruits, and his diet is fullyrotated. Within weeks, Branson had hundreds of words…hewas talking. The light came back into his eyes and his soulwoke up. He was retested and we were told that he was nolonger on the autism spectrum (186-187).

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Though the AAP does not recognize this treatmentprotocol, many feel the results are too apparent to ignore.There are several other cases unique in their own way, butshare the same success story as Branson and Coral’s.Examples of other success stories can be found on both theDAN! ® website as well as in Ms. McCarthy’s book.

Another major controversy between the AAP and DAN!® physicians lies in differing theories behind childhoodvaccinations. AAP physicians feel that childhoodvaccinations have no impact on the onset of autism, whereDAN! ® physicians feel that vaccinations can be a triggeringcomponent (as noted earlier) by overwhelming the body’simmune system, and due to the preservatives in thevaccinations (thimerosal, etc). There is far less mercury invaccines today then their used to be, but many do containaluminum. Research is still out on the potential side-effectsof aluminum. The AAP follows the traditional vaccinationschedule for fear that abandoning that schedule will lead tochildhood illnesses. DAN! ® physicians recognize thatconcern, but feel that the vaccination schedule can bespread out over a longer period of time (particularly fornewborns) without posing risk of illness. DAN! ® physiciansclaim the major benefit to the alternative vaccinationschedule is prevention of the child’s immune system frombeing overwhelmed by the high number of vaccinations;which is thought to be a factor in triggering the onset ofautism. Often times, an autistic child’s immune system isalready compromised, and the vaccination dose schedulemay overwhelm the child’s ability to process thevaccinations properly; leading to illness, brain damage, andpotentially autism.

This idea of withholding vaccinations of course does notnecessarily apply to every child. But the point in thisargument is that many physicians need to accept the factthat not all children are born healthy enough to be able tohandle all the vaccines immediately. Parents should askquestions first. Could it be possible to modify the vaccinationschedule so that children whose immune system may becompromised do to having a known family history of geneticproblems may get their vaccinations over a longervaccination cycle? McCarthy (2008) asks, “Shouldn’t therebe some type of screening for newborns to test for infectionand fungus prior to immunization?” (53). Both DAN! ® andAAP physicians have valid arguments for their case, soparents should be aware of risks on each side and seek asmuch advice on this topic as possible in order to make aninformed decision.

With all this controversy, it may be extremely hard toknow what avenue to choose as a parent of a child withautism. A good suggestion may be to talk to both an AAPand DAN! ® physician as to approach both methods openmindedly. Different treatments have different affects ondifferent children, and parents should not disregard anypotential treatment for your individual child.

Another treatment approach most physicians highlyrecommend (AAP and DAN! ® alike) is called EarlyIntensive Behavioral Intervention (EIBI). A similar treatmentis also available called Applied Behavioral Analysis (ABA).Both treatments are geared towards early intervention, buthave been highly successful in children of all ages. TimothyBegany explains that findings from Ohio Autism RecoveryProject confirm that children diagnosed with autism andmental retardation can improve or achieve normal

intelligence after receiving early intensive behavioralintervention (2003). Dr. James A Mulick, PhD, runs theComprehensive Autism Center at Children’s Hospital inColumbus. As quoted in Begany’s article, Dr. Mulick’smantra is “You become what you do”. Begany furtherexplains the EIBI treatment in the following manner; autisticchildren participating in the program undergo 40 hours ofweekly behavioral therapy for 3 years. Children first learnhow to imitate by mirroring arm and other motions. Thisprogresses with children gradually learning how to matchidentical objects, then similar objects, then categories, etc.Once they learn how to match, they begin work on talkingand socialization (2003). Programs like this are proven towork. The level of success though varies from child to child.Some children will still struggle to communicate, while themore successful children may move off the autism spectrumall together (no longer considered autistic). Much of thisdepends on the severity of the autism at the beginning aswell as the level of commitment to treatment. Treatment canbe performed on site, or arrangements can be made to havea therapist provide in-home treatments.

Coverage and Affordability

A major issue for most parents of autistic children is thelack of coverage by most insurance companies. At this time,few if any private insurance companies cover alternativetreatments proposed by the DAN! ® protocol. In fact, mostinsurance companies do not even cover diagnostic testingor traditional treatment for autism because they consider ita mental health disorder. Mental health care is consideredoptional care by most insurance companies; hence nocoverage. The out-of-pocket expense for families withoutcoverage can be overwhelming. Different studies offerdiffering figures, but all costs are imposing to most families.One report in the April issue of Archives of Pediatrics &Adolescent Medicine states,

Direct medical costs are quite high for the first five yearsof life (average of around $35,000), start to declinesubstantially by age 8 years (around $6,000) and continueto decline through the end of life to around $1,000, …directnon-medical costs vary around $10,000 to approximately$16,000 during the first 20 years of life, peak in the 23- to27-year age range (around $27,500) and then steadilydecline to the end of life to around $8,000 in the last agegroup (2007).

Church references a study run by Yale University in2004, which reports the average annual health careexpenditure per child with autism at nearly $6000, with theannual tab for specialized private schools reachingapproximately $60,000 (2009).

Financial assistance is available to help cover out-of-pocket expenses. Several states provide state-fundedcoverage for autism. According to the U.S. Department ofDefense Military Health,

Eight states have specific laws addressing insurancecoverage for autism: Georgia, Indiana, Kentucky, Maryland,New York, South Carolina, Tennessee, and Texas. Elevenother states require coverage for autism through their lawsthat mandate coverage for mental illness: California,Connecticut, Illinois, Iowa, Kansas, Louisiana, Maine,Montana, New Hampshire, New Jersey, and Virginia (2007).

The World Now website notes that Pennsylvania has

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recently become the first state to federally fund care foradults with autism (2007). One of the most outspokenadvocates for the fight against autism is Pennsylvania StateRepresentative Mike Doyle. Congressman Doyle serves asCo-Chair for the Congressional Autism Caucus. He haspushed for reform related to autism in HR 3200: America’sAffordable Health Choices Act of 2009. The Autism Societyof America website has stated, because of RepresentativeMike Doyle, several key provisions in HR 3200 will have apositive impact on families in the autism community, suchas:• Prohibiting insurers from excluding coverage based on

pre-existing conditions.• Prohibiting insurers from selectively refusing to renew

coverage.• Requiring a standardized annual out-of-pocket spending

limit so that no family faces bankruptcy due to medicalexpenses.

• Prohibiting annual and lifetime benefit caps.• Coverage of mental health disorders.• Coverage of rehabilitation and maintenance services

(2009).For those who live in other states which do not provide

coverage, and who do not have insurance which coversautism; other help is available. Most states offerscholarships to those who qualify. For example, the AutismSpeaks website notes that, “Ohio has an AutismScholarship Program which will reimburse out-of-pocketexpenses up to $20,000 per eligible child per year” (2009).This scholarship is not based on income, but instead ondiagnostic need. A full assessment is required for eligibilitywhich can be done at most any children’s hospital.Additionally, most states have a center for medicalhandicapped individuals. In Ohio, this is known as theBureau for Children with Medical Handicaps (BCMH). Thisis a tax supported entity which, among other things, willsubsidize autism treatment to those who qualify. Subsidiesmay be based on income or diagnostic need. Another optionis available at the local level. Most counties have a board ofMental Retardation and Developmental Disabilities (MRDD).This is a local tax supported entity, which often willreimburse for out-of-pocket medical expenses to those whoqualify. Qualifications again, may be determined based onincome or medical need. Individuals are encouraged topursue all of these avenues. Contact information can easilybe found on-line doing a quick Google TM search, atphysician offices, or even in local phone books.

Support Groups

Numerous support groups exist for struggling parents.Parents should speak to their child’s pediatrician or DAN!physician for a list of local support groups. Many supportgroups can also be found on-line. The Autism Society ofAmerica, Autism Speaks, the Autism Research Instituteeach has listed a variety of support groups on theirrespective websites. Support is also found in more trendyformats by way of social networking sites such asFacebook©, MySpace©, LinkedIn©, etc.

Conclusion

Autism is a developmental disability which affects nearly1 in 150 individuals. Many signs and symptoms indicating

autism can easily be found on nearly any autism website. Anearly diagnosis and aggressive treatment is highlyrecommended. Traditional and nontraditional treatments areavailable, and both should be considered. Many treatmentshave been very successful and have led to stunningsuccess. Medical costs are extraordinarily high, but muchhelp is available to those who pursue it. The fight againstautism is young, but quickly finding support and momentum.In time, a cure may be found. Until then, be strong, becommitted, and pursue all avenues. Our children arecounting on you.

References

1. About.com: Autism. What Causes Autism? (2009).Retrieved, July 27, 2009 from http://autism.about.com/od/whatisautism/p/autismcauses.htm

2. About.com: Autism. (2009). What Is a Defeat AutismNow (DAN!) Autism Doctor? Retrieved, July 27, 2009from http://autism.about.com/od/alternativetreatmens/f/dandoc.htm

3. AUTISMINFO.com. (2002). Quick Facts About Autism.Retrieved, July 28, 2009 from http://www.autism-info.com/QuickFacts.htm

4. Autism Society of America. (2008). Characteristics ofAutism. Retrieved, July 27, 2009 from http://www.autis-msociety.org/site/PageServer?pagename=about_whatis_char

5. Autism Society of America. (2009). Thank Rep. Doyle -Autism Insurance in Health-Care Reform. Retrieved,July 17, 2009 from https://secure2.convio.net/ asa/site/Advocacy?pagename=homepage&page=UserAction&id=311

6. Autism Speaks. (2009). Arguments in Support of PrivateInsurance Coverage of Autism-Related Services.Retrieved, July 27, 2009, from http://www.autis-mvotes.org/atf/cf/%7B2A179B73-96E2-44C3-8816-1B1C0BE5334B%7D/Arguments_for_private_insurance_%20coverage.pdf

7. Begany, T. (2003). Some Autistic Children Benefit FromBehavioral Intervention. Neurology Reviews, 7. ChildDevelopment Media. (2008).

8. But He Knows His Colors - Characteristics of Autism inChildren Birth to Three. Retrieved, August 15, 2009,from http://www.childdevelopmentmedia.com/ assess-mentplanning/30117p.html

9. Church, E. J. (2009). Using Medical Imaging ToDecipher Autism. Radiologic Technology , 531, 533.

10. Defeat Autism Now! Autism Research Institute. (2009).Why Attend A Defeat Autism Now!® Conference?Autism is Treatable. Retrieved, July 28, 2009fromhttp://www.defeatautismnow.com/dallas/overview.html

11. EurekAlert! (2007). Autism Costs Society an Estimated$3M Per Patient. Retrieved, July 28, 2009 fromhttp://www.eurekalert.org/pub_releases/2007-04/jaaj-acs032907.php

12. McCarthy, J. (2008). Mother Warriors - A Nation ofParents Healing Autism Against All Odds. New York:Dutton. P. 52, 186-187.

13. The National Autistic Society. (2008). About Autism.Retrieved, July 27, 2009, from http://www.nas.org.uk/nas/jsp/polopoly.jsp?d=225

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14. The National Autistic Society. (2008). What’s it Like toHave Autism or Asperger Syndrome? Retrieved, July27, 2009, from http://www.nas.org.uk/nas/ jsp/polopoly.jsp?d=1062

15. U.S. Department of Defense Military Health SystemMHS Blog. (2007). TRICARE Autism Coverage.

Retrieved, July 27, 2009 from http://www.health.mil/mhsblog/Article.aspx?ID=140

16. World Now. (2008). Pennsylvania is First State ForFederally-Funded Care For Adults With Autism.Retrieved, July 28, 2009 from http://www.krnv.com/Global/story.asp?S=8485579

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Comparison of Real-time Ultrasound Imaging and PressureBiofeedback training for performing Abdominal Drawing-inManeuver in low back painBajaj S., K. Chitra, S. Shallu

Department of Physiotherapy, ISIC Institute of Health and Rehabilitation Sciences, Indian Spinal Injuries Centre, New Delhi 110 070

Background and Introduction

Researches are being undertaken worldwide tounderstand the muscle related dysfunctions present in LBPsufferers. It is an established fact that LBP is associated withimpaired function of transversus abdominis (TrA) andmultifidus muscles. The abdominal drawing-in maneuver(ADIM) is commonly used as a foundational component oflumbar stabilization training program. This exercise involvesa motor learning approach, for preferential activation of TrA,which is facilitated with the use of augmented sensoryfeedback such as pressure biofeedback unit andrehabilitative ultrasound imaging. The purpose of the studywas to compare the two feedback tools used for teachingpatients ADIM and to derive a faster and efficient tool to helppatients acquire the skill in a timely fashion.

Methods

Twenty two patients with chronic low back pain havingtransverse abdominis muscle weakness were randomizedin two groups for feedback training, one with real-timeultrasound imaging and second with pressure biofeedbacktraining. Number of trials and number of days required forlearning the correct maneuver were noted as outcomemeasures for the two groups. To evaluate the patient’slearning a retention test was conducted after 2 days.

Results

Number of trials and number of days required forlearning the correct maneuver were significantly less withpatients receiving feedback training with real-timeultrasound as compared to training with pressurebiofeedback (p<0.01). Patients learnt efficiently withultrasound feedback as indicated by 100% results onretention testing done after 2 days.

Conclusion

RUSI provides an efficient, extrinsic visual feedback toolfor learning ADIM in patients with chronic recurrent low backpain making it a useful and specific clinical teaching tool forphysiotherapists.

Keywords

Low back pain, transverse abdominis dysfunction,lumbar stabilization, real-time ultrasound imaging, pressurebiofeedback unit.

Introduction

Low back pain (LBP) and problems associated with the

lumbar spine have become an acknowledgeable healthproblem despite advances in knowledge and considerablegrowth in technology for its identification over the past twodecades1. About 70-85% of all people have LBP at somepoint in their lives2. The growing awareness of low back painas a major clinical problem has prompted increased interestand research into the assessment, treatment, andmanagement of this continuing clinical epidemic.

Recent research has demonstrated that people withchronic LBP have neuromuscular dysfunction and fatigue ofthe back and abdominal muscles3. It is an established factthat LBP is associated with impaired function of transversusabdominis (TrA) and multifidus muscles4,5. The deficitsfound in these local muscles relate to their co-ordination andmotor control rather than their ability to generate force(strength). There is a delay in activation resulting in a lossof pre-programmed function for support, anticipatoryfunction, ability to function independent of other trunkmuscles and phasic activity, due to change in the CNScontrol strategy. If such deficits remain unmanaged theydirectly affect spinal support and leave the spine vulnerableto reinjury and recurrences of LBP6-10.

It was found that in patients with LBP, the feedforwardstrategy of TrA activation was significantly delayed. Thus,the alterations in recruitment of TrA clearly reflects theneuromotor control deficiencies associated with low backpain. It had been therefore suggested, in early 1990’s thataddressing the active stability role of the muscle, usingspecific exercises aiming for TrA activation will improve bothsubjective and objective outcomes of treatment11,12.

Nowadays, the prescription of exercises for TrA traininghas been termed as motor control exercise13,14. specificspinal stabilization exercise15,16,17 and more recently specificmotor control stability exercise18. This type of exerciserepresents an important subgroup of exercise regimedescribed as core stability. The ability to contract TrAindependently, in isolation from the other abdominalmuscles, is proposed as an important goal in rehabilitatingpatients with back pain7. The abdominal drawing-inManeuver (ADIM) is commonly used as foundationalcomponent of lumbar stabilization training program3,7.Preferential activation of TrA, which is facilitated with theuse of augmented sensory feedback such as pressurebiofeedback unit and rehabilitative ultrasound imaging.

Visual feedback for muscle re-education is provided bythe muscle thickness change which patient observes on themonitor and is considered to be an indicator of muscleactivation. The qualities of convenience, real-timeobservation of movement and its non-invasive nature makesits use of interest to clinical and research physiotherapists.But along with its advantages there are certain limitations,such as it is not readily available in a regular clinical settingand is expensive. Previous studies using RUSI feedback

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had given suboptimal training stimulus with only singleepisode of supplemental feedback for muscle re-education.Also the benefit of providing it on subjects having difficultyactivating TrA at baseline has not been studied.19 Thestudy was conducted on selected population of active dutymilitary members and not on general population. So therelative efficiency and efficacy of this qualitative feedbacktool is compared with another feedback tool which is readilyavailable, that is, Pressure biofeedback unit (PBU).

Pressure biofeedback provides a useful visualbiofeedback during treatment, and is an objective measureof fatigue time of the deep abdominal muscles20. Thepressure biofeedback unit is frequently used clinically as anaid to stabilization re-education. Previous research hasindicated that specific testing using the pressurebiofeedback unit was reliable in identifying the presence andabsence of low back pain and TrA dysfunction.

Since PBU provides an indirect quantitative feedbackmethod for monitoring the effectiveness of treatment, it isconsidered to be more time consuming, requires moreconcentration, accuracy and precision for correctperformance. Therefore, comparison is done so as to findout the best possible visual biofeedback tool which wouldhelp LBP patients learn ADIM more faster and efficiently.

Methodology

Twenty two patients with a history of low back pain formore than 3 months duration and with TrA dysfunctionparticipated in the study. Patients were recruited byadvertisement and notification. The inclusion criteria forsubjects included 3 months or more chronicity of low back,VAS should be mild to moderate, age < 45 years, ODI lessthan 40% and poor performance on formal test.

Subjects with any previous abdominal or back surgery,trauma, neoplastic cause, infective and inflammatorypathology, lumbosacral nerve root compromise andpregnancy were excluded.

An informed consent was taken from all the patients whomet with the inclusion criteria. Then the patients wererandomized into two groups: RUSI Group and PBU group.Basic introductory and teaching session of 20-25 minuteswas given for both groups before randomization was done.The patients were familiarized about the location of TrAmuscle in their body with the help of illustrations anddiagrams (Appendix J). The function of the muscle, to drawin the abdominal wall and to provide support to the trunk isexplained to the patient. And the purpose of the abdominaldrawing-in exercise in providing spinal stabilization, so asto address the dysfunction of TrA muscle in LBP was alsohighlighted.

The formal test was done to look for TrA activation insubjects, and was performed in a prone lying position.Patient is then given a verbal command “take your bellybutton up and in towards your spine, at the end ofexhalation”. The patient is NOT given any visual feedback.

In group 1, visual feedback from RUSI was given withevery trial for a maximum number of ten trials in a day toimprove his/her performance. Rest of 1 min. between trialswas given in order to avoid undue fatigue. Muscle can bepalpated gently but deeply into the abdominal wall whileholding the contraction, by placing thumbs or middle threefingers, 1 inch medial and 0.5 inch below to the anterior

superior iliac spine. Check was kept on the substitutionsperformed during the ADIM e.g. posterior pelvic tilt,excessive external oblique activity, weight bearing throughfeets and breath holding. A follow up was conducted onsubsequent days till the patient masters the skill and thesame procedure was followed with PBU group and numberof trials and number of days as required by patients forlearning were evaluated.

Once the patient performed consistency of theperformance criteria , feedback was discontinued andpatients were asked to turn up after 2 days for retention test.

After similar, screening and evaluation patient wasrandomly assigned to group 2 for feedback training withPBU. Patient was positioned in the same supine crook lyingposition with hip flexed to 450 on a firm board. PBU consistsof three chamber air-filled pressure bag, a catheter and asphygmomanometer gauge. The pressure bag is 16.7 x 24cm in size and is made from non-elastic material. Thesphygmomanometer has a range from 20 mm Hg to 100mm Hg, with a 2 mm Hg intervals on the dial. Movement orchange in position causes volume changes in the pressurebag, which is registered on the device. Bag is placed belowthe lumbar curve from L1 to S1.and a baseline pressure at40 mm Hg was maintained., as soon the patient performedthe 3 consecutive contractions correctly, he wasdiscontinued from the training, was given a home exerciseprogramme thereafter, and was asked to return after twodays.

Data analysis

The variables available for analysis were number of daysand number of trials for both RUSI and PBU groups. Thedata was managed on an excel spreadsheet and wasanalyzed using a SPSS software. Descriptive statistics(mean, standard deviation) were computed for each studiedvariable. For between the group comparison: Unpaired t-test was used for the statistical analysis to compare theeffect of dependent variable on independent variable inbetween the two groups. The level of the significance wasfixed at p ≤ 0.01 for the study analysis.

Results

Baseline charecteristicsResults show that there was homogeneity of baseline

variables in both the groups of age, height, weight, BMI,DOS, ODI and VAS.

Between the group comparison of the mean number ofdays and mean number of trials, show a statisticallysignificant difference at p< 0.01. The mean number of daysand mean number of trials required by RUSI group came

Table 5.1: Demographic details of subjects

VARIABLES RUSI Group PBU Group t value(N=11) (N=11)

Gender (M/F) Male Female Male FemaleNumber 4 7 5 6Age (yrs) MEAN + SD 30.90 + 8.96 32.54 + 6.57 0.49 N.S

Height (cms) MEAN + SD 163.27 + 9.59 161.30 + 10.41 0.46 N.SWeight (kgs) MEAN + SD 59.63 +8.64 58.68 + 9.79 0.24 N.SBMI(kg/m2) MEAN + SD 22.5 + 1.4 22.4 + 1.58 0.12 N.SDOS (mths) MEAN + SD 12.18 + 8.07 13.27 + 10.40 0.27 N.S

ODI (%) MEAN + SD 17.72 + 6.58 19.42 + 6.01 0.63 N.SVAS MEAN + SD 3.27 + 1.10 3.09 + 0.94 0.42 N.S

N.S - Not significant t value at p < 0.01

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out to be significantly less than PBU group for learning thecorrect performance.

The results shown in the table above, clearly predict thatmost patients in both groups required at least two days forimproving the proficiency of the skill.

Results predicted by the above table clearly shows thatmost patients in both the groups required trials more than 10but less than 20 for improving the proficiency of their skill.

Table shows that all patients in RUSI group passed theRetention Test conducted after two days of their skillacquisition, whereas a few percentage of the patients inPBU group did not pass the test.

Discussion

The previous recommendations for the use of real-timeultrasound feedback to teach ADIM is supported by thisstudy20,21. The benefit of real-time ultrasound in learning thecorrect ADIM was evidenced by the fact that both, the RUSIgroup and PBU group were given the visual feedback duringand after every trial, yet RUSI group had a significantlygreater number of subjects who achieved the correctperformance in lesser number of trials and days ascompared to PBU group.

A study performed by Teyhen 2005,19 did not detect thebenefit of ultrasound biofeedback for low back pain patientswho had difficulty in preferentially activating TrA at thebaseline. Thereby, benefit from ultrasound biofeedbackcould not be achieved for such patients who theoreticallyare, potential candidates for lumbar stabilization training. Inthe present study, however, the focus of treatment approachwas to improve activation patterns of TrA by facilitatingfaster motor learning. Clinical prediction rule, by Hicks,22was used in the study to assist in the clinical decisionmaking for classification of patients for ADIM.

This study applies the principles of motor learning inimproving the proficiency of the exercise skill of isometricallycontracting TrA using two specific biofeedback tools. It is

Fig. 5.1: Between the group comparison for mean number of trials

Table 5.3: Between group comparison of the number of days required bypatients for improving proficiency of the skill.

Number of Days RUSI group PBU group1st day 22nd day 8 53rd day 1 44th day 2

Fig. 5.2: Between the group comparison for mean number of days

Table 5.4: Between the group comparison of the number of trials required bypatients in each group for improving proficiency of the skill.

Number of trials RUSI group PBU group0-10 2

10-20 7 520-30 2 430-40 2

Fig. 5.3: Between the group comparison of the number of days taken bypatients in each group for correct performance.

Table 5.5: Between group comparison of Retention Test after two days

RETENTIONTEST

RUSI group PBU group100% Pass 18.1% Fail

0% Fail 91.9 % Pass

Fig. 5.4: Between the group comparison of the number of trials taken bypatients in each group for correct performance.

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useful to consider how visual feedback may enhance theprocess of learning to contract a muscle. The results of thestudy indicated (Table5.3) that LBP patients in both thegroups, learnt the skill, mostly on the second day of training,which could be explained on the basis that during the initialstages of learning(cognitive stage), time is spent trying tounderstand the demands of the task, what to do, what tofeel and to “get the idea” of isolating the correct contraction.This is because, subjects with LBP have shown to havedecreased proprioception23, which affects their ability toprovide and process internal feedback, thereby augmentedfeedback is indicated. Both the tools used in this studyproved advantageous and important in providing visualfeedback of muscle action and as a result enhancedlearning in LBP patients where internal representation ofmovement pattern gets affected because of pain. As it isclearly highlighted in the results,(Table5.2) that the meannumber of days and trials required for skill acquisition usingRUSI were, 1.9 and 12 respectively, whereas for PBUgroup, it were 2.72 and 21.45 respectively. From thesefindings, it is clearly evident that more time was required bypatients in PBU group to learn the skill in contrast to patientsin RUSI group who learnt in almost half the time. This couldbe explained with the concept of knowledge of performance(KP) and knowledge of results (KR) feedback, which weregiven to the subjects during and after every trial.

Feedback or information about performance (KP) isknown to be critical for learning,24 and how feedback isprovided influences motor learning25. This form of feedbackhas been advocated as a most effective method26. Since KPis information concerning the movement itself, it wasdemonstrated on the RUSI monitor, as patient performedthe contraction. Immediate visualization of the patient’s owncontraction could have enhanced skill acquisition. On theother hand, deflection of the needle above or below thetarget pressure provided KP to patients in PBU group. Thedirect visualization of the muscle physiology was perceivedmuch faster and was retained better in RUSI group as it isevident from figure 5.5, demonstrating the retention testresults. It was observed that two patients in PBU groupcould not pass the test criteria administered two days27 afterlearning the correct performance, that is, performing the firstthree absolute correct contractions consecutively. Theymade use of two additional contractions and thus did notqualify the test.

KR is the information regarding the outcome, provided tothe learner after the performance of a task24. It is defined as

a verbal, terminal, augmented feedback28. The informationabout the increase in muscle thickness that occurs whenTrA contracts (amount of increase in cms), or length of thein seconds for which the contraction was held providedbiofeedback in the form of KR, to subjects in RUSI group.For PBU group, the magnitude of pressure readingachieved after the muscle contraction or the time for whichthe contraction was held provided the KR feedback. Role ofKR in performance is important, as it influences learning byits direct motivational role, where more attention and effortare brought to bear on the task24.

The present study shows that RUSI is effective inproviding precise visual feedback which is in support withthe findings of previous literature27,29,30,31. It is a beneficialtool that facilitates consistency of performance of ADIM in apopulation with LBA32. It provides feedback to the physicaltherapist about an individual patient’s performance33. Theimprovement in training using RUSI, in the present study,could be the result of adequate feedback provided till thepatient masters the correct skill.

Limitations of the study

Blinding of the investigator recording the readings atboth initial and retention test measures was not done, whichmight have lead to possible bias on the examiner’s part.Sample size taken was less.

Recommendations for future research

Future interventions are recommended to be done withdouble blinded studies and larger retention periods.Incorporation of the re-learnt motor skill into the functionalaspects of an individuals living should be investigated. AlsoRUSI can be used as an assessment tool for evaluating theeffect of gender bias and BMI affecting abdominal musclethickness in subjects with or without low back pain.

Conclusion

RUSI provides an efficient extrinsic visual feedback toolfor learning ADIM in patients with chronic recurrent LBP,making it a useful and specific clinical teaching tool forphysiotherapists.

References

1. Mooney V. Where is the pain coming from? Spine. 1987;12(8):754-759.

2. Andersson GB. Epidemiologic features of chronic lowback pain.Lancet. 1999;354:581-85.

3. Richardson CA and Jull GA. Muscle control-pain control.What exercises would you prescribe?.Manual Therapy.1995;1:2-10.

4. Hodges PW, Richardson CA. Inefficient muscularstabilization of the lumbar spine associated with lowback pain. A motor control evaluation of transversusabdominis.Spine.1996;21(22):2640-2650.

5. Peter O’Sullivan et al Altered patterns of abdominalmuscle activation in patients with chronic low back pain.Australian Journal of Physiotherapy.1997;43(2):91-98.

6. Richardson CA, Jull G, Toppenberg, Mark Comeford.Techniques of active lumbar stabilization for spinalprotection: A pilot study.Australian Journal of

Fig. 5.5: Between the groups comparison for Retention Test after two days

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Physiotherapy. 1992;38:105-112.7. Richardson C, Jull G, Hodges P and Hide J. Therapeutic

exercise for spinal segmental stabilization in low backpain. Scientific basis and clinical approach,ChurchillLivingstone,Edinburgh;1999.

8. Twomey LT, Taylor JR. Physical Therapy of the lowback.3rd edition.London,U.K:Churchill Livingstone;2000.

9. Ng GYF and Richardson CA. The effects of trainingtriceps surae using progressive speed loading.Physiotherapy Theory and Practice .1990;6:77-84.

10. M.J Comeford, S.L Mottram. Movement and stabilitydysfunction-contemporary developments. ManualTherapy. 2001;6(1):15-26.

11. O’Sullivan, P.B.Twomey, Allison G. Evaluation ofspecific stabilizing exercises in treatment of chronicspondylosis or spondylolisthesis.Spine. 1997a; 22(24):2959-2967.

12. Saal JA and Saal JS. Non operative treatment ofherniated lumbar intervertebral disc with radiculopathy:An outcome study.Spine.1989;14(4):431-437.

13. Chris G Maher et al. The effect of motor control exercisevs. placebo in patients with chronic low back pain.BMCMusculoskeletal Disorders.2005;6:54

14. Luciana G Macedo et al. Motor control or graded activityexercises for chronic low back pain?A randomizedcontrolled trial. BMC Musculoskeletal disorders.2008;9:65.

15. Ferreira ML et al. Comparison of general exercise, motorcontrol exercise and spinal manipulative therapy forchronic low back pain:A randomized trial.Pain2007;131:31-37.

16. Ferriera PH, Ferriera ML, Hodges PW. Changes inrecruitment of the abdominal muscles in people with lowback pain. Spine.2004;29(22):2560-2566.

17. Ferriera PH, Ferriera ML, Christopher G Maher, RobertD Herbert, Kathryn. Specific stabilization exercise forspinal and pelvic pain:A systematic review. AustralianJournal of Physiotherapy .2006;52:79-88.

18. Sean GT Gobbins. Retraining of asymmetry inrecruitment of transverse abdominis. OrthopaedicDivision Review 2008:29-34.

19. Teyhen D et al. The use of ultrasound imaging ofabdominal drawing in maneuver in subjects with lowback pain. J Orthop Sports Phys Ther.2005;35(6):346-355.

20. Richardson CA, Jull G, Rowena Toppenberg, MarkCameford, Bang Bui. Towards a measurement of active

muscle control for lumbar stabilization. AustralianJournal of Physiotherapy. 1993;39(3):187-193.

21. Hides J., Richardson C, Jull G. Ultrasound imaging inrehabilitation. Australian Journal of Physiotherapy.1995;41:187-193.

22. Hicks GE, Fritz JM, Delitto, Stuart Mc. Gill. Preliminarydevelopment of a clinical prediction rule for determiningwhich patients with low back pain will respond to astabilization exercise program. Archives of PhysicalMedicine & rehabilitation. 2005;86:1753-1762.

23. Parkhurst M., Burnett Carolyn. Injury and proprioceptionin lower back. J Orthop Sports Phys Ther.1994;19(5):282-295.

24. Salmoni A.W, Schimdt R.A and Walter,C.B. Knowledgeof results and motor learning. Psychological Bulletin.1984;95:355-86.

25. Schmidt R.A and Winstein C.J. Reduced frequency ofknowledge of results enhances motor skill learning.Journal of Experimental Psychology, learning, Memoryand cognition .1990;16:677-691.

26. Gentile, A.M. A working model of skill acquisition withapplication to teaching. Quest.1972;17:3-23.

27. Henry SM. The use of Real-time ultrasound feedback inteaching Abdominal hollowing exercises to healthysubjects. J Orthop Sports Phys Ther.2005;6:338-345.

28. Richard A, Schmidt. Optimising summary knowledge ofresults for skill leaning. Human Movement Science.1990;9:325-348.

29. Kim HJ, Kramer. Effectiveness of visual feedback duringisokinetic exercise. J Orthop Sports Phys Ther.1997;26(6):318-323.

30. Wright D.L et al. How close is too close for precision ofknowledge of results?. Research Quarterly for Exerciseand Sport.1997;68(2):172-176.

31. Teyhen D. Rehabilitative Ultrasound Imaging: Theroadmap ahead. J Orthop Sports Phys Ther.2007;37(8):431-433.

32. Worth SG, Henry SM, Bunn JY. Real-time ultrasoundfeedback and abdominal hollowing exercises forpatients with low back pain. New Zealand Journal ofPhysiotherapy. 2007;35(1):9-11.

33. Goldby LC, Moore A.P, Marion Trew. A randomizedcontrolled trial investigating the efficiency ofmusculoskeletal physiotherapy on chronic low backdisorder. Spine. 2006;31(10):1083-1093.

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Effect of dominant hand training on intermanual transfer to subdominant hand in patients with cerebral tumorsD. Satheesh*, Ajay Sharma

*Incharge, Delhi Society for Welfave of Special Children, Okhla, New Delhi

Abstract

Back ground and purpose

The purpose of this study was to find out there is anyeffect of dominant hand training (RT), on intermanualtransfer to subdominant hand (LT) in patients after cerebraltumor surgery.

Subjects and methods

Subjects were 32 patients with the mean age of48.21±5.85, height 166.56±6.23 cms, and mean weight67.68±5.03 kgs with upper limb weakness secondary tocerebral tumors. Using peg board to analyze motorperformance. Raw scores were standardized for dataanalysis using paired‘t’ test under SPSS 11 windowssoftware.

Results

Over the 2 weeks period the experimental group patientshas significantly shown improvement. Reduction in meantime to complete the task on dominant hand is 74.38±9.57sec to 63.25±8.69 sec and in non dominant hand145.81±12.58 sec to 139.94±12.41 sec. But in control grouphas no significant difference (p=0.0018) and the task73±10.41 sec to 72±10.24 sec.

Conclusion and discussion

The findings suggest that the task improvement is onlyby intermanual transfer. So that measuring changed inexperimental group. But in control group sufficientimprovement only by familiarization of the task thoughclinically significant.

Key words

Cerebral tumors, Intermanual transfer, Collsal fibres.Task improving performance.

Neoplasm frequently affects the nervous system.Primary tumors of the CNS are the second most commoncancer in children, and in adults are more than Hodgkin’sdisease1. The median age adjusted incidence rate forprimary brain tumors is between 4 and 5 cases/100000/year. For primary tumors, patients are usuallyreferred to Neurosurgeons and Neurologists and initialtherapy is always operative1.

Despite the prognosis for limited survival associated withprimary brain tumors, these individuals have shownprogress in rehabilitation settings similar to that noted inclients with diagnosis of stroke or traumatic brain injury2.Advances in medical and surgical treatment for clients withtumors have resulted in improved survival rate and longerlife expectancy. However, individuals are often faced with

functional impairments resulting from the disease process.These impairments can be physical, cognitive or both andthey require an interdisciplinary team approach to bestfacilitate the individuals returned to a meaningful lifestyle.

Among various physical impairments, loss of handfunctions has a profound effect on the individual’s life3. Theability of an individual to accomplish everyday activitiesdepends on the anatomical integrity, sensation, coordination and strength of his hands. Hence handrehabilitation becomes an important therapeutic goal inthese patients3. Many therapeutic strategies have beenused to improve hand function, such as NDT, MRP, andPNF. These strategies focus on the impaired segment tofacilitate its recovery.

A few known Neuropsychological theories/modelssuggest transfer of training from one hand to the other hand,which are known as Inter manual transfers.

It is well known that practice of novel movements withone hand affects subsequent performance of the otherhand4. So-called intermanual transfer has beendemonstrated for number of task such as finger tapping,keyboard pressing, inverted or reverse writing, figuredrawing4.

There is ample evidence to suggest that the effect ofopposite hand training on the performance of the untrainedhand depends on the hand used for initial training. Thetransfer direction reported most often is the transfer fromthe dominant right to the subdominant left hand5. In contrast,there are only few reports of superior transfer effect fromthe left to the dominant right hand as compared to thetransfer from the right towards the left hand.

This intermanual transfer, if effective in patients withbrain tumors, can greatly augment the conventionaltherapies and facilitate better recovery of hand functions.

However, over the decades, studies related tointermanual transfer have been performed in normalsubject. There is no published evidence suggestingeffectiveness of intermanual transfer in patients followingbrain tumors. But the theories suggesting intermanualtransfer are strong enough to explore their effectiveness inpatients following brain tumors. Hence we decided on thisparticular concept.

Methodology

Thirty eight subjects following surgery for cerebraltumors were explained about the purpose and nature of thestudy and informed consent obtained from the subjectswilling to participate.

Subjects then underwent baseline evaluation to check ifthey met the inclusion/exclusion criteria.

Handedness MeasurementStrongly right handed subjects as determined by

Edinburgh Handedness Inventory were included in thestudy. Thirty-two patients meeting the inclusion / exclusion

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criteria were asked to report in the Physiotherapydepartment OPD out patient department on the followingMonday.

Subjects reporting to the Physiotherapy departmentwere randomly allocated to experimental (Group A) andcontrol (Group B) groups, using odd even method.

Motor taskThe pegboard used in this study measured 40cms x 20

cms and had 25 peg holes arrange in 5 columns with fivepeg holes in each column. The peg holes were squareshaped and measured 1.5 cms x 1.5 cms. Two consecutivecolumns wee separated from each other by 5.5 cms andpeg holes in each column were separated from each otherby 2.5 cms. The pegs were of uniform thickness but variedin length. There were five pegs each of 15 cms, 12.5 cms,7.5 cms, and 5 cms.

The subjects were asked to place the pegs into the holesas quickly as possible. The dependent variable was the timeit took to place the pegs successfully into all the twenty-fiveholes. (Timing was not interrupted in the event of a droppedpeg). The subjects had to start the movements from apredetermined starting position in front of apparatus.(Approx 150-245mm)

Motor trainingBefore motor training subjects were in both groups was

evaluated for motor performance (amount of time taken tocomplete the peg board task) for dominant and subdominant hands seperatively with a gap of 15 minutesbetween each hand evaluation. Subjects in Group Areceived motor training in the pegboard task on thedominant hand (right hand). Practicing consisted of eightsessions, four sessions a week resulting in two weeks ofpractice.

DurationSubjects in Group B did not receive any motor training in

the pegboard task. Subjects in both Groups received theirroutine physiotherapy treatment sessions throughout thestudy period.

After the completion of eight practice sessions, taskperformance (time taken to complete the peg board task)were evaluated on the next day for dominant andsubdominant hand in both groups.

Result

The results of the study are summarized here under. 32subjects following surgery for cerebral tumors in the agegroup of 40-60 years, included in their study.

Demographic profiles of the subject in the experimentaland control groups were compared using independentsample t test. There was no statically significant differencebetween the groups.

Test for pre training between group differences for taskperformance. The mean scores of motor performance onthe dominant and sub dominant hand were comparedbetween the groups using independent sample t test. Thetest revealed statistically non significant difference betweenthe groups for both dominant hand and sub dominant hand.

The above mentioned comparison suggests that boththe groups were similar to begin with in relation to theirdemographic profile and motor performance scores.

Test for pre-training, post training within group differencefor motor performance

Within group pre to post training comparison of meanscores of motor performance on the dominant and subdominant hands we compared using paired t test.

1. Experimental groupDifference in mean values of motor performance on the

both dominant and sub dominant hands statisticallysignificant.

2. Control groupDifference in mean of motor performance was

statistically significant for the dominant hand and statisticallyinsignificant for the sub dominant hand.

Test for post-training between group differences formotor performance.

The mean scores of motor performance on the dominanthand were compared between the groups usingindependent sample t test. The test revealed staticallysignificant difference between groups for both dominant andsub dominant hand.

Discussion

The main objective of this study was to find out the effectof dominant hand training on intermanual transfer to subdominant hand in adults with cerebral tumors. We alsoanalyzed whether training of the pegboard task results inclear practice effects of the motor task.

Current models of intermanual transferA number of models have been put forward to explain

Comparison of Pre and Post Treatment Task Performance

on Right Side in Group 1 & 2

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10

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Grp 1 Grp 2

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Comparison of Pre and Post Treatment Task Performance on Left Side in

Group 1 & 2

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D. Satheesh / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2 67

the dependence of intermanual transfer performance on thehand used at acquisition and the orientation of the transfertask, via,• The callosal access model.• The cross activation model and• The model of coordinate processing or their Profiency

model.Asymmetric transfer effects are described in the so-

called cross activation model and callosal access model.Prominent transfer effects from the right towards the lefthand are explained by the cross activation model. Thecallosal access model is appropriate to describe positivetransfer from the left to the right hands. The so-called modelof coordinate processing explains the specific control thenormal task and mirror task.

Callosal Access ModelThe callosal access model was derived from findings

showing that the right hand benefits more from the oppositehand training than did the left hand (Taylor and Heilamn1980). This model assumes that motor programs are storedin the dominant (mainly left) hemisphere, irrespective of thehand used for initial hand skill training40.

As a consequence, the right hand will have direct accessto these motor engrams while the left hand will only haveindirect access via corpus Callosum. (Tay & Hei 1980 andGreger Thut, Norman D. Cook)39. As a result,interhemispheric connections are involved during therepetition of a learned task with the left hand, but not duringsubsequent transfer to the right hand17.

According to this model the dominant (usually right)hand will benefit more from subsequent subdominant handtraining than vice versa. The two models are based on thosestudies, which revealed a greater benefit for the subdominant (usually left) hand after dominant hand training.

Cross activation model or motor overflow theory; (Parlowand Kinsbourne)4.

This theory suggests that, the generation of two motorprograms, one located in each hemisphere. However, bothprograms are thought to operate in a coupled manner.When subjects learn with their dominant hand, the twomotor programs are stored independently in the dominantand sub dominant motor cortex. Because the dominanthand will rely on these superior motor programs. Thus, thesub dominant motor cortex will receive a copy of thisupdated motor programs, which will work independentlyfrom the dominant motor cortex when the subdominanthand is required to perform the practiced task. Therefore,learning with the dominant hand will facilitate subsequentperformance of the sub dominant hand formation of themotor program should rely on the inferior motor programlocated in the subdominant motor cortex, resulting in inferiorperformance of the dominant hand4,40.

The Proficiency modelThis theory postulates that, the formation of unilateral

engrams that are stored in hand motor areas contralateral tothe trained hand. Because of the general advantage of theleft hemispheric motor area controlling the right hand,improving right hand skill through training will improve thesuperior left side motor control center, leading to optimalinformation center to the right hand centers located in theopposite hemisphere. In contrast, training with thesubdominant hand will only improve the inferior motorprograms. Therefore, the dominant hand motor area cannot

benefit from this inferior motor control information coordinateprocessing4,40.

This model describes intermanual transfer performanceof the motor task and mirror task and considers therepresentation of learned information in different frames ofreference. During visuomotor integration, usually derivedrepresentations of the target are transformed intoappropriate motor patterns (Soetching and Flanders 1989;Wolpet et al 1995). The translation between coordinates ofdifferent reference frames is essential for these processes(Kawato et al,.1988; Anderson et al,. 1993). The location ofthe movement target is initially coded in an external, eye-centered reference frame and is mapped into abody-centered frame used for motor output. In the following,coordinates that describe the location of an object extrinsicto the subjects as mediated by vision are referred to asextrinsic coordinates19,40. In contrast, intrinsic coordinatesdescribe the orientation of body segments with reference tothe body midline (Soetching and Flanders 1989).

Recall as acquired cooperates during intermanualtransfer40.

Intermanual transfer of movements learned previouslywith one hand and exceuted with the other hand either inthe original orientation or in the mirror orientation can beexplained by specific coordinates established duringlearning period (Inamizu and Kawato 1998; Malfait et al,.2002; Criscimagna-Hemminge 2003). During the control ofthe normal task, extrinsic coordinates are similar to thoseduring the repetition of the learned task. In contrast, duringthe movement executions hand from opposite hand trainingmay be due to the recall of intrinsic coordinates during themirror task and due to learned extrinsic coordinates duringthe normal task.

Extrinsic coordinates are indicated by thick arcuatedarrows representing the direction of the movement in extrapersonal space. Intrinsic coordinates are indicated byangles and which present the angles betweenshoulder and upper arm during the movement. Initial armand pen positions (cross) are indicated in Grey. The positionafter finishing the movement is presented in black. Duringthe mirror task, intrinsic coordinates are the same as in thelearned task (), whereas extrinsic coordinates needmodification (), while extrinsic coordinates are recalled intheir unchanged form.

The modification of coordinates occurring duringintermanual transfer40.

It suggests that both extrinsic and intrinsic coordinatesare accessed in any transfer task. First, in ventral premotorcortex (Kurata and Hishi, 2002), and superior parietalcortex. (Lacquanati et al,.1995; Scott et al,.1997; Buneo etal 2002) a significant proportion of neurons as modulatedby changes of both visual and motor parameters. Such cellspresumably code both extrinsic and intrinsic coordinatesduring control of the transfer hand in intermanual tasks.Furthermore, visual information stored in extrinsiccoordinates is generally essential for the planning of visuallyguided movements (Servos and Goodale 1994). Thus,accurate performance of movements transferred from thetrained to the untrained hand depends on informationencoded in both reference frames and, consequently,intermanual transfer requires not only recall of coordinatesacquired during training, but also involves processes ofmodification. Both the recall of extrinsic and the modification

D. Satheesh / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 268

of intrinsic coordinates are necessary during the normaltask. And likewise the recall of intrinsic and the modificationof extrinsic coordinates are required during the mirror task.

In this study we used a variant of the pegboard taskwhich is widely used in Neuropsychology for examination ofmotor functions42,43. Although this task is associated with avariety of functions, it is definitely a specific kind ofsensorimotor task in which particular visual stimuli require aspecific response. Previous Neuroimaging studies haveshown that motor tasks triggered or guided by visual cuesevoked strong cortical activation bilaterally in the ventral anddorsal premotor cortex (vPMC and dPMC), in the leftsensorimotor (M1 & S1), in the left supplementory motorcortex (SMA), bilaterally in the inferior lobe, in the rightinferior cerebellum, and in the left ventro lateral thalamus44-

47. These findings highlight the fact that the pegboard task ismost likely accompained by distributed activation in bilateralfronto parietal network. The cerebellum, the basal gangliaand the thalamus. The distributed activation requires timeconsuming intrahemispheric and intrahemispheric transferof information and also time consuming process within eachnode of this network. The results of our study can beanalyzed against the backdrop of this information.

The Practice and Transfer EffectsThe dominant hand in the control group was subjected

to 8 training sessions of 15 minutes each in theexperimental group.

There was strong practice effect for the trainineddominant hand with significant reduction in the mean timetaken to complete the pegboard task from 74.38+9.57 secto 63.25+8.69 sec. But the most interesting finding was thefact that there was practice effect for the untrained (subdominant) hand with a statistically significant reduction inmean time from 145.81+12.582 sec to 139.94+12.412 sec.Therefore one might assume that some kind ofinterhemispheric transfer had occurred.

As mentioned, the pegboard task is a typical visuomotortask most likely accompained by neural activationsbilaterally in the vPMC and dPMC. The most critical part ofthis task is not the movement itself, which is controlled bythe primary motor cortex, but rather the adjustment ofmovement parameters (eg. distance between the holes,size of the pegboard) by means of visual information.According to the above mentioned brain imaging data, it isknown that visual information associated with motorfunctions is transferred from the visual cortex bilaterally viathe dorsal stream to the dPMC. Thus even the right handwhen the pegboard task is performed uni-manually (causingstrong activations with in the left dPMC and left M1), theright dPMC and possibly the adjacent right M1 is alsoactivated. Learning to perform the pegboard task the righthand will therefore automatically lead to an improvement ofvisuo motor associations in both hemispheres, in whichcase performing the motor task with the untrained hand willrely on improved visuo motor associations.

There also may be further process such as the trainingprogram located in M1 or PMC or the interhemisphericexchange of information between both PMCs which are alsostimulated.

There also may be further processes such as the trainingor motor program located in M1 or PMC or theinterhemispheric exchange of information between bothPMCs which are also stimulated.

In the control group, there was a statistically significantdifference (p=0.018) in the mean time taken to complete thetask with the (dominant hand) on two occasions, separatedfrom each other by 10 days. Though statistically significant,the difference in mean time (from 73+10.412 sec to72+10.244 sec) may not be clinically significant. Thisdifference in mean time between initial and final readingcould be due to familiarization of the task.

There was no statistically significant difference in thetime taken to complete the task on sub dominant hand whenmeasured on two occasions separated from each other by10 days. Just being familiar with the task alone could nothave been sufficient to improve task performance on thesub dominant involved / weak extremity. These resultsdemonstrate that the intermanual transfer exists in patientswith cerebral tumors. It is essential to have training periodand just familiarization with a task alone is not sufficient toimprove performance in the affected sub dominantextremity.

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D. Satheesh / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 270

Effect of ankle position on isometric quadriceps strengthening inosteoarthritis of knee jointKatyal Shveta*, Nishat Quddas**, Zubia Vequar***

*M.P.Th (Ortho) Senior Research Fellow (Physiotherapy), Central Research Institute for Ayurveda, New Delhi, **M.P.Th(Ortho) Lecturer, Hamdard University, New Delhi, ***M.P.Th (Ortho) Lecturer, Jamia Milia Islamia University, New Delhi

Abstract

Objective

The one exercise commonly used to strengthen theanterior thigh musculature is quadriceps setting exercise.But despite being the most frequently performed exercise,there still remains lack of agreement as to the mostsatisfactory way of performing this exercise. There is a lot ofdiscrepancy with regard to the effects of ankle position whileperforming this exercise. The purpose of this study was toexamine if ankle position influences the isometricquadriceps strength and to further find the most effectiveposition of the ankle while performing the exercise.

Methods

45 subjects were included for a 3 weeks protocol andrandomly assigned to three groups (dorsiflexion, naturalresting and plantar flexion position of ankle). Isometricstrength, Reduced Western Ontario and McMastersUniversities Osteoarthritis Index (WOMAC) score andVisual Analog Score (VAS), were measured. OnewayANOVA was applied for the analysis of isometric strengthbetween the group and for Reduced WOMAC and VASscores Kruskal Wallis test was used for analysis betweenthe groups.

Results

At the end of the protocol, there was a statisticallysignificant difference in terms of isometric strength betweenthe three groups. The dorsiflexion group showed betterincrease in the strength as compared to the natural restingand plantar flexion groups. However the values of isometricstrength in both natural resting position and plantar flexionposition were statistically insignificant with respect to eachother.

On comparing the final Reduced WOMAC and VASscore, there was no statistically significant differencebetween the dorsiflexion, natural resting and plantar flexionposition.

Conclusion

The results of the study suggest that active dorsiflexionposition of ankle, while performing quadriceps settingexercise is best suited in an attempt to facilitate quadricepsstrength in patients with OA knee. The ankle position whileperforming setting exercise for quadriceps; however has noinfluence on the functional score and pain intensity.

Keywords

Quadriceps, osteoarthritis, ankle position, isometricstrength.

Osteoarthritis (OA) is a ubiquitous condition thatfrequently affects the knee joint and can cause severe painand disability1,2. Based on 2003-2005 data from the NationalHealth Interview Survey (NHIS)3, an estimated 46.4 million(21.6%) of adults in US have diagnosed arthritis and 18.9million (8.8% of all adults) have arthritis-attributable activitylimitation.

The goal of physical therapy in the patients who haveOA is to improve function, minimize discomfort, and limitfurther injury. This tends to be a multifactorial processinvolves obtaining acceptable pain control, optimizing rangeof motion of the entire kinetic chain, functional strengtheningof involved extremity and aerobic exercise4.

The one exercise commonly used to strengthen theanterior thigh musculature is quadriceps setting exercise.This exercise is performed by isometrically contracting thequadriceps femoris muscle and has been recommended asthe preferred technique for activating the vastus medialismuscle5,6,7.

But despite being the most frequently performedexercise, there still remains lack of agreement as to themost satisfactory way of performing this exercise. A fewstudies have been conducted in an attempt to indicate thatthe level of activity of quadriceps muscle can be affected bythe position of the ankle, but the results are not completelyin concordance with each other5,7,8.

Gough and Ladley reported that activity of vastusmedialis, vastus lateralis or rectus femoris was higher duringthe active dorsiflexion of ankle5. The findings of Teppermanet al did agree in part with the earlier data reported byGough et al. Teppperman8 demonstrated that both activedorsiflexion and plantar flexion positions of foot serve tofacilitate isometric contraction of the quadriceps and weresuperior to the natural resting position of the foot. Findingsof Dianna et al further add to the disagreement where theresults demonstrated that activation of VMO and VL is notsignificantly different with the natural and dorsiflexedposition of ankle. Although the difference was notstatistically significant but there was a tendency towardsgreater EMG with ankle in dorsiflex position7.

This diversity of opinion and paucity of scientificevidence on patient population prompted this presentenquiry. The results would help in determine the optimalankle position for strengthening knee extensors duringpathological conditions and post surgical rehabilitation.

Methods and materialsSubjects

A total of 45 (7 men and 38 women) patients with OAwere included in the study. The details of the subject aregiven in table no 1. The criteria for inclusion were:radiological evidence of primary osteoarthritis with grade≥2 on the Kellgren Lawrence scale; both male and femalepatients; age between 40-65 years; unilateral or bilateralinvolvement, in case of bilateral involvement more

Katyal Shveta / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2 71

symptomatic knee was included; pain in and around theknee. Subjects were excluded if they had any limitation inthe ankle range of motion, history of bony or soft tissueinjury to knee joint, backache with radiating pain to leg, anycentral or peripheral nervous system involvement, receivedsteroids or intra articular injection within previous threemonths, systemic inflammatory disease e.g. Gout,Rheumatoid arthritis, Ankylosing spondylitis, had metallicimplants, uncooperative patient, mentally unstable patient,subjects with BMI ≥40 kg/m2 (morbid obesity).

ProcedureAfter screening for inclusion and exclusion criteria the

subjects were randomly assigned into either of 3 groupswith 15 subjects in each group and informed consent wasobtained from the subjects.Group A: Quadriceps exercise with ankle in dorsiflexionposition + shortwave diathermy.Group B: Quadriceps exercise with ankle in natural restingposition + shortwave diathermy.Group C: Quadriceps exercise with ankle in plantar flexedposition + shortwave diathermy.

The outcome measurements were isometric strength ofquadriceps femoris, Reduced Western Ontario andMcMasters Universities Osteoarthritis Index (WOMAC) andVAS score.

Measurement of isometric strengthThe isometric strength of quadriceps femoris was

measured using a strain gauge at baseline (before thetreatment) and recorded as STG 0, at the end of 2nd weekand recorded as STG 14 and at the end of the 3rd week,recorded as STG21. Strain gauge is found to be a reliableand a valid instrument for measurement of strength9,10.During the testing subject was made to sit on the quadricepstable with the knee joint in 60 degrees of flexion. Thigh wasstabilized with a belt; the shin pad was adjusted at 5.1cm (2in) superior to the medial malleolus. The fulcrum of the leverarm was aligned with the most inferior aspect of the lateralepicondyle of the femur. Strain gauge was attached to distalend of the quadriceps table arm.

Subject was given verbal encouragement in order tomotivate the subject to attain maximum effort during the 5-second contractions. Each test included 3 consecutive5-second trials with 30 sec rest between the trials. Themean of 3 readings was used for the purpose of analysis.

Measurement of functional indexThe functional status was assessed using Reduced

WOMAC scale. The scale is found to be reliable and a validtool11. The readings were taken at baseline (before thetreatment), at the end of the 2nd week and at the end of the3rd week and marked as WOMAC 0, WOMAC 14 andWOMAC 21 respectively.

Measurement of pain intensityPain was assessed using a horizontal visual analog

scale which is a reliable and valid tool12,13. The readingswere taken at baseline (before the treatment) and markedas VAS0, at the end of 2nd week as VAS14 and at end of3rd week as VAS 21.

InterventionAll the subjects received shortwave diathermy at the

affected knee joint and quadriceps setting exercise.Intervention was given for 2 weeks (5 days/ week) followedby 1 week of home exercise program.

Shortwave diathermy was given prior to the exercisesession with patient in supine lying and knee joint inextended position. Pad electrodes with a contraplanarplacement across the medial-lateral aspect of the knee wereused. The intensity was adjusted to produce a sensation ofmild warmth. Patient was made to appreciate the warmthby asking him/ her to blow at the hand. The degree ofwarmth felt at the knee was same as that felt at the hand.Diathermy was given for 20 minutes14. The diathermy wasapplied for the initial 2 weeks (5 days / week) i.e. a total of10 sessions.

Maximal voluntary quadriceps setting exercises wastaught to the patients in supine lying with knee extendedand a towel roll below the knee joint. Patients wereinstructed to extend their knee by pushing the back of theknee into plinth without using hip extension to substitute forknee extension.

Table 1: Detail of Subjects

Group A Group B Group CNumber of patients 15 15 15

Age 52.80+ 7.7 53.53+ 7.0 55.07+6.3(Mean+SD)

Weight 68.86+ 8.4 68.80+6.73 67.86+4.9(Mean+SD)

Height 158.6+ 4.6 159.2+5.2 159.00(Mean+SD)

BMI 27.35+2.9 27.23+3.0 26.81+1.7(Mean+SD

Fig. 1: Comparison of strength between the three groups

STRENGTH

6.61

9.4511.76

5.767.99

9.23

6.768.65

10.3

0

2

4

6

8

10

12

14

16

DAY 0 DAY 14 DAY 21

DAYS

ST

RE

NG

TH

(K

g)

GROUP A

GROUP B

GROUP C

Table 2: Comparison of strength between the groups

Group A Group B Group C OnewayMean + SD Mean + SD Mean + SD ANOVA

N =15 N =15 N =15 F PSTG 0 6.61 + 1.81 5.76 + 1.67 6.76 + 1.31 1.669 0.201

STG 14 9.45 + 2.02 7.99 + 1.93 8.65 + 1.43 2.402 0.103STG 21 11.76 + 1.92 9.23 + 2.09 10.30 + 1.70 6.581 0.003

Fig. 2: Comparison of VAS score between the three groups

VAS SCORE

6.9

4.26

2.46

3.96

2.5

6.36

3.6

1.9

6.8

0

1

2

3

4

5

6

7

8

9

DAY 0 DAY 14 DAY21

DAYS

VA

S S

CO

RE

GROUP A

GROUP B

GROUP C

Katyal Shveta / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 272

In the dorsiflexion group patients were instructed toperform maximal active dorsiflexion, before maximalquadriceps setting was initiated. Similarly in the plantarflexion group the subjects were instructed to performmaximal active plantar flexion before quadriceps settingexercise. However in the natural resting group the foot ofthe exercise extremity was allowed to assume a natural ornormal resting position during the contraction of thequadriceps, without contraction of ankle muscles to maintainthe position of ankle. The hold time for isometric contractionwas 10 sec followed by a rest period of 5 sec in betweenthe contractions. Each patient completed 2 sessions in aday. In the first week, each session consisted of 1 set of 10repetitions of quadriceps exercise performed once at thehospital and once at home. In the 2nd week the number ofsets in a session was increased to 2, each set consisted of10 repetitions and a rest period of 2 min was given betweenthe sets. In the 3rd week the diathermy was discontinuedand patient was put on a home exercise protocol whichconsisted of 2 sessions of quadriceps exercise. Thenumbers of sets in a session were now increased to 3.Subjects were given an exercise log table to maintain therecord of the exercise sessions.

Statistical AnalysisA pre- post experimental design was used for the study.

The values collected were that fit the dependent variables-isometric strength, functional index using Reduced WOMACscores, pain intensity using VAS. The base line value forisometric strength, functional index and pain intensity weretaken on day 1 (designated as STG 0, WOMAC 0 and VAS0 respectively). The second reading for all the variables wastaken on day 14 ( designated as STG 14, WOMAC 14, VAS14 respectively) and the final reading was taken at the end

of 3 weeks i.e. on day 21 (designated as STG 21, WOMAC21, VAS 21 respectively). The data was analyzed using theSPSS-10 software.

Repeated measure ANOVA was applied for comparisonof strength within the groups. Oneway ANOVA was appliedto compare the strength between the groups. The values ofall the 3 groups i.e. Group A, B and C were compared at thebaseline, on day 14, and day 21.

The WOMAC scores within the group were analyzedusing Friedman test and the analysis between the groupswas done using Kruskal Wallis test. Similarly for VAS scoreswithin the group were analyzed using Friedman test and theanalysis between the groups was done using Kruskal Wallistest.

The tests were applied at 95% confidence interval and pvalues set at 0.05. The results were taken to be significantif p < 0.05.

Results

Isometric strengthThe results obtained on comparing the readings at day

0 (STG 0) and at the end of the treatment session (STG 21)showed a significant improvement in all the 3 groups(p<0.05). The mean improvement in group A was found tobe 5.15+ 0.11, in group B it was 3.47 + 0.42 and in group Cit was found to be 3.54+ 0.39.

The baseline reading i.e. STG 0 for all the 3 groups wasstatistically insignificant (p=0.201). On comparing the STG14 between 3 groups i.e. group A, B and C an insignificantdifference was obtained (p= 0.103), (Table no 2) but furtherpost hoc analysis revealed a significant difference betweengroup A and group B (p = 0.034) where group A had a mean+ SD of 9.45 + 2.02 and group B had a mean + SD of 7.99+ 1.93. Group B and C showed an insignificant difference(p= 0.327) and so did group A and C (p= 0.238)

Comparison of the final reading i.e. STG 21 usingOneway ANOVA revealed a significant difference betweenthe groups (p= 0.003). Further details were obtainedthrough Post Hoc analysis where a significant differencewas observed between group A and group B (p= 0.001) andthen in group A and group C (p=0.043). The differencebetween group B and group C was however insignificant (p= 0.134). Group A had a mean + SD of 11.76 + 1.92, groupB had a mean + SD of 9.23 + 2.09 and group C had a mean+ SD of 10.30 + 1.70.

Pain IntensityAlthough all the three groups showed statistically

significant improvement on comparing the baseline and thefinal readings, but when comparing for intergroup differencethe improvements were statistically insignificant. All the 3groups were statistically insignificant at the baseline i.e. forVAS 0 (p= 0.487), again for VAS 14 the readings betweenthe groups were found to be insignificant (p= 0.582). Thereadings at the end of the treatment protocol i.e. VAS 21were also found to be statistically insignificant whencompared between the groups (p= 0.253). (Table no 3)

Functional IndexAll the three groups showed statistically significant

improvement on comparing the baseline and the finalreadings, but when comparing for intergroup difference theimprovements were statistically insignificant.

For all the 3 groups the baseline value i.e. WOMAC 0

Table 3: Comparison of VAS between the groups

Group A Group B Group C Kruskal Mean+ SD Mean + SD Mean+ SD Wallis test

N=15 N=15 Chi- Psquare

VAS 0 6.90 + 1.13 6.80 + 1.41 6.36 + 1.21 1.43 0.487VAS 14 4.26 + 1.39 3.96 + 1.44 3.60 + 1.25 1.08 0.582VAS 21 2.46 + 1.07 2.50 + 1.45 1.90 + 1.24 2.896 0.235

Fig. 3: Comparison of Reduced WOMAC score between the three groups.

WOMAC SCORE

13.069.26

22.6

14.8

10.4

20.66

12.48.6

20.8

0

5

10

15

20

25

30

DAY 0 DAY 14 DAY 21

DAYS

WO

MA

C S

CO

RE

GROUP A

GROUP B

GROUP C

Table 4: Comparison of Reduced WOMAC scores between the groups.

Group A Group B Group C KruskalMean + SD Mean + SD Mean + SD Wallis

N=15 N=15 N=15 Chi- Psquare

WOMAC 0 20.80 + 4.26 22.60 + 3.24 20.66 + 1.29 3.285 0.193WOMAC 14 13.06+ 4.11 14.80 + 3.40 12.40 + 2.82 4.276 0.118WOMAC 21 9.26+ 3.41 10.40 + 3.13 8.60 + 1.95 2.310 0.315

Katyal Shveta / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2 73

was statistically insignificant (p=0.193). The readings at day14 (WOMAC 14) were also found to be insignificant for allthe 3 groups. (p=0.118).The final reading i.e. WOMAC 21was again statistically insignificant (p= 0.315) in betweenthe groups. (Table no 4)

Discussion

This study was conducted in an attempt to identify theeffect of ankle position on the quadriceps strength inpatients with osteoarthritis of knee. The findings suggestthat ankle position influences the strength of quadricepsfemoris while performing quadriceps setting exercise. Theresults further indicate dorsiflexion effort to be better incomparison to the plantar flexion and natural restingposition.

Ankle position influencing Quadriceps Femoris strengthThe results of the present study accord with the findings

of Gough and Ladley5 where they reported the effectivenessof ankle dorsiflexion performed concurrently with staticquadriceps contraction in comparison to plantar flexion,natural resting, inversion and eversion positions of ankle.Further the findings of Zakaria, Harburn and Kramer7 are inconcordance with the above results. Their results showedthat even though the ratio of Vastus Medialis Obliqus (VMO)and Vastus Lateralis (VL) EMG activity did not differ fromone another under natural resting and dorsiflexed positionbut the addition of active dorsiflexion to the setting exercisedid increase the mean of VMO and VL by 20%.

However study by Hwang, Abrahim and Chou15

suggested that the effort effect from the ankle joint wasmore during plantarflexion instead of the dorsiflexedposition. Tepperman8 et al on the other hand suggestedthat the average value of the quadriceps EMG output wassignificantly larger during both ankle dorsiflexion andplantarflexion positions. Thereby suggesting both thesepositions to be equally effective in facilitating quadricepscontraction.

Since there are controversial results on this factor ofankle position, thus it was not easy to hypothesize thereasons for the obtained results in the present study. Anattempt has been made to explain the results by means ofconnections made by the afferents from tibialis anteriormuscle spindle on the quadriceps motor neuron pool.Muscle spindles have primary and secondary afferent nerveendings i.e. Ia and II fibers respectively16. These afferentfibers have been found to have non-monosynaptic excitationon muscles acting around the knee joint17. Studies have alsodemonstrated this combination of ankle and knee duringfunctional activities such as walking. This concept wasfurther supported by the results obtained by Marchand etal18.They proposed that afferents from tibialis anterior assistthe contraction of quadriceps during walking via spinalinterneurons to stabilize the knee joint and maintain theupright posture during walking.

Since it has been postulated that increase in strength isdue to both neural and morphological changes with one ofthe important neural factor being an increase in the motorunit recruitment and excitability19,20,21,22. So the presentfindings can be explained by means of connections made bythe afferents from tibialis anterior onto the quadriceps motorneurons, where this connection leads to enhancedcontraction of quadriceps motor neuron pool and thus

producing greater strength in comparison to other anklepositions.

Reduction in pain intensityAll the three groups showed a significant reduction in

pain and improvement in functional index scale from theirbaseline values. But when compared between the groups,there was no significant difference observed. Thussuggesting that all the three positions of ankle to be equallyeffective in reducing pain.

The factors that produced a reduction in pain could beSWD and isometric exercise. As Adegoke et al23 and Jan etal24 suggested that use of diathermy leads to a significantimprovement in patients with OA of knee. Theyhypothesized that the effects of SWD may arise fromimproved circulation around the knee joint, enhancedexcretion of waste metabolites and by relieving musclespasm.

Though effective alone, but a combination of SWD withexercise has been found to be more effective in reducingthe pain. It has been postulated that isometric increases thehyaluron levels in the OA knee. With repeated musclecontractions there occurs a synovial cell stimulation which isresponsible for activating hyaluron synthesis. This viscoushyaluron is much suited to joint lubrication and can thus helpin alleviating pain25.Thus the factor that could have lead toa reduction in pain were SWD and isometric exerciseregardless of the ankle position.

Improvement in functional scoresThe reduced WOMAC score showed improvement in all

the three groups from the baseline value. But whencompared between the groups the results were found tostatistically insignificant. Thereby suggesting all the threeankle position to be equally effective in improving thefunctional status of the patients. Pain is a major contributoryfactor to the disability in the patients with OA knee. Hence,a reduction in pain can explain a concomitant improvementin the functional status of the patients. Our findings are inconcordance with those obtained by Jan and Adegoke etal23,24. The results showed improvement in the functionalscores along with a significant reduction in pain with the useof SWD alone23or combined with exercise24.

Conclusion

The results of the study showed that quadriceps settingexercise was more effective with active ankle dorsiflexionthan plantar flexion and natural resting position in improvingthe quadriceps strength.

The dependent variables of interest which were strength,pain intensity and reduced WOMAC scores were found toimprove from the baseline value in all the three groups butgreater improvement in strength was with active dorsiflexionposition. The ankle position while performing settingexercise was not found to affect the improvements infunctional score and pain intensity measures.

References

1. Elizabeth M, Badley, Iris Rasooly, Gregory K. Webster.Relative importance of musculoskeletal disorders as acause of chronic health problems, disability, and healthcare utilization: Findings from the 1990 Ontario HealthSurvey. J Rheumatol. 1994; 21:505–14.

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2. Peat G, McCarney R, Croft P. Knee pain andosteoarthritis in older adults: a review of communityburden and current use of primary health care. AnnRheum Dis. 2001; 60:91–7.

3. Gerberding L, Popovic T, Stephens J, Solomon S,Bernhardt M, Aguilar R. Centers for Disease Controland Prevention. Prevalence of doctor-diagnosedarthritis and arthritis attributable activity limitation-UnitedStates, 2003-2005.Morb. Mortal Wkly Rep. 2006;55:1089-1092.

4. Bashaw RT, Tingstad EM.Rehabilitation ofosteoarthritic patient: focus on the knee. Clin SportsMed.2005; 24:101-131.

5. Gough JV, Geoffery L. An investigation into theeffectivness of various forms of quadriceps exercise.Physiotherapy. 1971; 356-361.

6. Soderberg GL, Cook. An EMG analysis of quadricepsfemoris during muscle setting and SLR. Phys Ther.1983; 63:1434-1438.

7. Zakaria D, Harburn KL, Kramer JF. Preferentialactivation of vastus medialis oblique, vastus lateralisand hip adductors muscles during isometric exercise infemales. J Orthop Sports Phys Ther.1997; 26: 23-28.

8. Tepperman PS, Mazliah J, Naumann S, Delmore T.Effect of ankle position on isometric quadricepsstrengthening. Am J Phys Med 1986; 65(2): 69-74.

9. Khalil W, Jerome W, Earl C, Gordon M. Objectiverecording of muscle strength. Arch Phys Med andRehab1950; Feb: 90-100.

10. William Kennedy. The development and comparison ofan electrical strain gage dynamometer and a cabletensiometer for objective muscle testing. Arch PhysMed and Rehab 1965; Dec: 793-803.

11. Whitehouse S.L., Lingard E.A., Katz J.N, LearmonthI.D. Development and testing of a reduced WOMACfunction scale. J Bone Joint Surg (Br) 2003; 85-B: 706- 711.

12. Bijur P.E., Silver W, Gallagher J. Reliability of the VASfor measurement of acute pain. Academic EmergencyMedicine 2001; 8:1153-1157.

13. Donald D, McGarth P, Rafii A, Buckingham B. Thevalidation of visual analog scale for chronic andexperimental pain. Pain 1983; 17:45-56.

14. Jan MH, Chai HM, Wang CL, Lin FY, Tsai LY. Effectsof repetitive shortwave diathermy for reducing synovitisin patients with knee osteoarthritis: an ultrasonographicstudy. Phys Ther 2006; 86:236-244.

15. Hwang IS, Abraham LD, Chou SW. The effect of anklejoint position and effort on quadriceps reflex sensitivity.Clin Neurophysiol.2000; 111:1175-1183.

16. Guyton AC, Hall JE. Textbook of Medical Physiology.10th ed. Philadelphia: W.B.Saunders 2001.

17. Chaix Y, Marque P, Meunier S, Deseilligny E,Simonetta M. Further evidence for non- monosynapticgroup I excitation of motoneurones in the human lowerlimb. Exp Brain Res.1997; 115:35-46.

18. Marchand V, Nielsen JB. Modulation of nonmonosynaptic excitation from ankle dorsiflexor afferentsto quadriceps motoneurones during walking. JPhysiol.2002; 538(2): 647-657.

19. Staron RS, Karapondo DL, Kraemer WJ, Fry AC,Gordon SE, Falkel JE, et al. Skeletal muscleadaptations during early phase of heavy resistancetraining in men and women. J Appl Physiol.1994;76(3):1247-1255

20. Moritani T, De Vries. Neural factors versus hypertrophyin the time course of muscle strength gain. Am J PhysMed.1979; 58(3):115-130.

21. Duchateau J, Semmler J, Enoka RM. Trainingadaptations in the behavior of human motor units. JAppl Physiol.2006; 101:1766-1775.

22. Pucci AR, Griffin L, Cafarelli E. Maximal motor unit firingrates during isometric resistance training in men. ExpPhysiol.2006; 91:171-178.

23. Adegoke B, Gbeminiyi. Efficacy of ice and shortwavediathermy in the management of OA of knee. Afr JBiomed Res.2004; 7:107-111.

24. Jan MW, Lai JS. The effects of physiotherapy onosteoarthritic knee of females.J Formos Med Assoc.1991; 90:1008-1013.

25. Miyaguchi M, Kobayashi A, Kadoya Y, Ohashi H,Yamano Y, Takaoka K. Biochemical changes in jointfluid after isometric quadriceps exercise for patientswith osteoarthritis of knee joint. Osteoarthritis Cartilage.2003; 11:252-259.

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Craniocervical flexors endurance training: Treatment approachfor cervical spondylosisShweta Gupta1, Shallu Sharma2, Chitra Kataria3

1Post Graduate Student, 2Associate Professor, Department of Physiotherapy, 3Principal, Department of Rehabilitation, ISICInstitue of Health and Rehabilitation Sciences, Vasant Kunj, New Delhi 110 070, India

Objective

To study the efficacy of craniocervical flexors endurancetraining on pain and disability in patients with cervicalspondylosis.

Design

Pre-test post-test experimental design.

Participants

Twenty four patients with chronic neck pain having earlydegenerative changes in the cervical spine wererandomized into two six-week intervention groups.

Interventions

Craniocervical Flexors Endurance Training andConventional Isometric Training.

Main outcome measures

The primary outcomes measures were pain scores onVisual Analogue Scale and disability scores on NeckDisability Index.

Result

At the end of six-week intervention, CraniocervicalFlexor Endurance training revealed significant improvementin pain and disability scores in comparison to ConventionalIsometric Training (p ≤ 0.05). On within group analysis bothexercise groups demonstrated significant improvement inboth the parameters.

Conclusion

Craniocervical Flexors Endurance Training is effectivein improving pain and disability in patients with cervicalspondylosis. The effect of conventional Isometric Exercisescannot be neglected. It is suggested that these can beintegrated into the rehabilitation regimen once there is re-establishment of muscular balance between the deepsegmental and superficial cervical flexor muscles.

Key words

Cervical spondylosis, neck pain, disability, craniocervicalflexors endurance training, isometric exercises.

Introduction

The cervical spine is surrounded by complex

arrangement of muscles that contribute to static anddynamic control of the head and neck1. In cervical spine,osseoligamentous system contributes 20% to mechanicalstability while 80% is provided by neck musculature2. Withinthe anterior muscles, the deep cervical flexors (longus colliand longus capitis), serve a vital role in control of spinalelements, which cannot be replicated by more superficialanterior muscles (sternocleidomastoid and anteriorscalene)2.

The cervical spine can be affected by number ofpathologies leading predominantly to neck pain3. About two-third of the population have neck pain at some time in theirlives and prevalence is highest in middle age4,5. Neck paincauses severe disability in 5% of the affected people. Thespinal column is exposed to many continuously recurringloads resulting in consequential changes in its morphologyduring the life span described as chronic degenerativeprocess (spondylosis)6. Development of bony osteophytesand excrescenes in the region of vertebral bodies are thehallmark of spondylosis6.

Cervical spondylosis manifests itself in middle-aged orelderly patients. Degenerative changes start in intervertebraldisc with subsequent involvement of other surrounding softtissue structures7. The involved structure can lead to originof neck pain due to presence of nociceptive fibers. Thepatients with cervical spondylosis present with neck pain,stiffness and muscle weakness8. Type III syndrome9,10 ofcervical spondylosis is pain predominant with noneurological deficits, sub-axial neck pain is most often dueto muscular and ligamentous causes.

A disturbance in neck flexor synergy has beencommonly observed in patients with neck pain. Thisdisturbed neck flexor synergy presents as altered pattern ofmuscle activity, where impairment in DCF appears to becompensated by increased activity in superficial muscles(sternocleidomastoid and anterior scalene)11,12. The musclerecruitment patterns are also influenced by changes in jointkinematics of the anatomical region that they control13. It ishypothesized that the morphological changes in cervicalspondylosis and subsequent changes in joint kinematicscan result in alteration of muscle recruitment patterns. Apilot study was conducted prior to the study in which it wasobserved that patients with cervical spondylosisdemonstrated poor performance on craniocervical flexiontest.

In order to address the impairments related to neck painaltered muscle synergy and disability, DCF endurancetraining utilizing craniocervical flexor exercises using apressure biofeedback unit can be of great use. Theexercises aims at normalizing the muscle recruitmentpatterns and hence retraining the motor program14. Theexercise is based on the research that indicates poor

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performance of neck pain patients on craniocervical flexiontest.

The previous studies have not addressed theimpairment of deep cervical flexors and its treatment optionsin specific pathologies of cervical spine. The present studyaddresses the endurance related deficits of DCF andimpairment in neck flexor synergy in patients with cervicalspondylosis. The present study aims to study the efficacyof craniocervical flexor endurance training on pain anddisability in patients with degenerative cervical spondylosis.The study hypothesizes that craniocervical flexor endurancetraining will improve pain and disability in comparison toconventional isometric training in patients with cervicalspondylosis.

Methodology

Twenty four patients aged between 30-70 years withhistory of chronic neck pain of greater than three monthsduration with radiological evidence of early spondylosisparticipated in the study. The study was conducted atrehabilitation department of Indian Spinal Injury Centre.Patients were recruited by advertisement and notification.The study was approved by a review panel prior to itscommencement. The patients with score of 5-24 on theNeck Disability Index, palpable cervical joint tenderness andpoor performance on craniocervical flexion test wereincluded in the study.

Patients were excluded if they had any history of traumato cervical spine, any neurological signs, any type of specificneck and upper quarter muscle training in preceding sixmonths and any medical disorder contraindicating physicalexercises.

An informed consent was taken from all the patients whomet with the inclusion criteria. Patients were allowed towithdraw at any time during the study course without anyprior information. Then the patients were randomized intotwo groups by another rater: Experimental group(Craniocervical Flexor Endurance Training) andConventional group (Cervical Isometric Training).

The pre-intervention recording of dependent variableswas done. Patient reported pain scores (on rest and at

activity) and disability were recorded on Visual AnalogueScale and Neck Disability Index respectively. The patientsstarted with their respective exercise regimens on thesubsequent day.

Exercise RegimensBoth the exercise regimens were conducted over a

period of six weeks. None of the exercise session waslonger than 30 minutes. Subjects were asked to report theundertaking of any other specific intervention or medicationfor their neck pain during the study period, subsequent towhich they were to be discontinued from the study.

Craniocervical Flexor Endurance Training InterventionThe patient was made to lie on a firm board in supine

crook lying position. The exercise used an air-filled pressuresensor (Stabilizer) which was placed sub-occipitally tomonitor the subtle flattening of the cervical lordosis thatoccurs with the contraction of longus colli and longus capitis.

The patient was guided by the feedback from thepressure sensor to sequentially reach five pressure targetsin 2-mm Hg increments from a baseline of 20 mm Hg to finallevel of 30 mm Hg. Patients were instructed to gently nodtheir head as though saying ‘yes’. The therapist identifiedthe target level that the patient can hold steadily for 10seconds without retorting to retraction and dominant use ofsuperficial neck flexor muscles. Any quick jerkycraniocervical flexion movement was avoided. Contributionfrom superficial flexors was monitored by the therapist at allstages using observation or palpation.

Training was commenced at the target level that thepatient could achieve with correct movement ofcraniocervical flexion without dominant use or substitution

Fig. I: Between the groups comparison of Vas at rest:

Table I: Baseline characteristics of the experimental and conventional groups

Experimental Group Conventional GroupMean ± S.D. Mean ± S.D. t-Value

Age 43.97 ± 9.93 50.83 ± 10.7 1.64N.S.

Paindur 55 ± 63.5 55 ± 57.0 0N.S.

VASR 4.75 ± 0.86 4.08 ± 0.79 1.97N.S.

VASA 7.08 ± 0.99 6.5 ± 0.90 1.50N.S.

NDI 34.29 ± 12.16 36.18 ± 8.34 0.44N.S.

N.S. denotes that the t-value is non-significant at p ≤ 0.05.

Fig. II: Between the group comparison of Vas on activity

Table II: Between the group comparison of vas at rest

Vasr Experimental Group Conventional Group t-ValueN=12 N=12

Mean ± S.D. Mean ± S.D.VASR0 4.75 ± 0.86 4.08 ± 0.79 1.97N.S.VASR1 4.0 ± 0.95 4.0 ± 0.74 0N.S.VASR2 3.33 ± 0.88 3.5 ± 0.6 0.52N.S.VASR3 2.25 ± 0.96 3.08 ± 0.67 2.46*VASR4 1.66 ± 0.88 2.66 ± 0.65 3.15*VASR5 0.58 ± 0.67 2.0 ± 0.85 4.53*VASR6 0.08 ± 0.29 2.0 ± 0.83 7.37*

*denotes that the t-value is significant at p ≤ 0.05.N.S. denotes that the t-value is non-significant at p ≤ 0.05.N: Number of patients.S.D.: Standard deviation.VASR: Visual analogue scale score at rest.VASR0: Pre-intervention visual analogue scale score.VASR1: Visual analogue scale score at week1.VASR2: Visual analogue scale score at week2.VASR3: Visual analogue scale score at week3.VASR4: Visual analogue scale score at week4.VASR5: Visual analogue scale score at week5.VASR6: Visual analogue scale score at week6.

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by superficial muscles. The patients were trained to sustainprogressively inner ranges of craniocervical flexion usingvisual feedback from the pressure sensor. For each targetlevel the patient was trained to perform ten repetitions withten seconds hold each.

Once the patient was able to reach the target level of 30mm Hg, training was progressed to antigravity sittingposition. The learnt DCF control was integrated into theneck movements. The patient was made to practice amovement which comprised of controlled eccentric actionof flexors into cervical extension range followed byconcentric action of these muscles to return the head toneutral upright position. The exercise was progressed bygradually increasing the range to which head was movedinto extension as control improved and introducing isometricholds throughout the range.

Conventional Isometric Training InterventionThe patients were shown their assigned exercises and

were taught the isometric exercises for cervical flexors,extensors, and lateral flexors as used in clinical settings.The patients were instructed not to move the head and neckduring the performance of any of the isometric exercisesand were instructed to perform these exercises in front of amirror to ensure that the head does not moves.

All patients were provided a sheet with photographicillustrations of exercises for home reference. The patientswere asked to maintain an exercise diary so as to keep acheck on daily exercise schedule. This provides a referencestandard for the therapist to monitor the patient’scompliance.

Data analysis

The data was analyzed using a SPSS software.Descriptive statistics (mean, standard deviation) werecomputed for each studied variable. For within the groupcomparison: Paired t-test was used for the statisticalanalysis to compare the pre-intervention and post-intervention measure of independent variable within eachgroup.

For between the group comparison: Unpaired t-test wasused to compare the effect of independent variable ondependent variable in between the two groups. The level ofthe significance was fixed at p ≤ 0.05 for the study analysis.

Results

Between the Group ComparisonsBaseline characteristics: As shown in table I there was nostatistically significant difference in between the baselinecharacteristics of the two groups indicating that there ishomogeneity in the groups at baseline.

Between the group comparison of VAS at rest: Asshown in table II and figure I in between the groups therewas no statistically significant difference in patient reportedpain scores on visual analogue scale at rest till week 2.Third week onwards significant difference was illustrated for

Fig. III: Between the group comparison of neck disability index scores

Fig. IV: Pre- and post-intervention comparison of Vas score at rest in theconventional group

Table III: Between the group comparison of vas on activity

Vasa Experimental Group Conventional Group t-ValueMean ± S.D. Mean ± S.D.

VASA0 7.08 ± 0.99 6.5 ± 0.90 1.50N.S.VASA1 6.33 ± 0.88 6.41 ± 0.99 0.22N.S.VASA2 5.5 ± 1.0 5.75 ± 1.14 0.57N.S.VASA3 4.33 ± 0.79 5.33 ± 0.88 2.93*VASA4 3.33 ± 0.89 4.5 ± 1.0 3.02*VASA5 2.16 ± 0.83 4.0 ± 0.85 5.32*VASA6 1.42 ± 0.79 3.75 ± 0.87 6.88*

*denotes that the t-value is significant at p ≤ 0.05.N.S. denotes that the t-value is non-significant at p ≤ 0.05.N: Number of patients.S.D.: Standard deviation.VASA: Visual analogue scale score on activity.VASA0: Pre-intervention visual analogue scale score on activity.VASA1: Visual analogue scale score on activity at week 1.VASA2: Visual analogue scale score on activity at week 2.VASA3: Visual analogue scale score on activity at week 3.VASA4: Visual analogue scale score on activity at week 4.VASA5: Visual analogue scale score on activity at week 5.VASA6: Visual analogue scale score on activity at week 6.

Table IV: Between the group comparison of ndi scores

NDI Experimental Group Conventional Group t-ValueN=12 N=12

Mean ± S.D. Mean ± S.D.NDI0 34.29 ± 12.16 36.18 ± 8.34 0.44N.S.NDI1 27.99 ± 11.65 34.18 ± 7.41 1.55N.S.NDI2 22.81 ± 11.59 32.59 ± 7.57 2.45*NDI3 18.15 ± 10.19 28.07 ± 7.94 2.66*NDI4 14.31 ± 6.87 25.46 ± 8.11 3.25*NDI5 9.09 ± 7.21 21.62 ± 8.88 3.80*NDI6 6.28 ± 5.92 20.35 ± 8.21 4.82*

*denotes that the t-value is significant at p ≤ 0.05.N.S. denotes that the t-value is non-significant at p ≤ 0.05.N: Number of patients.S.D.: Standard deviation.NDI: Neck disability index score.NDI0: Pre-intervention neck disability index score.NDI1: Neck disability index score at week 1.NDI2: Neck disability index score at week 2.NDI3: Neck disability index score at week 3.NDI4: Neck disability index score at week 4.NDI5: Neck disability index score at week 5.NDI6: Neck disability index score at week 6.

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VAS scores in between both the groups. The experimentalgroup showed better improvement in patient reported VASscores.

Between the group comparison of VAS on activity: Asshown in table III and figure II in between the groups therewas no statistically significant difference in reported painscores on visual analogue scale on activity till week 2. Thirdweek onwards statistically significant difference wasillustrated for VAS scores between both the groups. Theexperimental group showed better improvement in patientreported VAS scores.

Between the group comparison of Neck Disability Indexscores: As shown in table IV and Figure III in between thegroups there was no statistically significant difference in NDIscores till week 1. Second week onwards statisticallysignificant difference was illustrated for NDI scores betweenthe groups. The experimental group showed betterimprovement in NDI scores.

Pre-intervention and post-intervention comparison ofvariables in conventional group: As shown in table V andfigures IV, V, VI; within the conventional group there wasstatistically significant difference in pre- and post-intervention measures of both variables. There wassignificant improvement in pain scores both on rest andactivity along with disability scores following conventionaltreatment for period of six weeks.

Pre-intervention and post-intervention comparison ofvariables in experimental group

As shown in table VI and figures VII, VIII, IX; within theexperimental group there was statistically significantdifference in pre- and post-intervention measures of boththe variables. There was significant improvement in painscores both on rest and at activity and disability scorefollowing experimental treatment for period of six weeks.

Discussion

It has been identified from the literature that chronic non-specific neck pain attributes to impaired activation ofDCF15,16. The background of the current study was to identifythe similar deficits in patients with neck pain due to aparticular pathology. In the current study it washypothesized that there would be reduced activation of DCFmuscles in patients with degenerative cervical spondylosis.The patients demonstrated poor performance oncraniocervical flexion test (activation score of less than 24mm Hg) signifying the impaired activation of DCF musclesin this patient population.

The outcome variables: pain intensity and disability wereanalyzed every week in both the groups for a period of sixweeks. On within group comparison, it is evident from theresults that in both the groups there is statistically significantpost-intervention reduction in self-reported neck pain scoresand subsequent disability scores. In the craniocervicalendurance training group, the improvement in pain scoresand disability scores occurred significantly in eachsubsequent week. In the conventional group there was nosignificant improvement in pain and disability scores in thefirst week of treatment, following which there occurredsignificant improvement in both the variables. The findingsof the present study are in support to previous studies whichrecommended therapeutic exercises as treatment option forstrength and endurance related issues in neck painpatients17. The exercises performed for a period of six toeleven weeks in patients with chronic neck pain resulted insignificant reduction of neck pain and disability, increase inisometric neck muscle strength along with significant gainsin range of motion18-23.

Craniocervical flexor endurance training seems to haveno immediate effects on pain scores but after two weeks of

Fig. V: Pre- and post-intervention comparison of vas score on activity in theconventional group

Fig. VI: Pre- and post-intervention comparison of ndi score in theconventional group

Table V: Pre- and post-intervention comparison in the conventional group

Variable Pre-Intervention Post-Intervention t-Value(Week0) (Week 6)

Mean ± S.D. Mean ± S.D.VASR 4.08 ± 0.79 2.0 ± 0.83 10.79*VASA 6.5 ± 0.90 3.75 ± 0.87 15.33*NDI 36.18 ± 8.34 20.35 ± 8.21 8.60*

*denotes that the t-value is significant at p ≤ 0.05.VASR: Visual analogue scale score at rest.VASA: Visual analogue scale score on activity.NDI: Neck disability index score.

Table VI: Pre- and post-intervention comparison in experimental group

Variables Pre-Intervention Post-Intervention t-Value(Week0) (Week 6)

Mean ± S.D. Mean ± S.D.VASR 4.75 ± 0.86 0.08 ± 0.29 18.21*VASA 7.08 ± 0.99 1.42 ±0.79 19.93*NDI 34.29 ±12.16 6.28 ± 5.92 10.64*

* denotes that the t-value is significant at p ≤ 0.05.VASR: Visual analogue scale score at rest.VASA: Visual analogue scale score on activity.NDI: Neck disability index score.

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training, the craniocervical flexor endurance training groupshowed significant improvement in patient reported painscores which increased throughout the treatment period ofsix weeks. The craniocervical flexor endurance regimeemphasizes on retraining the altered motor control14. Painrelief is concomitant with patient mastering isolation ofcorrect muscle action and developing holding ability24. Re-establishment of motor control induces local afferent inputinto the system to modulate pain perception14. It has beensuggested that the induced afferent input may stimulateneural inhibitory system at various levels in spinal cord andmay also activate descending inhibitory pain pathways. It isalso possible that early intervention to reduce the barrage ofnociceptive input may reduce potential motor controldysfunction13. These proposed explanations serve as aplatform to justify the effects of endurance training onchronic neck pain in cervical spondylosis in the presentstudy.

The disability score measured by Neck Disability Indexaims to assess different aspects of the clinical symptoms ofneck pain consisting of pain intensity, daily activities, work,and social activities. The improvement in the disability scorecan thus be attributed to combined effects of reduction inneck pain, facilitation of neck muscle function, andimprovement in activities of daily living.

During rehabilitation of patients with cervical spondylosisand subsequent chronic neck pain special emphasis mustbe placed on re-educating the deep muscles and generalstrengthening exercises are suggested to be introducedonce the imbalance between deep and superficial necksynergists has been addressed for better outcomes.Cervical spondylosis being a progressive disorder demandsa treatment option which can delay the progression andsymptomatology. It can be proposed that the effects ofcraniocervical flexors endurance training will rectify theloading mechanics of cervical spine and can reduce theprogression of degenerative changes.

Limitations of the study

Double blinding was not done for the study; the therapisttraining the patients and the patients themselves does knowabout the treatment regimens but the weekly assessmentswere done by the second therapist. The conventionalisometric exercises were given as a home regime to thepatients and the reported compliance to the exercises was

Fig. VII: Pre- and post-intervention comparison of vas score at rest in theexperimental group

Fig. VIII: Pre- and post-intervention comparison of vas score on activity in theexperimental group

Fig. IX: Pre- and post-intervention comparison of ndi score in theexperimental group

taken at the face value. The sample size of the study wassmall.

Recommendations for future researches

A study with follow up period of one to two years isrecommended to analyze the integration of training inactivities of daily living and subsequently see the effects onsymptomatology. A study investigating theelectromyography changes in superficial and deep flexormuscles following craniocervical flexor endurance trainingregime can be undertaken to address fatigue related issuesof superficial muscles in cervical spondylosis.

Conclusion

It is concluded that patients of cervical spondylosis withmild to moderate neck pain and disability, will be benefitedfrom the craniocervical flexor endurance training. In earlyphases of rehabilitation the use of craniocervical flexorendurance training is judiciously recommended. Howeverthe effect of cervical isometric exercises cannot beneglected. It is proposed that these can be integrated oncethe issues related to deficits in muscle activation of DCFhave been addressed. Re-training of deep cervical flexors isreflected in holistic improvement of patients’ functionssuggestive of beneficial and positive effect of the

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craniocervical flexor endurance training on symptomatologyof patients with degenerative cervical spondylosis.

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14. Jull G, Trott, Patrica PT, Potter, Helen. A RandomizedControlled Trial of Exercise and Manipulative Therapyfor Cervicogenic Headache. Spine 2002;27(17): 1835-1843.

15. Falla D, Jull G, Hodges, Paul (2004). Patients with neckpain demonstrate reduced electromyographic activity ofthe deep cervical flexor muscles during performance ofcraniocervical flexion test. Spine 2004;29(19): 2108-2114.

16. Falla D, Jull G, Hodges. Feedforward activity of thecervical flexor muscles during voluntary armmovements is delayed in chronic neck pain. Exp BrainRes 2004;157: 43-48.

17. Quebec task force on Spinal disorders. Scientificapproach to the assessment and management ofactivity-related spinal disorders: a monograph forclinincians. Spine 1987;12(7S): S1-S54.

18. Bronfort, Evans, Nelson, Brian et al. A RandomizedControlled Trial of Exercise and Manipulation forpatients with chronic Neck pain. Spine 2001;26(7): 788-797.

19. YLinen, Takala EP, Nykanen M et al. Active neckmuscle training in the treatment of chronic neck pain inwomen: RCT. JAMA 2003;289(19): 2509-2516.

20. Highland TR, Vie LL, Dreisinger TE, Russell GS.Changes in isometric strength and range of motion ofisolated cervical spine after eight weeks of clinicalrehabilitation. Spine 1992;17(6S): S77-S82.

21. Johnston, Jull G,Souvlis. Neck movement and muscleactivity characterstics in female office workers with neckpain. Spine 2008;33(5): 555-563.

22. Taimela, Takala, Pekka. Active treatment of chronicneck pain: A prospective randomized intervention.Spine 2008;25(8): 1021-1027.

23. Wang et al (2003). Effecetiveness of physical therapyfor patients with neck pain. American Journal ofPhysical Medicine and Rehabilitation; 82(3): 203-218.

24. Richardson CA, Jull G. Muscle control – pain control.What exercises would you prescribe? Manual Therapy1995;1: 2-10.

Shweta Gupta / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2 81

Attitude of physiotherapy students towards communicationskills and effects of an interactive lecture - A randomizedcontrolled trialVaishali*, Sailakshmi Ganeshan**, C.V. Raghuveer***

*Associate Professor, Dept. of Physiotherapy, Kasturba Medical College,Mangalore, **Associate Professor & HOD, Dept.of Physiotherapy, Kasturba Medical College, Mangalore, ***Prof. & Dean Kasturba Medical College, Mangalore

Abstract

Introduction

Communication is essential in almost all aspects ofhealth care, from history taking to providing information tothe patient. Communication skills have a significant impacton patient care and correlate with improved healthoutcomes and health care quality.

Purpose of study

To assess the attitudes of undergraduate and postgraduates physiotherapy students towards communicationskill learning and to study the effect of an interactive lectureon communication skill on the attitude of undergraduate andpostgraduate students towards learning communicationskill’s.

Methodology

Study design: Randomized controlled trial

Subjects

All Undergraduate, Interns, and Post graduate studentsof Physiotherapy requiring direct interaction with patientswere included in this study.

Testing instrument

The Communication Skills Attitude Scale (CSAS) wasused to assess the attitudes towards communication skilllearning.

Results

The mean base line score of CSAS was calculated forthe experimental & control group which was 86.38 and 87.5respectively. Repeated measures ANOVA showed nostatistically significant difference between the experimental& Control group.

Conclusion

Positive result was shown towards communication skilllearning among the physiotherapy students. However, theattitude did not improve after a brief interactive lecture oncommunication skills.

Introduction

Communication is essential to almost all aspects ofhealth care, from history taking to providing information to

the patient1. History taking contributes 60-80% of the datafor diagnosis2.

Evidence-based studies show that doctors’ interpersonaland communication skills have a significant impact onpatient care and correlate with improved health outcomesand health care quality3,4. Ineffective communication skillsare associated with malpractice claims and medicationerrors5. Communication is a core clinical skill that can betaught and learned. A doctor performs 160 000- 300 000interviews during a lifetime career, making the medicalinterview the most commonly performed procedure inclinical medicine6. Competency in interpersonal andcommunication skills is required at all levels of medicaltraining7,8.

Communication is an interactive process. A person’sexperience and education strongly influence howinformation is interpreted. This idiosyncratic way in whichan individual interprets information is often referred to as aperson’s frame of reference. The therapist and the patientwill view the health complaint from different frames ofreference. For the patient, the complaint is a matter of alarm.There have always been events prior to the decision to visitthe doctor. The patient will often have limited informationabout the medical background and has his/her owninterpretations of what the complaint might signify. For thetherapist, the patient’s complaint represents the matter oflogic. The therapist to a greater extent is responsible forexplaining the patient regarding his disease and givingnecessary advice.

Effectiveness of communication improves when thehealth care worker tries to understand the patient’sperspective, including the patient’s situation, belief, point ofview, fear, worries and attributions. Improved doctor- patientcommunication has been shown to result in increasedsatisfaction of patient, increased patient’s cooperation,decreased duration of hospital stay. In particular, doctormust be able to provide advice and explanation to patientand relatives in a form they can understand. He should alsobe a good listener. Good communication skill is extremelyimportant in the Health care profession3. Communicationskills is equally important for a Physiotherapist especiallydue to the fact that a Physiotherapist has to spend moretime with the patient and his family to ensure effectiverehabilitation. However, communication skills’ learning is notpart of the undergraduate physiotherapy curriculum in India.

Attitude may be defined as psychological tendencieswhich are expressed by evaluating particular stimuli or withobject with favour or disfavour9. Attitudes aboutcommunication would thus play a major role incommunication behaviors. Foundations of knowledge aboutcommunication in undergraduate or post graduatecurriculum would pave a strong base for development ofthese skills as a clinician and as a therapist. This association

Vaishali / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 282

felt to exist between attitudes and behaviors makes theneed to examine the students’ attitude towardscommunication skill learning.

Statement of problem

Communication skills’ learning is not part of the currentundergraduate or postgraduate physiotherapy curriculum inIndia. There is a need to assess the attitude of theundergraduates and post graduates towardscommunication skill learning.

Purpose of study

To assess the attitudes of undergraduate and postgraduates physiotherapy students towards communicationskill learning.

To study the effect of an interactive lecture oncommunication skill on the attitude of undergraduate andpostgraduate students towards learning communicationskill’s.

Methodology

Study design: Randomized controlled trial

Study setting

Department of physiotherapy, Kasturba Medical CollegeMangalore, Manipal University.

Subjects

All Undergraduate, Interns, and Post graduate studentsof Physiotherapy requiring direct interaction with patientswere included in this study.

Testing instrument

The Communication Skills Attitude Scale (CSAS) wasused to assess the attitudes towards communication skilllearning.

The Communication Skills Attitude Scale (CSAS)consists of 26 items, 13 of which are in the form of positivestatements and 13 negative statements aboutcommunication skill learning. Each item is accompanied bya 5-point Likert scale, ranging from 1(strongly disagree) to5 (strongly agree).

Procedure

A total of 160 students were recruited for this study aftertaking their written consent.

The study population was randomly assigned to twogroups using a computerized random program. Afterobtaining the informed consent, the questionnaire wasadministered to both the control and the experimentalgroups. For the experimental group interactivecommunication skill training was taken for one and half hourby a medical professional with vast experience in teachingcommunication skill. The control group did not receive anytraining. The subjects were given verbal instructions not todiscuss the training contents with the other group so thatthey would be blinded to each other. The same

questionnaire was distributed after two weeks to both thegroups for studying the long term or carry over effects of thistraining.

Data analysis

Data was analysed using the Statistical Package for theSocial Science (SPSS version 12). Repeated measure wasused to find out the difference between the experimentaland the control group.

Results

The mean base line score of CSAS was calculated forthe experimental & control group which was 86.38 and 87.5respectively. This is depicted in figure 1.

Repeated measures ANOVA showed no statisticallysignificant difference in the average change of the scores inattitude towards communication skills learning between theexperimental & Control group.

Discussion

Our results showed no statistically significant differencein the average change of the scores in attitude towardscommunication skills learning between the Experimental &Control group.

In our study there was heterogeneous subjectpopulation, so there may have been a difference in theopinions and attitudes between subjects.

The outcome measure (CSAS) used in our study was alikert scale; it would have been unresponsive to detectminimal changes with intervention.

The pre-intervention attitudes was positive to begin with,thus for the intervention to be effective and statisticallysignificant, there should be a large difference which can bedetected between the groups. Also the intervention was onlyfor one and a half hours of interactive lecture. Probably if itwas for a longer duration and an ongoing process, therewould have been a difference in the score.

There was no blinding of the testers to the interventionand this would have added bias to outcome assessment.

Further studies may be done with much larger samples

Vaishali / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 283

Fig. 1: Shows the mean baseline score of CSAS for the two groups.

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84 Vaishali / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2

and multi center assessments and more continued trainingprogram on communication skills.

Conclusion

Positive result was shown towards communication skilllearning among the physiotherapy students. However, theattitude did not improve after a brief interactive lecture oncommunication skills.

It may be worthwhile to introduce Communication skill’slearning as part of the Undergraduate PhysiotherapyCurriculum to improve patient-therapist interaction.

Acknowledgements

1. All Undergraduate, Interns, and Post graduate studentsof Physiotherapy who consented to participate in ourstudy

2. Ms. Asha Kamath, Senior Gr. Lecturer ,Dept ofCommunity Medicine, Kasturba Medical College,Manipal

3. Faculty of Department of Physiotherapy, KasturbaMedical College, Mangalore

Competing InterestsNilFunding SupportNil

References

1. Eagly AH, chaiken S. The psychology of attitudes.NewYork: Harcourt Brace Jovanovich;1993

2. Sliverman, J., Kurtz, S & Draper,J.(1998) Skill for Co-mmunication with Patients (Oxon, Radcliffe MedicalPress

3. Hampton, J.R., Harrison, M.J.G. Miichell, J.R &Seymour, C(1975) Relative contribution of historytaking, physical examination and laboratoryinvestigation to diagnose and management of medicalout-patient. Birtish Medical Journal486-489.

4. Stewart MA. Effective physician–patient communicationand health outcomes: a review. Can Med Assoc J1995;152:1423–33.

5. Nobile C, Drotar D. Research on the quality of parent–provider communication in pe. diatric care: implicationsand recommendations. J Dev Behav Pediatr2003;24:279–90

6. Kohn LT, Corrigan JM, Donaldson MS, eds. To Err isHuman. Building a safer health system. Washington,DC: National Academy Press 1999

7. Lipkin M Jr. Sisyphus or Pegasus? The physicianinterviewer in the era of corporatization of care. AnnIntern Med 1996;124:511–13.

8. Institute for International Medical Education. Globalminimum essential requirements in medical education.Med Teach 2002;24:130–5.

9. Whelan GP. Educational commission for foreignWhelanGP. Educational commission for foreign medicalgraduates: clinical skills assessment prototype. MedTeach 1999; 21:156–60.

85Veena. Bembalgi / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2

A cross sectional study of skeletal deformities in post menopausalwomen in urban and rural areasVeena Bembalgi

Asst. Professor, KLES College of Physiotherapy, JGCC Campus, Vidyanagar, Hubli

Abstract

Bone loss occurs universally with aging, but amongwomen there is an acceleration of bone loss that coincidestemporally with menopause1. Detection of bone mass canbe done by non-invasive techniques like Dual energy X-rayabsorptiometry, bone densitometry etc which canspecifically quantify bone loss, but these are not costeffective & not available everywhere. Therefore a needarouse to assess the skeletal deformities in absence ofexpensive investigations by simple clinical measures whichcan be used at community level too.

Equipments used

Surveyor’s Flexi curve ruler, Carpenter tri-square, Plumbline, Measuring Tape, Bathroom Weighing scale.

Materials used

New York Posture Rating Scale (NYPRS), DataCollection Sheet and Consent Form.

Study Design

Cross Sectional Study.

Sampling method

Stratified sampling method.

Sample size

300 subjects, urban areas (Group U): 150 subjects, ruralareas (Group R): 150 subjects in the age group 45-55 years(Gr A), 56-65 years (Gr B), 66-75 years (Gr C) and whohave attained menopause.

Procedure

Posture of the subjects was evaluated by a quantitativeposture rating score using New York Posture Rating Scaleusing the plumb line method and Surveyor’s flexi curve ruler.

Outcome measures

Index of lumbar lordosis, Index of thoracic kyphosis andNYPRS score.

Results

There were no significant differences between theposture of urban & rural populations except in the Index ofLordosis (Gr. A (urban v/s rural) - p: 0.01, Gr. B (urban v/s

rural) p: 0.003, Gr. C (urban v/s rural) p: 0.002. NYPRSscores showed a declining pattern from age group of 45-55years to 56-65 yrs to 66-75 yrs in both urban & rural groups.

Conclusion

It was concluded from the study that posture of the urbanand rural postmenopausal women is the same exceptdifference in lumbar lordosis and that the posture tends toworsen with advancing age in both rural and urban women.

Key words

Post menopausal women, skeletal deformities, thoracickyphosis, posture, flexi curve ruler, New York PostureRating Scale.

Introduction

Menopause brings about musculo-skeletal pain due topostmenopausal osteoporosis or post menopausal boneloss. Bone loss occurs universally with aging, but amongwomen there is an acceleration of bone loss that coincidestemporally with menopause, the rate of bone loss being 5%per year1.

Detection of bone mass can be done by non-invasivetechniques like dual energy X-ray absorptiometry, bonedensitometry, etc which can specifically quantify bone lossbut is very expensive & not available even in most urbanplaces. Some biochemical tests like serum calcium, urineand faecal calcium, serum osteocalcin, etc are available butthe major drawback being that these tests are non specificand less accurate for bone loss assessments. Hence onecannot judge the extent of bone damage and itsconsequences on posture2.

Skeletal deformities and to some extent subjective boneloss can be detected by radiography which is relativelycheaper and available in urban areas but may not beavailable in rural areas. The ground reality is that a vastmajority of the people in the developing country like ourscannot afford to pay for a diagnosis of bone mass density orbone loss that uses modern techniques3. Therefore, a needarouse to assess the skeletal deformities in the absence ofexpensive investigations by simple clinical measures whichcan be used at community level too, so as to find out minorchanges in the skeleton which could indicate the beginningof loss of bone mass and consequently occurrence ofdeformities, if left unintervened.

No studies have been conducted so far to compareskeletal deformities in urban and rural female population ofvarious age groups using non-invasive and less expensivecommunity tools. Analysis of age related bone loss patternsin females revealed a progressive loss of axial bone mass

86 Veena. Bembalgi / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2

which begins sometime in the third decade and decrease inappendicular bone mass which begins in the fifth decadewhich accelerates during sixth and seventh decade4. We didnot include women in the age group of thirty to forty fivesince most women achieve their natural menopause in lateforties unless it is an induced menopause.

Hence the earliest and most affected is the axialskeleton or the vertebral column. This occurs becauseosteoporosis sets in first in trabecular bone as in thevertebrae and then involves cortical bone of theappendicular skeleton2. Women above 70 years of age aretwice more prone to men of that age to develop multiplewedge fractures of the thoracic vertebrae leading to apainless dorsal kyphosis called “Dowager’s hump”5.Increase in thoracic kyphosis leads to flattening of lumbarlordosis6. Most common changes in the axial skeleton inpost menopausal women are the increased dorsal kyphosis,forward head position and flattened lumbar spine7.

A majority of vertebral fractures due to osteoporosis arefound incidentally on a radiograph taken for some otherpurpose8. Therefore in many women; these changes in theskeleton go unnoticed until the deformities occur. Unlesssuch deformities are evident to naked eyes, loss of bonemass that is occurring gradually will not be evident. Subtleskeletal deformities beginning to occur can be an indicationof gradually increasing bone loss. Therefore, assessmentof skeletal deformities in early stages is important to identifyand intervene to prevent severe skeletal deformities.

Another factor to be considered is that, loss of bonemass also depends on level of activity. In one study, it wasfound that incidence of osteoporosis was 47% in asedentary population compared to only 23% in the hardphysical labour occupation. Regular physical activity has apowerful osteogenic effect and it is important for preventionof bone loss9. In another study done, on fracture rates dueto decreased bone mass in post menopausal women, atGeelong in Australia, the authors showed that fracture rateswere lower in rural population and this difference wasattributed probably to high physical activity in the ruralcommunity owing to agricultural occupations10.

India being an agricultural country with 75% populationresiding in the rural areas, most of our rural population isengaged in farming and hence high physical activitycompared to the urban population who by and large has lessphysical or mechanical activity. But on the other hand urbanpopulation has better access to medical facilities, exposureto various awareness programs regarding health problems,have better knowledge about prevention of health problemsand hence assumingly better nutritional status as comparedto rural population. Hence considering these view points,there is a need to know if these factors affect the skeletaldeformities in urban and rural post menopausal population.Epidemiology of osteoporosis in the Indian population hasbeen studied,11 but with no specific reference to urban orrural women population. The objectives of the study wereto find out the status of skeletal deformities in postmenopausal women of different age groups in urban andrural population and to compare the severity of thedeformities.

Methodology

300 post menopausal women in the age group of45years to 75 years were recruited in the study. 150

participants were from the urban areas (Group U) recruitedfrom patients visiting the physiotherapy OPD and fromwomen attending the “Women’s health care camp for peri-menopausal and post menopausal women” organized bythe obstetrics and gynecology department of KLES Hospital,Belgaum. 150 rural postmenopausal women (Group R)were recruited from the primary health centre and house tohouse visit in Sindholi and Mastimardi villages of BelgaumDistrict. Women with history of amenorrhea of minimum oneyear duration were considered post menopause as per thedefinition of menopause given by WHO scientific group.12Women with congenital deformities, deformities due toinfections, neoplastic causes, metabolic, rheumatoidarthritis, trauma and neuromuscular disorders wereexcluded from the study.

Stratified sampling method was used. The participantswere grouped into strata of 45-55years, 56-65years, and 66-75years with 100 participants in each stratum (50 urbanwomen and 50 rural women). Hence group AU consisted of50 subjects from urban population in the age group of 45-55years. Similarly, group BU consisted of 50 subjects fromurban population in the age group of 56-65 years, and groupCU consisted of 50 subjects from urban population in theage group of 66-75 years.

Same classification of Group AR, Group BR and GroupCR was considered for the rural population

Procedure

All recruited participants were explained the nature andpurpose of the study and a written informed consent wastaken from them. Explanation was given in the locallanguage especially for the rural population. Thedemographic data was obtained from them.

Participants were then asked to stand the way theyusually do, i.e. in a comfortable and natural manner. Aplumb line was hung vertically so that the plumb fell slightlyanterior to the ankle. Body alignment (posture) in respect tothe plumb line was assessed in the sagittal plane. Then theplumb line was hung posteriorly in the midline from theoccipital protuberance, along the spinous processes toassess posture in the frontal plane. Posture assessmentwas done as per the NYPRS criteria for rating posture andwas scored as 5/3/1. Higher scores indicated good posture.

The second measurement taken was using a 40 cmcalibrated Surveyor’s Flexi curve ruler to measure the Indexof Kyphosis and Index of Lordosis in the thoracic and lumbarspine respectively. This instrument is a malleable rulerwhich retains the contour or shape of the spine whenmolded against the spinous processes of the vertebralcolumn. The intra and inter rater reliability of this instrumentis good (ICC= 0.99).13 For this measurement the participantwas asked to expose the spine till the Posterior superior iliacspine (PSIS). The C7 spinous process was identified byhaving the participant bend the head down and palpatingthe first prominence in the mid line at the lower end of theneck. This method of identification of C7 spinous processwas given by Ensurd et al 199714. The upper end of the flexicurve was placed at C7 spinous process and positionedalong the central portion of the spine. The flexi curve wasthen contoured along the length of the spine on the skin tillthe PSIS level. This level was noted on the calibrated flexicurve. The PSIS was chosen instead of lumbo–sacraljunction as it was an easier surface marking to identify. The

87Veena. Bembalgi / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2

curvatures of the thoracic and lumbar spine, thus obtainedwere then traced on a sheet of paper on which a horizontalline was drawn. The cervical end of the flexi curve wasplaced on the line and the distilled end marked by the PSISlevel made to coincide with the horizontal line. The curvaturewas then traced on to paper. Thoracic height (A), thoraciclength (C), lumbar height (B), and lumbar length (D), weremeasured as defined by Milne and Lauber 1974.15 (FigureNo 1)• Thoracic height (A) was the greatest distance measured

from the thoracic curve to the horizontal line • Thoracic length (C) was defined as distance on the

horizontal line from C7 to junction to thoraco-lumbarcurve or the point where the thoracic curve bisected thehorizontal line.

• Lumbar height (D) was calculated as the greatestdistance from the lordosis curve to the horizontal line

• Lumbar length (B) was the distance on the horizontalline from thoraco-lumbar junction to the PSIS marking

Index of kyphosis (IK%) was calculated as thoracicheight divided by thoracic length and converted topercentage.

Index of lordosis (IL%) was calculated as lumbar heightdivided by lumbar length and converted to percentage.

Results

The graph pad software was used for statistical analysis. 1. New York Posture Rating Scale (NYPRS): The NYPRSscore was the highest in the age group of 45-55 years (GrA) in both urban and rural women with means 52.43+8.61

and 51.78+7.05 respectively. It decreased to mean of47.9+7.38 in urban and 48.84+6.93 in rural women in theage group of 56-65years (Gr B). It further decreased tomean of 47.3+ 6.7 and 44.7+8.85 in urban and rural womenrespectively in the age group of 66-75years (Gr C). (ReferGraph No1).

The means of NYPRS score showed a decreasing trendin posture scores as age advanced.

The difference between the age groups of 45-55yrs &56-65yrs in urban women showed significant difference withp<0.001 and between 45-55yrs and 66-75yrs with p<0.001.But no significant difference was found in the NYPRSscores in the age group between 56-65yrs and 66-75yrs.Similarly, in the rural population there was a highlysignificant difference between Gr AR and Gr CR withp<0.001, but no difference between Gr BR and Gr CR. Theinter group comparison (between urban and rural) showedno significant difference in posture scores in any agegroups.

2. Index of Kyphosis: The means for Index of Kyphosis inall subgroups were 10.5+2.88% in Gr AU and Gr ARwas11.57+ 3%, 12.27+2.86% in Gr BU and 11.4+3.52% GrBR. Similarly, 11.69+3.06% in Gr CU and 11.21+ 3.46% inGr CR. (Refer Graph No 2).

These values were more or less consistent in all thesubgroups in both rural and urban populations. The intragroup difference in all subgroups was not significant.

Inter group comparison too showed insignificantdifferences in all the subgroups between urban and ruralwomen.

3. Index of Lordosis: The Index of Lordosis, interestinglywas higher than the Index of Kyphosis in all the subgroupsin both the urban and rural populations. The means of IL%in Gr AU was 15.92+4.6%, Gr BU was 16.16+ 3.76% and GrCU was 14.28+4.4%. In the rural subgroups, means of IL%were Gr AR 13.88+3.73%, Gr BR 13.76+4.24% and Gr Crural was 11.71+3.95%.

The means of subgroups in the urban population werehigher than the means of the rural subgroups. (Refer GraphNo 2 and Table No 1)

Intra group comparison between urban subgroupsthough did not show any significant differences in IL% in thedifferent age groups, but in the rural subgroups there was asignificant difference between Gr AR and Gr CR. Intergroupcomparisons between urban and rural women showedsignificant differences in all the 3 subgroups with p=0.01 inGr A urban v/s rural, p=0.003 in Gr B urban v/s rural and p=0.002 in Gr C urban v/s rural.

Discussion

Physical activity of women in the rural areas is highowing to the farming occupation and heavy household workwhich involves grinding, pounding, sweeping, mopping, etcusing simple tools requiring manual labour. In contrast,urban women perform these activities with modern

Fig. 1: Determination of Index of Kyphosis and Index of Lordosis by flexicurvetracing.

Graph 1:

NYPRS Scores

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Table 1:

Sl no Parameters Urban RuralGr A U Gr B U Gr C U Gr A R Gr B R Gr C R

Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD1 NYPRS 52.43 8.61 47.9 7.38 47.3 6.7 51.78 7.05 48.84 6.93 44.7 8.852 IK% 11.57 3 12.27 2.86 11.69 3.06 10.5 2.88 11.4 3.52 11.21 3.463 IL% 15.92 4.6 16.16 3.76 14.28 4.4 13.88 3.73 13.76 4.24 11.71 3.95

A= Thoracic height, B= Lordotic height, C= Length from C7 to thoraco-lumbar junction D= Length from thoraco-lumbar junction to PSIS level

88 Veena. Bembalgi / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2

mechanized tools requiring less physical activity. But sincethe educational status and access to information aboutpreventive aspects of health is better with the urban women,most of them take care of their health by indulging in goodeating habits, regular exercising etc.

Access to medical facilities is better in urban areas dueto availability of hospitals, clinics, investigative facilities etc.In the present study the villages from which the participantswere recruited were covered extensively by the ROME (ReOrientation of Medical Education) under the rural healthscheme recommended by the Shrivastava Committee andstarted by State Government in 1997. This scheme involvedmedical colleges in the total health care of selected primaryhealth centers with the objective of providing primary healthcare. Jawaharlal Nehru Medical College, Belgaum used toconduct this programme in these villages, where healthcamps were conducted every week in these villages. Freemedications were also provided which included calciumsupplements too. Therefore when considered from oneperspective, though life styles in the urban and rural womenvary considerably, activity level to some extent and medicalfacilities to some extent compensate for each other. Thismay be the reason why no significant differences werefound in the posture or skeletal deformities in urban andrural postmenopausal women except in Index of lordosis.

The NYPRS scores showed a decreasing trend in bothurban and rural women with advancing age indicating thatdetection of bone loss by observational methods can bedone in early stages for early intervention. Clinical orobservatory methods have not been studied as extensivelyas other biochemical or bone densitometry tests. Thereforemore such studies using clinical findings need to be done inremote areas where there is a dearth of even basic healthcare facilities. Normative values for the Indian populationneed to be established for Index of Lordosis and Kyphosis.The present study can be employed to detect the severity ofdeformities and hence can be used for screening of variousdeformities and their consequences on posture inpostmenopausal women.

Conclusion

It was concluded from the study that posture of the urbanand rural postmenopausal women is the same except

difference in lumbar lordosis and that the posture tends toworsen with advancing age in both rural and urban womenequally.

References

1. Rubin C.D. Growth hormone, aging and osteoporosis,South-western internal medicine conference. Am J.Med. Sci., 1993;305:120-9.

2. Pierre D. Delmas. Osteoporosis: Eitiology, diagnosisand Management. 2nd Edition, Published by Lipincott-Raven, Philadelphia,1995.

3. Sankaran Balu, Osteoporosis, 1st edition, copyrightBalu Sankaran, Mumbai, 2000.

4. Roberto Pacifici and Louis V. Avioli. The osteoporoticsyndrome. Detection, prevention and treatment. 4thedition, Academic press, London, 2000.

5. Velimir Matkovic et al. Krussen’s handbook of physicalmedicine and rehabilitation, 4th edition. W.B.Saunderspublication, Philadelphia, 1990.

6. Twomey C.T., Taylor J.R. Sagittal movements of thehuman lumbar vertebral column: A quantitative study ofthe role of posterior vertebral elements. Arch Phys MedRehabil, 1983; 64: 322

7. Tim Kauffmann. Functional performance in older adults,1st edition. F.A.Davis company, Philadelphia, 1994.

8. Cooper C., Atkinson EJ, O’Fallon WM, Melton J III.Incidence of clinically diagnosed vertebral fractures: Apopulation based study in Rochester Minnesota, 1985-1989.J.Bone Miner, Res.,1992;7:221-227.

9. Hamill Joseph and Kathleen M Knutzen. Biomechanicalbasis of human movement, 1st edition, LipincottWilliams and Wilkins publication, USA, 1995.

10. Sanders K. M., Nicholson G.C., Ugoni A.M et al.Fracture rates lower in rural than urban communities:The Geelong Osteoporosis study. Journal ofEpidemiology and community health 2002; 56: 466-470.

11. Pande Ketan C. Prevelance of low bone mass inhealthy Indian population, JIMA 2002;100(8):1-3.

12. Report of a WHO scientific group: Research onmenopause, Geneva, World Health Organisation, 1981.WHO technical report series, vol 670, Physical activityand bone health, 1st edition, human kineticspublications USA, 2001

13. C.M. Arnold, B. Beatty, E.L. Harrison, W. Olszynski.The reliability of 5 clinical postural alignment measuresfor women with osteoporosis. Physiotherapy Cannada2000:286-294.

14. Ensurd KE, Black DM, Harris F, Ettinger B, CummingsSR. Corelates of kyphosis in older women. The fractureintervention trial research group. J. Am Geriatr. Soc.,1997;45:682-687.

15. Milne JS and Lauder IJ. Age effects in kyphosis andlordosis in adults. Ann Hum.Biol, 1974;1:327-337.

Graph 2:

IK and IL

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89Vikas Trivedi / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2

Comparative Analysis of Knee-laxity measurements by a left-hand- and a right-hand-dominant physiotherapist in patients withAnterior Cruciates ligament injuries and healthy control groupVikas Trivedi1, Vaibhav Agarwal2

1Associate Professor, Dept. of Orthopaedics, Subharti Medical College, 2Assistant Professor, Subharti PhysiotherapyCollege, Meerut

Abstract

The purpose of the study was to analyze and compareKT-1000 knee laxity as examined by a left-hand- and a right-hand-dominant physiotherapist in a group of patients withan anterior cruciate ligament (ACL) injury and a group ofpatients, 2 years after ACL reconstruction. A cross-sectionalexamination of two groups of patients pre-operatively andpost-operatively after ACL reconstruction and examinationof healthy controls on two different occasions wasperformed. In the ACL-deficient group, 14 patients had aright-sided ACL injury and 08 patients a left-sided ACLinjury. The corresponding figures in the post-operativegroup were 13 patients with a right-sided ACL injury and 07patients with a left-sided ACL injury. 20 healthy personswithout any known knee problems served as controls. Oneleft-hand- and one right-hand-dominant experiencedphysiotherapist performed all the examinations. The left-hand-dominant physiotherapist measured significantlyhigher absolute laxity values in the left knee, both injuredand non-injured ones, compared with the right-hand-dominant physiotherapist. This was found irrespectively ofwhether the patients belonged to the ACL deficient or thepost-operative group. In the healthy control group, the right-hand-dominant physiotherapist measured significantlyhigher knee-laxity values in the right knee compared withthe left-hand-dominant physiotherapist. Correspondingly,the left-hand-dominant physiotherapist measuredsignificantly higher knee laxity values in the left knee. Weconclude that KT-1000 arthrometer laxity measurementscan be affected by the hand dominance of the examiner.This might affect the reliability of KT-1000 arthrometermeasurements.

Keywords

ACL injury - Knee laxity measurement - Left-/right-handdominance of Physiotherapist.

Introduction

To quantify anterior–posterior knee laxity, severalarthrometers have been developed1,4,9,22,33. The KT-1000arthrometer was developed to provide an objectivemeasurement in the sagittal plane for the translation of thetibia relative to the femur and it is currently the mostfrequently used arthrometer8,10.

Factors that may affect knee-laxity measurement whenusing the KT-1000 are knee angle, force applied, musclerelaxation and tibial rotation5,6,9,11,15,18,21,24,26,27,33,36. To ourknowledge, the consistency between reliability tested left-hand- and a right-hand-dominant examiner has not yet beenanalyzed. As the hand dominance might possibly cause amethodological error.

The aims of the study were:1. To analyse and compare the anterior absolute and side-

to-side KT-1000 laxity in the right and left kneeexamined by a left-hand- and right-hand-dominantphysiotherapist in a group of patients with an anteriorcruciate ligament (ACL) deficient knee and a group ofpatients 2 years after ACL reconstruction,

2. To measure and analyse the anterior absolute and side-to-side knee laxity in a group of persons without anyknown knee problems, examined by a left-hand- andright-hand-dominant physiotherapistOur hypothesis was that no significant differences in KT-

1000 arthrometer knee-laxity measurements would befound between a left-hand- and a right-hand-dominantphysiotherapist.

Patients and methods

22 patients (20 males and 2 females) with a mean ageof 27years who were scheduled for ACL reconstruction and20 patients (19 males and 1 female) with a mean age of 26years who attended a 2-year follow-up examination wereincluded in the study. In the ACL-deficient group, 14 patientshad a right-sided ACL injury and 08 patients a left-sidedACL injury. The corresponding figures in the post-operativegroup were 13 patients with a right-sided ACL injury and 07patients with a left-sided ACL injury. 20 healthy personswithout any known knee problems served as controls. Oneleft-hand- and one right-hand-dominant experiencedphysiotherapist performed all the examinations.

All patients had a normal contra lateral ACLArthroscopic assisted quadrupled hamstring graft

reconstruction and interference screw fixation was done.Associated intra-articular injuries, such as meniscalruptures and cartilage lesions, were addressed at the timeof the index operation.

20 healthy persons without any known knee problemson side, 18 males and 2 females, with a median age of 26years, served as controls.

Physiotherapist examiners

One left-hand-(RPT/L) - and one right-hand-(RPT/R)-dominant experienced physiotherapist performed all theexaminations of the patients in the ACL deficient, and thepost-operative group, as well as the examination of thehealthy persons.

The left-hand-dominant physiotherapist performed allthe KT-1000 arthrometer measurements pulling with the lefthand and, in the same way, the right-hand-dominantphysiotherapist performed all the measurements pulling withthe right hand (Fig. 1a,b). The intraclass correlationcoefficients (ICC) between the RPT/L and RPT/R for the

90 Vikas Trivedi / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2

absolute KT-1000 measurements were between 0.71 and0.86. The intra-reliability for the absolute measurements onthe right and left knee in the healthy control group were0.83–0.94 for RPT/L and 0.71–0.86 for RPT/R.

KT-1000 Arthrometer examination Procedure

The instrumented KT-1000 examination was performedwith the patient/person in the supine position. Both legswere placed on a thigh support with the knees in 30° offlexion. A footrest and a strap around the thighs kept thelegs in a neutral position [12, 25]. The arms were placedalongside the body and the patient/person was asked torelax (Fig. 1a, b). The instrument was calibrated to zerobefore each displacement test. The anterior displacementof the tibia in relation to the femur was registered at 89 N.Atleast three measurements of each knee were performedand the average value was registered. Bothphysiotherapists were blinded to each other’s test results,as well as to the aim of the study.

Results

There were no significant differences between the studygroups in terms of age or gender.

The absolute values for the anterior displacements ofthe injured and non-injured knees, and the side-to-sidedifferences in the ACL-deficient group and post-operativegroup for right-sided and left-sided ACL injured patients arepresented in Tables 1 and 2. The absolute values for theanterior displacements of the right and left knees, togetherwith the side-to-side differences in the healthy control group,are presented in Table 3.

The RPT/L measured significantly higher laxity values inthe left knee than RPT/R. This was found in the injured andnon-injured knees in both the ACL-deficient group and thepost-operative group.

In the healthy control group, the RPT/R measuredsignificantly higher knee-laxity values in the right knee. TheRPT/L measured significantly higher knee-laxity values inthe left knee on all test occasions in the healthy controlgroup (Table 3).

At all occasions, the numerical side-to-side laxity valuewas higher for RPT/L if the left side was injured,correspondingly the numerical side-to-side laxity value washigher for the RPT/R if the right side was injured (Table 1,2).

Discussion

We were not able to verify our hypothesis that nosignificant differences in KT-1000 arthrometer knee-laxitymeasurements would be found between a left-hand- and aright-hand-dominant physiotherapist.

One interesting finding was that, the RPT/L measuredsignificantly higher laxity values for the left knee comparedto the RPT/R, irrespective of whether or not the left kneewas injured, both in the ACL deficient and the post-operativegroup. The side-to-side differences in the right-sided ACLinjured group were consistently higher for the RPT/R, butthey were only statistically significant in the post-operativegroup. Correspondingly, the side-to-side differences werenumerically higher fort the RPT/L in the left sided ACL

Fig. 1 a: KT-1000 arthrometer measurements as performed by one right-hand dominant physiotherapist.b: KT-1000 arthrometer measurements as performed by one left-handdominant physiotherapist

Table 1: Summary of all the KT-1000 anterior absolute and side-to-sidedifference measurements (mm) for the patients with a right-sided ACL injury,in the pre-operative and the post-operative group.

Right-sided ACL injury RTP/L RTP/R RPT/LMean Mean versus(SD) (SD) RPT/R

P valueInjured side 7.5 (2.4) 7.4 (2.5) 0.75

(R)ACL-deficient group Non-injured 5.4 (3.0) 4.0 (2.5) 0.002

(n = 14) 89 N side (L)Side-to-side 2.1 (2.6) 3.4 (3.3) 0.006 difference

Injured 7.5 (2.5) 7.0 (2.7) 0.33side (R)

Two-year follow-up group Non-injured 5.4 (2.1) 4.0 (1.7) 0.004 (n = 13) 89 N side (L)

Side-to-side 2.1 (2.3) 3.0 (2.6) 0.08difference

Table 2: Summary of all the KT-1000 anterior absolute and side-to-sidedifference measurements (mm) for the patients with a left-sided ACL injury,in the pre-operative and in the post-operative group

Left-sided ACL injury RTP/L RTP/R RPT/LMean (SD) Mean (SD) versus

RPT/RP value

Injured 7.0 (3.3) 5.8 (2.9) 0.02 side (L)

ACL-deficient group Non-injured 5.3 (2.2) 4.8 (2.0) 0.24(n = 08) 89 N side (R)

Side-to-side 1.7 (2.8) 1.0 (2.6) 0.18difference

Injured 7.1 (2.8) 5.4 (2.3) 0.007 side (L)

Two-year follow-up Non-injured 6.3 (2.7) 5.6 (2.3) 0.34group (n = 07) 89 N side (R)

Side-to-side 0.8 (3.2) −0.2 (2.7) 0.09difference

Table 3: Summary of all the KT-1000 anterior absolute and side-to-sidedifference measurements (mm) in the healthy control group (n = 20)

RPT/L RPT/R RPT/LMean (SD) Mean (SD) versus

RPT/RP value

Right knee 4.2 (1.9) 4.9 (1.9) 0.01First test 89 N Left knee 4.1 (1.8) 2.9 (1.7) <0.001

Side-to-side difference 0.1 (1.6) 2.0 (1.9)** <0.001 Right knee 4.1 (1.8) 4.9 (2.1) 0.005

Second test 89 N Left knee 3.9 (1.6) 2.8 (1.6) <0.001 Side-to-side difference 0.2 (1.4) 2.1 (2.0)** <0.001

The RPT/R measured significantly higher laxity values in the right kneecompared with the RPT/LThe RPT/L measured significantly higher laxity values in the left kneecompared with the RPT/RThe RPT/R measured significantly higher laxity values in the right kneecompared with the left knee* A significant difference was found between the right and left knee (P < 0.01);** (P < 0.001)

91Vikas Trivedi / Indian Journal of Physiotherapy and Occupational Therapy. April - June 2010, Vol. 4, No. 2

deficient groups. However, without being statisticallysignificant. This is in line with a previous study in whichanother right-hand-dominant physiotherapist examined agroup of ACL injured patients31.

Using the KT-1000 arthrometer, Hang et al.14 andSkinner et al.34 analysed the differences in laxity betweenthe left and the right knee and found no significantdifferences. On the other hand, Rosene et al.29 found asignificant increase in laxity in the left knee compared withthe right in male athletes, but not in females. Torzilli et al.[37] analysed healthy men and found increased laxity in theright knee, while Karageanes et al.19 found increased laxityin the right knee in female athletes throughout the menstrualcycle. In none of these studies was the hand dominance ofthe examiner discussed.

The instructions for the KT-1000 arthrometer include andprimarily describe factors that might affect knee-laxitymeasurements. These factors are related to the patient, theknee angle, the force applied, muscle relaxation and tibialrotation. No comments are, however, made on the positionof the examiner, or the hand that should be used during theexamination procedure8,9. In the present study, we haveshown that the hand dominance of the examiner is also afactor that can affect the measurements.

The strength of this study is a cross-sectional andblinded for the aim design.

Conclusion

We conclude that a KT-1000 arthrometer laxitymeasurement is affected by the hand dominance of theexaminer.

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