Indian Journal of Physiotherapy and Occupational Therapy

An International Journal

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

Volume 5 Number 1 January - March 2011

website: www.ijpot.com

INDIAN JOURNAL OF PHYSIOTHERAPY ANDOCCUPATIONAL THERAPY

EditorDr. Archna Sharma

Head, Dept. of Physiotherapy, G.M. Modi Hospital, Saket, New Delhi 110 017E-mail: editor.ijpot@gmail.com

Executive EditorDr. R.K. Sharma, New Delhi

National Editorial Advisory BoardProf. U. Singh, New DelhiDr. Dayananda Kiran, IndoreDr. J.K. Maheshwari, New DelhiDr. Suraj Kumar, New DelhiDr. Renu Sharma, New DelhiDr. Veena Krishnananda, MumbaiDr. Jag Mohan Singh, PatialaDr. Anjani Manchanda, New DelhiDr. M.K. Verma, New DelhiDr. N. Padmapriya, ChennaiDr. G. Arun Maiya, ManipalProf. Jasobanta Sethi, BangaloreProf. Shovan Saha, ManipalProf. Narasimman S., MangaloreKamal N. Arya, New DelhiDr. Nitesh Bansal, NoidaDr. Aparna Sarkar, NoidaDr. Amit Chaudhary, FaridabadDr. Subhash Khatri, BelgaumDr. S.L. Yadav, New DelhiDr. Sohrab A. Khan, Jamia Hamdard, New Delhi

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Print-ISSN: 0973-5666 Electronic - ISSN: 0973-5674, Frequency: Quarterly (4 issues per volume).

“Indian journal of physiotherapy and occupational therapy” An essential indexed double blind peer reviewed journalfor all Physiotherapists & Occupational therapists provides professionals with a forum to discuss today’s challenges -identifying the philosophical and conceptual foundations of the practics; sharing innovative evaluation and tretmenttechniques; learning about and assimilating new methodologies developing in related professions; and communicatinginformation about new practic settings. The journal serves as a valuable tool for helping therapists deal effectively withthe challenges of the field. It emphasizes articles and reports that are directly relevant to practice. The journal is nowcovered by INDEX COPERNICUS, POLAND. The journal is indexed with many international databases, Like PEDro(Australia).The Journal is now covered with EBSCO (USA) database. The journal is registered with Registrar on Newspapers forIndia vide registration DELENG/2007/20988

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Contentswww.ijpot.com

Jan.-March. 2011Volume 5, Number 1

Indian Journal of Physiotherapy and Occupational Therapy. Jan. - March. 2011, VOL 5 NO 1

1 Footwear effects on balance and gait in elderly women of Indian population between the ages 55and 75 yearsAditi Bhatia, Sumit Kalra

5 The effect of short term dynamic and isometric resistance training in knee osteoarthritisAjit Singh, Shekhar

9 Multimodal therapy in cervicogenic headache- a randomized controlled trialAkanksha Sharma, Unaise Abdul Hameed, Shalini Grover

14 Combined effectiveness of Maitland’s mobilization and patellar taping in patellofemoralosteoarthritis: A randomised clinical trialAlok Kumar, Ganesh B. R.

18 Maximal oxygen consumption as a function of anthropometric profiling in a group of trainedIndian athletesAmrith Pakkala, Ankita Dutta, N.Veeranna, S.B.Kulkarni

21 Titanic splintB.Anandha Priya, Snehal Pradip Desai

24 Normative data of Jebsen Taylor Hand Function Test [modified version] on indian populationB.Anandha Priya, Snehal Pradip Desai

27 Effect of 2-week and 4-week wobble board exercise programme for improving the muscleonset latency and perceived stability in basketball players with recurrent ankle sprainA.S. Dinesha , Arun Prasad.B

33 A comparative study of the therapeutic effect of pelvic floor exercises and perineometer amongwomen with urinary stress incontinenceMs. K. Vairajothi, T.V. Chitra, Professor, R.Baranitharan, V.Mahalakshmi

36 A study of effects of gluteal taping on TD-parameters following chronic stroke patientsBhatri Pratim Dowarah

40 Role of physiotherapy in palliative careBinoy Mathew K V.

43 Comparing effectiveness of antero-posterior and postero-anterior glides on shoulder range ofmotion in adhesive capsulitis - a pilot studyHarsimran K, Ranganath G, Ravi SR

47 Effect of 12 weeks weight bearing and non weight bearing aerobic exercises on overweight andobese individualsJ. Deepa, Monalisa Pattnaik, P.P Mohanty, Venkadesan. R

52 Effect of functional strength training on functional motor performance in young children withcerebral palsyDharam Pani Pandey, Vimal Tyagi

56 Effect of post isometric relaxation on pain intensity, functional disability and cervical range ofmotion in myofacial pain of upper trapeziusDheeraj Lamba, Satish Pant

60 The effect of foot orthoses on energy consumption in runners with flat footF.Farmani, M.Sadeghi, H.Saeedi, M.Kamali

63 A study of prevalence of Developmental Coordination Disorder (dcd) at kattankulathur, chennaiMr.ganapathy Sankar U, Ms. S.saritha

66 Dynamic standing balance in individuals with osteoarthritis knee- a comparison with matchedcontrolsR.HariHaran

70 Effect of play therapy in children with attention deficit hyperactivity disorder - a single blindedrandomized controlled studyJagatheesan Alagesan, Sardesai A. Shradha, Sankar B. Mani

73 A study of effectiveness of wheelchair skill training program (wstp) in teaching wheelie tooccupational therapy studentsKamal Narayan Arya

77 Perception and functional wellbeing of patients receiving physiotherapy services in amultispecialty hospital – prospective observational trialT. Lavinia Marwein1, Baskaran Chandrasekaran, Bidhan Chandra Sharma

80 Effect of concurrent quantitative feedback training on intra-rater and inter-rater reliability ofgrade iii mobilization over fourth lumbar spinous processNidhi Gautam, Shallu Sharma

85 Efficacy of deep transverse friction massage in treatment of chronic ankle sprainPooja K Arora, Sujata Yardi, Kunal Pathak

90 Comparative analysis of 12 minute walk test and modified shuttle walk test in normal subjectsRicha Rai, Sujata Yardi

95 Cervical spinal mobilization versus TENS in the management of cervical radiculopathy: Acomparative, experimental and randomized controlled trialRonald Prabhakar, G. J. Ramteke

100 Home based constraint-induced therapy for children with hemiplegic cerebral palsy: A pilotstudySaleh AL-Oraibi, Hashem Abu Tariah

103 Taping and OKC exercises versus taping and CKC exercises in treating patients with patellofemoralpain syndromeYehia N. Abd Elhafz , Mohammed S. Abd El Salam , Samiha M. Abd Elkader

107 Cardiovascular responses to McKenzie lumbar spine exercises in hypertensive individualsPrabhu. R, Nambiar V.K, Ravindra .S, Kommineni. P

112 Care allowance for people in need of care in Turkey: An ethical and social evaluationSema OÐLAK , Erdem ÖZKARA

116 Comparative study of anaerobic capacity in sprinters and foot ball playersD.s.sakthivelavan, S.sumathilatha

119 Effect of varying abdominal pressures on pulmonary function in seated tetraplegic patients: Acase reportShweta Gore, Sivakumar T.

122 Stabilization exercises in postnatal low back painTarek A. Ammar, Katy Mitchell, Amir Saleh

125 Efficacy of neural mobilization in sciaticaSharma Vijay., Sarkari E. and Multani N.K

128 Prevalence of various health problems in traditional goldsmithAnup Pednekar, Anu Arora, Sujata Yardi

133 Effect of 12-weeks posterior tibial nerve stimulation in treatment of overactive bladderAnwar Abdelgayed Ebid

137 Comparison of manual physical therapy and conventional physical therapy programs inosteoarthritis of kneeDheeraj Lamba, Satish Chandra Pant

140 Efficacy of home based pulmonary rehabilitation program on pulmonary functions and quality oflife in asthmatic childrenGanesan Kathiresan , Andrew J Newens

142 The relative efficacy of mobilization with movement versus Cyriax physiotherapy in the treatmentof lateral epicondylitisPooja Bhardwaj, Amit Dhawan

147 Use of electrical stimulator to detect neurosensory changes - a case reportPrachur Kumar, C.S Ram, Suhas.S.Godhi

150 Relationship between depression and duration from the onset of injury in traumatic spinalcord injured patientsRenu Singh, Ms. Ruby Aikat

154 Efficacy of Mulligan Concept (NAGs) on Pain at available end range in Cervical Spine: A RandomisedControlled TrialKumar D, Sandhu J S, Broota A

Indian Journal of Physiotherapy and Occupational Therapy. Jan. - March. 2011, VOL 5 NO 1

1Aditi Bhatia / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol.5, No.1

Footwear effects on balance and gait in elderly women of Indianpopulation between the ages 55 and 75 yearsAditi Bhatia*, Sumit Kalra***Student, **Lecturer, Banarsidas Chandiwala Institute of Physiotherapy, New Delhi.

Abstract

PurposeTo determine effects of different footwear and barefoot conditionon measurement tools like FRT, TUG and TMW in elderly womenof Indian population.

SubjectsSixty women, aged 55 to 75 years.

MethodsEach subject performed the Functional Reach Test (FRT), TimedUp and Go (TUG) and Ten Metre Walk (TMW) while wearingwalking shoes, heel shoes, and barefooted. One-way repeated-measures analysis of variance (ANOVAs) and a Tukey HonestlySignificant Difference test were used to compare the outcomesfor the 3 footwear conditions.

ResultsSubjects performed better in the FRT when barefooted orwearing walking shoes compared with when they wore heelshoes. For TUG and TMW, the women were slowest wearingheel shoes, with no significant differences in walk shoes andbarefoot.

ConclusionFor administration of measurement tools like FRT, TUG andTMW in clinical settings and for research purposes, footwearshould be consistently standardised from one patient or subjectto another or from one facility to another. Moreover, balanceand gait in elderly women can be improved through correctfootwear recommendation.

IntroductionPhysical function refers to the normal performance of an

individual in managing ADLs and represents an important aspectof the individual’s overall health. Physical function impairs ifbalance and gait are altered. Many falls experienced by olderpeople result from age-related deterioration of the balance andneuromuscular systems(1). Most falls occur during motor tasks(2)

and footwear has been identified as an environmental risk factorfor both indoor and outdoor falls(3). By altering somatosensoryfeedback to the foot and ankle and modifying frictional conditionsat the shoe-sole/floor interface, footwear influences posturalstability and the subsequent risk of slips, trips, and falls, therebyimpairing balance and gait.

Wearing different footwear or being barefooted influencesbalance and gait. When walking barfooted, proprioception andplantar sensitivity provide optimal input to the postural controlsystem. However, wearing a shoe,provide more grip than theplantar sole of the foot, protecting the foot from mechanical insultand irregularities in walking surfaces, thereby reducing the riskof slipping(4).

Moreover, in heeled shoes, heel elevation is associatedwith an increased risk of falling in older people by elevating andshifting the wearer’s center of mass (COM) forward, high-heelshoes affect balance control and lead to postural and kinematicadaptations(5). In a plantar-flexed ankle position adopted whenwearing elevated heel shoes, calcaneal eversion is reduced,which is often noted in high-heeled gait, and foot rollover in theshoe is absent(6), these later adaptations might prevent the footfrom pronating, affecting the foot’s natural shock-absorptionmechanism(4) and thus leading to falls.

Heeled shoes cause abnormal forces across patellofemoraland medial compartments of knee which are typical anatomicalsites of degenerative joint changes(7). First metatarsophalangealjoint reaction forces were twice as large in high heels comparedto barefoot walking(8).

With increasing risk of slips, trips and falls due to footwear,evaluation of physical impairments and functional limitations hasbecome an essential part of research related to clinical practisefor proper diagnosis as to give proper and accurate managementand early rehabilitation. Evaluation of balance and gait can bedone by available multiple instruments such as SharpenedRhomberg, One Leg Stance Test, Functional Reach, Timed UpAnd Go, Berg Balance Scale, Gait Speeds etc(9). Among thephysical performance measures that fulfill these requirementsare the Functional Reach Test (FRT), the Timed Up and GoTest (TUG), and measures of self-selected gait speed such asthe 10-Meter Walk Test (TMW). All 3 of these scales arecontinuous measures and, therefore, theoretically moreresponsive to change than categorical scales(10).

The FRT captures the ability to control movement of thecenter of gravity over a fixed base of support, in the standingposition with excellent test-retest reliability(11). Concurrent validityas a marker of physical frailty in community-dwelling elderlypeople(12), predictive validity in identifying risk of falls incommunity-dwelling male veterans(13) and sensitivity to changein balance in inpatient male veterans undergoing physicalrehabilitation(14) have been reported for the FRT. Older adultshave shorter distances of functional reach when compared withyoung adults(15). The average reach length of females is 13.5%smaller than that for the corresponding males(16).

The TUG is typically used to evaluate basic mobility inelderly people. Podsiadlo and Richardson(17) reported anexcellent intrarater reliability and interrater reliability for asubgroup of 22 people. Women performed significantly pooreron TUG(18). TUG shows a trend towards age related declines asmeasured for both male and female subjects(19).

The TMW is a measure of self-selected walking speed(20)

which, according to Cress et al(21) is the best predictor of self-perceived function and overall physical performance. Thecomfortable walking speed of older adults was an average of71% to 97% slower than that of young adults(22). Gait velocitywas higher for women than for men(23).

Standardization of test procedures is often critical for reliablegeneralization of results from one patient to another. The typeof footwear worn by the patient or subject is not consistentlystandardized in the administration of the FRT, TUG, and TMW.Inprevious studies in which the FRT was used as an outcomemeasure, the authors rarely mentioned footwear when describingthe measurement procedures(24). Footwear also is notstandardized for the TUG or TMW and reported as regular

2 Aditi Bhatia / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1

footwear and as normal walking shoes(25) respectively.Several investigators have reported other effects of

footwear. Few studies included older women like a study doneby Solveig et al(32), reported that walking shoes, heel shoes andno shoes affect the gait pattern of older women of Americanpopulation. However, no study encompassed the effect offootwear on FRT, TUG, and TMW scores amongst elderly womenof Indian population.

The purpose of our study was to determine the effects offootwear on FRT, TUG, and TMW scores in elderly women ofIndian population. The focus of our study was limited to elderlywomen because they are at higher risk for disablement than aremen(26). In addition, women wear high-heeled dress shoes thatmay have a great impact on balance and gait performance.

We hypothesized that elderly women of Indian populationshow low FRT scores, larger TUG scores and slower selfselected gait speeds with heel shoes, with no significantdifferences in walk shoes versus barefoot condition.

MethodSubjects-60 healthy female subjects were taken.Inclusion criteria-(1) Between age group of 55 to 75 years,(2) Owned at least one pair of walking shoes and at least one

pair of dress shoes (with heel height of atleast 1 inch)(3) Wore these shoes at least occasionally(4) Had at least 90 degrees of shoulder flexion(5) No history of any balance problem(6) Able to stand unsupported for 30 seconds or more,(7) Could walk independently at least 20 m and turn 180

degrees,(8) Did not wear a lower-extremity brace or orthosis,(9) Should be able to stand barefoot on the floor.Exclusion criteria-(1) Ability to understand standardised test instructions,(2) Any psychological disorder,(3) Any neurological disorder,(4) Any recent or acute fracture of lower limb,(5) Any recent lower limb surgery,(6) Any inflammatory condition, joint infection of lower limb

joints,(7) Any diabetic or lower limb neuropathy,(8) Tendoachilles not stretchable to 90 degrees,(9) Any shoulder pathologies or deformities,(10) Any spinal pathology,(11) Wore any lower extremity brace or orthosis,(12) Foot deformities, foot abnormalities like painful corns and

ulcers.Instrumentation-1. Walking shoes2. Dress shoes of atleast 1 inch heel3. Yardstick4. Measuring tape5. Digital stop watch6. Chair with arm rest, cushioned back and seat. The chair

should have seat height 44cm, seat depth 44cm and armheight 63cm.

ProcedureAll the subjects who were willing and fulfilling inclusion

criteria were taken for the study and explained about the testingprocedure. They were asked to sign an informed consent. Thesubjects were asked to perform FRT, TUG and TMW under threefootwear conditions (barefoot, walk shoes and heel shoes) fortwo trials. To avoid undue fatigue subject rested 3minutesbetween footwear conditions and 1minute between differentfunctional measurements.

Data analysisA one-way repeated-measures ANOVA was used for each

test to compare the outcomes on the FRT, TUG, and TMW forthe 3 different footwear conditions. A post hoc comparisonsamong footwear conditions were performed using the TukeyHonestly Significant Difference (Tukey HSD) test with asignificance level of P<.05. The 95% confidence interval (95%CI) also was calculated for each point estimate.

Results

Table 2: Comparison of TUG in different footwear conditions(barefoot) walk shoes and heel shoes)

TIMED UP AND GO TEST (TUG) in secondsBAREFOOT WALK HEEL

SHOES SHOESMEAN 12.375 12.208 14.477STANDARD 3.709 3.696 3.856DEVIATION

Table 1: Comparison of FRT in different footwear conditions(barefoot) walk shoes and heel shoes)

FUNCTIONAL REACH TEST (FRT) in cmBAREFOOT WALK HEEL

SHOES SHOESMEAN 8.267 8.162 6.612STANDARD 2.672 2.682 2.371DEVIATION

Table 3: Comparison of TMW in different footwear conditions(barefoot) walk shoes and heel shoes)

TEN METRE WALK (TMW) in metre/secondBAREFOOT WALK HEEL

SHOES SHOESMEAN 0.544 0.554 0.465STANDARD 0.129 0.133 0.098DEVIATION

Graph-1 Comparison of FRT in different footwear conditions(barefoot, walk shoes and heel shoes)

Graph-2 Comparison of TUG in different footwear conditions(barefoot, walk shoes and heel shoes)

3Aditi Bhatia / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1

Graph-3 Comparison of TMW in different footwear onditions(barefoot, walk shoes and heel shoes)

gait speed than with no shoes.Though barefoot walking increases precise foot position

awareness, but elderly women cannot be advised to walk withoutshoes because barefoot walking can cause cuts, abrasions,bruises, punctures, wounds from foreign objects. Moreoverhookworm larvae can easily burrow through a bare human foot.In addition individuals with diabetes mellitus which affectsensation with in feet are at a greater risk of injury when walkingwithout shoes so they can only be advised to walk with shoeswith no or minimal heel.

It is also important to note that during the testing, subjectswore their own shoes, because testing in new shoes mayinfluence postural responses to footwear. Moreover in clinicalsettings, subjects are generally assessed in their own shoes.

This study also indicates that during assessments andfollowups of elderly women of balance and gait abilities,comparative analysis should be drawn in similar footwearcondition with its proper documentation.

Results of current study suggest that correct footwearrecommendation can help to improve balance and gait abilitiesin elderly women. But further research is needed to identifyimportant shoe characters that can help to improve balance andgait abilities in elderly women.

ConclusionBased on the findings of this study, it can be concluded

that scores of FRT, TUG and TMW are affected by type offootwear condition in elderly women. It is also important to keepthe footwear constant and properly documented when using FRT,TUG and TMW in clinical settings and research purposes. Inaddition, improvement of gait and balance in elderly women canbe undertaken by proper footwear intervention and it issuggested that elderly females should be advised to wearminimal heel shoes as it can prevent further risk of falls as theycan walk barefoot.

References1. Lord SR, Sherrington C, Menz HB. Falls in older people:

Risk factors and strategies for prevention. 2nd ed.Cambridge (England): Cambridge University Press; 2001.

2. Hill K, Schwarz J, Flicker L, Carroll S. Falls among healthy,community-dwelling, older women: A prospective study offrequency, circumstances, consequences and predictionaccuracy. Aust N Z J Public Health. 1999; 23(1):41-48.

3. Berg WP, Alessio HM, Mills EM, Tong C. Circumstancesand consequences of falls in independent community-dwelling older adults. Age Ageing. 1997;26(4):261-68.

4. Jasmine C. Menant, Hylton B. Menz, Bridget J. Munro,Stephen R. Lord. Optimizing footwear for older people atrisk of falls. JRRD, 2008; 45: 1167-1182

5. Snow RE, Williams KR. High heeled shoes: Their effect oncenter of mass position, posture, three-dimensionalkinematics, rearfoot motion, and ground reaction forces.Arch Phys Med Rehabil. 1994;75(5):568-76.

6. Ebbeling CJ, Hamill J, Crussemeyer JA. Lower extremitymechanics and energy cost of walking in high-heeled shoes.J Orthop Sports Phys Ther. 1994;19(4):190-96.

7. D.Kerrigan, J.Lelas, M.Karvosky. Women’s shoes andosteoarthritis. The Lancet, Vol 357:1097-1098.

8. McBride ID, Wyss UP, Cooke TD, Murphy L, Phillips J,Olney SJ. First metatarsophalangeal joint reaction forcesduring high-heel gait. Foot Ankle. 1991 Apr;11(5):282-8

9. Anemaet, Wendy K. Functional Tools for Assessing Balanceand Gait Impairments. Topics in GeriatricRehabilitation.1999;15(1):66-83

10. Maki B. Gait changes in older adults: predictors of falls orindicators of fear? J Am Geriatr Soc.1997; 45:313–320.

The ANOVAs revealed an overall footwear condition effectfor FRT scores of subjects (F=7.908; df=2; P<.001), for TUGscores (F=6.807; df=2; P<.001), and for TMW scores (F=9.739;df=2; P<.001).

Tukey HSD post hoc pair-wise comparisons revealed thatthe subjects performed better on the FRT when they werebarefoot or wore walking shoes compared with when they woreheel shoes(HSD.05=5.060 and HSD.05=4.655 respectively) withno significant difference between the barefoot and walking shoeconditions(HSD.05=.405).

Subjects when performing TUG performed better in barefootand walking shoes compared with when they wore heel shoes(HSD.05=4.33 and HSD.05=4.68 respectively) with no significantdifference between the barefoot and walking shoe conditions(HSD.05=.344).

In TMW test, subjects performed better in barefoot andwalking shoes compared with when they wore heel shoes(HSD.05=4.996 and HSD.05=5.628 respectively) with no significantdifference between the barefoot and walking shoe conditions(HSD.05=.632).

DiscussionThe results of the study indicates that in elderly women,

type of footwear is an important factor while measuring andanalysing findings of common clinical tests like FRT,TUG andTMW.

The results of this study indicates that FRT scores are betterin walk shoes or no shoes in comparison to heel shoes.

The results of FRT scores are quite consistent with findingsof Lord and Bashford(27) who studied the effects of footwear onbalance in 30 women aged 60 to 89 years using a swaymeter.These women performed better in flat shoes or barefoot thanwhen they wore high heeled shoes.

The lack of differences in FRT scores between barefootand walking shoes condition is consistent with study by Briggset al(28). They found no effect of wearing shoes versus not wearingshoes on performance in sharpened Rhomberg and OLSTamong older women with no known pathology.

Footwear effects on TUG and TMW showed worseperformances with heel shoes with no significant differncesbetween barefoot and walk shoes walking. These performancesin heel shoes condition agrees with observations of Snow RE etal(29) whose studies demonstrated slower gait in high heeledshoes compared with low heeled shoes. The decreased scoresof TUG and TMW in heels is supported by work of de Lateur(30)

which states that increased heel heights corresponds todecreased gait speeds and step length.

According to Menant et al(31), elevated heel shoes lackcomfort, stability and lead to a conservative walking patterncharacterised by increasing step width and double support time.

The study also indicates that there is no significantdifference in walk shoes versus barefoot condition of TUG andTMW scores, contradicting the study of Solveig et al(32) whichstates that walk shoes give lower TUG scores and faster selected

4

11. Duncan PW, Weiner DK, Chandler J, Studenski SA.Functional reach: a new clinical measure of balance. JGerontol A Biol Sci Med Sci.1990; 45:M192–M197.

12. Weiner DK, Duncan PW, Chandler J, Studenski SA.Functional reach: a marker of physical frailty. J Am GeriatrSoc.1992; 40:203–207

13. Duncan PW, Studenski SA, Chandler J, Prescott B.Functional reach: predictive validity in a sample of elderlymale veterans. J Gerontol A Biol Sci Med Sci.1992; 47:M93–M98.

14. Weiner DK, Bongiorni DR, Studenski SA, et al. Doesfunctional reach improve with rehabilitation? Arch Phys MedRehabil.1993; 74:796–800.

15. Hageman P, Blanke D. Age and Gender Effects on PosturalControl Measures, Archives of Physical Med and Rehab.Vol 76:961-965.

16. Sen Gupta AK, Das B. Maximum Reach Envelope forSeated and Standing Females and Males for Industrial WorkStation Design. Ergonomics 2000;43 (9): 1390-404.

17. Podsiadlo D, Richardson S. The timed “Up & Go”: a test ofbasic functional mobility for frail elderly persons. J AmGeriatr Soc.1991; 39:142–148.

18. Luc vereck, Floris Wuyts. Clinical assessment of balance:normative data, gender and age effects. InternationalJournal of Audiology, 2008, vol-47, pages 67-75.

19. Teresa M Steffen, Timothy A Hacker, Louise Mollinger. Age-and Gender-Related Test Performance in Community-Dwelling Elderly People: Six-Minute Walk Test, BergBalance Scale, Timed Up & Go Test, and Gait Speeds.Phys Ther. 2002;82:128–137.

20. Duncan PW, Studenski SA. Balance and gait measures.In: Lawton MP, Teresi JA, eds. Annual Review ofGerontology and Geriatrics: Focus on AssessmentTechniques. New York, NY: Springer Publishing Co Inc,1994:76–92.

21. Cress ME, Schechtman KB, Mulrow CD, et al. Relationshipbetween physical performance and self-perceived physicalfunction. J Am Geriatr Soc.1995; 43:93–101.

22. Bohannon RW. Comfortable and maximum walking speedof adults aged 20-79 years: reference values anddeterminants. Age Ageing.1997; 26:15–19.

23. Tommy Oberg, MD, Alek Karsznia, Kurt Oberg. Basic gaitparameters:Reference data for normal subjects,10-79 yearsof age. Journal of Rehabilitation Research andDevelopment. 1993;Vol.30:210–223

24. West SK, Rubin GS, Munoz B, et al. Assessing functionalstatus: correlation between performance on tasksconducted in a clinic setting and performance on the sametask conducted at home—The Salisbury Eye EvaluationProject Team. J Gerontol A Biol Sci Med Sci.1997;52:M209–M217.

25. Schenkman M, Cutson TM, Kuchibhatla M, et al. Reliabilityof impairment and physical performance measures forpersons with Parkinson’s disease. Phys Ther.1997; 77:19–27.

26. Lewis M. Older women and health: an overview. WomenHealth.1985; 10:1–16.

27. Lord SR, Bashford GM. Shoe characteristics and balancein older women. J Am Geriatr Soc.1996; 44:429–433.

28. Briggs RC, Gossman MR, Birch R, et al. Balanceperformance among noninstitutionalized elderly women.Phys Ther.1989; 69:748–756

29. Snow RE, Williams KR. High heeled shoes: their effect oncenter of mass position, posture, three-dimensionalkinematics, rearfoot motion, and ground reaction forces.Arch Phys Med Rehabil.1994; 75:568–576.

30. de Lateur BJ, Giaconi RM, Questad K, Ko M, Lehmann JF.Footwear and posture: Compensatory strategies for heelheight. Am J Phys Med Rehabil. 1991 Oct;70(5):246-54.

31. J. Menant, J. Steele, H. Menz, B. Munro, S. Lord. Effects ofwalking surfaces and footwear on temporo-spatial gaitparameters in young and older people. Gait & Posture,Vol29; 392-397

32. Solveig A Arnadottir and Vicki S Mercer Effects of Footwearon Measurements of Balance and Gait in Women betweenthe Ages of 65 and 93 Years Phys Ther Vol. 80, No.1,January 2000, pp.17-27

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5

The effect of short term dynamic and isometric resistance trainingin knee osteoarthritisAjit Singh*, Shekhar***Assistant Professor, Department of Orthopaedics, Rohilkhand Medical College, Bareilly, **Assistant Professor, Department ofPhysiotherapy, Jaipur College of Physiotherapy, Jaipur

Corresponding author:Dr Ajit Singh, Assistant Professor , Department of Orthopaedics,Rohilkhand Medical college, Pilibhit bypass Road, Bareilly. PIN-243006.E-mail: ajitsingh2409@gmail.comPhone number: (0581)2526011Mobile number: 09319930079, 9458407500

Abstract

Background and purposeSince strength training affects the outcome of OA knee,

thus this study aims to assess the effect of short term (3 weeks)multiple angle isometric resistance training and dynamicresistance training on pain and function among adults with OAknee.

Study designA pre-post experimental design.

SubjectsA total of sixty subjects were selected on the basis of

inclusion and exclusion criteria; Group 1 (n=30) wasadministered with multiple angle isometric resistance trainingand Group 2 (n=30) was administered with dynamic resistancetraining.

MethodsThe muscle strength was measured using strain gauge,

pain of the subjects was evaluated on Visual analog Scale,function of knee was measured on reduced WOMAC scale.

ResultsThe result indicates that both the interventions were equally

effective in reducing pain, improving isometric strength ofquadriceps, and improving functional status.

Conclusion Dynamic or isometric resistance training improves

functional ability and reduces knee joint pain of patients withknee OA.

KeywordsDisability; dynamic resistance training; isometric exercises;

knee osteoarthritis.

IntroductionOsteoarthritis (OA) is common, progressive health problem

among adults. It is the most prevalent disease in our society,with a world wide distribution and is the second most commoncause of disability among older adults1. It is estimated that 80%

of all adults at or over age 65 years exhibit radiographic evidenceof OA2. When symptoms of the disease affect the knee, as in10% of all adults, it results in a limited ability to complete activitiesof daily living (ADLs)3. Many studies have indicated that theprimary lesion of OA is in the articular cartilage4. Quadricepsstrength, knee pain, and age are more important determinantsof functional impairment in elderly subjects than the severity ofknee osteoarthritis as assessed radiographically5. Among these,quadriceps weakness may be the most amenable to treatmentfor the prevention of knee OA.

Treatment options in OA knee may be classified asnonpharmacologic, pharmacologic, or surgical. Given theirrelatively low toxicity and cost, nonpharmacological strategies(such as physical therapy, including exercise) are recommendedas the first-line treatment for the knee OA6. The primary goals ofphysical therapy are to reduce pain and decrease disability7.Physical therapy encompasses a variety of treatment modalitiesfor knee OA, including manual joint mobilization, exerciseprescriptions, hydrotherapy, massage, knee tapping, kneebraces, and shoe insole. Numerous studies have documentedthe symptomatic benefits of isometric exercise for individualswith knee OA.6,8,9,10 Functional ability requires movement of thejoint over a functional range. Isometric resistance trainingimproves muscle strength only at joint angle at which the trainingtakes place11,12, this specificity of training principle may limit howmuch isometric training can affect performance of functional taskthat requires joint movement beyond the joint angle prescribedin the isometric training. A possible advantage of isometrictraining may be that it does not stress the joint over a functionalrange of motion. Reduced joint movement may result in lesspain during and after the resistance training.

In contrast, dynamic resistance training in non-OA subjectsimproves the strength of the trained muscle over the entire rangeof motion(ROM). It has been reported that dynamic resistancetraining correlates with improve knee strength, increasedneuromuscular performance on selected functional tasks.Although, dynamic resistance training improves strengths andfunctioning over the training ROM, the joint is being loaded whileit is moved, which may result in pain in OA patients.

Since strength training affects the outcome of OA knee,thus this study aims to assess the effect of short term multipleangle isometric resistance training and dynamic resistancetraining on pain and function among adults with OA knee.

MethodThe study was conducted using pretest post test

experimental design at Ortho & Physiotherapy OPD, RohilkhandMedical College, Bareilly on 60 subjects who were randomlydivided into two equal groups. A total of sixty, both male(n=33)and female(n=27) patients were included in the study. Thecriteria for inclusion were: pain in and around knee; radiologicalevidence of primary osteoarthritis with grade II, III on Kellgrane-Larance scale13; age between 50 -75 years; unilateral or bilateralinvolvement, in case of bilateral more symptomatic knee wasincluded. Subjects were excluded if they had any deformity ofknee, hip, or back, limitation in knee range of motion, history ofbony or soft tissue injury to knee joint, backache with radiatingpain to leg, any central or peripheral nervous systeminvolvement, received steroid or intra articular injection within

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previous six months, systemic inflammatory disease e. g. gout,rheumatoid arthritis, ankylosing spondylitis, had metallic implant,uncooperative patients or mentally unstable. Patient takingnon-steroidal anti- inflammatory drugs had been on stable doseover the last two weeks.Procedure

After screening for inclusion and exclusion criteria thesubjects were randomly assigned into two groups with 30subjects in each group and informed consent was obtained fromthe subjects. Randomization was done by permuted blockrandomization. Intervention

All the subjects received hot pack at the affected knee jointand resistance training exercises according to their respectivegroups. The intervention was given for three weeks (3 days/week). Hot packs were given after the exercise session withpatient in supine lying.Group A: hot packs with multiple angle isometric resistancetraining at 30 , 60 and 90 degree of knee flexion.Group B: hot packs with dynamic resistance training.The outcome measurements in this study were isometric kneeextensor strength at 30 , 60 and 90 degree of flexion, reducedWOMAC14 score and VAS15 score.Measurement of isometric strength

The isometric strength of quadriceps femoris was measuredby using a strain gauge at baseline (before intervention) andrecorded as ISO01, ISO02, ISO03 and at the end of interventionrecorded as ISO31, ISO32, ISO33 for isometric strength at 30,60, 90 degree of knee flexion respectively. During the testingsubjects were made to sit on quadriceps table with knee joint at30 , 60 and 90 degree of flexion .thigh was stabilized with belts;the shin pad was adjusted at 5.1 cms (2 inches) superior to themedial malleolus. The fulcrum of the lever arm was aligned withthe most distal part of lateral epicondyles of the femur. The straingauge was attached to the distal end of the quadriceps tablearm.

Subjects were given verbal encouragement in order tomotivate to attain maximum effort during the 5 secondscontraction. Each test included 3 consecutive trials with 30seconds rest in between the trials. The mean of 3 readings wasused for the purpose of analysis.Measurement of functional score

The functional score was assessed by using reducedWOMAC scale. The reading were taken at baseline (beforeintervention) and after the end of three weeks and marked asWOMAC0 and WOMAC3 respectively.Measurement of pain intensity

Pain was assessed using a horizontal analog scale. The

reading were taken at the baseline and at the end of interventionand marked as VAS0 and VAS3 respectively.

Data analysisA pre-post experimental (parallel group) study was used

for the study. Data was analyzed using the SPSS 15 software.Paired t-test was used for comparison of strength with the groups.Independent t-test was used to compare the strength betweenthe groups, the values of both of the two groups i.e. group A andGroup B were compared at baseline and post intervention. Thetest was applied at 95% confidence interval. The results weretaken to be significant if p<0.05.

ResultsWithin group analysis in Group A and B revealed that there

was a statistically significant difference (p<0.05) in isometricstrength of quadriceps at 30, 60, and 90 degrees of knee flexionafter 3 weeks of training, when compared to the baseline values.The mean improvements in isometric strength in Group A at 30o

was 3.34±1.06; at 60o was 4.12±1.52 and at 90o was 3.55±1.06.Within Group B the mean improvements in isometric strength at30o was 3.75±1.47; at 60o was 4.51±1.32 and at 90o was3.71±1.29. (Table. 1)

Both Group A and B showed a statistically significantdifference (p<0.05) in VAS Score after 3 weeks of training whencompared with baseline values. The mean improvements in VASScore was 4.3±1.6 in Group A and 4.36±1.56 in Group B.(Table.2).

Within group analysis in both groups revealed that therewas a statistically significant difference (p<0.05) in WOMACScore after 3 weeks of training when compared with baselinevalues. The mean improvement in WOMAC Score was11.4±4.15in Group A and 12.33±4.08 in Group B .(Table. 3)

DiscussionThis study provides important information about the efficacy

of Dynamic resistance training and Multiple angle isometricresistance training on quadriceps strengthening in OA patients.Both the two groups showed a significant reduction in pain,improvement in isometric strength of quadriceps, andimprovement in functional index scale from their base line values.But when compared between the groups, there was no significantdifference observed. Thus, the old idea that isometric exerciseis the only correct exercise for people with arthritis is challengedby this study.

Table 3 : Within group analysis of WOMACPre TestMean±SD Post TestMean±SD t p

Group A 20.73±3.75 9.33±2.76 10.68 <.05Group B 22.67±3.79 10.33±3.73 11.7 <.05

Table 1 : Isometric strength of quadriceps at 30, 60, and 90 degrees of knee flexion after 3 weeks of training.Knee Flexion Pre TestMean±SD Post TestMean±SD t value p value

Group A At 300 5.01±1.71 8.34±2.31 -12.19 <.05At 600 6.25±2.07 10.37±2.89 -10.45 <.05At 900 5.66±1.98 9.21±2.39 -12.93 <.05

Group B At 300 4.70±1.26 8.46±1.53 -9.87 <.05At 600 6.12±1.47 10.63±1.76 -10.12 <.05At 900 5.50±1.44 9.22±1.59 -11.07 <.05

Table 2 : Within group analysis of VAS ScoresPre TestMean±SD Post TestMean±SD t p

Group A 6.84±1.17 2.57±1.11 10.32 <.05Group B 6.83±1.38 2.47±1.39 10.89 <.05

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The results of the resistance training tested in the currentstudy appear to have a greater percentage impact on improvingactual functional measures and reducing pain than previousexercise interventions. The Fitness Arthritis and Seniors Trial16

reported a modest 8%to 10% improvement in pain andfunctioning scores as a result of 18 months of aerobic orresistance exercise among their sample of knee OA patients.This modest, although signiûcant, effect of a long-term exerciseprogram, which included resistance training, was also reportedby Rogind et al17. Even the previously cited reviews10,18 of theliterature indicated that exercise seems to have a small tomoderate effect on joint pain and functional outcome measureswith a more moderate effect on self-perceived measures offunctioning. Our ûndings suggest that resistance traininginterventions reduced pain and increased functional abilitysimilarly or to a greater extent than the previously studiedinterventions and that too in a lesser duration. This may bepossibly due to the fact that, the present interventions wereprimarily resistance training and may have required a higherintensity of training than the previous studies. The results of thisstudy support the efficacy of resistance training program inmanagement of OA patients, which is in agreement with variousother studies which support that activities involving strengtheningof quadriceps are helpful in the management of OA kneepatients19.

Several investigators20,21have reported declines in thesensorimotor function of the quadriceps (proprioception) amongknee OA patients. This decline may be a primary factorcontributing to the development and progression of knee OA22.If proprioception is impaired, the timing of the eccentriccontraction of the quadriceps during weight-bearing activitieswill be clumsy, thus resulting in higher impact and impulsiveloads being transmitted through the joint23. These higher loadsbeing transmitted through the knee joint will lead to microtraumato the articular cartilage and/or the subchondral bone, whichare characteristics of knee OA24. A hypothesized outcome ofresistance training of the leg is an increased sensitivity in thesensorimotor structures of the quadriceps including the musclespindles and Golgi tendons25. Resistance training has beenshown to increase the alpha motor discharge or tone of themuscles trained. This alpha motor neuron activity is reciprocallyinfluenced by muscle spindles and Golgi complex within themuscles. Thus, regular resistance training may lower the impactand impulsive loads through the knee joint not by only increasingthe strength of the muscle surrounding the knee joint but alsoby increasing sensitivity and coordination of the proprioceptorswithin the quadriceps muscle26.

Pain is a major factor to the disability in the patients withosteoarthritis knee. Hence, reduction in pain can explain aconcomitant improvement in the functional status of the patients.Disability in OA is due not only to the arthritis but also to theinactivity associated with the disease and with aging. It hasbeen postulated that resistance training increases the hyaluronlevels in the OA knee patients. With repeated muscle contractionthere occurs a synovial cell stimulation which is responsible foractivating hyaluron synthesis. This viscous hyaluron is muchsuited to joint lubrication and thus help in alleviating pain. Thusit can be the factor that could have lead to a reduction in painafter resistance training.

References1. Felson DT, Naimark A, Anderson J, KazisL, Castelli

W,Meenan RF. The prevalence of knee osteoarthritis inthe elderly. The Framingham Osteoarthritis Study. ArthritisRheum 1987; 30: 914-8.

2. Lawrence JS, Bremner JM, Bier F. Osteo-arthrosis:prevalence in the population and relationship betweensymptoms and x-ray changes. Ann Rheum Dis 1966; 25:1-24.

3. Rejeski WJ, Craven T, Ettinger WH Jr, McFarlane M,Shumaker SJ. Self-efûcacy and pain in disability withosteoarthritis of the knee. Gerontol B Psychol Sci Soc Sci1996; 51: 24-9.

4. Mao-Hsiung Huang, Rei-Cheng Yang, Chia-Ling Lee, Tien-Wen Chen, And Ming-Cheng Wang. Preliminary Results ofIntegrated Therapy for Patients With Knee Osteoarthritis.Arthritis Care & Research 2005; 53(6): 812–20.

5. McAlindon T E, Cooper C , Kirwan J R , Dieppe P A ,Determinants of disability in osteoarthritis of the knee.Annals of the Rheumatic Diseases 1993; 52: 258-262.

6. Jordan K, N Arden, et al. EULAR recommendations 2003:An evidence based approach to the management of kneeOsteoarthritis: report of a task force of the StandingCommittee for International Clinical Studies IncludingTherapeutic Trials (ESCISIT). Ann Rheum Dis 2003; 62:1145-1155.

7. Vogels E, Hendriks H, Vanbar M et al. Clinical practiceguidelines for physical therapist in patients with OA of thehip or knee. Royal Dutch society for physical therapy, 2003.

8. Alan E. Mikesky, Steven A. Mazzuca, Kenneth D. Brandt,Susan M. Perkins, Teresa Damush and Kathleen A L.Effects of Strength Training on the Incidence andProgression of Knee Osteoarthritis, Arthritis & Rheumatism2006; 55(5): 690-699.

9. Gail D D, Stephen C A et al, Physical Therapy TreatmentEffective For Osteoarthritis Of The Knee: RandomizedComparison Of Supervised Clinical Exercise And ManualTherapy Procedures Versus A Home Based ExerciseProgram. Physical Therapy 2005; 85: 1301-1317.

10. Robert J Petrella, Is exercise effective treatment ofosteoarthritis of the knee?, Br J Sports Med 2000;34:326-331.

11. K Kubo, K. Ohgo et al, Effects of isometric training atdifferent knee angles on the muscle tendon complex in vivo.Scand J Med Sci Sports 2006; (16): 159-167

12. Jonathan PF, Hawker K, Leach B, Little T, Jones DA.Strength training: Isometric training at a range of joint anglesversus dynamic training. J Sports Sci 2005; 23: 817-824.

13. Kellgren JH, Lawrence JS. Radiological assessment ofosteoarthrosis. Ann Rheum Dis 1957; 16: 494-501.

14. Whitehouse SL, Lingard EA, Katz JN, Learmonth ID.Development and testing of a reduced WOMAC functionscale. J Bone Joint Surg Br 2003;85:706–11.

15. Donald, Buckingham et al. The validation of visual analogscale for chronic and experimental pain. Pain 1983; 17,45-56.

16. Ettinger WH Jr, Burns R, Messier SP, et al. A randomizedtrial comparing aerobic exercise and resistance exercisewith a health education program in older adults with kneeosteoarthritis. The Fitness Arthritis and Seniors Trial (FAST).JAMA 1997;227:25-31.

17. Rogind H, Bibow-Nielson B, Jensen B, Moller H, Frimodt-Moller H, Bliddal H. The effect of a physical training programon patients with osteoarthritis of the knees. Arch Phys MedRehabil 1998;79: 1421-7.

18. Van Baar ME, Assendelft W, Dekker J, Oostendorp R,Bijlsma J. Effectiveness of exercise therapy in patients withosteoarthritis of the hip or knee. Arthritis Rheum1999;42:1361-9.

19. A Pendleton, N Arden,M Dougados,M Doherty, BBannwarth, et al, EULAR recommendations for themanagement of knee Osteoarthritis: report of a task forceof the Standing Committee for International Clinical StudiesIncluding Therapeutic Trials (ESCISIT), Ann Rheum Dis,2000;59:936–944.

20. Koralewicz LM, Engh GA. Comparison of proprioception inarthritic and age-matched normal knees. J Bone Joint SurgAm 2000;82:1582-8.

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21. Barrett DS, Cobb AG, Bentley G. Joint proprioception innormal, osteoarthritic and replaced knees. J Bone JointSurg Br 1991;73: 53-5.

22. Hurley MV. Quadriceps weakness in osteoarthritis. CurrOpin Rheumatol 1998;10:246-50.

23. Radin EL, Martin B, Caterson B, Boyd R, Goodwin JJ.Effects of mechanical loading on tissues of the rabbit knee.J Orthop Res 1984;2:221-34.

24. Radin EL, Yang KH, Riegger C, Kish VL, O’Connor M.Relationship between lower limb dynamics and knee jointpain. J Orthop Res 1991;9:398-405.

25. Hutton RS, Atwater SW. Acute and chronic adaptations ofmuscle proprioceptors in response to increased use. SportsMed 1992;14: 406-21.

26. Hakkinen K, Kallinen M, Izquierdo M, et al. Changes inagonist-antagonist EMG, muscle CSA and force duringresistance training in middle-aged and older people. J ApplPhysiol 1998;84:1341-9.

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Multimodal therapy in cervicogenic headache- a randomizedcontrolled trialAkanksha Sharma*, Unaise Abdul Hameed*, Shalini Grover***MPT Student, Faridabad Institue of Technology, Faridabad. *Assistant Professor, DTHS, MREI, **Assistant Professor, DTHS,MREI.

Abstract

Study designThe study was a randomized controlled trial. This study

was reviewed and approved by the research review committeeat Faridabad Institute of Technology. (Faridabad)

Aims and objectivesTo determine the effectiveness of multimodal therapy that

is a combination therapy including cervical mobilization andexercise therapy in patients with cervicogenic headache.

Summary of background dataThere is lack of quality of Randomized Controlled Trials

analyzing the combined use of cervical mobilization as well asexercise therapy intervention although there is evidencesuggesting that multimodal treatment therapy is superior for neckdisorders Moreover much of the research on cervicogenicheadache has concentrated on the use of spinal manipulationtechniques alone as well as in combination with other modalitiesbut the use of vertebral mobilization techniques along withexercise therapy in the form of multimodal therapy have certainlybeen ignored.

MethodsIn this study 27 subjects who met the inclusion criteria were

randomized into three groups- multimodal therapy, exercisetherapy and control group. The primary Outcome measures wereHeadache Frequency, Intensity and Duration. Secondaryoutcome measures were – Neck Disability Index Score andPerformance Index of Deep Neck Flexors.

ResultsThe results of the study demonstrates that patients with

cervicogenic headache receiving multimodal therapyexperienced a significantly greater improvement in HeadacheFrequency, Intensity, Duration, Neck Disability and PerformanceIndex of Deep Neck Flexors when compared to exercise therapygroup as well as control group. Also exercise therapy alone alsoresulted in significant improvement across all outcomes; howeverthe level of significance is less than multimodal therapy group.Moreover the control group did not demonstrate significantimprovement across all outcomes at all level of comparison withrespect to time.

ConclusionMultimodal therapy is significantly more effective than

exercise therapy as well as control intervention in patients withcervicogenic headache.

IntroductionHeadaches which are believed to originate from structures

in the neck have been given various names, ranging from broad

terms such as “cervical”, “occipital” and “cervicogenic to specificterms such as third nerve occipital headache1 .The prevalenceof cervicogenic headache in the general population is estimatedto be 0.4% – 2.5%, but is as high as 20% in patients with chronicheadache. The mean age of patients with this condition is 42.9years and it is four times more prevalent in women2.

The World Cervicogenic Headache Society3 has definedcervicogenic headache as referred pain perceived in any partof the head and caused by a primary nociceptive source in themusculoskeletal tissues that are innervated by the cervicalnerves.

Cervicogenic headache arises primarily frommusculoskeletal dysfunction in the upper three cervicalsegments4. The pathway by which pain originating in the neckcan be referred to the head is the trigeminocervical nucleus,which descends in the spinal cord to the level of C3/4, and is inanatomical and functional continuity with the dorsal gray columnsof these spinal segments. Hence, input via sensory afferentsprincipally from any of the upper three cervical nerve roots maymistakenly be perceived as pain in the head, a concept knownas convergence5.

The location of symptoms is usually unilateral and doesnot change sides; they begin in the neck and spread to the head.Pain can range from a dull, deep ache to a heavy pressure ofmoderate or severe 6, 1. Cervicogenic headaches may be present

upon waking or can begin or worsen in intensity as the daygoes on, especially with sustained neck postures or movements.While this type of headache can begin at any age, it oftenincreases in frequency and intensity over a period of years andmay or may not accompany a history of neck trauma or cervicaljoint degenerative disease6.

The most effective form of treatment for cervical headachehas not been established, but a variety of invasive andnoninvasive treatments have been reported. Many authors havereported the effectiveness of manual therapy in reducing oralleviating headache but little attention has been afforded to themuscle system, although muscle impairments are listed as acharacteristic of cervicogenic headache7 and specific deficits inwhat can be identified as muscle control of the region have beenidentified8.9. Moreover very few studies have incorporated thecombined use of manual as well as exercise therapy in form ofmultimodal therapy10, 11, 6 although there is evidence to suggestthat multimodal therapy is superior for neck disorders 12.

It should be noted that, out of these aforementioned studies,study by Beeton K., Jull G.11 and Shannon M. Peterson 6 is asingle case study with one subject so the results cannot begeneralized to the entire cervicogenic headache population. Thework of Jull et al.10 provides the highest level of evidenceregarding the impact of the combined program or multimodaltherapy, but there is lack of more of such kind of evidence tomake definitive recommendations about the effectiveness ofmultimodal therapy to the cervicogenic headache population.

So the present study aims to fulfill the gap in literatureregarding the use of multimodal therapy including cervical spinemobilization as well as exercise therapy interventions in patientswith cervicogenic headache.

MethodsThe study was a randomized controlled trial. Under

convenience sampling, subjects were recruited from the

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physiotherapy department of Bhagwan Mahavir Hospital (Delhi).The subjects were screened using a screening form relevant tothe inclusion and exclusion criteria. Those who fulfilled thesymptomatic criteria underwent a physical examination ofcervical spine, which included manual palpation of upper cervicaljoints relevant to the inclusion criteria. Qualifying subjects werethen randomly allocated to one of the three groups- group A(Multimodal therapy group), group B (Exercise therapy group)and group C (Control group) by simple random sampling. 9subjects in each group completed the treatment.

Inclusion criteria -: 1) Age -20-50 years. 2) Unilateral orunilateral dominant side headache associated with the neck painwhich may project to the forehead, orbital region, temples, vertex,or ears. 3) Headache frequency of at least 1 per week over aperiod of 2 months to 5 years. 4) Pain precipitated or aggravatedby specific neck movements or sustained neck posture. 5)Resistance to or limitation of active and passive (accessory orphysiological) neck movements in the upper cervical spineocciput, and/or palpable tenderness. 7) All subjects fulfilled thefirst four criteria and had at least one component of fifth criterion.8) Sufficient English language skills to complete thequestionnaire.

Exclusion criteria-:1) Subjects with bilateral headaches. 2)Subjects with features suggestive of migraine. 3) Subjects withconditions or diseases which are contraindicated for mobilizationtreatment: Paget’s disease, rheumatoid arthritis, ankylosingspondylitis, spondylolistheses, cervical fractures, osteoporosis,osteomyelitis, malignancy, pregnancy, and spinal cordsyndromes. 4) Subjects with radicular signs and symptoms intothe upper limbs or exhibited a positive vertebral artery test duringthe screening evaluation. 5) Subjects with hypermobility ofcervical spine.Interventions

Group A (Multimodal therapy group ) received cervical spinemobilization , exercise therapy intervention including low loadexercise regimen and active ROM exercises of cervical spineand postural correction intervention , Group B (exercise therapygroup) group received low load exercise regimen , active ROMexercises of cervical spine and postural correction interventionand Group C (Control group) received postural correctionintervention only.(1) Cervical spine mobilization- Treatment consisted of

mobilization techniques to the limited and painful segmentfound on passive accessory and physiological testing. Thesubjects were given cervical spine mobilization (postero-anterior central vertebral pressure) as described byMaitland13.

Fig.1: Postero-anterior central vertebral pressure

jerky craniocervical flexion movement.Training commenced at the target level that the subject

could achieve with a correct movement of craniocervical flexion.They were then trained to be able to sustain progressivelyincreasing ranges of craniocervical flexion using feedback fromthe pressure sensor, which was placed behind the neck. Foreach target level, the contraction duration is increased to 10seconds, and the subject was trained to perform 10 repetitions.At that stage, the exercise was progressed to train at the nexttarget level.Fig. 2: Training the craniocervical action with the use offeedback pressure biofeedback

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(2)Low load exercise regimen-This program used low-loadendurance exercises to train muscle control of cervicoscapularregion14. The subject were guided by the feedback from thepressure sensor to sequentially reach 5 pressure targets in 2–mm Hg increments from a baseline of 20 mm Hg to the finallevel of 30 mm Hg. Subjects were instructed to “gently nod theirhead as though they were saying ‘yes’.” The physical therapistthen identified the target level that the subject could hold steadilyfor 10 seconds without resorting to retraction, and without a quick,

(3)Active range of motion exercise included cervical spineflexion, extension, side flexion and rotation. The subjects wereadvised to perform 10 repetitions of each exercise twice a day.

(4) Postural correction intervention included training to sitin an upright neutral posture while gently retracting and adductingtheir scapula. Training of neck flexors and scapular muscleswas also incorporated in postural correction interventionperformed with 10 repetitions twice daily. Exercises which wereincluded are upper cervical flexion in supine as well as sitting,cervical rotation in sitting ,lower trapezius exercise in prone andfacing wall, arm slide and scapula adduction.

Treatment was given three times per week for four weeks,for a minimum of eight and maximum of twelve sessions.Outcome measures-:

The primary outcome measures were -:(a) Change inheadache frequency was recorded as the number of headachedays in the past week, (b) Change in headache intensity wasrated on a Visual analogue scale (VAS) ,(c) Headache durationwas the average number of hours that headaches lasted in thepast week.

The secondary outcome measures were-: (a) Disability (asmeasured by Neck disability index\NDI). (b) Performance indexof deep neck flexors was calculated using craniocervical flexiontest.

Statistical analysisReadings of the variables taken at the baseline and at the

end of first , second , third and fourth week were analyzed forintragroup differences using repeated measure ANOVA andpaired samples t-test with Bonferroni correction. Intergroupdifferences were analyzed using one way ANOVA.

For intergroup differences result was considered significantif p value d” 0.05 and for intragroup differences result wasconsidered significant if p-valued”0.01.

ResultsAnalysis of headache frequency between group A and B at

baseline, at the end of 1,2, 3 and 4 week suggested that therewas no significant difference between the group. Analysis ofheadache frequency between group B and C suggested thatthere was no significant difference between the group. Analysisof headache frequency between group C and A at baselinesuggested that there was no significant difference between the

11

group at the baseline and at the end of 1st, 2nd week but significantdifference was found at the 3rd ( p=0.05) and 4thweek (p=0.011)

Analysis of VAS scores between group A and B at baseline, at the end of 1st,2nd, 3rd and 4th week suggested that there wasno significant difference between the group at the baseline butsignificant difference was found at the end of 1st(p=0) 2nd (p=0),3rd

(p=0) and 4th(p=0) week. Analysis of VAS scores between groupB and C suggested that there was no significant differencebetween the group at the baseline and at the end of 1st week at2nd ,3rd and 4th week. Analysis of VAS scores between group Cand group A suggested that there was no significant differencebetween the group at the baseline but significant differencewas found at the end of 1st(p=0), 2nd(p=0), 3rd (p=0)and 4th

(p=0)week.Analysis of headache duration between group A and B at

baseline , at the end of 1,2, 3 and 4 week suggested that therewas no significant difference between the group at the baseline,but significant difference was found at the end of 1st(p=0.019),2nd( p=0.007) , 3rd (p=0.001) and 4th(p=0.001) week. Analysis ofheadache duration between group B and C suggested that therewas no significant difference between the group at the baselineand at the end of 1st, 2nd,3rd and 4th Analysis of headache durationbetween group C and group A suggested that there was nosignificant difference between the group at the baseline , at theend of 1st, 2nd week but significant difference was found at theend of3rd(p=0.001) and 4th(p=0.001) week .

Analysis of NDI scores between group A and B at baseline, at the end of 1,2, 3 and 4 week suggested that there was nosignificant difference between the group at the baseline, butsignificant difference was found at the end of 1st(p=0) 2nd

(p=0),3rd(p=0) and 4th (p=0)week. Analysis of NDI scoresbetween group B and C suggested that there was no significantdifference between the group at the baseline and at the end of1st week at 2nd, 3rd and 4th week. Analysis of NDI scores betweengroup C and group A suggested that there was no significantdifference between the group at the baseline but significantdifference was found at the end of 1st (P=0), 2nd (p=0), 3rd(p=0)and 4th (p=0)week.

Analysis of performance index of deep neck flexors betweengroup A and B at baseline, at the end of 1,2, 3 and 4 weeksuggested that there was no significant difference between the

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group at the baseline but significant difference was found at 1st

(p=0), 2nd (p=0) ,3rd (p=0)and 4th (p=0)week. Analysis ofperformance index of deep neck flexors between group B andC suggested that there was no significant difference betweenthe group at the baseline but significant difference was found at1st (p=0.003), 2nd (p=0), 3rd (p=0) and 4th(p=0) week. Analysis ofperformance index of deep neck flexors between group C andGroup A suggested that there was no significant differencebetween the group at the baseline, but significant differencewas found at the end of 1st (p=0) ,2nd (p=0),3rd (p=0)and 4th (p=0)week.

Fig. 5: Comparison of mean values of headache duration frombaseline to 4thweek.

Fig. 6: Comparison of mean values of NDI scores from baselineto 4th week.

Fig. 7: Comparison of mean values of performance of deepneck flexors from baseline to 4th week

Fig. 8: Percentage of improvement in all outcome measuresacross all three groups.

Fig. 3: Comparison of mean values of headache frequencyfrom baseline to 4th week.

Fig. 4: Comparison of mean values of headache intensity frombaseline to 4th week.

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DiscussionThe results of the study demonstrates that patients with

cervicogenic headache receiving multimodal therapyexperienced a significantly greater improvement in headachefrequency, intensity, duration, neck disability and performanceindex of deep neck flexors when compared to exercise therapygroup as well as control group. The results of the present studyare in accordance with the studies by Beeton and Jull G11, Jullet al0 and Shannon M. Peterson6.

It is important to understand the underlying mechanisms oftreatment effect, although they were not addressed directly inthe study. Mobilization has been suggested to affect painprocessing at the spinal cord level via a phenomenon known asthe gate control theory, which was first described by Melzackand Wall15 in 1965. Moreover there is research to suggest thatafferent input induced by manual therapy procedures maystimulate neural inhibitory systems at various levels in the spinalcord and may also activate descending inhibitory pathways forexample lateral periaqueductal grey area of midbrain16.

Also worth mentioning is the fact that multimodal therapyaddressed both articular as well as muscular dysfunction whichare characteristics of cervicogenic headache8 thereby resultingin significantly more improvement in multimodal therapy groupthan exercise therapy or control group.

Results of the present study also demonstrated thatexercise therapy alone also resulted in significant improvementacross all outcomes; however the level of significance is lessthan multimodal therapy group. The significant improvement inthe exercise therapy group can be attributed to low load exerciseregimen which was used to train muscle control of cervicoscpularregion. Also the results are in accordance with the single casestudy by Beeton and Jull11, in which the headache log revealedthat the complete resolution of headache at 6 weeks coincidedwith the time frame when DCF training was initiated.

So exercise therapy could be used as an alternative therapyin patients with cervicogenic headache manifesting certain otherconditions which contraindicate the use of cervical spinemobilization.(Example- pregnancy, rheumatoid arthritis,osteoporosis , malignancy etc.).

In the present study although control group did notdemonstrate significant improvement across all outcomes atall level of comparison with respect to time but significantimprovement was still seen in headache frequency , VAS score, headache duration , neck disability index scores as well asperformance index of deep neck flexors. This improvement canbe attributed to the postural correction intervention beingimparted to the group and also to the recovery associated withpassage of time.

An important issue to address is the role of placebo.Placebo effect refers to an improvement in the patients’ condition,which is not directly attributable to the treatment. It is not yetknown why this occurs but without a control group for comparisonit is hard to know if a placebo effect is taking place. Theimprovement may occur because the patient had a “belief” inthe treatment and /or confidence in the practitioner. Theimprovement may also have occurred as a natural course ofthe condition regardless of the intervention. This is an importantconsideration as only the work of Jull et al.10 utilized controlgroup for comparison. The present study too utilized a control

Table 1: Percentage of improvement in all outcome measures across all three groups.Outcome measure Percentage of improvement

A (Multimodal therapy) B (Exercise therapy) C (Control)Headache frequency 56.89% 29..66% 15.69%Headache intensity 83.89% 18.24% 8.0 %Headache duration 60% 26.48% 18.76%Neck disability index score 92.92% 20.62% 12.36%Performance index of 401.27% 311.67% 46.67%deep neck flexors

group to know if placebo effect is taking place or not.The treatment protocol used in the present study included

cervical mobilization and not the manipulation because there isample literature to suggest that there are substantial risksassociated with cervical manipulation such as stroke or death.

The present study describes the multimodal approach forthe management of cervicogenic headache by physical therapist.It is essential that the underlying impairment of decreasedmobility, strength, endurance and postural control to beaddressed while dealing with the subjective complaints of thepatient. A comprehensive treatment approach in the form ofmultimodal therapy addresses all these impairments byemphasizing on restoration of normal joint mobility, strengtheningof postural muscles and postural retraining.

Result may be difficult to generalize to other population inwhich the patient differ from the sample. Also because a feweligible subjects refused to participate in the study, so populationeventually composed of volunteers. Although it does not affectthe validity of the finding it may limit generalizibility to otherpopulation and setting.

Other limiting factors were inability to keep the subject ortherapist unaware intervention being delivered i.e. lack ofblinding, small sample size as well as absence of follow up.

ConclusionThe Conclusion of the study is that the multimodal therapy

that is a combination of cervical spine mobilization and exercisetherapy is significantly more effective than exercise therapy aloneand no treatment in patients with cervicogenic headache.

The results of the study demonstrates that patients withcervicogenic headache receiving multimodal therapyexperienced a significantly greater improvement in headachefrequency, intensity, duration, neck disability and performanceindex of deep neck flexors when compared to exercise therapygroup as well as control group.

References1. Sydney Kim Schoensee, Gail lensen, Garvice Nicholson,

Marilyn Gossman, Charles Katholi: The Effect ofMobilization on Cervical Headaches. JOSPT. 21 (4):184-196, 1995.

2. David M. Biondi, DO .Cervicogenic Headache: A Reviewof Diagnostic and Treatment Strategies, JAOA, 105 (4) ;16-22, April 2005 .

3. World Cervicogenic Headache Society. CervicogenicHeadache Definition. Available at: http: //www. Cervicogenic.com/definit2.html. Accessed: 1998.

4. Bogduk N. Headache and the neck. In: Goadsby P,Silberstein S, editors. Headache. Melbourne, Australia:Butterworth-Heinemann; 1997.

5. Toby Hall, MSc, Post-Grad Dip Manip Ther, Kathy Briffa,PhD, and Diana Hopper, PhDClinical Evaluation ofCervicogenic Headache: A Clinical PerspectiveJ Man ManipTher. 2008; 16(2): 73–80.

6. Shannon M. Petersen, Articular and Muscular Impairmentsin Cervicogenic Headache: A Case Report, J. Orthop SportPhys Ther.2003; 33:21–30.

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7. International Headache Society Classification Committee.Classification and diagnostic criteria for headachedisorders, cranial neuralgias, and facial pain. Cephalalgia1988; 8:9–96.

8. Jull G, Barrett C, Magee R, et al. Further characterizationof muscle dysfunction in cervical headache. Cephalalgia1999; 19:179–85.

9. Watson DH, Trott PH. Cervical headache: An investigationof natural head posture and upper cervical flexor muscleperformance. Cephalalgia 1993; 13: 272–84.

10. Gwendolen Jull, Patricia Trott, Helen Potter et al ARandomized Controlled Trial of Exercise and ManipulativeTherapy for Cervicogenic Headache, SPINE Volume 27,Number 17, pp 1835–1843,2002.

11. Beeton, K., & Jull, G. Effectiveness of manipulativephysiotherapy in the management of cervicogenic

headache: a single case study. Physiotherapy, 80(7), 417-423, 1994.

12. Aker PD, Gross AR, Goldsmith CH, et al. Conservativemanagement of mechanical neck pain: Systematic overviewand meta-analysis. BMJ 1996; 313:1291–6.

13. Geoffary Douglas Maitland. Maitland vertebral manipulation7th edition 2005 p-229-301.

14. Jull G. Management of cervical headache .Manual therapy1997;2(4);182-90.

15. Melzac R, Wall PD. Pain mechanisms: a new theory.Science. 1965; 150:971-979.

16. M. Sterling, G. Jull et al Cervical mobilization: concurrenteffects on pain sympathetic nervous system activity andmotor activity Manual Therapy, volume-6, May 2001, page72-81.

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Combined effectiveness of Maitland’s mobilization and patellartaping in patellofemoral osteoarthritis: A randomised clinical trialAlok Kumar*, Ganesh B. R.***Physiotherapist,**Assistant Professor, KLE’U Institute of Physiotherapy Belgaum, Karnataka

Abstract

Purpose of the studyTo find out the effectiveness of medial and lateral taping

with Maitland’s mobilization in patellofemoral joint osteoarthritis.

Materials & methods60 subjects having clinical diagnosis of osteoarthritis of

patellofemoral joint were randomly allocated to two study groups.Group A received Short wave diathermy (20mins/day), Maitlandmobilization, Isometric exercises, Medial taping using adhesivetape and group B received lateral taping and other treatmentsame as group A for 6 times / week for 2 weeks. The outcomewas assessed in terms of VAS, and Western Ontario andMcMaster University Osteoarthritis Index on first and last day ofintervention.

ResultsThe demographic data was well matched in both the groups.

Pain intensity in terms of VAS and Western Ontario andMcMaster University Osteoarthritis Index decreased significantlyin both the groups after the treatment. Comparing the two groupsbetter effect was seen in group B (p=0.0001)for VAS and(p=0.0001) for WOMAC.

ConclusionThe present study demonstrates evidence to support the

use of physical therapy regimen in the form of medial and lateraltaping along with conservative physical therapy treatment inrelieving pain, well being in subjects with subacute and chronicpatello femoral osteoarthritis. The study also demonstrated thatlateral Taping Technique were more effective in decreasing painand disability.

KeywordsPatellofemoral osteoarthritis, Taping, Maitland Mobilisation,

SWD, Exercises.

IntroductionThe knee joint is one of the most common sites of

involvement because of its weight bearing requirement, highmobility and lack of intrinsic stability. Patellofemoral jointosteoarthritis is one of the most common musculoskeletaldisorder1.

It is reported to affect 15-30% active adult population 21-25% of the adolescents and greater then 25% among the athleticgroup. Incidence reported to be higher in females. It isconsistently reported with the activities such as ascending anddescending stairs, squatting1. Patellofemoral pain in elderlypatient is usually due to degenerative arthritis of the knee joint.Symptoms presented in the patellofemoral arthritis are painaround and anterior to patella, crepitus, giving away of the knee

and episode of patellofemoral instability along with stiffness andswelling2. Extensor mechanism provides stability topatellofemoral joint during physical activity. Tracking is thechange in the position of patella relative to femur during kneeflexion and extension3. Patellofemoral pain syndrome is relatedto abnormalities of extension mechanism. Many authors haveproposed the primary cause of patellofemoral pain syndrome islateral tracking of patella3. Clinically Patellofemoral osteoarthritisdemonstrated squatting, stair ascending and descending, cyclingand sitting with knee flexed or prolonged period of time4.Degenerative changes are usually more prominent in the medialcompartment of the knee, leading to varus (bow leg) deformities5.

Physiotherapy treatment options have been recommendedto relieve pain which includes short wave diathermy, Maitland’smobilisation, isometric exercise and taping etc. Among whichshort wave diathermy plays an important role in pain relief,decrease tissue viscosity and with this muscular and tendinouscontractures. Additionally, the deep heating effect of continuousshort wave diathermy induces an anti-inflammatory response,stimulate connective tissue repair, reduce joint stiffness, musclespasm and pain6.

Maitland’s mobilization is another physiotherapy technique,which involves to reduce pain and stiffness by using variousgrades of mobilization7.

Exercise is another approach in the treatment ofPatellofemoral arthritis, which is targeted to improve thequadriceps muscle strength. Isometric contraction of quadricepsmuscle helps to increase the strength and prevents themaltracking of patella8.

Many studies have shown patellar taping is helpful todecrease pain and improve patellar tracking. Knee taping is oneof the strategy recommended by American College ofRheumatology, based on the theory of patellar maltracking.McConnell has divised a system of treatment for patellofemoralarthritis by taping the patella in medial and lateral direction9.

A study was done on patellofemoral pain syndrome usingthree different methods of taping techniques (Medial, Lateral &Neutral) and found that all three methods of taping produced asignificantly greater degree a pain relief. Further they concludedthat lateral taping is effective in immediate reduction of pain10.

Hence the present study is being undertaken with theintention to compare the combined effectiveness of Maitland’smobilisation and patellar taping in patellofemoral osteoarthritis.

HypothesesNull Hypothesis {Ho}: There will be no beneficial effect to thesubjects treated with Maitland’s mobilization and medial or lateralpatella taping.Alternative Hypothesis {Ha}: There will be beneficial effect tothe subjects treated with Maitland’s mobilization and medial orlateral taping.Objectives of the Study1. To assess the effectiveness of medial taping technique with

Maitland’s mobilization in patellofemoral joint osteoarthritis2. To assess the effectiveness of lateral taping technique with

Maitland’s mobilization in patellofemoral joint osteoarthritis3. To compare the effectiveness of medial and lateral taping

with Maitland’s mobilization in patellofemoral jointosteoarthritis

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Materials and methodsSource of Data: KLES Dr. Prabhakar Kore hospital and MRCand BM Kankanwadi Ayurveda Hospital and MRC Belgaum.

Method of collection of dataStudy Design: Randomised Clinical Trial.Sample Size: 60 Participants.Duration of Data Collection: 9 MonthsParticipants: Both men and women with pain in anteroior kneejoint and radiologically diagnosed as patellofemoral arthritis &who are referred to the physiotherapy OPD, KLES Dr. PrabhakarKore hospital and MRC and BM Kankanwadi Ayurveda HospitalBelgaum.Sampling Methods: Simple random sampling method will beused for this study. 60 participants will be randomly allocatedinto two groups as follows.

Group A: Short wave diathermy + Maitland mobilization +Isometric exercises + Medial taping.30 participants.

Group B: Short wave diathermy + Maitland mobilization +Isometric exercises + Lateral taping: 30 participants.

Materials usedRecord or data collection sheet,Consent form, Wooden

Plinth, Towel, WOMAC, Tape.

Equipment usedShort wave diathermy,[Electrowave 400 Technomed] Made

in India

Inclusion criteria1. Participants with radiological diagnosed as patellofemoral

osteoarthritis.2. Both Men and women > 40 years ofage.3. Average knee pain e” 3 cm on visual analogue scale.4. Those who are willing to participate in the study.

Exclusion criteria1. Concomitant pai n from other knee structures, hip or lumbar

spine. 2. Traumatic injury to the knee joint with in 6 months of study.3. Severe medical condition precluding safe testing or a past

allergic tape reaction.4. Metallic implants in the lower limbs.5. Impaired thermal sensation.

ProcedureAll participants with patellofemoral arthritis who report to

the physiotherapy department will be screened. After findingtheir suitability as per the inclusion and exclusion criteria theywill be requested to participate in the study. A written consentwill be obtained from the participants. Their demographic data,weight, height and initial assessment of VAS score and WOMACwill be recorded. After this 60 participants were randomlyallocated to 2 groups of 30 each.Group A: short wave diathermy, Maitland’s mobilisation,isometric exercises and medial patellar taping.1. Subject will be in sitting/supine position and short wave

diathermy pads will be applied in contraplanar method for20 minutes per day.19

2. Maitland Mobilization: Oscillatory movements are given tothe patella in different directions as required. Patient insupine position and therapist stands by the right side.Medial glide: Pads of the thumb are placed on the lateral

border and push the patella medially.(Photo No.1)

Lateral glide: Pads of the thumb are placed on the medial borderand push the patella laterally.(Photo No. 2)

Superior glide: Place the heel of the hand against inferiormargin of the patella and directs the forearm superiorly.(PhotoNo. 3)

Inferior glide: Place the heel of the hand against superiormargin of the patella and directs the forearm inferiorly.(PhotoNo.4)

[Photograph No.1]

[Photograph No.2]

[Photograph No.3]

[Photograph No.4]

All the four Maitland’s patellar glides will be given to boththe groups (A & B).

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3. Isometric exercises: Static quadriceps exercises will begiven in long sitting/supine position with a towel placedunderneath the popliteal fossa and will instruct the patientto press the rolled towel. Contraction will be maintained for6 seconds and repeated for 10 times with 10 seconds restbetween each repetition.15

4. Medial taping- The patella is displaced medially usingmanual pressure and then maintained in own position bytape across the middle of the patella using light to moderatepressure.

Group B: short wave diathermy, Maitland’s mobilisation,isometric exercise and lateral patellar taping.1. Lateral taping- Same technique is used but the patella is

glided in the lateral direction. Tape will be retained for 24hrs.

2. Rest of the procedure are same as Group A.

Review of litratureAn ultrasonographic study was done to see the effects of

repetitive shortwave diathermy in patients with knee osteoarthritisand indicates that shortwave

diathermy in patients with knee osteoarthritis cansignificantly reduce both synovial thickness and knee pain11.

The current findings and the statistical difference confirmsthat a combination of Maitland mobilization with isometric kneeexercise is more effective than isometric knee exercise indecreasing pain, dysfunction, stiffness and improving thefunctional capacity in patients with Patellofemoral arthritis7.

Comparative study of different patella taping techniques,like medial, neutral and lateral tape showed that medial tape ismore effective in reducing pain in patient with Patellofemoralpain syndrome irrespective of how taping was applied12.

A study was done on patellofemoral osteoarthritis usingthree different methods of taping techniques ( Medial, Lateral &Neutral) and found that all three taping technique produced asignificantly greater degree a pain relief. Further they concludedthat lateral taping is effective in immediate reduction of pain13.

A study was done to determine the efficacy of physicaltherapy and exercises for osteoarthritis of the knee and authorsconcluded that patients with osteoarthritis who are treated witha regimen that combines manual physical therapy with isometricexercise have improved function and less reported pain andstiffness than patients who are not treated with a physical therapyprogram. This type of treatment may decrease the need for kneesurgery14.

Data analysisThe independent variables were SWD, Maitland’s

mobilization, isometric exercises, medial, lateral taping anddependent variables were Pain (VAS) and WOMAC. Analysiswas performed by statistical means, standard deviation andPaired and Unpaired t test is used for comparison within thegroups and between the groups.

ResultsIn the present study, within group analysis showed that pain

relief and WOMAC was statistically significant in the two thegroups (p<0.0001). where as considering in between groupanalysis reviled that Group B (p= 0.0001) was highly significantas compared to Group A.

DiscussionThe present clinical trial was conducted to compare the

effectiveness of medial and lateral patellar taping combinedwith Maitland’s Mobilization with a common treatment ofshortwave diathermy and exercises to the two groups.

The results from the statistical analysis of the present studysupported alternative hypothesis which stated that there will bebeneficial effect to the participants treated with medial and lateralpatellar taping with Maitland’s mobilization. The mean values ofdata from present study indicates that the group B treated withcombination of lateral patella taping with Maitland’s mobilizationshowed better pain relief on visual analogue scale and thephysical function capacity.

Mei Hwa Jan et al attempted a study to quantify thethickness of synovial sac and pain index before and afterapplication of short wave diathermy for patients with kneeosteoarthritis. The result of study showed that the application ofshort wave diathermy in patients with knee osteoarthritis cansignificantly reduce both synovial thickness and kneepain6.Hence in present study it can be postulated that painreduction could be because of short wave diathermy application.

A study showed that patellar taping using a medial glide,neutral glide, and lateral glide technique produced a significantaverage reduction in pain in patients with patellofemoral painsyndrome. Both neutral glide and lateral glide producedsignificantly greater degrees of pain relief than the medial glidetaping technique13.

A clinical analysis study of alignment, pain parameters,common symptoms and functional activity level showed thatthere were no radiographic signs of malalignment of the patella.This strongly supports the previous studies that the success ofpatellar taping is not based upon realignment of the patella13.

The present study demonstrated that the application ofMaitland’s Mobilization had shown significant change in painand physical functional outcome. However, these findings areconsistent with studies conducted in other joints of the bodythat have shown similar effects with the Maitland’s Mobilisationtechniques. Wright in 1995 has postulated that the mechanismsresponsible for manual therapy treatment results in decrease inpain on VAS. The results also showed changes in joint, muscle,pain and motor control systems15.

On the contrary, Maitland’s mobilisation technique wasfound effective in decrease in pain and stiffness. Manipulativetherapy lays stress on treatments to regain both angular andlinear movements. Different grades of mobilization, accordingto Maitland’s concept, will produce selective activation of differentmechanoreceptors. Clinically, resistance due to pain andstiffness melts under mobilization or manipulation16.

WOMAC a self reported measure designed to determinepatients response to three different functional criteria namelythe pain, stiffness and physical function. This could be attributedto frequent complaints of patellofemoral joint stiffness in individualwith patellofemoral pain syndrome as individuals with chronicpatellofemoral pain syndrome often misinterpret chronic painas stiffness17.

Patellofemoral osteoarthritis presents a serious health careproblem and produces a huge burden on society. Simple, safe,physical treatment procedures such as lateral taping combinedwith other simple non invasive interventions such as Maitland’sjoint mobilization could be of great value. This provides a lowcost, easy means of treatment in subjects with Patellofemoralosteoarthritis.

ConclusionIn conclusion, the present randomized clinical trial provided

evidence to support the use of physical therapy regimen in theform of Lateral Patellar Taping and Maitland’s Mobilisation inrelieving pain, stiffness and, functional well being in subjectswith patellofemoral osteoarthritis. In addition, results supportedthat combination therapy is of great value which can be usefulin improving quality of life as patellofemoral osteoarthritis is aheterogeneous condition.

References

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1. Naslund J , Nusland UB, OdenbringS, Lundeberg T.Comparision of Symptoms and Clinical finding in subgroupsof individuals with patellofemoral Pain. PhysiotherapyTheory and Practice 2006;22(3);105-18

2. Cibulka MT, Threlkeld J. Walkens patello femoral pain andasymmetrical Hip Rotations 2005;85(11):1201-7

3. S. Werner, E. Knutsson, E. Eriksson. Effect of patella onconcentric and eccentric torque and EMG of knee extensorand flexor muscles in patients with patellofemoral painsyndrome. Knee surgery, sports traumatol, arthrosocopy;1993; 1:169-177.

4. Aroll B, Ellis Pegler, Edwards A, Sutcliffe G. Patellofemoralpain syndrome. American Journal of the Sport Medicine1997; 25(2) : 207-11.

5. Harrison’s principles of Internal medicine. McGraw HillCompanies. 2005; 16th ed vol.II: 2036-2045.

6. By Mei - Hwa Jan, Huei-Ming Chai, Chung-Li Wang, Yeong-Fwu Lin and Li-Ying Tsai. Effects of repetitive shortwavediathermy for reducing synovitis in patients with kneeosteoarthritis: an ultrasonographic study. Physical therapyjournal, 2006; vol 86(2): 236-244.

7. G.D.Maitland. Peripheral manipulation,3rd edition; 2003:250-55.Butter worth-Heinemann.

8. Key M crossley,Bill vicenzino. Targeted physiotherapy forpatellofemoral joint arthritis. BMC MusculoskeletalDisorders 2008, 9:122doi:10.1186/1471-2474-9-122.

9. G Kelly Fitzgerald and Carol Oatis. Role of Physical Therapyin management of knee osteoarthritis. Current Opinion inRheumatology, 2004; 16:143-147.

10. Tony Wilson, Nicholas carter, Gareth Thomas. A multicenter,single- masked study of medial, neutral and lateral patellar

taping in individuals with patellofemoral pain syndrome.Journal of orthopaedics sports physical therapy; 2003;volume 33(8):437-443.

11. By Mei - Hwa Jan, Huei-Ming Chai, Chung-Li Wang, Yeong-Fwu Lin and Li-Ying Tsai. Effects of repetitive shortwavediathermy for reducing synovitis in patients with kneeosteoarthritis: an ultrasonographic study. Physical therapyjournal, 2006; vol 86(2): 236-244.

12. Ng, G.Y. Cheng, J. M. The effects of patellar taping on painand neuromuscular performance with Patellofemoral painsyndrome. Clinical rehabilitation, 2002 ;16:821-27.

13. Tony Wilson, Nicholas carter, Gareth Thomas. A multicenter,single- masked study of medial, neutral and lateral patellartaping in individuals with patellofemoral pain syndrome.Journal of orthopaedics sports physical therapy; 2003;volume 33(8):437-443.

14. Deyle G D et al. Effectiveness of manual physical therapyand exercise in osteoarthritis of the knee. A randomizedcontrol trial. Ann Intern Med, American Academy of FamilyPhysician 2000; 132: 173-81.

15. Wright A. Hypoalgesia post manipulative therapy: A reviewof the potential neurophysiological mechanism. ManualTherapy 1995;1:6-11.

16. Wyke, B. D: Articular Neurology and Manipulative therapy,R. M. Lincoln Institute of Health Sciences 1980, 67-72.

17. Karrie L, Hamstra WC, Swanik B, Ennis TY, Swanik KA.Joint Stiffness and pain in individuals with patellofemoralpain syndrome; 2005; 35: 495- 501.

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Maximal oxygen consumption as a function of anthropometricprofiling in a group of trained Indian athletesAmrith Pakkala*, Ankita Dutta**, N.Veeranna***, S.B.Kulkarni*****Associate Professor, Dept. of Physiology, PES Institute of Medical Sciences & Research, Kuppam, AP, **Resident, PES Institute ofMedical Sciences & Research, Kuppam, ***Ex-Professor, Dept. of Physiology, Karnataka Institute of Medical Sciences& Research,Hubli, ****Ex-Principal & Head, Dept. of Physiology, Karnataka Institute of Medical Sciences& Research, Hubli

AbstractPhysiologists have been interested in studying

cardiopulmonary responses to physical exercise and measuringwork capacity of healthy individuals as indices of physical fitnessof population groups. The locomotive apparatus and serviceorgans constitute the main part of the total body mass in higheranimals including humans.

This study aims to correlate the distribution of VO2 max inthe study group with various anthropometric parameters like age,height & weight. This gives an idea about the natural distributionwithin the athlete group. Although it is well known that maximaloxygen consumption depends on age and other anthropometricparameters like height, weight and body surface area data onIndian subjects and a profiling on these lines in such studies oncardio-pulmonary efficiency are lacking.

Keywordsanthropometric distribution, VO2 max, athletes

IntroductionHigher animals are basically designed for mobility.

Consequently, their locomotive apparatus and service organsconstitute the main part of the total body mass. An engineeringapproach to view the body would be as a “working machine”1.The human body’s potential performance capability has alwaysfascinated exercise scientists. The shape and dimensions ofthe human skeleton and musculature are such that the humanbody cannot compete with a gazelle in speed or an elephant insturdiness, but in diversity man is indeed outstanding.2

This study aims to correlate the distribution of VO2 max inthe study group with various anthropometric parameters like age,height & weight. Although it is well known that maximal oxygenconsumption depends on age and other anthropometricparameters like height, weight and body surface area data onIndian subjects and a profiling on these lines in such studies oncardio-pulmonary efficiency are lacking. This gives an idea aboutthe natural distribution within the athlete group.

Historical aspectsExercise physiology arose mainly in early Greece and Asia

minor although related topics concerned even earliercivilizations.3

• The greatest influence on Western Civilization came fromGreek Physicians – Herodicus (5th century B.C);Hippocrates (460-377 BC) and Galen (131-201 AD)

• The first formal exercise physiology laboratory wasestablished in the U.S. in 1891 at Harvard university. Georgewells Fitz, played a major role in its establishment4,5

• Austin Flint Jr. in 1877 published a textbook of physiologywhere many topics related to exercise were discussed.

• Per-Olof Astrand from Karolinska Institute Medical Schoolin Stockholm, Sweden in 1954 prepared data on thephysical working capacity of both sexes aged 4 to 33 years.This important study – along with collaborative studies withhis wife Irma Ryhming propelled Astrand to the forefront ofexperimental exercise physiology.

• Sir Joseph Barcroft (1872-1947) – pioneered fundamentalwork concerning the functions of hemoglobin.

• Christian Bohr (1855-1911) – Studied solutioning of gasesin various fluids including Hb solutions.

• Otto Meyerhof (1884-1951) studied energy changes duringcellular respiration.

• Martti J. Karnoven (1991) devised the method to predictoptimal exercise heart rate.

Physical work capacityCompetitive sports events represent the classical test of

physical fitness or performance capacity. The following factorsserve as a frame of reference:• Physical Performance• Energy output

o Aerobic processeso Anaerobic processes

• Neuromuscular functiono Strengtho Technique

• Psychological factorso Motivationo Tactics

All the factors listed above can be modified by training,better techniques and superior equipment2.

Physiologists have been interested in studyingcardiopulmonary responses to physical exercise and measuringwork capacity of healthy individuals as indices of physical fitnessof population groups6.

Cardio-pulmonary EfficiencyIt is well known that athletes who excel in endurance sports

generally have a large capacity for aerobic energy transfer.

Maximal oxygen uptake (VO2 max)The requirement of oxygen by the various tissues of the

body is met by the combined cardiovascular and pulmonarysystems, which function as a unit termed the oxygen transportsystem of the body.

If a person is subjected to progressively increasingworkloads, there is a linear relationship between work load andoxygen uptake until maximal oxygen uptake is reached7.

Maximal oxygen uptake is defined as the highest oxygenuptake the individual can attain during physical work, breathingair at sea level2.

Tests of Maximal Aerobic powerVO2 max is the first choice in measuring to assess a

person’s cardio-respiratory fitness8. It is a fundamental measureof physiologic functional capacity for exercise3, 9, 10.

Criteria for maximal oxygen consumption2 :There are 2 main criteria showing that VO2 max has been

measured:1. There is no further increase in oxygen uptake despite further

increase in work load.

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2. The blood lactate concentration is above 70 to 80 mg/100mlof blood.

Material and methodsThe present study was conducted in the department of

physiology, Karnataka Institute of Medical Sciences, Hubli as apart of cardio-pulmonary efficiency studies on a group of maleathletes (n=30).

Informed consent was obtained and clinical examinationto rule out any underlying disease was done. Healthy youngadult males between 18-25 years who regularly undergo trainingand participate in competitive middle distance (800 metre, 1500metre) running events for at least past 2 years were consideredin the athlete group. Smoking, clinical evidence of anaemia,obesity, involvement of cardio-respiratory system was consideredas exclusion criteria.

Detailed procedure of exercise treadmill test was explainedto the subjects.

Methods of directly assessing aerobic powerThere are three general methods of appraising maximal

oxygen consumption.(i) treadmill (running and walking)(ii) cycling (bicycle ergometer) and(iii) stepping (step bench).

Treadmill methods11:The following are several reliable test procedures:

1. Mitchell, Sproule, Chapman method 12.2. Saltin – Astrand method13

3. Ohio state method8.The manner in which the work load can be increased in

these tests is either discontinuous or continuous. Expired air iscollected in a Douglas bag and analyzed for oxygen content.

Methods of indirectly assessing aerobicpower

Tests for direct assessment of VO2max are limited in thatthe test is difficult, exhausting and often hazardous to performregardless of the type of ergometer used. For this reason, severalmethods for predicting VO2 max from sub maximal exercise datahave been developed.1. Astrand – astrand nomogram14.

This was originally constructed from data gathered onyoung (18 to 30 years), healthy, physical education students,and it is based on the idea that heart rate during sub maximalexercise increases approximately linearly with oxygen uptakeand the nomogram was said to be more accurate if heart ratesbetween 125 and 170 beats per minute were used to makepredictions of max VO2. For subjects older than 25 years, agecorrection factors must be used2. The fox equation 15

This is a simple method for predicting VO2 max in males. Itis based on a linear equation relating the directly measured VO2max to the sub maximal heart rate (HR sub) response.

The equation is :Predicted VO2max (lit/min) = 6.3 - (0.0193 x HR sub)The standard error of the method for prediction of VO2

max from sub maximal exercise test is about 10 percent inrelatively well trained individuals of the same age and whenemployed as a screening test a consistent difference betweenmeasured and predicted maximal oxygen uptake of a few 100ml/min is of no importance.

Predictions from non-exercise data16.

A unique approach to VO2max prediction for quick screeningof large groups of individuals involves collecting specific non-exercise data from a questionnaire.

Data input to predict VO2max1. Sex (Female = 0; Male = 1)2. BMI3. Physical activity rating (PA-R). A point value between 0 and

10 representing overall physical activity level for theprevious 6 months.

4. Perceived functional ability (PFA). Sum of the point valuesbetween 0 and 13 for questions about current level ofperceived functional ability to maintain a continuous paceto cover a distance of 3 miles without becoming breathlessor overly fatigued.

EquationVO2 max (ml/kg/min) =44.895 + (7.042 X sex) – (0.823 X BMI) + (0.738 X PFA) +

(0.688 X PA-R).

Results

C) Weight distribution of athletesWeight (kg) Athletes

No. Percentage46-56 9 3057-66 15 5067-76 6 20Total 30

A) Age Group distribution of Athletes.Age (years) Athletes

No. Percentage18-19 11 36.6720-21 4 13.3322-23 5 16.6724-25 10 33.33Total 30

B) Height distribution of athletes.Height (cm) Athletes

No. Percentage155-165 19 63.33166-175 6 20.00176-185 5 16.67Total 30

E) Cross table of Distribution of VO2 max (lit/min) with Age (Yr)(Athletes)

VO2 Max ) Age (Yrs) of subjects(lit/min 18-19 20-21 22-23 24-252.8 – 3.0 7 1 3 73..01-3.20 2 - 1 13.21-3.40 2 1 - 13.41-3.60 - 2 - -3.61-3.80 - - 1 1

Total = 11+4+5+10=30

D) Participation profile of athletesParticipation status No. PercentageNational / All India 7 23.33Inter universityState / Zonal 14 46.67District / University 9 30Total 30

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G) Cross Table of distribution of VO2 max (lit/min) with body height(cm) AthletesVO2 Max Height (cm) of subjectslit/min 155-165 166-175 176-1852.8-3.0 13 3 23.01-3.20 2 1 13.21-3.40 4 - -3.41-3.60 - 2 -3.61-3.80 - - 2

Total = 19+6+5 = 30

F) Cross table of distribution of VO2 max (lit/min) with bodyweight(kg) (Athletes)VO2 max Weight (Kg) of subjects(lit/min) 46-56 57-66 67-762.80-3.00 8 7 33.01-3.20 1 3 -3.21-3.40 - 4 -3.41-3.60 - 1 13.61-3.80 - - 2

Total = 9 + 15 + 6 = 30

References1) Fox E et al, “The Physiological Basis for Exercise and

Sport”, 1993, 5th Edition, 660 – 67pp.2) Astrand P.O. and Rodahl. K., “Textbook of Work Physiology”

1970, First Edition, 279, 305 – 15, 354 – 59 pp.3) Mc Ardle W.D. et al, “Exercise Physiology” 2001, 5th edition,

231 – 248 pp.4) Gerber E.W., “Innovators and institutions in physical

education,” 1971, Philadelphia: Lea & Febiger.

5) Kroll W, “Perspectives in physical education” 1971, NewYork: Academic Press.

6) Jain A.K. et al, “Cardio respiratory responses to steady statein sedentary men 20 – 30 years old”. Ind J. Chest Dis &Allied Sc 1983; 25: 172 – 185.

7) Mitchell J.H. and Blomqvist G., “Maximal oxygen uptake”.N. Engl J Med 1971; 284: 1018 – 1022

8) Fox E, “Differences in metabolic alterations with sprintversus endurance interval training”. Metabolic Adaptationto prolonged physical Exercise, Basel, Switzerland:Birkhauser Verlag 1975; 119 – 126 pp.

9) Mc Ardle W.D. et al, “Reliability and inter – relationshipsbetween maximal oxygen intake, physical work capacity,and step – test scores in college women.” Med Sci Sport1972; 4: 182.

10) Taylor H.L. et al, “Maximal oxygen intake as an objectivemeasure of the cardio – respiratory performance”. J. ApplPhysiol 1955; 8: 73 – 80.

11) Wilmore J.H., “The assessment of and variation in aerobicpower in world class athletes as related to specific sports.”Am J Sports Med 1984; 12(2) : 120 – 126.

12) Mitchell J et al, “The physiological meaning of the maximaloxygen intake test”. J. Clin Invest 1957; 37: 538 – 547.

13) Saltin B and Astrand P.O., “Maximal oxygen uptake inathletes”. J. Appl Physiol 1967; 23: 353 – 358.

14) Astrand P and Rhyming I, “A nomogram for calculation ofaerobic capacity (physical fitness) from pulse rate duringsub maximal work”. J.Appl Physiol 1954; 7: 218 – 22

15) Fox E, “A simple, accurate technique for predicting maximalaerobic power”. J. Appl Physiol 1973 ; 35 (6) : 914 – 916

16) George J.D. et al, “Non – exercise VO2 max estimation forphysically active college students”. Med Sci Sports Exerc1997; 29: 415.

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Titanic splintB.Anandha Priya*, Snehal Pradip Desai***Occupational Therapist, No.72, Anna Street, Babu Nagar, Pattabiram, Chennai-72, Tamil Nadu, India, **Lecturer, OccupationalTherapy, O.T School &Centre, Seth G. S. Medical College & K. E. M. Hospital, Parel, Mumbai, Maharashtra India

Abstract

ObjectiveTo study the design and effectiveness of the Titanic Splint

to position and maintain the shoulders as well as elbows inantideformity position in bilateral axillary and elbow burns.

MethodTwenty two female clients with acute bilateral axillary and

elbow burns were included in the study. An initial evaluation ofpassive range of motion was done at the time of prescription ofthe splint. The Titanic splint was given to all the clients and theywere followed up for a period of 6 months.

ResultApplication of the Titanic splint for bilateral axillary and elbow

burns is a safe, comfortable, easy way of splintage resulting inbetter compliance and maintenance of range.

IntroductionBurns of the upper extremity result in severe deformities

leading to functional and aesthetic problems. The extent of thedeformity is directly related to the severity of the initial injury.The development of contractures is common sequelae after burninjuries. If a body part is left immobile for a prolonged periodafter injury the skin and the fascia across the part gets contractedalong with capsular contraction and shortening of tendons andmuscle groups. This rapid process can be prevented by aprogram of Active & Passive Range of Motion, anti-deformitypositioning and splinting. Splints are used to maintainantideformity position for joints that are directly or indirectlyaffected by burn injury.

Burns of the upper extremity involving the shoulder, axillaand volar aspect of the elbow may lead to severe contractureswith restrictions of shoulder and elbow movements. The skinand fascia gets contracted along with contractures of the musclesPectoralis Major, Deltoid and Subscapularis.When the lateralpart of the trunk and medial part of the arm have burn wounds,it may heal together leading to loss of axillary space. Axillaryburns often result in limited abduction of arm and present a majorhindrance in rehabilitation. Chronic pain leads the client to adductthe arm in a position closer to the body than normal, and thisallows the contracture to develop more easily. An inability toabduct the shoulder is a disability that greatly hampers everydayactivities.

Whenever there are burns in the volar aspect of the elbow,the skin and fascia of the cubital fossa gets contracted with orwithout contracture of the anterior capsule and Biceps, Brachialisand Brachioradialis muscles. To prevent the above –mentionedproblems, in case of burns in the axilla and elbow, the limb shouldbe positioned with the Shoulder in 90 degrees abduction andelbow in extension. When burns involve both the extremities, allfour joints i.e., bilateral shoulders and bilateral elbows need tobe splinted. Generally, bilateral abduction splints and bilateralelbow guards are prescribed in the above condition. Wearing

all four splints together becomes cumbersome for the client. Atthe same time, donning and doffing of the splints also becomesvery difficult.

Aim of the studyThe aim of the present paper was to study the design and

effectiveness of an innovative splint named TITANIC SPLINT thathelps to position and maintain both the shoulders as well aselbows in antideformity position and which can be used insteadof the conventional splints.

This splint should be given in the early stages of acuteburns before the client starts to lose range of motion at theaffected joints.

Review of literatureMany studies had been conducted on the splinting

techniques for the management of axillary burns. Each studyhas its own merits and demerits. The following are list ofpreviously conducted studies:

*Abhyankar (1) designed a positioning device named“Salute Splint” for positioning the shoulder after contracturerelease of the axilla. The main drawback of the splint is that itcauses unwanted flexion contracture of the shoulder and alsoof the elbow if the volar aspect of the elbow is involved.

*Chown GA (2) designed a “modified high-density foamaeroplane splint” to increase comfort and compliance by theclients and family members, and decreased fabrication time byhealth professionals. Even though the splint has manyadvantages, the clients might feel uncomfortable wearing thesplint if they sustain burns in the lateral aspect of the trunk.Moreover as per the author’s comments, if increased wear timeis desired when the client is upright or ambulating, then atraditional thermoplastic splint may need to be incorporated into the splinting regime.

*Manigandan. C, Gupta. K, Venugopal. K, Ninan.S, Cherian.R. E,

Bedford. E, Padankatti. S, M&Paul. K(3,4,5) designed a“multipurpose, self -adjustable aeroplane splint”, which providesprolonged stretch to contracted tissues and acts as a serial castin increasing the shoulder range. This adjustable aesthetic splintcan hold the arm in as much as 150 –160 degrees of abductionand can be worn inside the client’s regular garment. The demeritof the splint is that it was not designed for treating acute burns.

*Obaidullah, Ullah & Aslam (6) conducted a descriptivestudy on 40 clients who had chronic extensive axillarycontracture. All the clients were treated with simple release andskin grafting followed by “Figure of 8 Sling”. The Figure of 8Sling is widely available and is used for clients with fracture ofthe clavicle. According to the researchers, pre-operatively theshoulder abduction range was 0-80 degrees and postoperativelyat 1 year of follow-up the ranges improved to 0-140-180 degrees.The main demerit of the splint is that, it cannot be used by theclients in their acute stage of burns.

MethodologyThe present study was conducted in Occupational Therapy-

Plastic Surgery Department. The Titanic Splint was given to 22

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female clients with 60-90 degrees of acute burns. Clients whohad bilateral axillary and elbow burns were included in the study.All the clients had a minimum qualification of 10th standard andmost of them were housewives except 2 clients who wereinvolved in clerical job.

All the clients were undergoing regular OccupationalTherapy treatment in the Department. Therapy was focused onimproving joint range of motion and preventing the formation oftightness and contractures. Evaluation of passive range ofmotion was done at the time of prescription of the splint andafter every 2 months duration. The clients were followed up fora period of 6 months.

Materials required for the fabrication of thesplint1. Broad thick aluminum strip2. High Density Thermoplastic-Poly Vinyl Chloride3. Cotton niwar4. Rivets5. Glue6. Ethaflex

Fabrication of the titanic splintThe following are the steps that are involved in the

fabrication of the Titanic splint:

Fabrication of the elbow guard1. The longitudinal distance between the half of the arm and

half of the forearm is taken.2. The circumference of the mid of the arm and mid of the

forearm is taken and half of the measurement is noted.3. The measurement is marked on the high density

polyethylene sheet (Poly Vinyl Chloride-PVC).4. The poly Vinyl Chloride (PVC) sheet is cut according to the

measurement. (Fig: 1)

BC&DE= 5 inch distance from the client’s body.CD=Distance between the two shouldersEF=Distance between 2 inch distal to the leftshoulder joint to mid of left elbow guard.A-F=Total length of the aluminum strip

2. A broad thick aluminum strip is cut based on the A-Fmeasurement (Fig: 3)

5. The cut PVC is molded according to the contour of theclient’s extremity and the edges of the elbow guard aresoftened so that it does not hurt the client (Fig: 2).

To Measure for the aluminum strip1. The client is made to lie in supine position and the elbow

guards are placed on the client’s extremity in position andthe following measurements are taken:

AB=the distance between the mid of the right elbowguard to 2 inch distal to the right shoulder joint

3. The measurements of AB, BC, CD, DE&EF are marked onthe aluminum strip.

4. A 90 degree bend is made at the point B.5. Second 90 degree bend is made at the point C (as shown

in fig: 4).6. The third 90 degree bend is made inwardly at the point D.7. The fourth 90 degree bend is made from the point E (as

shown in fig; 4).

8. Once all the measurements are marked and all the anglesare made, the aluminum strip will be in the design as shownin the figure (4).

Making of the titanic splintThis is the last step and involves attachment of the elbow

guard to the aluminum strip1. Holes are drilled both in the elbow guard and the aluminum

strip as shown in figure (5)

2. The elbow guards are attached to the aluminum strip byriveting.

3. The portion of the elbow guard which comes in contactwith the client’s body surface is padded using Ethaflex.(Note- If the client’s dressing is bulky, there is nonecessary for padding, since the dressing it self protectsthe skin from compression of the elbow guard)

4. Velcros are stitched to the cotton niwar (2 inches in breadth)and the niwar is stuck to the elbow guards as shown in thefigure (6) for harnessing the splint. In final step, the client is

Fig-3: Measurement of the Aluminum Strip

Fig-4:

Fig-6:

Fig-5: Making of the Titanic SplintFig-1:

Fig-2:

Table 1: Outcome with the usage of the splintTotal number of clients 22Number of clients who maintained 19their shoulder & elbow rangesNumber of clients who lost their shoulder 3& elbow ranges

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made to wear the splint, and checked for proper fit andcomfort.

Wearing scheduleClients were required to wear the splint throughout the day

and night with intermittent mobilization during the daytime. Thefamily members were educated about the method of donningand doffing of the splint. The splint should be worn for a periodof 6 months.

Results and discussionCompliance regarding the splint wearing schedule was

verified by verbally questioning the clients and their familymembers. At the end of 6 months, the clients were evaluatedfor their shoulder and elbow ranges.

Among the 22 clients selected for the study, 19 clientsmaintained their shoulder and elbow ranges. Only 3 clients losttheir shoulder and elbow ranges since they had poor complianceof wearing the splint.

Titanic splint – its merits over the restThe following are the advantages of the Titanic Splint over

the conventional splints:1. Single splint replaces the use of four splints (2shoulder

abduction splints and 2 elbow guards)2. Simple design3. Lightweight and cost effective4. Comfortable-The area covered by the Titanic splint is very

less. This helps in easy dressing of the burnt area of thelateral aspect of the trunk.

5. Easy to construct-The time taken for the construction ofthe splint is less (approximately 1-1 1/2 hours)

6. Durable- High Density Thermoplastics are comparativelystronger than Low Density Thermoplastics

7. Easy donning and doffing8. With modification, it can be used to improve the horizontal

abduction range.9. If elbows are not involved in burns the same splint can be

modified to keep the elbows free.

Disadvantages1. Maintains but does not improve the ranges (same as

conventional splint)2. Cannot be prescribed for clients with unilateral burns.

Bent Aluminum strip positioned over the Elbow guard Final fabricated Titanic Splint

ConclusionTo conclude the application of Titanic splint for bilateral

axillary and elbow burns is a safe, comfortable, easy and morecompliant way of splintage. This study used a small conveniencesample from one facility. Further studies have to be done on alarger scale to analyze the results obtained using the splint.

References1. Abhyankar S.V. The salute splint for axillary contractures:

British Journal of Plastic Surgery, 2001, 54(3), 213-5.2. Chown G.A. The high- density foam aeroplane splint: a

modified approach to the treatment of axillary burns. Burns,2006,32 (7), 916-9.

3. Manigandan. C, Gupta A.K, Venugopal. K, Ninan.S &Cherian R.E A multipurpose, self-adjustable aeroplanesplint for the splinting of axillary burns.Burns. 2003, 29,276-9.

4. Manigandan C, Bedford.E, Ninan.S, Gupta.A.K, PadankattiS.M &Paul.K). Adjustable aesthetic aeroplane splint foraxillary burn contractures. Burns, 2005 31(4), 502-4.

5. Manigandan C, Gupta.A.K, Ninan.S & Padankatti.S.M.Re– emphasizing the efficacy of the multipurpose, self –adjustable, aeroplane splint for the splinting of axillaryburns.Burns.2005,31, 500-1.

6. Obaidullah, Ullah. H & Aslam. M . Figure - of - 8 sling forprevention of recurrent axillary contracture after release andskin grafting. Burns, 2005. 31(7), 283-289.

7. Roger L. Simpson & Michael C. Gartner. Management ofburns of the upper extremity. In Hunter – Rehabilitation ofthe hand and upper extremity. Mackin, Callahan, Skirven,Schneider, Osterman, (5th edi.), vol-1, Mosby. 2002.

8. Marlys J.Staley & Reginald L.Richard.Burns. In. PhysicalRehabilitation: Assessment and Treatment. SusanB.O’Sullivan.(4th edi. ), Jaypee Brothers. 2001.

AcknowledgementWe would like to thank Dr. Amrish Baliarsingh Prof. & Head

(former), Plastic Surgery Dept., K. E. M. Hospital, Mumbai forgranting permission for conducting the study.

We would like to extend our sincere thanks to Dr. VinitaPuri, Associate Prof.(former) Plastic Surgery Dept, K.E.M.Hospital, Mumbai for her timely help.

Last but not the least we would like to thank our clients fortheir cooperation.

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Normative data of Jebsen Taylor Hand Function Test [modifiedversion] on Indian PopulationB. Anandha Priya*, Snehal Pradip Desai***Occupational Therapist, ESIC Hospital, K.K.Nagar, Chennai 600078, Tamil Nadu, **Lecturer, OT School & Centre, Seth G.S.Medical College, K.E.M Hospital, Parel, Mumbai 400 012

The functions of the hand are multiple, though the mostimportant are the sensory function of touch and the function ofprehension. The hand has numerous other functions that playessential roles in our lives - functions of expression throughgestures, visceral functions in carrying food to the mouth,emotional and sexual functions in caressing, and aggressivefunction in the form of closed fist for defense, functions relatingto body care and thermoregulatory function.

The ability of a person to use his hands effectively ineveryday activity is dependent upon anatomic integrity, mobility,muscle strength, sensation and coordination. For this reason,hand function should be tested by tasks representative ofeveryday functional activities.

Jebsen taylor hand function testThe Jebsen Taylor Test of Hand Function is a commonly

used standardized test for assessing a person’s functional handuse. It evaluates unilateral hand skills and provides an objectiveassessment of hand function involved in activities of daily living.The test includes a series of seven subtests that provide a broadsampling of hand functions. All the subtests are performed withthe non-dominant hand first followed by the dominant hand.

The seven subtests arei. Writing ( Printing a 24 letter sentence of third grade reading

difficulty )ii. Turning over 3" X 5 “ cards ( Simulated page turning )iii. Picking up small common objects (pennies, paper clips,

bottle caps) and placing them in a container.iv. Simulated feedingv. Stacking checkers (Test for eye-hand coordination)vi. Moving large empty cans (Number 303 cans)vii. Moving large weighted cans (0.45 kg or one pound cans)

Aim of the studyThe aim of the study was to find out the norms of Jebsen

Taylor Hand Function Test (Modified version) on Indianpopulation.

Normative data are available for males and femalesbetween the age group of 20-60 years, for both the dominanthand and the non- dominant hand (1)

Hackel and colleagues (2) provide normative values ofJebsen Taylor Hand Function Test for people aged 60-90 years.Many studies had been conducted to assess the improvementin hand function using the Jebsen Taylor Test for clients withmild to moderate stroke, arthritis, acquired neurological disordersand outcome of tendon transfer in tetraplegia secondary to spinalcord injury, The test has been used with children from 8 years ofage (3, 4).

MethodologySubjects

The test was administered on 300 samples, 30 males and30 females (normal subjects) in each of the following age groups; 20 -29 years, 30-39 years, 40 - 49 years, 50 - 59 years and 60

– 94 years.The samples were from various geographical locations, with

various educational qualifications and various occupations(Farmer, Driver, Student, Housewife, Clerical workers etc.), butwithout any neurological or musculoskeletal problems.

The test was also administered on 30 patients with stablehand disability – post burn contracture hand, Volkman’sischaemic contracture, crush injured hand etc. The mean agewas 33 ±16.5 years.

InstrumentationThe following materials were used in the Jebsen kit:1. Writing (Modified writing)

• Black ball pen• Ruled sheets• 1 clip board with stand• 1 clip board (or) writing board.

2. Simulated page turning• Ivory cards [one side plain and one side marked as

cross].3. Lifting small common objects

• 1 empty can• 2 paper clips• 2 regular sized bottle caps• 2 one rupee coins.

4. Simulated feeding• 5 kidney shaped beans• 1 empty can

5. Stacking checkers• 4 brown colored wooden checkers.

6. Lifting large light objects.• 5 empty cans.

7. Lifting large heavy objects.• 5 heavy cans.

Other materials required• 1 wooden board• 1 stop watch• 1 C clamp

Procedure – scoringVerbal consent was taken from all the subjects who were

included in the study. The sequence of performing the subtestswas explained.

Each subject was seated on a chair of 33" height in frontof a desk of 29" height and 35.5"breadth in a well lighted room.Subtests were administered using verbal instructions.

The tests were performed with the non-dominant hand firstfollowed by the dominant hand. The subtests are scored byrecording the number of seconds required to complete eachtask using a stopwatch. Increased time to complete the subtestsis related to decrease in functional use of hand.

The wooden board was secured to the desk with a “C”clamp, when performing the following subtests – simulatedfeeding, stacking checkers, lifting larger light objects and liftinglarger heavy objects.1. Modified Writing

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The subject is asked to copy the designs that are printedon a paper and fastened to a bookstand .Before administeringthe test; the subject is asked to wear glasses, if needed.2. Simulated Page Turning

The subject is asked to turn the cards over one at a time,as quickly as possible. The cards may be turned in any way asthe subject wishes. Timing is from the word “GO” until the lastcard is turned over.3. Lifting Small Common Objects

In this subtest, the subject is asked to pick up the objectsone at a time and place them in the can. Timing is from theword”GO”until the sound of the last object striking the inside ofthe can is heard.4. Simulated Feeding

The subject is asked to pick up the kidney bean with thefingers and drop it inside the empty can. Timing is from the word“GO” until the last bean is heard hitting the bottom of the can.5. Stacking Checkers

In this test, the subject is asked to stack the checkers onthe board .Timing is from the word “GO” until the fourth checkermakes contact with the third checker.6. Lifting Large Light Objects

This subtest involves placing the empty can on the board.Timing is from the word “GO” until the fifth can has been released.7. Lifting Large Heavy Objects

In this test, the subject is required to place the heavy canson the board. Timing is from the word “GO” until the fifth canhas been released.

Data analysis and resultsData were collected in terms of the total time taken to

complete each subtests with both the hands. Mean and standarddeviation were calculated.

Table -1 shows the mean time taken and standarddeviations for normal subjects for the dominant hand.

Table-2 shows the mean time taken and the standarddeviations for normal subjects for the non- dominant hand.

To evaluate the reliability of test results in a given individual,30 patients with stable hand disabilities were tested on 2occasions. The time interval between the initial evaluation andfinal evaluation was 2 weeks. The data were analyzed byobtaining the Pearson-Product Moment Correlation Coefficient.Most of the components in the dominant hand had significantly

high correlation(r=1). Subtest modified writing had moderatecorrelation(r=0.7).Subtests picking up small common objects andsimulated feeding had low correlation(r=0.5, o.4)

In the non- dominant hand, subtests simulated feeding,lifting large light objects and lifting large heavy objects hadsignificant correlation(r-1). The remaining subtests had very lowcorrelation(r=0.1, 0.5).

Practice Effect- Using the test – retest reliability data on 30patients, a ‘t- test ‘of the difference between the means of thetwo occasions was obtained for each hand and test. All failed toachieve significance at 0.05 level of significance.

DiscussionThe subtests of the original test were modified according

to Indian population. The following modifications were done inthe test.

The subtest writing: consisted of copying a sentence of 24letters and which is of third grade reading difficulty. To administerthe Jebsen Test even on uneducated population “writing thesentence” was modified as “copying the designs.”

The subtest simulated feeding has been modified as pickingup the kidney bean with the fingers and dropping it in the emptycan; as eating with hand is in general practice among Indianpopulation.

Instead of pennies, Indian coins were used in the subtest,picking up of common objects.

It will be noted from the tables 1& 2 that the mean timetaken to complete each subtest was less than 10 seconds exceptfor writing and page turning. . Analysis of the data of the normalsamples revealed significant age and sex differences, the trendbeing that the oldest age group performed all subtests slowerthan the younger age groups. This supports the concept thatthere will be a decline in the normal hand function as ageincreases. Interrater reliability was checked on normal samplesand there was no significant difference between the meanscores.

Education was not a hindrance in performing the test.Uneducated people were also able to copy the designs like theeducated people. Occupation also had an effect on theperformance of the test. Persons having jobs involving finercoordination (Glass cutter, watch repairer etc.) had betterperformance in the following subtests – lifting common objects,stacking checkers and simulated feeding.

Since the non-dominant hand is not used so frequently as

Table 2: Mean time and standard deviations for normal Subjects - Non dominant hand.Factor Males FemalesAge range, years 20 to 59 60 to 94 20 to 59 60 to 94Total no: of Subjects 120 30 120 301 Modified writing 55.9±20.8 84.8±26.1 65.4±37 96.7±19.42 Page turning 9.4±3.3 11.7±3.2 8.4±3 11.5±23 Picking up small common objects 7.7±2.7 9.9±2.2 7±1.7 10.6±1.74 Simulated feeding 5.9±1.1 6.8±1.5 5.6±0.9 7.1±0.45 Stacking checkers 3.7±0.8 5±1.4 3.7±0.8 4.7±0.66 Lifting large light objects 3.7±0.7 4.7±0.7 3.6±0.7 4.8±0.67 Lifting large heavy objects 4.1±0.9 5±0.9 4±0.9 5±0.6

Table 1: Mean time and standard deviations for normal subjects- Dominant hand.Factor Males FemalesAge range, years 20 to 59 60 to 94 20 to 59 60 to 94Total no: of Subjects 120 30 120 301 Modified writing 30.2±1.4 52.7±15.2 37.3±26 58.9±8.22 Page turning 7.9±4.1 10.3±2.9 7.1±2.6 10.6±1.73 Picking up small common objects 6.9±2.5 8.5±2.2 6.3±1.4 9.9±1.64 Simulated feeding 5.3±0.9 6.9±1.4 5.2±0.8 6.6±0.35 Stacking checkers 3.3±0.7 4.5±1.3 3.2±0.7 4.2±0.36 Lifting large light objects 3.4±0.7 4.4±0.7 3.5±0.7 4.6±0.67 Lifting large heavy objects 3.7±0.9 4.6±0.8 3.8±0.7 4.8±0.6

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compared to the dominant hand, the time taken for completionof all the subtests was longer. This was more evident in thesubtest writing.

Certain facts were observed in the patients while performingthe test. Gross motor functions were less affected whencompared to the fine motor functions, in most of the patientswho sustained Median nerve injury, Ulnar nerve injury, combinedUlnar and Median nerve injury, clawing of hand due to any reasonetc.

Patients who had strong long flexor contracture could easilyperform subtests which involved finer coordination as comparedto subtests which involved gross motor coordination.

Stability of the proximal parts and strength of the proximalmuscles are also important in efficient functioning of hand. Thiswas evident while testing a patient with proximal weakness.

ConclusionThe Jebsen Test of Hand Function is reliable, easily

performed and involves tasks that are functionally related. Thetest is easy to administer within a short period of time and thematerials used are also readily available. In the present study,the test is modified according to the Indian situation. The dataobtained can be used to assess the hand functions required foractivities of daily living.

Table 3: Test – Retest Reliability using 30 patients with StableHand Disability Correlation Coefficient

Test Dominant Non dominanthand hand

1 Modified writing 0.7 0.52 Page turning 1 0.13 Picking up small 0.5 0.1

common objects4 Simulated feeding 0.4 15 Stacking checkers 1 0.16 Lifting large light objects 1 17 Lifting large heavy objects 1 1

References

1. Robert et.al. “An objective and standardized Test of Handfunction .Archives of Physical Medicine and Rehabilitation,June,-1969, 50(6), 311-319.

2. Mary E Hackel ,George A Wolfe, Sharon M Bang, Judith SCanfield: Changes in Hand Function in the Aging adult asDetermined by the Jebsen Test of Hand function , PhysicalTherapy , May 1992 , Vol. 72 , No. 5(373-377).

3. Fess, E.E.(2002).Documentation :Essential Elements of anUpper Extremity Assessment Battery. In Hunter- Mackin –Callahan, Rehabilitation of the Hand and upper extremity,Volume- 1, (page No. - 278), Fifth Edition.Philadelphia:Mosby.

4. Virgil Mathiowetz and Julie Bass Haugen.Evaluation ofMotor Behaviour: Traditional and Contemporary views. InTrombly C A., Occupational Therapy for physicaldysfunction, Fourth Edition (Page No.174-175).Philadelphia: Williams Wilkins.

AcknowledgementWe would like to extend our sincere thanks to Dr. R. E.

Rana, Former Head of Plastic Surgery Department and Dr. IndiraR. Kenkre, Former Head of Occupational Therapy Department,Seth G.S. Medical College &K.E.M Hospital for their guidanceand help

We are thankful to Dr. Shashi Oberoi, Head of OccupationalTherapy Department, D.Y .Patil Medical College, Navi Mumbaifor her timely help.

We are thankful to staffs and colleagues of OccupationalTherapy Department, Seth G.S. Medical College forencouragement and support.

Last but not the least; we would like to thank all theparticipants for their cooperation.

B. Anandh Priya M.O.Th / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1

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Effect of 2-week and 4-week wobble board exercise programmefor improving the muscle onset latency and perceived stability inbasketball players with recurrent ankle sprainAS Dinesha*, Arun Prasad B ***Physiotherapy Instructor Medical training Center and Command Hospital Air Force, Bangalore, **Department of Musculoskeletaland Sports Physiotherapy, Padmashree Institute of Physiotherapy, Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka.

CORRESPONDING AUTHOR :Prof. Arun Prasad.BPadmashree Institute of Physiotherapy, #23, Gurukrupa Layout,80 feet road, Nagarabhvi, Bangalore-560072bapganesha@gmail.com (+91 9886172495)

AbstractThis study was carried out to find the effects of 4-week

and 2-week wobble board training in improving of muscle onsetlatency and perceived stability in basketball players diagnosedwith recurrent ankle sprain, as there is decreased muscle onsetlatency of peroneus longus and tibialis anterior muscle andperceived instability following ankle sprains.

DesignDifferent subject experimental – Pre to Post test design.

SettingClinical setting.

ParticipantsTwenty seven male and three female recurrent lateral anklesprain individuals.

Outcome measureSurface EMG of PL (peroneus longus) and TL(tibialisanterior),this was measured during sudden 200 inversion usingtrap door mechanism, AJFAT(ankle joint functional assessmenttool) questionnaire was used to rate each participant’sperception of their ankle stability.

ResultsThe outcome difference of PL latency between Group A (2

weeks) (15.73+_6.01) and Group B(4weeks) (30.20+_6.44)shows a strongly significant difference and effect size is VL (verylarge) i.e.2.26 (p<0.001**).

The outcome difference of TA latency between Group A(21.13+_11.47) and Group B (30.53+_8.48) shows a moderatelysignificant difference and effect size is L (large) i.e.0.91(p<0.016*).

The outcome difference of AJFAT between Group A(9.20+_3.29) and Group B (15.80+_3.45) shows a stronglysignificant difference and effect size is VL (very large) i.e.1.88(p<0.001**).

ConclusionResults demonstrated that the 4-weeks wobble board

exercise programme significantly decreased muscle onsetlatency of the TA and PL in response to a sudden 20° ankleinversion as compared to 2 weeks wobble board exerciseprogramme.

Hence this study concluded that 4 weeks wobble board

exercise was better than 2 weeks wobble board exercise trainingfor improving muscle onset latency and perceived stability inankle sprains.

KeywordsAnkle sprain; Proprioception; Electromyography.

BackgroundAnkle sprains are amongst the most common injuries within

the athletic population with an incidence rate as high as 80%.1

Injury to the most commonly affected lateral ligament complexis a result of a combination of excessive plantar flexion andinversion.2 Furthermore, and of significant concern, is thereoccurrence of ankle sprains reported that as many as 73% ofathletes had recurrent ankle sprains and 59% of these hadsignificant residual symptoms (e.g. pain, weakness, crepitus,instability, swelling, stiffness) that affected their performance.3

These symptoms may be a consequence of residual mechanicalinstability, functional instability, or a combination of both.Mechanical instability involves muscle weakness and joint laxity;however, many people have no mechanical deficit but experiencerecurrent ankle sprains because they have functionally unstableankles (FUAs).4 Functional instability of the ankle defined by asa feeling of giving way in the ankle and redefined as a subjectivecomplaint of weakness often in the absence of mechanicalinstability.5 The pathogenesis of FUAs is complex but is reportedto involve sensorimotor, mechanical, and muscular deficiencies.6

Loss of proprioception, resulting in lack of balance and jointposition sense, is considered to be particularly important.7

Proprioception involves stimulus detection, processing, andthe initiation of a reactive output via the neuromuscular system.7

Konradsen & Ravn, 1997 reported a delay in the onset time ofthe peroneal muscles to a sudden ankle inversion in individualswith a FUA, which may explain why sprain reoccurrence is sofrequent.8 Other studies found no difference in onset latency ofperoneal muscles between individuals with and without FUAs.9

After initial acute treatment a rehabilitation regimen is pivotalin speeding return to activity and preventing chronic instability.In recent military series it was found that lack of rehabilitation ofankle sprains delayed return to duty for several months.Prolonged immobilization after ankle sprains is a common error;functional stress stimulates the incorporation of strongerreplacement collagen. Functional rehabilitation begins on theday of injury and continues until pain-free gait and activity areattained. The four components of rehabilitation are range ofmotion rehabilitation, muscle strengthening exercise,proprioceptive training and activity specific training.15

strengthening of weakened muscles is essential for rapidrecovery and important in preventing injury.16 Exercise shouldfocus on the conditioning of peroneal muscles, because ofinsufficient strength in this muscle group has been associatedwith ankle instability and recurrent injury. Resistance exerciseshould be performed with an emphasis on eccentriccontraction.17 As a patient achieves full weight bearing withoutpain; proprioceptive training is initiated for recovery of balanceand postural control. The simplest device for proprioceptivetraining is wobble board, a small discoid platform attached to ahemisphere base.13 Use of these devices in concert with a series

28

of progressive drills can effectively return patients to a highfunctional level.18,19 A multi station proprioceptive exerciseprogramme can be recommended for prevention andrehabilitation of recurrent ankle inversion injuries.20 Use ofproprioceptive balance board program is effective for preventionof ankle sprains recurrences.21 The wobble board is commonlyused in the rehabilitation of FUAs; it is designed to assist thereeducation of the proprioceptive system by improvingmechanoreceptor function and restoring the normalneuromuscular feedback loop.22 The effectiveness of wobbleboard training in the improvement of markers of proprioceptionin individuals with no history of ankle instability has been welldocumented.23

Previous research has also shown that wobble boardtraining improves single leg stance ability and postural sway inparticipants with a FUAs.22 Electromyography (EMG) has beenused in the assessment of proprioception as it allows the timingand degree of muscle activity to be determined during afunctional task. Soderberg, Cook, Rider, & Stephenitch, (1991)investigated the activity of the TA, PL, and gastrocnemius inparticipants with FUAs during exercise on a wobble board,although they did not investigate the effect of any rehabilitationprogram per se.24

Our aim was to describe the effect of 4-weeks wobble boardexercise training on recurrent ankle sprain. To find out the effectof 2-weeks wobble board exercise training on recurrent anklesprain. In addition compare the effects of 4-weeks and 2-weekswobble board exercise on recurrent ankle sprain.

Study DesignA experimental pre to post test design with 30 players were

randomized in to one of the two groups, 15 players in Group A(Type of exercise- Wobble board exercise 2 weeks) and 15players in Group B (Type of exercise-wobble board exercise 4weeks) was undertaken to find out the effect of 4-weeks and 2weeks wobble board exercise training on recurrent ankle sprain.

Material and methods

3.1 Source of dataSports Authority of India (SAI), Bangalore.Sports Authority of Karnataka (SAK),Kanteerva stadium, Bangalore.Padmashree Clinic of Physiotherapy,Nagarabhavi, Bangalore.

3.2 SubjectsSubjects for the study were selected and assigned toone of the two groups by simple random sampling.All cases diagnosed as recurrent ankle sprain ofbasketball players by the medical officer and referredto physiotherapy department for the treatment.

3.3 Materials usedWobble board, Surface EMG, Customized platform,Goniometer, Ankle Joint Functional Assessment Tool(AJFAT) questionnaire

3.4 Sample size:30 subjects of both the genders.Wobble board exercise for 2 weeks.7Group B=15 players Wobble board exercise for 4 weeks.

3.5 Inclusion criteria for both groupsParticipants between 20-30 years of age, both genders,

Participants should have a subjective complaint of a weak ankleand a history of at least 2 ankle sprains of lateral complex overpast 1year Participants should have a negative anterior drawertest.3.6 Exclusion criteria for both groups

History of TA rupture, fracture, dislocation in foot and anklecomplex, Abnormal biomechanics[i.e. calcaneus varus of 20ºand valgus of 10º,a medial tibiofemoal angle of 180-195º,genumrecurvatum less than 10º,and a medial hip rotation of 30-60ºand lateral hip rotation of 45-60º at 90ºflexion].45

Intervention done Participant’s individual consent was taken and outcome

measures used were AJFAT and muscle onset latency of TAand PL with EMG. The subjects were asked to complete theankle joint functional assessment tool questionnaire (AJFAT),which is used to rate each participant’s perception of their anklestability.22 Biomechanical alignment and mechanical stability ofpatients ankles were assessed using a goniometer .46 The bellyof the tibialis anterior (TA) and peroneus longus (PL) was locatedusing resisted ankle dorsi flexion with foot inversion and plantarflexion with eversion respectively. The area of maximal musclebulk will be palpated, shaved, and cleaned with an alcohol wipeto reduce skin-electrode impedance.Two 3.3 cm×2.3 cm Ag/AgCl electrodes were placed either side of the belly of the musclewith a distance of 5 mm between their edges, and parallel to theorientation of the underlying muscle fibers. Electrode positionsis measured in relation to anatomical landmarks andphotographed to ensure that the same positions were usedduring subsequent testing sessions.

47sEMG activity is recordedat a frequency of 1000 Hz over a 3-s period that included theopening of the trap door. Each participant will be performed thetest three times and group A were asked to return to the clinicafter 2 weeks of wobble board exercise and group B were askedto return to the clinic after 4 weeks of wobble board exercise forrepeat testing of outcome measures.

Group A=15 players,Type of exercise- Wobble board exercise for 2 wks 2.

1. Stand with feet parallel on the board, rock the board forwardand back

2. Stand with feet parallel on the board rock the board fromside to side

3. Stand with feet wide apart on the board rock the front of theboard from side to side in a circulating movement

4. Repeat exercises 1-3 but with your knees slightly bent andyour hands on your buttocks Continue exercises 1–4 for30 s, rest for 10 s and repeat

5. Stand on the previously injured leg and keep the boardlevel for 10 s, repeat six times, rest for 10 s and repeatIf in stage 5, balance can be maintained without losing

stability of the board, then complete with the eyes closed

Group B=15 playersType of exercise- Wobble board exercise for 4 wks.

1. Stand with feet parallel on the board, rock the board forwardand back

2. Stand with feet parallel on the board rock the board fromside to side

3. Stand with feet wide apart on the board rock the front of theboard from side to side in a circulating movement

(a) Stand with feet parallel (b) Rock the board forward andbackward

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group.48, 49

Statistical software: The Statistical software namely SPSS15.0, Stata 8.0, MedCalc 9.0.1 and Systat 11.0 were used forthe analysis of the data and Microsoft word and Excel have

AJFAT Group A Group B P valuePre 26.53±2.80 27.27±2.37 0.446intervention (22-31) (24-34)Post 35.73±3.69 43.07±1.98 <0.001**intervention (30-42) (40-47)% Change 34.67% 57.93% -P value <0.001** <0.001** -

PL (mili-sec) Group A Group B P valuePre 84.53±6.68 90.53±5.99 0.014*intervention (68-97) (81-99)Post 68.80±6.39 60.33±4.27 <0.001**intervention (58-84) (52-67)% Change 18.61% 33.36% -P value <0.001** <0.001** -

5. Stand on the previously injured leg and keep the boardlevel for 10 s, repeat six times, rest for 10 s and repeatIf in stage 5 balance can be maintained without losing

stability of the board, then complete with the eyes closedWOBBLE BOARD EXERCISEEmg recording

Trapdoor in (a) closed position and (b) the open positionin 200 of ankle inversion

Analysis of data Descriptive statistical analysis has been carried out in the

present study. Chi-square and Fisher Exact test has been usedto test the significant proportion of study characteristics betweentwo groups. Student‘t’ test (Two tailed, Independent) has beenemployed to test the significance of study parameters betweenthe two groups of subjects. Student ‘t’ test (Dependent) has beenused to find the significance of study parameters within each

been used to generate graphs, tables etc

ResultsEffect of 4-week and 2-week wobble board exercise

programme for improving the muscle onset latency andperceived stability in basket ball players with recurrent anklesprain was analyzed after evaluating for the followingparameters.1. Muscle onset latency of peroneus longus and tibialis

anterior was measured by mili seconds using ENMG.2. Functional outcome was measured using Ankle Joint

Functional Assessment tool Questionnaire.

parameters Group Group P value Effect sizeA B

PL 15.73 30.20 <0.001** 2.26 (VL)±6.01 ±6.44

TA 21.13 30.53 0.016* 0.91 (L)±11.47 ±8.48

AJFAT 9.20 15.80 <0.001** 1.88 (VL)±3.29 ±3.45

Comparison of PL (mili sec) of two groupsResults are presented in Mean ± SD (Min-Max)

Comparison of TA (mili sec) of two groupsResults are presented in Mean ± SD (Min-Max)

Comparison of AJFAT of two groupsResults are presented in Mean ± SD (Min-Max)

Comparison of outcome in two groups of players(Difference of Pre and Post)

Figure 9: Comparison of PL (mili sec) of two groups Pre andpost exercise period’s findings of PL (mili sec) shown in Fig-9.Figure 10: Comparison of TA (mili sec) of two groups Pre andpost exercise period’s findings of TA (mili sec) shown in Fig-10Figure 11: Comparison of AJFAT of two groups Pre and postintervention findings of AJFAT score shown in Fig-11.

Fig. 9:

(c) Rock the board from side to side (d) Exercises 1-3 but withyour knees slightly bent

(e) Side to side in a circulating movement (f) Stand on Previouslyinjured leg.

(g) Balance maintained complete with the eyes closed

4. Repeat exercises 1-3 but with your knees slightly bent andyour hands on your buttocks Continue exercises 1–4 for30 s, rest for 10 s and repeat

30

The comparison of pre and post outcome difference in twogroups of players shown in Fig-12(a), 12(b) &12(c).

ankle inversion was significantly reduced by 4 weeks of wobbleboard exercise as compared to 2 weeks wobble board exercise.Participant’s perception of their ankle stability also improved overthe course of the exercise programme.

Significant differences existed in reaction time of PL musclein pre exercise score between the Group A and Group B(p=0.014*) it may be because of number of times of recurrentinjury.

Neither muscle onset latency or perceived stability werestatistically different between the two groups at the start of theinvestigation, which indicates that the changes observed werelikely to be due to duration of wobble board training alone.

Whilst this investigation found the wobble board programmeto cause a significant decrease in the latency of both the TA andPL, however, reveals that the 4-weeks exercise group’s PLlatency reduced by 33.36% and TA is reduced by 33.95%.

The exercise programme demanded that the participantslearn to react to a variety of movements on the wobble board.

The large reductions in onset latency observed in the 4-weeks exercise group (TA=33.95%.PL=33.36%) initially suggestthat such movements resulted in an improvement in themechanoreceptor function, which restores the neuromuscularloop (Rozzi et al., 1999).

However, it has been reported that neither otolith(Waddington & Shepherd, 1996) nor proprioceptive (Konradsen,Voigt, & Hojsgaard, 1997) generated responses could protectthe ankle until 130 ms or 176 ms, respectively, after stimulusdetection.

As the trapdoor mechanism similar to the one used in thisstudy rotates through 20° in approximately 80 ms it is likely thatthese responses would be too late to produce sufficient eversiontorque to prevent injury from sudden inversion (Konradsen etal., 1997).

Further research is required to investigate when during therehabilitation period wether wobble board induced improvementsin muscle latency and perceived stability begin to plateau.

ConclusionThe findings of this study advocate the use of 4-weeks

wobble board exercise programme as part of the rehabilitationfor individuals with FUAs who experience recurrent ankle sprains.

Results demonstrated that the 4-weeks wobble boardexercise programme significantly decreased muscle onsetlatency of the TA and PL in response to a sudden 20° ankleinversion as compared to 2 weeks wobble board exerciseprogramme.

Hence this study concluded that there is significantdifference between 2 weeks and 4 weeks wobble board exerciseprogramme.

Whilst these improvements may still not be enough toproduce sufficient torque to prevent injury from sudden inversion,it is likely that they would reduce the risk of recurrent injury byincreasing joint stiffness.

Acknowledgementswould like to acknowledge Prof.Arun Prasad.B for his kind

TA (mili-sec) Group A Group B P valuePre 85.60±7.87 89.93±7.48 0.133intervention (70-98) (74-99)Post 64.47±6.31 59.40±5.76 0.029*intervention (54-76) (52-70)% Change 24.68% 33.95% -P value <0.001** <0.001** -

Fig. 12 (a):

Fig. 12(c):

Fig. 12(b):

Fig 11:

Fig. 10:

Discussion

The results of this study showed that the time for activation(i.e. the onset latency) of the TA and PL in response to rapid

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encouragement and support. I would also like to thank eachpatient who participated in the study.

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A comparative study of the therapeutic effect of pelvic floorexercises and perineometer among women with urinary stressincontinenceK. Vairajothi*, T.V. Chitra**, R. Baranitharan***, V. Mahalakshmi*****Post Graduate Student, PSG College of Physiotherapy, **Dept. of OG, PSG Hospitals, ***Professor & Vice Principal, PSG Collegeof Physiotherapy, ****Associate Professor, PSG College of Physiotherapy, Coimbatore, Tamil Nadu

BackgroundStress urinary incontinence is responsible for approximately

50% of the symptoms of urinary incontinence in women between25 and 49 years of age. Though surgery has been widelyaccepted as the treatment choice for this condition, there hasrecently been an increased interest in the conservativemanagement. There is a need to study effect of biofeedbackassisted pelvic floor muscle exercise in women with urinary stressincontinence with a limited number of treatment sessions.

ObjectiveTo improve pelvic floor muscle strength.To compare the effect of Perineometer with pelvic floorexercise training versus pelvic floor exercise alone inwomen with urinary stress incontinence.To reduce the severity of urinary stress incontinence.

MethodologyQuasi experimental design Pre test post test with a

comparison group was used. 20 women with stress urinaryincontinence (Group A – Perineometer with pelvic floor exerciseand Group B – pelvic floor exercise alone) using convenientsampling method were selected. Pre and post test data includingthe digital evaluation of pelvic floor muscle strength,perineometer pressure readings & severity index were takenand were statistically evaluated.

ResultThere was a significant difference in pelvic floor muscle

strength (‘t’ value for digital evaluation and Perineometer were6.14 and 5.12 respectively; p< 0.001). There was a significantimprovement in the severity of incontinence within the groups,with mean difference of 2.5 and 1.5 for Group A and Brespectively. There was no statistically significant improvementof Severity index score between the groups (‘t’ value was 1.726; p>0.05).

ConclusionPerineometer training along with pelvic floor exercises has

significant effect in improving the pelvic floor muscle strengththan pelvic floor exercises alone in women with urinary stressincontinence thereby promoting continence.

KeywordsPerineometer, Incontinence, Pelvic floor exercises

IntroductionStress Urinary Incontinence is the most common form of

urinary incontinence in women. The International continencesociety (ICS) defines stress urinary incontinence as the complaint

of involuntary leakage on effort or exertion or on sneezing orcoughing. The perineometer appears to be a highly reliablemethod of measuring pelvic floor muscle strength and endurance(Nahid Rahmani et al.,2009)1. Supervised pelvic floor muscleexercises presented better results in objective and subjectiveevaluations than did unsupervised exercises (Miriam Raquel etal., 2007)2. Stress urinary incontinence is responsible forapproximately 50% of the symptoms of urinary incontinence inwomen between 25 and 49 years of age. Though surgery hasbeen widely accepted as the treatment choice for this condition,there has recently been an increased interest in the conservativemanagement (Mariana T Rett et al, 2007)3. There is a need tostudy effect of biofeedback assisted pelvic floor muscle exercisein women with stress urinary incontinence with a limited numberof treatment sessions. The present study was done with an aimto improve the pelvic floor muscle strength and to compare theeffect of perineometer with pelvic floor exercise training versuspelvic floor exercise alone in women with urinary stressincontinence and to reduce the severity of urine leakage with alimited number of treatment sessions.

MethodologyNormally delivered primigravidae, multigravidae and

postmenopausal women with stress urinary incontinence whovisited the out patient Department of Obstetrics and Gynecology,Department of Physiotherapy, PSG Hospitals from July toNovember 2009 were the population included for this study.Quasi experimental design pretest posttest with a comparisongroup and a convenient sampling technique were adopted inthis study. Women with stress urinary incontinence of Slight toModerate severity (severity index) between the age group of 25and 60 years (including post hysterectomy women) experiencingurine leak for > 3 months with pelvic floor muscle grade between2 and 4 (clinical scale for grading digital evaluation of musclestrength) were included. Women with other type of incontinence,recent pelvic surgeries, intrauterine devices and any other pelvicfloor dysfunction were excluded for this study. Ethical clearancewas obtained from the Human Ethics Committee of PSG Instituteof Medical Science and Research Institute and informed consentwere received from the participating women. Out of the 20women selected, 10 women (Group A) underwent Perineometertraining along with pelvic floor exercises and 10 women (GroupB) were taught pelvic floor exercises alone. The total duration oftreatment was 6 weeks for both the groups.

Treatment protocolBase line assessment of pelvic floor muscle strength by

digital evaluation and using perineometer were taken for boththe group on the day of assessment. Severity of incontinencewas assessed using severity index. Women in Group A weregiven training for pelvic floor muscles using Perineometer onthe day of assessment and were taught pelvic floor exercises (3sessions of exercise with 5 minutes for the first week andgradually increasing the duration to 20 minutes at 4th week. Onthe 5th and 6th week the exercises are performed for 30 minutes2 or 3 sessions / day). Pelvic floor exercises were taught to thewomen in Group B on the same protocol. Follow up assessmentsof pelvic floor muscle strength were taken every 2nd week till six

34

weeks of treatment for both the groups. Severity index scoreswere taken on the day of assessment and sixth week. Thebaseline data and the data obtained on the final day of treatmentwere used for statistical analysis.

ResultsThe mean difference of Group A was 1.8 (SD = 0.42) and

the t value was 13.5; p<0.001 and in Group B the mean differencewas 1.1 (SD = 0.31) with ‘t’ value was 11.2; p<0.001 showingthe improvement of pelvic floor muscle strength within the groups(Table 1 & Graph I).

The independent‘t’ test was performed between Group A

and Group B to analyze the significance of the pelvic floorexercise with perineometer training. The ‘t’ value was 6.14;p<0.001 and 5.2; p<0.001 for digital evaluation and Perineometerfeedback indicating a significant effect of pelvic floor exercisewith perineometer pressure feedback training and pelvic floorexercises than pelvic floor exercise alone in improving pelvicfloor muscle strength in women with stress urinary incontinence.The calculated ‘t’ value for the severity index was 1.726 ; p>0.05,and hence there is no statistically significant improvement inthe severity of incontinence between the groups (Table 3). Therewas a significant improvement in the severity of incontinencewithin the groups, with mean difference of 2.5 and 1.5 for GroupA and B respectively (Graph III).

Table 2: Paired‘t’ test values, the Mean, Mean difference and Standard deviation of Perineometer pressure readings in Group A andGroup B.GROUPS Mean Mean Difference Standard Deviation ‘t’ value P valueGROUP A Pre test 7 33.6 13.32 7.97 P<0.001

Post test 40.6GROUP B Pre test 7 10.8 4.43 7.70 P<0.001

Post test 17.8

Table 3: Independent “t” values, Mean Difference and Standard deviation of Pelvic floor Muscle strength and Severity indexOutcomemeasures Mean difference Standard deviation ‘t’ value P valueClinical Scale for Grading Digital 0.7 0.26 6.14 P<0.001Evaluation of Muscle strengthPerineometer pressure 22.8 9.93 5.2 P<0.001feedback readingsSeverity index score 0.6 0.79 1.726 P>0.05

Table 1: Paired “t” test values, the Mean, Mean Difference And Standard Deviation of Pelvic floor muscle Strength Using DigitalEvaluation of Group A and B

GROUPS Mean Mean Difference Standard Deviation ‘t’ value P valueGROUP A Pre test 2.1 1.8 0.42 13.5 P<0.001

Post test 3.9GROUP B Pre test 2.1 1.1 0.31 11.2 P<0.001

Post test 3.2

Graph II: Mean Difference for Perineometer pressure Readingsin Group A and Group B

Graph I: Mean difference for Pelvic floor muscle strength inGroup A and Group B

Table 2: Paired‘t’ test values, the Mean, Mean difference andStandard deviation of Perineometer pressure readings in GroupA and Group B.

DiscussionTreatment of stress urinary incontinence with pelvic floor

exercises associated to biofeedback caused significant changesin the parameters analyzed, with maintenance of good results 3months after treatment. (Maria V et al 2006)3. Biofeedbackmethod revealed better PFM strength results with respect todigital palpation. (Aksac et al., 2003)6. Biofeedback therapyresulted in a better subjective outcome and higher contractionpressures of the pelvic floor muscles (Pages IH et al., 2001)7.

There is good agreement between digital assessment ofpelvic floor contraction strength and vaginal perineometry (P.J.Isherwood et al., 2005)4. This study also used both digitalevaluation and Perineometer for assessing the pelvic floor

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muscle strength. It was found that there was a good improvementin pelvic floor muscle strength following Perineometer trainingwith pelvic floor exercises than pelvic floor exercises alone.

Pelvic floor exercise is an accepted conservative treatmentmodality used for mild to moderate cases that have not yetcompleted their families. Pelvic floor exercise with biofeedbackis a very important treatment modality, requiring a highlymotivated patient and a physiotherapist specialized in pelvicfloor exercise (Gordon et al., 1999)8. Adding biofeedback to pelvicfloor muscle exercises might be more effective than pelvic floormuscle exercises alone six treatments. (Berghams et al., 1996)9.

This study analyzed the influence of pelvic floor exercises andbiofeedback on objective parameters. Moreover, theperineometer biofeedback patients showed them to be moresatisfied may be because of the supervision and weeklyassessment.

The subjective parameter chosen for analysis in this studywas the severity index score. Though the severity of incontinencewas found to be reduced within the groups, there was nosignificance difference between the groups. The complementaryeffect of biofeedback on pelvic floor rehabilitation program isstill a controversial subject. In 1998, Berghaman et al., foundthat there was strong evidence that biofeedback associated withpelvic floor exercises did not increase the efficacy of thetreatment. On the other hand, the meta analysis performed byWeatneral led to the conclusion that biofeedback was an effectiveaid in strengthening pelvic floor muscles for it presentedincreasing cure rates. Nevertheless, these studies differ greatlyregarding interventions conducted, research population,assessment measures and equipment used, making themdifficult to be compared.

The limitations of this study were relatively small group size,short duration and only the pelvic floor muscle strength andSeverity index were taken into the consideration in this study.The plan of the study did not take into account to compare theduration of exercises, bladder dairy and quality of life. Furtherresearch could be done by comparing the other biofeedbackdevice with Perineometer. The pelvic floor muscle strengthamong the pre and post menopausal women with stress urinaryincontinence can also be compared.

ConclusionPerineometer with pelvic floor exercise is an effective

intervention in improving the pelvic floor muscle strength therebyreducing the severity of incontinence. Considering the overalltreatment outcome, this study concludes that the perineometertraining was more effective than the pelvic floor exercise alonein the management of urinary stress incontinence.

AcknowledgementThe authors would like to thank the women who participated

in this study for their cooperation.

References1. Nahid Rahmani and Mohammad A. Mohseni. Application

of perineometer in the assessment of pelvic floor musclestrength and endurance, Journal of Bodywork andMovement therapies, 2009.

2. Miriam Raquel Diniz zanetti, Rodrigo de Aquino Castro,Adriana Lyyo Rotta. Impact of supervised physiotherapeuticpelvic floor exercises for treating female stress urinaryincontinence. Sao Paulo Medical Journal 2007, Vol 125Page no. 5.

3. MariaV. Cpetiai, Cassio L. Riccetto, Miriam Dambros, JoseT. Tamanini, Viviane Herrmann, Virginia Mullor. Pelvic floorexercises with biofeedback for stress urinary incontinences.International braj urol. 2006, Vol. 32 no.4

4. P.J. Ishenwood, A.Rane. Comparative assessment of pelvicfloor strength using a perineometer and digital evaluation,An International Journal of Obstetrics and Gynaecology.2005, Vol 107 Issue8, Page no. 1007-1011.

5. Aukee P, Immonen P, Leaksonen DE, Laippala P, PenttinenJ, Airaksinen O. The effect of home biofeedback trainingon stress incontinence. Acta Obstet Gynecol Scand. Oct2004:83(10):973-977.

6. Aksac B, Aki S, Karan A, Yaicin O, Isikoglu M, Eskiyurt N.Biofeedback and pelvic floor exercises for the rehabilitationof urinary stress incontinence. Gynecol. Obstet Invest. 2003,56(1):23-7.

7. Pages IH, Jahr S, Svhaufele MK, Conradi E, Comparativeanalysis of biofeedback and physical therapy for treatmentof urinary stress incontinence in women. Am J Phys MedRehabil 2001; 80 page no. 494-502.

8. Gordon D, Luxman D, Sarig Y, Groutz A. Pelvic floorexercise and biofeedback in women with urinary stressincontinence. Harefuah 1999 Apr 15:136(8): 593-6,660.

9. L.C.M. Berghmans, C.M.A. Frederiks, R. A. de Bie, E. H. J.Weil, L.w.H. Smeets. Efficacy of biofeedback when includedwith pelvic floor muscle exercise treatment for genuinestress incontinence, 1996, Vol15 Issue 1, page no.37-52.

10. Burgio KL, Robinson JC, Engel BT. The role of biofeedbackin kegel exercise training for stress urinary incontinence.Am J Obstet Gynecol. 1996 Jan; 154 91):58-64.

11. Sammer P, Bawer T, Nielson KK. Voiding patterns andPrevalence of incontinence in women’s a QuestionnaireSurvey. British Journal of Urology. 1990; 66; 12-15.

12. Margaret polden, Jill Mantle. Continence and Incontinence,Physiotherapy in obstetrics and Gynaecology, Jaypeebrothers, 1994. Page no.371-1

13. Jill Mantle, Jeanette Haslam, Sue Barton, Urinary functionand dysfunction, 2nd edition, 1990. Butterworth Heinemann,Page no: 358.

14. Eilen Brayshaw. Exercise for pregnancy and childbirthMusculoskeletal problems in pregnancy and postpartum,Elsevier Sciences Limited 2003. Page no.35.

15. Elizabeth Nobel, Essential Exercises for child bearing year;2003; page no.62-80.

16. Linda J. O’ Connor, Bs, PT Rebecca J. Gourley. Obstetricand Gynecologic Care in Physical therapy. 1999 Evaluationand treatment. Page no.252-253.

17. Hollis Herman, Elaine Wilder. Obstetrics and GynecologicPhysical therapy 1998, page no.108.

18. Dutta. D.C. Text Book of Gynaecology 4th Edition Genuinestress Incontinence in Contraception 2004, Page no. 366-370.

19. Health and Age: by Robert W. Griffith. Urinary Problemscenter. Dec 15, 2000.

20. Sundar Rao PSS, J.Richard. Introduction to biostatisticsand Research methods; Ed; Prentice Hall of India (P) Ltd,2006.

21. Nancy Burns and Susan K Grove. The Practice of Nursingresearch conduct critique and utilization. 5th Edition.Pennsylvania: Elsevier; 2005.

22. Mariana T Rett et al, “Management of stress urinaryincontinence with surface electromyography – assistedbiofeedback in women of reproductive age”, 2007, PHYSTHER, Vol 87, No. 2, Pg – 136 – 142.

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A study of effects of gluteal taping on TD-parameters followingchronic stroke patientsBhatri Pratim Dowarah*Assistant Professor, Department of Physiotherapy, J.R.N.R.V. University, Dabok, Udaipur, Rajasthan 313022

Need of the studyThe aim of the study is to determine whether gluteal taping

on the affected side improves walking for chronic stroke patients.

Objectives of the studyTo study the effects of gluteal taping to patients with chronic

stroke having abnormal (hemiplegic) gait.

Hypothesis

Experimental hypothesis:There will be significant improvement in walking pattern in

chronic stroke patients treated by control exercise program withgluteal taping.

Null hypothesis:There shall not be significant improvement in walking

pattern in chronic stroke patients treated by control exerciseprogram with gluteal taping.

Review of literatureSystematic research has shown that organized

multidisciplinary care and rehabilitation of the stroke enhancepatient’s survival independence, as well as reducing the lengthof in patient stay. It remains unclear, however, why specializedstroke units are more effective than usual care. A no ofcomponents have been identified as contributing to theefficacious care delivered in such units. These include thecomprehensive assessments of the medical problems,impairments and disabilities; active physiological management;early mobilization and avoidance of bed rest; skilled nursingcare; early setting of rehabilitation plants involving careers; andearly assessment and planning for discharge needs. Several ofthese factors are closely related to physical therapy which isoften perceived as one of the key disciplines in organized strokecare. The main foci of physical therapy after stroke are to restoremotor control in gait and gait related activities and to improveupper limb functions, as well as to learn to cope with existingdeficits in activities of daily living and to enhance participation ingeneral. Besides using physical exercises, physical therapistsoften apply assistive devices for gait, and employ otherequipments such as treadmills and electronic devices to supporttheir treatment. In addition, advice and instructions are providedto the patients, family and other members of the stroke teamregarding prevention of complication such as falls and shoulderpain. Today, the importance of evidence based medicine as aguide for the clinical decision making process is increasinglybeing recognized by physical therapists.

Gait is defined as the manner of moving the body from oneplace to another by alternatively and repetitively changing thelocation of the feet, with the condition that atleast one foot is incontact with the walking surface.11

Normal walking is characterized by a smooth successionof steps with first one leg and then the other. The time taken for

each step is similar, as is the distance covered with each stepduring forward progression.the gait cycle consists of two steps,as body weight is accepted and transferred over first one footand than the other during forward progression. A gait cycle thusincludes a stance and swing phase and two periods of doublesupport at the beginning and end of the stance as the weight istransferred from one leg to the other.59

The gait cycle is defined as the time interval between twosuccessive occurrences of one of the repetitive events of walking,convinent to use the instant at which one foot contacts with theground ( initial contact ) until the same foot contacts the groundagain. In each gait cycle, the stance phase usually last about60% of the cycle, the swing phase about 40% and each periodof double support about 10%. However, these varies wiyh thespeed of walking,the swing phase becoming proportionatelylonger and the atsnce and the double support phases shorteras the speed increases.22

Each phase of gait (stance and swing phase) has beendevided into the following:

Stance phase (heel strike, foot flat, mid stance, heel offand toe off) and

Swing phase (acceleration, mid swing and deceleration).The Los Amigos research and

education institute, including of Rancho Los Amigos MedicalCentre has developed a different terminology in which thesubdivisions have been redefined and named as; stance(initialcontact, loading response, midstance, terminal stance and pringswing) and swing (initial swing, midswing and terminal swing)1.

In each gait cycle, there are spatial (distance) and temporal(time) parameters, which are basic parameters of motion, andmeasurement of these variables, provide a basic description ofgait.

Temporal parameters include stance time, single limb anddouble support time, swing time, stride and step time, cadenceand speed.

Spatial parameters are stride length, step length, width ofwalking phase and degree of toe out. These variables provideessential quantitative information about a person’s gait andshould be included in any gait description.

The mechanism underlying gluteal taping is not known.McConnell has hypothesized that this particular gluteal tapingtechnique may alter the orientation of the gluteus maximusmuscles fibres. According to this hypothesis, the taping elevatesand stretches the belly of the muscle, increasing the overlapbetween the actin and myosin filaments and therefore thepotential cross-bridge interactions.7

The length tension curve is shifted to the left, with thegluteus maximus able to contract more forcefully, producingan increasing in hip extension after taping.23

Gluteal taping improves the propioceptive activity throughpull of the tape on the skin.24

The Kinesio taping method used to improve the upperextremity function in the adult with hemiplegia. The Kinesiotaping method in conjunction with other therapeuticinterventions may facilitate or inhibit muscle function, supportjoint structure, reduce pain, and provide proprioceptivefeedback to achieve and maintain preferred body alignment.Restoring trunk and scapula alignment after the stroke is criticalin an effective treatment program for the upper extremity inhemiplegia.25

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Humans can walk up to 4 m/s, but natural transitionbetween walking and running is roughly 2.2 m/s .26

Influence of walking speed on gait parameters to and outtheir normal ranges. The results can be used as a referencefor comparison with other pathological cases.27

Several works extract parameters of body and gait, suchas, stride length, cadence, height, joint angles to use in theclassification tasks. They analyze the identity informationcontained in the lower-body joint-angle trajectories using thedata measured with 3D motion capture system.28,29,30,31

Speed effects in gait recognition have not beenemphasized much. There are not many works that exploit therelationship of gait features with respect to walking speeds intheir techniques to help deal with walking speed variations ofpeople. They present a method that focuses on distinguishingnormal walking movement from other non-walking movementsusing low-level stride-based features. They present a model-based technique that estimates stride length and cadence asgait features and use the linear relationship between stridelength and cadence in their recognition step.29,32

Extensor muscle over activity is one of the components ofgait disorders in stroke patients. Extensor muscle over activityor spasticity is a real cause in gait disturbances.8

Studied between spastic and non-spastic limb, as well inbetween stance and swing phases of the gait cycle, reportedthat planterflexion spasticity is a factor contributing to the poorlocomotors performance.9

Reported an average stride length of 0.6 +/- 0.25 m/secand cycle duration of 2.3 +/- 0.8 m/sec. these limitations instride length and walking speed may be associated withadvancing the paretic limb efficiently in swing and in shiftingweight to the paretic limb in stance. Lack of hip extension duringterminal stance may result in a shorter stride length anddecreased gait velocity reported in hemiplegic subjects.10

Studied on 42 patients with unilateral 1st stroke who wereable to walk 10 meters and reported that the goal ofrehabilitation is to increase gait velocity and normalize the gaitpattern, treatment should focus on decreasing the double limbstance and unaffected single limb support phases of the gaitcycle.15

Measured temporal gait asymmetries in 25 patients withresidual stroke, Reported that both the extent and patterns oftemporal gait asymmetries with respect of the phases of thegait cycle were found to very. The basic rehabilitative implicationof these findings is that it is not possible to design a single gaitre-education program for all residual stroke patients; theexercises prescribed must addressed the unique differencesof each patients.16

Studies have been asserted that speed alone is aneffective indicator of the degree of gait abnormalities.17

All this study provides evidence that gluteal taping isworthy of further investigation as a strategy for improvingwalking patterns of chronic stroke patients .The participants inthe study had history of chronic stroke from months to yearswith walking problems , with application of the gluteal taping amodest increase in the walking pattern along with theimprovement in the unaffected leg. Further study is required todetermine how it improves the walking pattern of chronic strokepatients.

Materials and methodology

Design of study:It is an experimental study design, a sample of 30 patients

in both the groups were included in the experimental study witha pre-test and post-test study design.

The samples of patients were selected as the basis ofconvenient sampling. The sample confirmed with the diagnosisof stroke, by the consulting Neurologist, took part in the study.

It was experimental study, pre-test and post-test different

subjects design, a total of 30 patients were taken. Patients willbe treated with control exercise program along with gluteal tapingand were treated within 3 months.Sample design:

A total no. of 30 patients between the age group of 40-60years with chronic stroke i.e. 3 months was recruited byconvenient sampling. Patients were taken from L.L.R.MedicalCollege, Meerut, Annapurna Charitable Trust, Meerut andCollege OPD.

The entire patient were diagnosed & referred byNeurologist. The eligibility criteria were checked & informedconsent were taken from patients.Inclusion Criteria:• Cerebral artery involvement, both ischemic and

hemorrhagic.• Hemiplegic gait.• Age group 40-60 years• Chronic stroke patients (2-5 years).• Can walk without use of any aid• Decreased hip extension due to problems in gluteal

musclesExclusion Criteria• Pre existing deformity and other complications• Hip flexor and planter flexor contracture ( as evidenced by

Thomas test )• Allergy to adhesive sports tape• If they could not comprehend and follow simple verbal

instructions• Visual and hearing problems and cognitive deficits• Severe psychological disorders· Recurrent stroke

Methodology

Materials, Tools and Apparatus• Neurological evaluation chart• 10 meter paper track• Marker or water color or ink (vatika oil-washable)• Inch tape• Sport tape• Anti-skin infection tape or hypoallergenic tape ( micro-pore)• Reinforcement tape ( leucoplast ), Johnson• Pen, paper etc.Assessment tools:• Sport tape (Johnson & Johnson) :

Hypoallergenic tape was 1st applied without tensionto protect the skin .Sport tape was then applied with tensionover the protective tape. 3 pieces of tape were applied while thebuttock was supported by the therapist.• 10 meter paper track :

The paper track is mainly used for themeasurement of the parameters, in which 2.5 meters should beleft in the start and at the end. The patients were walked overthe mid section of a 10 meter track. The subjects walk over thetrack 3 times at their self selected speed.Protocol:

A total number of 30 patients were taken which wererandomly selected from the mentioned placed in Meerut, bothmale and female. Group A: Subjects are randomly assigned.Subjects were treated with normal control exercise program withexercises like PNF, mat exercises, passive movements,stretching and stimulation etc. Group B: Subjects were randomlyassigned. Subjects were treated with normal control exerciseprogram along with gluteal taping .Taping were applied toaffected side with patient standing.

All the patients had attended physiotherapy session dailyfor 3 months. During this time they were advised not to take anyother treatment or medications.

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ProcedureInformed consent was taken from each subject. Subjects

were then screened from inclusion / exclusion criteria. Subjectswere made to understand about the study and purpose of thestudy in their own language. Patients were then made to undergothe exercise protocol along with gluteal taping.

Gluteal Taping: Taping was applied to the affected side withthe subject standing by the therapist. Hypo allergic tape wasfirst applied without tension to protect the skin. Sport tape wasthan applied with tension over the protective tape. Three piecesof tape were applied while the buttock was supported by theresearcher. Tape was applied:1. From the medial aspect of the gluteal fold, pulled laterally

and superiorly towards the greater trochanter. And Fromthe medial aspect of the gluteal fold to the top of the buttockabove the gluteus maximus muscle belly, lifting the buttock.

2. From the superior end of the second piece of the tape tothe greater trochanter.The tape was applied only to the buttock and not to the

posterior thigh. Two dimensional adhesive markers of 1.5 cmwere placed over the mid axillary line of the iliac crest, the greatertrochanter, and the lateral femoral condyle of the affected sideand each subjects were fimed, both in a relax standing posture,to produce a neutral reference.

Subjects walked over the mid section of a 10 meter papertrack with color or ink in the sole of the foot, so that foot leftmarks on the walkway track three times at their self speed.18

Than the step length, stride length and step width is to bemeasured along with in terms of cadence and step time.19

Data analysisAll analysis were obtained using SPSS Windows version

11.0. Demographic data of patient including sex, age, diseaseduration, stride time, step length, step width, cadence and steptime were descriptively summarized. The dependent variablefor statistical analysis were, pain and disability. An á-level of0.05 was used to determine statistical significance. Statisticaltechniques used for analysis were student t-test or Man Whitney,whichever is applicable, to compare each point of time in thetwo groups. Both- within group and between group analysis wasdone to analyze the dependent variables. One way multivariateanalysis of variance (MANOVA) with repeated measure wasperformed to analyze the differences in the subjects with glutealtaping. Follow up analysis of variance were conducted if theMANOVA test demonstrated statistical significance.

ResultsIn this 30 subjects were randomly selected, and then were

allocated in group A and B. There were 19 males and 11 femaleswith a mean age of 56.93 + 3.12 ranging from 46-60 in group Aand a mean age of 56.53 + 3.79 with a minimum age of 48-60 ingoup B. A baseline reading was taken using Time-distanceparameters in the patients with chronic stroke.

Within group analysisHowever there is no significant difference between pre and

post physiotherapy treatment among the subjects in Group Abut the mean value shows that intervention has better effects inGroup B.

To look for the difference between the baseline readingstaken on the first day of the study with the post test readings ofTime-distance parameter by applying gluteal taping on the 90th

day an independent t-test was performed which showed asignificant difference in both group A as well as in group B (table 1 to table 5 ). It was found that there is a improvement inthe Time-distance parameter on application of gluteal taping in

the patients with chronic stroke which was found significant(p<=0.000). A similar results in group B was seen which wassignificant (p<=0.000).

DiscussionIn this study of moderate hemiplegics we tried to assess

the improvement in the hip extension using the gluteal tapingalong with exercises program. It is well established fact that thehemiplegics have gross abnormalities of gait produced due totheir inability to overcome the spasticity in the antigravitymuscles, resulting in non-reduction of limb length during gait.This relative lengthening of limb is compensated bycircumducting the lower limb. To avoid this abnormality, thepatient is specifically trained flexing activities. This problem iscompounded by the fact that most of the hemiplegics are elderlyhaving other neurological compensation including co-ordinationdifficulties.

It is mandatory to have hip, knee and ankle interactionduring gait especially during gait. The use of gluteal tapingimproves hip extension during gait cycle, this started as earlyas possible to avoid possible learned movement dysfunctions.

The Time-distance parameter as a primary parameter inthe evaluation of outcome as it involves the objective way ofmeasuring the effects of using gluteal taping on a real time basis.This test also encompasses the person co-ordination activitiesby increasing the hip extension.

The taping improves muscle activation through cutaneousstimulation (Garnett and Stephens 1981) or improvesproprioceptive acuity through the pull of the tape on the skin(Robbins at el 1995). The mechanism underling the glutealtaping not known, McConnell(2002) has hypothesized at thatthis particular taping technique may alter the orientation ofgluteus maximus muscle fibres. According to this hypothesis,the taping elevates and stretches the belly of the muscle,increasing the overlap between the actin and myocin filamentcan there fore the potential crossbridge interactions.

This study provides evidence that gluteal taping is worthyof further investigation as a strategy for improving hip extension.The participants in this study had of history of stroke rangingfrom year with well entrenched gait patterns. With the applicationof gluteal taping the patients increase their hip extension.

Future studiesIn future studies in this particular area it is recommended

that homogeneity of the patients should be done on a morespecific and discrete fashion. Follow up and recording ofsustained of the improvements will give more validity into theuse of gluteal taping. The segregation of the patients accordingto the arterial involvement and gender will make outcomemeasure more reliable. The reliable of the study can also be co-related with functional index to understand the translation ofthis improvement to functional outcome.

LimitationsThe study is done on an immediate basis i.e. the time-

distance was measured immediately on the use of gluteal tapingand no follow up was done. The lack of follow up has thedrawback that the sustained of this improvement and furtherprogression value is not revealed. The hemiplegics were of boththe sides (right and left). It is known that right sided hemiplegicsusually have some perceptual disorder also which is notconsidered in the study, but nevertheless can affect the outcome.

Though patients had homogeneity of suffering frommoderate hemiplegia according to Orpington Prongnostic Scale,their pre-morbid status was not recorded and also the fact thatthe spaticity was not graded asworth scale.

The patients were not ideally similar because though they

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suffered chronic hemiplegia, they were having different arterialin involvement, hence might have difference in their outcome.

ConclusionIt has been recorded from the study that use of gluteal taping

produces significant improvement in the time-distanceparameters with chronic stroke patients. It can be seen that useof gluteal taping in patient with hemiplegia is beneficial. Thiscan be used to enhance the functional outcome of these patients.Hence alternate hypothesis is accepted at p = 0.00 and the nullhypothesis is rejected.

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treatment”, 4th edition, J. P. Brothers, 519-521, 20002. V Dietz, J Quintern (1981). Electrophysiological studies of

gait in spasticity and rigidity. Brain, 104, 431-449.3. Merits of neurology – Lewis P Rowland4. Hsu A L, Tang P F and Jan M F: Analysis of impairments

influencing gait velocity and asymmetry of hemiplegicpatients after mild to moderate stroke, Archives of PhysicalMedicine and Rehabilitation, 84: 1185-1193, 2003

5. Lehman J F, Condon S M, Price R and DeLateur B J: Gaitabnormalities in hemiplegia: Their correction by ankle footorthosis, Archives of Physical Medicine and Rehabilitation,68:763-771, 1987

6. Kim C M and Emg J J: The relationship of lower extremitymuscle torque to locomotor performance in people withstroke, Physical Therapy, 83: 49-57, 2003

7. McConnell J: Recalcitrant chronic low back and leg pain-anew theory and different approach to management,Manual Therapy, 7: 183-192, 2002

8. Yelnik et al: Aclinical guide to assess the role of lower limbextensor over activity in hemiplegic gait disorder, 234-240

9. Anouk Lamontagne et al: Locomotor specific measure ofspasticity of P F muscle after stroke, Archives of PhysicalMedicine and Rehabilitation, 83;7: 924-929, 2002

10. Brandstater M E et al: Hemiplegic gait: Analysis of temporalvariables, Archives of Physical Medicine and Rehabilitation,64:585, 1983

11. Gary L Smidt: Gait rehabilitation, Churchill Livingstone, 254-258, 1990

12. Richards C. Knutssone: Evaluation of abnormal gaitpatterns by intermittent light photography and EMG, Scandjournal of rehabilitation medicine, 3:61, 1974

13. Ron Seymour: Prosthetics and orthotics lower limb andspine; Lippincott Williams and Wilkins, 416-419, 2002

14. Wooley S M et al: characteristics of gait in hemiplegia .Topstroke rehabilitation, winter, 7(4): 1-18, 2001

15. Goldie L. Smidth: Gait rehabilitation, Churcill livingstone,254-258, 1990

16. Wall J C et al: Gait asymmetries in residual hemiplegia,Archives of Physical Medicine and Rehabilitation, August67(8), 550-553, 1986.

17. Roth E J et al: Hemiplegic gait relationship between walkingspeed and other temporal parameters, American Journalof Physical Medicine, March-April, 76(2), 128-133, 1997.

18. Cerny K: A clinical method of qualitative gait analysissuggestion from the field, Physical Therapy, 63: 1125-1126,1983.

19. Foot print analysis, Archives of Physical Medicine andRehabilitation, 78, 1965.

20. Craik, R and Oatis, C A: Gait analysis: Theory andApplication, St. Louis. Mosby, 1995.

21. Ann E. Barr, Sherry I. Baykus: Basic biomechanics ofmusculoskeletal system: Biomechanics of gait, 18, 442-443, 2001

22. Whittle M.W: Gait analysis: An introduction, Buttermorth-Heinmann, 1999.

23. Garnett R and Stephens J A (1981) :Changes in recruitmentthreshold of motor units produced by cutaneous stimulationin man, Journal of Physiotherapy ,311:463-473

24. Robbins S, Waked E and Reppel R (1995) , Ankletaping improves proprioception before and after exercisein young men, British Journal of Sports Medicine 29:242-247.

25. Jaraczewaka E and Long ( 2006- summer ) ,Kinesio tapingin stroke : improving functional use of the upper extremityin hemiplegia , 13 (3) : 31 – 42

26. N. A. Borghese, L. Bianchi, and F. Lacquaniti, “Kinematicdeterminants of humanlocomotion.” Journal of Physiology1996: 494.3 863-879.

27. J. L. Lelas, G. J. Merriman, P. O. Riley, and D. C. Kerrigan,“Predicting peak kinematic and kinetic parameters from gaitspeed” Gait & Posture June 2002

28. A.Y. Johnson and A.F. Bobick, “A Multi-View Method forGait Recognition Using Static Body Parameters”, The 3rdInternational Conference on Audio- and Video BasedBiometric Person Authentication (2001)

29. C. Ben Abdelkader, R. Cutler, and L. Davis, “Stride andCadence as a Biometric in Automatic Person Identificationand Verification” 5th International Conference on AutomaticFace and Gesture Recognition 2002.

30. S. Niyogi and E. Adelson, “ Analyzing and recognizingwalking figures in XYT”, In Proc. of IEEE Conference onComputer Vision and Pattern Recognition, pages 469 - 474,1994.

31. R. Tanawongsuwan and A. Bobick, “Characteristics ofTime-Distance Gait Parameters across Speeds”, In GVUTechnical report, College of Computing, Georgia Instituteof Technology, 2003.

32. J. Davis and S. Taylor, “Analysis and Recognition of WalkingMovements” Inter- national Conference on PatternRecognition, Quebec City, Canada, August 11-15, 2002,pp. 315-318.

33. Ann E Barr, Sherry I Bauckus (2001), Basic Biomechanicsof Musculoskeletal system: Biomechanics of Gait, 18: 442– 443

34. Whittle M W: Gait analysis an Introduction, Oxford:Buttermorth–Heinemann, 1991.

35. Craik R L and Oatis E A: Gait analysis: Theory andApplications. St. Louis. Mosby; 1995

36. Tangman, et al; Rehabilitation of chronic stroke patients:changes in functional performance, Archives of PhysicalMedicine and Rehabilitation, 71:876, 1979.

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Role of physiotherapy in palliative careBinoy Mathew K V.Physiotherapist, Life Care Clinic, Kochi

IntroductionIn palliative care settings, physical therapists strive to

promote quality of life. Minimal research exists; however, to guidetherapists working with patients with terminal illness.1Physicaltherapy for patients receiving palliative care is directed atachieving symptom control, maximizing remaining functionalabilities, providing caregiver education, and contributing tointerdisciplinary team communication. 1

There is a paucity of physical therapy literature to educate,guide, and support therapists involved in caring for patients whoare dying. 1The World Health Organization estimates that 15million people will develop cancer in 2015, up from approximately9 million people in 1985. Based on this information, the numberof older adult patients with cancer who require services, includingphysical therapy, will continue to grow. 1

Palliative carePalliative care is the active total care of patients whose

disease is unresponsive to curative treatment. Palliative careaims to relieve suffering and improve the quality of life for patientswith advanced illnesses and their families through specificknowledge and skills, including communication with patients andfamily members; management of pain and other symptoms;psychosocial, spiritual, and bereavement support; andcoordination of an array of medical and social services. 1

The 6 fundamental principles of palliative care are:1. Affirm life and regard dying as a normal process.2. Neither hasten nor postpone death.3. Provide relief from pain and other distressing symptoms.4. Integrate the psychological and spiritual aspects of patient

care.5. Offer a support system to help patients live as actively as

possible until death.6. Offer a support system to help family members cope during

the patient’s illness and their bereavement. 1

It is based on an interdisciplinary approach that is offeredsimultaneously with other appropriate medical treatments andinvolves close attention to the emotional, spiritual, and practicalneeds and goals of patients and of the people who are close tothem.2Palliative care providers respect and attend to theindividual needs of each patient from a perspective of “total pain,”defined as physical pain, emotional pain, psychological painspiritual pain. 1

Palliative care should be offered simultaneously with allother medical treatment. 2Integration of palliative care as acomponent of comprehensive intensive care is now seen asmore appropriate for all critically ill patients, including thosepursuing aggressive treatments to prolong life.3It can bringconsiderable improvements in function and quality of life forseriously ill people and their families and can reducepsychological and spiritual distress.4 It is an approach that cangive a patient the opportunity to find purpose, self-worth, andcontrol at a time when they are experiencing a loss ofindependence. 4

Disability in patients with advanced cancer often resultsfrom bed rest, deconditioning, and neurologic andmusculoskeletal complications of cancer or cancer treatment.5

Physiotherapist in palliative careThe value of physiotherapy in palliative care has been

increasingly recognized over the past few decades, with a shiftin emphasis from a predominantly medical/nursing model of care,which focused primarily on symptom control, to a more inter-disciplinary, rehabilitative approach.6 In patients with advancingdisease, where functional limitations are unavoidable, thephysiotherapist is the expert in helping both patients and carerscope with these changes, whilst maximizing their potential toachieve realistic goals and thereby achieve optimal quality oflife. 6

Physiotherapy in the palliative setting should aim to enhancethe patient’s quality of life. This may be achieved by improvingfunction, or where this is not possible, by improving the patient’sand carer’s ability to cope with the patient’s deterioration. Afundamental goal of palliative care is the relief of pain and othersymptoms.7

Safe, effective physiotherapy intervention involves:• Medical screening prior to referral to physiotherapy;• Thorough assessment and regular reassessment of the

patient’s physical status with an acute awareness of theirpsychological, social, and spiritual well-being;

• An awareness of the multidimensional nature of symptomssuch as pain, dyspnoea, and fatigue and an holisticapproach to their assessment and management;

• Appropriate goal-setting according to the patient’s identifiedproblems and priorities;

• Modification of goals as the patient’s condition changes;• A problem-solving approach to management;• Clear and sensitive communication with the patient, carers,

and the inter-disciplinary team;• Effective communication between hospital, hospice, and

community settings;• The fostering of hope and prevention of feelings of

abandonment. 6

Physiotherapy approaches and techniques included are

Education and InstructionsPhysical therapy should focus on patient education

regarding comfortable and safe positions in which to rest or sit.5 Comfortable or relaxed positioning with pillows for relief ofcancer pain,especially pain caused by bone metastasis andabdominal discomfort.8 The physiotherapist may employ generalrelaxation techniques to control anxiety that often augments othersymptoms, including pain.

Patients with vertebral metastasis are taught not to rotatethe back.

Education in care giving techniques, such as transfertraining and positioning for comfort, of any person construed bythe patient as a family member may decrease a family’sperceived stress of providing care and a patient’s concern aboutbeing a burden.1Instruction by physical therapists in “hands-on”techniques reassures families that they will not hurt patientsand that it is important to touch, thus fostering social relationshipsand continuity in ways of relating that may have been disruptedby age and terminal illness. 1

Therapists could provide opportunities to discuss thepatients’ values and beliefs.Physical therapists who are able to

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listen to patients and discover the particular strategies thepatients are using may more effectively support these strategiesand integrate them into the format, focus, and goal setting usedin physical therapy interactions and interventions. 1 Therapistswho possess knowledge of their patients’ self-defining roles,routine pursuits, and valued relationships may be better equippedto tailor treatment to the individual. 1

By providing patients with opportunities to voice concerns,grief, and reflections related to what they are going through andby attentively listening to all that is said and intimated, cliniciansmay gain an understanding of their patients’ death-relatedanxieties. An intact knowledge of the physiological processesof death and variability in psychological reactions will enablephysical therapists to share with patients and families answersto general questions related to physiological signs and symptomsof active dying and the typical sequence of events. Openlycommunicating about the dying process, the normality offluctuating emotional levels and anticipatory grief may reducepatients’ fear of the unknown and reinforce coping abilities. 1

Therapeutic exerciseTherapeutic exercise aimed at improvement in muscle

strength, range of motion and balance. Weak muscles are foundand strengthened.Active, active assisted, passive and stretchingexercises relieve and prevent joint contracture, muscle spasmand deep vein thrombosis of the lower limbs. Proper sittingbalance is an important function, because it increasesindividuality and activity and decreases complications of the bedridden. 8 Exercise can counteract the effects of inactivity andimprove psychologic status. There is also some evidence thatimmune function may be improved by moderate exercise.Intensity of exercise should be at the lower end of the range. 5

Pain related to a specific activity or the impact of pain on theperformance of daily activities must be considered whenprescribing exercise. 5 Exercise is an effective holistic interventionas the patient may experience physical benefits such asimproved endurance, muscle strength and power, flexibility, andbalance in addition to psychological benefits such asimprovements in body image, confidence, social interaction, anddepression.6

Activities of Daily Living (ADL) exercises comprised bedexercises such as changing and maintaining positions, transferfrom bed to wheelchair and from wheelchair to toilet, as well aswheelchair exercises and ambulatory exercises. These exercisesare designed to enable patients to function with even a minimallevel of independence at the late terminal stage. 8

Endurance training aimed at physical fitness helps toincrease pulmonary and cardiovascular function. Chestphysiotherapy included diagraphmatic breathing exercises,relaxation exercises and postural drainage. 8

Physical modalitiesThe use of physical modalities such as massage, heat,

and cold can be implemented at bedside and aid in the painmanagement of patients. Their use may decrease the need forpain medications. Heat can be applied as hot packs, moist heat,and heat lamps. Heating soft tissues prior to a range of motionexercises and activity can decrease pain and muscle spasmand decrease joint stiffness. Heat should not be applied to skinareas that are insensitive, have been exposed to radiation, orare atrophic or acutely inflamed. Ice is usually applied as icepacks, ice compression wraps, or ice massage. Cold packsshould be sealed, flexible enough to conform to body contours,and applied to produce a comfortable and safe intensity of cold.Cold therapy as heat is contraindicated for areas of atrophicskin or skin that has been exposed to radiation therapy. Coldtherapy is also contraindicated for patients with Raynaudphenomenon or on ischemic limbs. 5

Transcutaneous Electrical Nerve Stimulation (TENS) is themost frequently used form of electro-therapy in the palliativesetting, generally used in the treatment of neuropathic, bone,and chronic pain. Physiotherapists working in palliative care arenow increasingly using acupuncture to treat pain in palliativepatients.9

Assistive DevicesThe prescription of assistive devices, such as canes,

walkers, and crutches, and the teaching of compensatorytechniques for mobility can aid in ambulation. 5 Environmentalmodification and simple equipment such as tub benches, raisedtoilets, and handlebars can have a significant impact in patients’overall function and aid in preserving independence in activitiesof daily living. 5 Supportive measures such as the provision ofcollars, slings, splints can also reduce pain whilst optimizingfunction and mobility. 5

Basically though the principles and approaches ofphysiotherapy are the same, in palliative care preciseobservations, frequent evaluations, sound clinical reasoning andcompassionate attitude is more important. Routine assessmenthas been shown to identify overlooked and unreportedsymptoms, facilitate treatment, and enhance patient and familysatisfaction Improved treatment of symptoms has beenassociated with the enhancement of patient and familysatisfaction, functional status, quality of life, and other clinicaloutcomes.

Palliative care and rehabilitation share common goals andtherapeutic approaches. Both disciplines have a multidisciplinarymodel of care, which aims to improve patients’ levels of functionand comfort The rehabilitation of terminally ill patients hasreceived little attention, and there is scarce data to support itsefficacy.5 Rehabilitation is the process of helping a person toreach the fullest physical, psychological, social, vocational, andeducational potential consistent with his or her physiologic oranatomic impairment, environmental limitations, desires, andlife plans. 5 During the rehabilitation of terminally ill patients,maintaining a balance between optimal function and comfortbecomes a key issue. Rehabilitation is unlikely to restore apremorbid level of function to these patients but may provide areasonable degree of independence and quality of life. 5

Rehabilitation goals for patients with advanced cancer must berealistic and take into consideration the stage of the disease;the patient’s medical status, cognition, and prognosis; and thesite of planned discharge. 5 Rehabilitation becomes an essentialcomponent of palliative care rather than an additional luxury.10 Itis an approach to care that focuses on setting goals, re-enablingpatients, and in helping them to adapt to their changedcircumstances so that they may live fulfilling lives

Rehabilitation in palliative care differs from rehabilitation ingeneral medicine. In palliative care, a rehabilitation programmemust be seen in the context of an illness that is uncertain andwill cause deterioration. Consequently, both patients andprofessionals need to understand the implications of a poorprognosis. 10

Palliative care clearly has an important role in patients withnon-cancer conditions who are in the advanced stages of theirillness and imminently dying. 10

The rehabilitative approach in palliative care is appropriatein all health care settings. Physician, Nurses Physiotherapists,occupational therapists, speech therapists, dietitians, socialservices, counselors are the main members of the palliative careteam. 10

Physiotherapy is an important part of the rehabilitationservice. The inclusion of physiotherapists in palliative care teamsin hospitals, hospices, and in the community is therefore of vitalimportance in helping to minimize patients’ discomfort andmaximize functional potential. 6

Factors related to functional improvement following a PT

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course were a higher albumin level and a diagnosis of dementia.Prospective trials of PT in palliative care patients are needed tobetter define response rate and predictors of response.9

Patients must be supported with strategies to cope with alife-threatening illness and, where possible, to come to termswith impeding death. In these circumstances, goals that fosterinsight and understanding may be more important than thosethat facilitate physical independence. For some individuals, thefocus may be their comfort, ease, and solace10.

Palliative care clearly has an important role in patients withnon-cancer conditions who are in the advanced stages of theirillness and imminently dying. The most common serious chronicdiseases that are relevant to a non-cancer rehabilitation practiceare chronic pulmonary disease, end-stage cardiac disease, andneurological disease. Chronic renal failure and end-stage liverdisease (ESLD) are also important to consider. Need forrehabilitation in respiratory, cardiac, neurology patients, etc., isunquestionable. 10

ConclusionThe physiotherapist has a vital role to play in maintaining

an optimal level of physical functioning in the palliative patient.This must be achieved via a process of realistic goal-settingwith the patient, being aware of the patient’s psychosocial needs,constant reassessment of the patient, and appropriate goal-modification. This translates to maximizing the patient’sindependence, and maintaining their hope in the face ofprogressive disability.

References1. Mackey KM,Sparling JW. Experiences of older women with

cancer receiving hospice care: significance for physicaltherapy. Phys Ther. 2000;80:459–468.

2. R. Sean Morrison, M.D., and Diane E. Meier, Palliative Care,N Engl J Med. 2004; 350

3. Nelson, Judith E.Danis, Marion. End-of-life care in theintensive care unit: Where are we now? Critical CareMedicine. 2001. 29(2) 2-9

4. Petty, T.L. Pulmonary rehabilitation in chronic respiratoryinsufficiency: 1. Pulmonary rehabilitation in perspective:historical roots, present status, and future projections.Thorax. 1993; 48, 855-862

5. Juan Santiago-Palma, Richard Payne. Palliative Care andRehabilitation. Cancer. 2001; 92: 1049–52.

6. Luke Doyle, Jenny McClure, Sarah Fisher.The contributionof physiotherapy to palliative medicine.Editors: Doyle,Derek; Hanks, Geoffrey; Cherny, Nathan I.; Calman,Kenneth.In Oxford Textbook of Palliative Medicine, 3rdEdition,Oxford University Press

7. O’Gorman, B. and Elfred, A. Physiotherapy. In Cancer PainManagement: A Comprehensive Approach (ed. K.H.Simpson and K. Budd), 2000. Oxford University Press;pp.63-73.

8. Yoshioka H.Rehabilitation for the terminal cancerpatient.Am J Phys Med Rehabil 1994;73:1999-206

9. Marcos Montagnini, Mohammed Lodhi, Wendi Born.Journal of Palliative Medicine.2003, 6(1): 11-17

10. Petty, T.L. Pulmonary rehabilitation in chronic respiratoryinsufficiency: 1. Pulmonary rehabilitation in perspective:historical roots, present status, and future projections.Thorax 1993 48, 855-862

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Comparing effectiveness of antero-posterior and postero-anteriorglides on shoulder range of motion in adhesive capsulitis - a pilotstudyHarsimran K*, Ranganath G**, Ravi SR***Department of Physiotherapy, Manipal University Karnataka, India. **Assistant Professor, Department of Physiotherapy, ManipalUniversity, Karnataka, India.

Corresponding Address:Harsimran KaurDepartment of Physiotherapy, Manipal college of Allied HealthSciences, Manipal University, Manipal, Karnataka, India.Email: simran.khurana.k@gmail.com

Abstract

ObjectiveTo compare the effectiveness of antero-posterior (AP) andpostero-anterior (PA) glide mobilization on external rotation rangeof motion (ROM) in patients with adhesive capsulitis.

MethodologyPatients referred to the department of physiotherapy with thediagnosis of primary adhesive capsulitis were included in thestudy. Subjects were from both gender groups between 35 to70 years of age, with capsular pattern of shoulder. Total of 15participants were included in the study by convenience samplingand were randomized to 2 treatment groups (antero-posteriori.e. AP and postero-anterior i.e. PA) by block randomization. APgroup consisted of 8 subjects & PA group consisted of 7 subjects.Out of 15 subjects 10 completed the study & 5 were lost tofollow up. Kaltenborn grade III mobilizations were provided toboth the groups, with direction of mobilizations directed anteriorlyin one group & posteriorly in the other group.Improvement inshoulder external rotation range of motion at 45° of abductionwas the primary outcome measure, with secondary outcomemeasures as Visual Analogue Scale (VAS) pain scores.

ResultsDescriptive analysis of 15 subjects using median andinterquartile values revealed that there was improvement in theprimary & secondary outcome measures in both the groups (AP& PA). There was no clinically significant difference betweenthe 2 groups.

ObservationBoth the glides antero-posterior (AP) and postero-anterior (PA)showed to be effective on external rotation range of motion inpatients with adhesive capsulitis.

KeywordsAdhesive capsulitis, mobilization, concex-concave rule

IntroductionAdhesive capsulitis or “frozen shoulder” is one of the

common pathologies leading to shoulder pain & dysfunction.1

Its prevalence in general population is reported to be 2%, withan 11% prevalence in individuals with diabetes.2 Denseadhesions & capsular restrictions in the dependent fold of thecapsule is characteristic of this condition.3 Adhesive capsulitis

is more common in women between fourth and sixth decade oftheir life.4

The onset of this condition is usually gradual and idiopathic,but it may also be acute and associated with history of minorinjury to the shoulder.5 Adhesive capsulitis has been dividedinto 2 types.3 Primary adhesive capsulitis, which refers to theidiopathic form of a painful and stiff shoulder & secondaryadhesive capsulitis, indicated as a loss of motion resulting frommany predisposing factors such as trauma, diabetes, stroke,upper extremity fractures or surgeries with immobilization.

Adhesive capsulitis is one of the most common, self limitingdisorders of the musculoskeletal system with a duration varyingfrom one to three years.6 Long term range of motion limitationslasting from 2 to 10 years may be suffered by 20-50% patientswith adhesive capsulitis. According to Cyriax, tightness in a jointcapsule results in a pattern of proportional motion restriction,called ‘capsular pattern’ in which the range of motion of externalrotation is more limited than abduction, which in turn is morelimited than internal rotation.7

In Frozen shoulder, there is global loss of both passive andactive range of motion of the glenohumeral joint with externalrotation usually being the most restricted physiologic movement,following the capsular pattern.8,9 This condition can be managedby physical therapy3, medical therapy5, corticosteroidintraarticular injections5, hydroplasty2, manipulation of the jointunder anaesthesia1 & surgical interventions.10 Physical therapycan include stretching, heating modalities, strengtheningexercises and mobilizations.5 Common joint mobilizationtechniques incorporated for improvement in range of motiondeficits are inferior, postero-anterior (PA ) & antero-posterior(AP) glides. According to Convex-Concave rule, the head of thehumerus glides anteriorly during external rotation.1 However inadhesive capsulitis different areas of capsular adhesions maybeseen, such as superior, anterior, inferior & posterior, causingthe humeral head to glide in a direction opposite to the capsulartightness, called the “Capsular Constraint Mechanism”.11

Arthrokinematics of the joints are considerd according tothe convex-concave rule.12,13 However deviations from this rulehave been reported in the literature.14,15 According to Howell etal with elevation and maximal lateral rotation of the arm, thecenter of the humeral head was positioned 4 mm posterior tothe center of the glenoid cavity, which is in contrast to the Convex-Concave rule.13,14 Similarly Harryman et al reported that withextension & lateral rotation, the humeral head translatedposteriorly, which according to him was due to asymmetricaltightening of the capsule during humeral rotation resulting intranslation of the humeral head in the direction opposite to thetightened capsule called “Capsular Constraint Mechanism”.13,15

Mid range mobilization (MRM), end range mobilization(ERM), & mobilization with movement (MWM) techniques havebeen advocated by Maitland,16 Kaltenborn,17 Mulligan.18

respectively. Kaltenborn’s concept of joint mobilization includesthree grades of mobilization.17Grade I are small amplitudedistraction applied with no stress on the capsule, grade II aredistraction/ glide applied to tighten the tissues around the capsule& grade III are large amplitude distraction/glide to stretch jointcapsule & surrounding periarticular structures.

Traditionally postero-anterior (PA) glides of the humeralhead have been used to improve external rotation range ofmotion, which is the direction of choice based on the Convex -

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Concave rule.17 However; Roubal et al & Johnson et al on thecontrary found that antero-posterior (AP) glide is effective inimproving external rotation range of motion in patients withadhesive capsulitis, which is in accordance with “CapsularConstraint Mechanism”.9,19

In order to assess the function of patients with shoulderproblems objectively, measurement of shoulder range of motionwith universal goniometer is advocated. Intratester andIntertester reliability of measuring passive range of motion forlateral rotation of the shoulder complex was found to be similari.e 0.96 and 0.97 respectively.20

MethodsA pre-test post-test study was conducted, involving the

patients referred to Physiotherapy department with the diagnosisof adhesive capsulitis. Subjects included in the study were males& females between 35 & 70 years of age, in their subacute orchronic stage with capsular pattern of shoulder i.e. externalrotation range of motion more limited than abduction, which inturn is more limited than internal rotation.Subjects with capsulartightness were differentiated from muscular tightness i.e.subjects with external rotation range restricted that worsenedwith abduction of shoulder were included in the study. Patientswith diabetes, neurological disorders, previous history of traumaor surgery of the affected shoulder were excluded from the study. Total of 15 patients were included in the study by conveniencesampling. Procedure was explained in detail & written informedconsent was obtained from them. Subjects were thenrandomized in 2 treatment groups by block randomization, groupAP (antero-posterior) & PA (postero-anterior). DuringRandomization 3 blocks were used, with each block consistingof 6 units (3 AP & 3 PA). Two blocks out of 3 were utilizedcompletely & from the 3rd block only 3 units were used. Afterallocation, group AP consisted of 8 & group PA consisted of 7

subjects.Investigators

Two investigators (qualified physical therapists) wereinvolved in the study. Primary investigator performed themobilization technique and second investigator was blinded tothe group allocation of the participants and measured range ofmotion before and after every treatment session.Outcome measures & instruments

Primary outcome measure selected was external rotationROM at 45°, with secondary measures as Visual Analogue Scale(VAS) pain scores. Universal Goniometer was used formeasurement of shoulder ROMs and 10 cm Visual AnalogueScale was used for recording pain scores.Procedure

Treatment technique selected was Kaltenborn grade IIImobilizations. Prior to intervention, demographic data i.e. age(in years), height (in cm), weight (in kg), dominant side, affectedside & duration of symptoms (in months) were recorded. Baselineclinical characteristics that were recorded prior to first treatmentsession included VAS pain scores, shoulder abduction ROM,internal rotation & external rotation ROM at 45° of shoulderabduction.

The shoulder range of motion was measured by theuniversal goniometer with the patient in supine on the treatmenttable. The baseline data & subsequent measurements after everytreatment session were recorded by the second investigator ofthe study. Subjects were followed up for 5 consecutive treatmentsessions, with 1 session provided per day. Prior to mobilization,moist heat was applied to the target shoulder for a time periodof 15 minutes. Patients were positioned appropriately on thetreatment table in supine position for AP glide mobilization(Figure 1) & in prone position for PA glide mobilization (Figure2). Affected limb was taken to available abduction range of motionand grade III Kaltenborn mobilizations were provided for 30

Table 1: Comparison of demographic data by group (Median & interquartile range)Group Gender Age(in years) Height(in cms) Weight(in kgs) Duration ofSymptoms

(in months)AP M=5F=3 52(50-57.8) 164.5(159-175.2) 67(55.2-77.8) 3(3-3.75)PA M=4F=3 56(49-62) 161.5(149-176.7) 62(57-75) 1.5(1-7)

AP = antero-posterior groupPA = postero-anterior groupM = MalesF = Females

Table 2: Comparison of clinical characteristics at baseline by group (Median & interquartile range)GP VAS ABD IR45 ER45AP 5.5(4.25-7) 90(90-107.5) 60(41.25-80) 33.5(30-42.5)PA 5(5-6) 90(85-120) 40(30-80) 20(16-55)

GP = GroupsVAS = Visual Analogue ScaleABD = Shoulder abductionIR45 = Internal rotation ROM at 45° abductionER45 = External rotation ROM at 45° abduction

Figure 2: Postero-anterior mobilizationFigure 1: Antero-posterior mobilization

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seconds duration. This technique was repeated for 5 times in 1treatment session. Physiologic movements of the affectedextremity were provided for 1 minute after every 30 seconds ofmobilization procedure. Post mobilization, moist heat wasapplied again for 15 minutes, followed by Codman’s exercisesand finger ladder exercises.3 Subjects were then advised tocontinue the same exercises at home.

Data analysisAs being a pilot study, statistical tests of significance were

not used. Data analysis was done using SPSS Version 16.0.Analysis was done by descriptive statistics. Median &Interquartile values were observed for all 15 participants. Theprimary outcome of the treatment was based on the change inmedian values of external rotation range of motion (at 45° & atend range of available abduction) from 1st treatment session tillthe 5th session and secondary outcomes were based on changein VAS pain score from 1st treatment session till the 5th session.

There was a loss to follow up of 5 participants out of 15,Median values of the lost data were included in the analysis forintention to treat analysis.

ResultsTotal of 15 subjects gave written informed consent and

participated in the present study. Out of them 10 participantscompleted all 5 treatment sessions and 5 were lost to follow up.From this lost data 3 were from AP group and 2 from PA group.Comparison of the median values of the demographic data (age,height, weight, duration of symptoms) of both the groups wasdone. (Table 1). Groups were also compared at baseline forVAS pain scores and shoulder range of motion (abduction,external rotation at 45° & end range of available abduction,internal rotation at 45° & end range of available abduction). (Table2). Median values of VAS and external rotation range of motion(at 45° & end of availiable abduction) were compared for changefrom 1st treatmant session to the 5th session. (Figure 3 & Figure4 respectively)

DiscussionThe results of present study show that both the mobilizations

(i.e. AP & PA) are effective in improving external rotation ROMin patients with adhesive capsulitis. Demographic data of boththe groups was seen to be similar, with the exception of durationof symptoms (DOS), where median value of DOS in AP groupwas 3 months and in PA group was one and half. There were 5males & 3 females in AP group and 4 males & 3 females in PAgroup. Hence both the gender had almost equal representation.

Baseline clinical characteristics , showed similarity in VAS painscores, abduction ROM & internal rotation ROM at availableend range of abduction. But variations were observed in external& internal rotation ROM at 45° abduction and external rotationat available end range of abduction.

Five subjects out of fifteen were lost to follow up. Threewere from AP group and two from PA group. Two subjects fromAP group underwent Manipulation under anaesthesia and otherthree subjects could not be followed due to personal constraints.Data of these five subjects was analyzed for intention to treatanalysis. None of the patients included in the study reported ofany kind of trauma or surgery minor or major of the affectedshoulder. All the 15 subjects were right side dominant & nineout of them had their non-dominant side as the affected side.Onset of symptoms was reported to be of gradual in nature inmost of the subjects. At baseline both the groups showedsimilarity with regards to VAS pain scores & reduction in painscores was observed in both the groups over a period of fivetreatment sessions. This reduction in pain was seen to be almostsimilar in both the groups and was considered to be clinicallysignificant.

In case of shoulder ROMs, improvement was observed inall the shoulder ranges in both the groups, with the exception ofinternal rotation ROM at 45° of abduction, where no change inROM was observed over five treatment sessions. This resultcould be attributed to the fact that internal rotation at 45°abduction in most of the subjects was nearly full prior to thetreatment & did not change in subsequent treatment sessions.Improvement observed in ROMs seems to be more in AP groupas compared to PA group, for abduction, external rotation at 45°& internal rotation at end range of abduction, whereas PA groupseems to better for external rotation at end range of abduction.However, the improvements observed are not clinicallysignificant. These changes observed could be due to smallsample size or standard measurement errors.

Results of our study seem to be different from the study byJohnson et al, where improvement in external rotation was foundin AP group, as no clinically significant improvement wasobserved in external rotation ROM at 45° and end range ofavailable abduction in our study. However the two studies arenot comparable as no statistical test of significance wasperformed in our study due to small sample size. Improvementsseen in the primary outcome (i.e. external rotation at 45°abduction) in both the groups could be attributable to either ofthe two mechanisms;Concave-convex rule which might beresponsible for improvement in PA group or capsular constraintmechanism which might be responsible for improvement in APgroup. There were some limitations of the present study likeexternal rotation ROM was not measured at the same availableend range abduction , where the initial value was measuredand Daily pre-treatment VAS & external rotation ROM values

ABD= abduction ROM, IR45= internal rotation at 45° abduction,ER45= external rotation at 45° abduction

Figure 4: Comparison of ROMs by group (Median & interquartilerange)

Group —:

RO

M (D

EGR

EES)

X-axis: Groups, AP = antero-posterior group, PA = postero-anterior groupY-axis: Difference in VAS scores pre & post treatment

Figure 3: Comparison of VAS scores by group (Median &interquartile range)

VAS

SCO

RE

DIF

F

Group —:

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were not recorded.

ConclusionBoth the glides antero-posterior (AP) and postero-anterior

(PA) showed to be effective on external rotation ROM in patientswith adhesive capsulitis. Study with larger sample size and

keeping all the limitations in mind is recommended.

References1. Roubal PJ, Dobritt D, Placzek JD. Glenohumeral gliding

manipulation following interscalene brachial plexus blockin patients with adhesive capsulitis. J Orthop Sports PhysTher. 1996; 24: 66-77.

2. Andre R, Thierry HM. Adhesive capsulitis. Upper limbmusculoskeletal conditions. Physical Medicine &Rehabilitation articles [Online]. [2009 Oct 15] [Cited 2010April 10]. Available from: http://emedicine.medscape.com/article/326828.

3. Carolyn K, Lynn C. Therapeutic exercise: Foundations &Techniques. 4th edition. Columbus: F A Davis Co; 2002.

4. Smith LL, Burnett SP, McNeil JD. Musculoskeletalmanifestations of Diabetes Mellitus. Br J sports Med 2003;37: 30-38.

5. Neviaser RJ, Neviaser TJ. The frozen shoulder- Diagnosisand management. Clin Orthop Relat Res 1987 (223): 59-64.

6. Neviaser JS. Arthrography of the shoulder joint. Study offindings in adhesive capsu-litis of the shoulder. J Bone JointSurg Am 1962 Oct; 44: 1321-59.

7. Donald A N. Kinesiology of the musculoskeletal system. 3rd

edition. Elsevier science health science; 2002.8. Nicholson GG. The effects of passive joint mobilization on

pain and hypomobility associated with adhesive capsulitisof the shoulder. J Orthop sports Phys ther 1985; 6: 238-246.

9. Andrea J. J. The effect of anterior versus posterior glidejoint mobilization on external rotation range of motion inpatients with adhesive capsulitis. J Orthop sports Phys ther2007 March; 37 (3): 88-99.

10. Paul D G, F Buck W. Adhesive capsulitis and dynamicsplinting- a controlled cohort study. BMC Musculoskeletaldisorders 2009; 10: 111.

11. Peter J.R. Shoulder kinematics in subjects with frozenshoulder. Arch Phys Med Rehab 2003 October; 84: 1473-1479.

12. Kaltenborn FM. Manual Mobilization of the Extremity Joints.4th edition Olaf Norlis Bokhandel (Oslo); 1989.

13. Ar-Tyan H, Tom H, Jia H, Chuong V, Larry H, Sally H et al.Changes in abduction and rotation range of motion inresponse to simulated dorsal and ventral translationalmobilization of the glenohumeral joint. Physical Therapy2002 June; 82 (6): 544-556.

14. Howell SM, Galinat BJ, Renzi AJ, Marone PJ. Normal andabnormal mechanics of the glenohumeral joint in thehorizontal plane. J Bone Joint Surg Am 1988; 70: 227–232.

15. Harryman DT II, Sidles JA, Clark JA. Translation of thehumeral head on the glenoid with passive glenohumeralmotion. J Bone Joint Surg Am 1990; 72: 1334–1343.

16. Maitland GD. Treatment of the glenohumeral joint bypassive movement. Physiotherapy 1983; 69: 3–7.

17. Kaltenborn FM. Manual Therapy for the Extremity Joints.2nd edition. Olaf Norlis Bokhandel (Oslo); 1976.

18. Mulligan BR. Mobilisations with movement. J ManualManipulative Ther 1993; 1: 154 –156.

19. Placzek JD, Roubal PJ, Freeman DC, Kulig K, Nasser S,Pagett BT. Long-term effectiveness of translationalmanipulation for adhesive capsuli-tis. Clin Orthop Relat Res1998 Nov; 356: 181-91.

20. Boone Dc. Reliability of goniometric measurements. Phystherapy 1978; 58: 1355.

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Effect of 12 weeks weight bearing and non weight bearing aerobicexercises on overweight and obese individualsJ. Deepa1, Monalisa Pattnaik2, P.P Mohanty3, Venkadesan. R4

Post Graduate Student1, Lecturer2, Head of the Department3, Swami Vivekananda National Institute of Rehabilitation Training andResearch (SVNIRTAR), Cuttack, Orissa, Lecturer4, Lovely Professional University, Jalandhar, India

Abstract

ObjectiveTo find out the effect of 12 weeks weight bearing and non weightbearing aerobic exercises on overweight and obese individuals

MethodsThirty subjects were selected and divided into three groups; 10in each, namely group I, group II and group III. Subjects in groupI received weight bearing aerobic exercise, subjects in the groupII received non weight bearing aerobic exercise and subjects inthe group III received no treatment. Treatment outcomes wereassessed on the basis of abdominal circumference, skin FoldThickness, body mass, resting heart rate and resting systolicBP.

Results & ConclusionThere is no difference between weight bearing aerobic exerciseand non weight bearing aerobic exercise performed at similarintensity, duration and frequency with regard to abdominalcircumference, skin fold thickness, body mass, resting heart rateand resting systolic blood pressure. This suggests that nonweight bearing aerobic exercise and weight bearing aerobicexercise are equally beneficial as a weight reduction program

KeywordsObesity, Aerobic exercise, Weight bearing, Non weight bearing

IntroductionObesity is defined simply as a condition of abnormal or

excessive fat accumulation in adipose tissue, to that extent thathealth may be impaired1. Obesity is a world wide epidemic6,with more than one billion adults overweight, at least 300 millionof them being clinically obese and is a major contributor of globalburden of chronic diseases and disability2. Health careprofessionals should be concerned about overweight and obesitybecause of the well established relations between excess bodyweight and such medical conditions as Hypertension, Coronaryheart disease, Type II diabetes mellitus, Stroke, Osteoarthritisand other chronic disorders, that reduce the quality of life2,3,4,5,6.In 1997, World Health Organization published a landmarkdocument recognizing obesity as a world wide disease1. TheWHO recently stated that “the growth in the number of severelyoverweight adults is expected to be double that of underweightduring 1995 – 2025” (WHO 1998). An Indian study recentlyrevealed that almost 20% adults who were not overweight orobese still had central obesity, putting them at a greater risk ofdeveloping associated disease (Gopalan 1998)7. Obesity inadulthood is associated with an increased risk of disabilitythroughout life and a reduction in the length of time spent freeof disability, but no substantial change in the length of time spentwith disability1,7. Strong evidence links obesity to increasedmorbidity and mortality6,8,9. Excess body weight is a result of an

imbalance between energy intake and energy expenditureresulting in the storage of the excess energy, primarily as fat10.The important fact that is to be considered is that in case ofobese persons the deposition of the fat takes place in the exterior(subcutaneous tissue), around the internal organ, and theintermuscular space, which makes the obese person furtherinactive8. On the other hand, sustained elevation of energy outputto levels greater than those of energy input creates an energyimbalance that reverses this process10. Based on scientificevidence, there are a number of intervention strategies that canbe used to induce and maintain significant weight loss11. In thehuman system, energy expenditure has three primary outlets:(i). Resting metabolic rate. (ii) The thermic effect of food. (iii).Physical activity, of the three outlets, physical activity is the onemost readily manipulated. An increase in physical exercise thusappears to be a logical method for achieving the negative energybalance necessary for weight loss10, 32. In human beings, adiposetissue constitutes the major form of energy storage. It followslogically that in situations of negative energy balance, fat storeswill be called upon to make up the energy deficit, thus reducingthe total amount of body fat and producing a loss in weight10.Although caloric value remains the cornerstone of obesityreduction, physical activity in the form of structural exercisecontributes to the creation of an energy deficit by increasingtotal energy expenditure & that the exercise induced weight lossis associated with greater reduction in total body fat, apreservation of lean tissue mass & an increase in cardio-respiratory fitness, in comparison with equivalent diet inducedweight loss12. Aerobic exercise for the obese population shouldconcentrate on the frequency of sessions. Low intensity exerciseis often considered the most appropriate method of increasingenergy expenditure for weight loss purposes because theproportion of lipid organized under these conditions is higherthan that oxidized during vigorous exercise10, 12. Robert Ross etal in the year 2000 conducted a randomized controlled trial whichaimed at determining the effects of equivalent diet or exerciseinduced weight loss & exercise without weight loss onsubcutaneous fat, visceral fat, skeletal muscle mass & insulinsensitivity in obese men. The study was conducted with 52obese men for 3 months. He concluded that weight loss inducedby increased daily physical activity without caloric restrictionsubstantially reduces obesity and exercise without weight lossreduces abdominal fat and prevents further weight gain13. Thereare people who are referred for weight reduction programmebut still cannot carry out common weight reduction programmeswhich involves weight bearing activities like walking, running,jumping, stair climbing etc. eg. Osteoarthritis and ligament injurypatients whose conditions may be worsened when they carryout such activities. So there is a necessity to design weightreduction program for such disabled people.

A current comment on energy expenditure is differentmodes of exercise written for the American college of sportsmedicine by Len Kravitz Ph. D & Chantal A. Vella M.S hasexplained that at the same level of intensity, most persons willexpend more calories performing a weight bearing activity14. Butstill the individual effects of weight bearing and non weightbearing exercise on obesity & compared effects of the weight –bearing and non weight bearing exercise remains to beinvestigated. Therefore this study is aimed to determine theeffectiveness of weight bearing and non weight bearing aerobic

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exercise in overweight and obese individuals.

MethodsSubjects: A total of 30 subjects with obesity were selected

in SVNIRTAR, between Nov 2005 to Dec 2006 by randomsampling method. They volunteered to take part in the studyand met the following inclusion criteria: (i) Male/female. (ii)Age: 20-45 yrs. (iii) BMI: 25-35. (iv) Subjects who meet thephysical activity readiness questionnaire.Exclusion criteriawere (i). Uncontrolled Hypertension. (ii) Pregnancy. (iii) Use ofany medication that affect the body composition, lipids or glucosemetabolism. (iv) Activity restriction due to disease, unstablecardiac or pulmonary disease, significant arthritis. (v) DiabetesMellitus. All participants gave their written informed consentbefore participation in the study. Before initiation of the study,institutional review board approval was obtained.

ProcedureThe subjects were divided into three groups; 10 in each,

namely group I, group II and group III. After the assignment intogroups, a day before the exercise program started, all thesubjects were subjected to baseline measurements. The restingheart rate, resting blood pressure, abdominal circumference,skin fold thickness and body mass were tested in order, by theinvestigator. The therapy was started the day after themeasurement was taken. Subjects in group I received weightbearing aerobic exercise, subjects in the group II received nonweight bearing aerobic exercise and subjects in the group IIIreceived no treatment. All the subjects were informed not tochange their eating habits and not to take any medications toreduce weight, and subjects in the control group (group III) werealso asked not to participate in any extra physical activities morethan they do normally. The subjects in group I & II receivedaerobic exercise 5days in a week for 12 weeks, at an intensityof 40% to 50% of THR calculated using Karvonen’s formula. Itwas confirmed that none of the subjects in the study receivedany other form of exercise. The data were collected after 12weeks and was statistically analysed.

Data analysisThe dependent variables were analysed using 3 X 2

ANOVA, with repeated measures of the second factor. Therewas one between factor with three levels (Group – weight bearingaerobic exercise, non weight bearing aerobic exercise andcontrol group), and one within factor with two levels (Time –pre, post). All pair wise, post-hoc comparisons were done usinga 0.05 level of significance.

ResultsABDOMINAL CIRCUMFERENCE: There was a main effect fortime F 1,27,0.05 = 26.817, p = 0.000 and there was also a maineffect for time X group interaction, F 2,27,0.05 =11.397, p = 0.000.However there was no main effect for group F 2,27,0.05 = 0.516, p= 0.603. Tukey’s HSD analysis showed that both the weightbearing and non weight bearing aerobic exercise group improvedsignificantly compared to the control group. However, there wasno significant difference between the exercise groups.

SKIN FOLD THICKNESS: There was a main effect for time, F1,27,0.05 = 81.343, p = 0.000 and there was no main effect forgroup, F 2,27,0.05 = 2.164, p = 0.134. However the main effectwas qualified by time X group interaction, F 2,27,0.05 = 32.828, p =0.000. Tukey’s HSD analysis showed that both the weightbearing and non weight bearing aerobic exercise group improvedsignificantly compared to the control group. However, there wasno significant difference between the exercise groups.

BODY MASS: There was a main effect for time, F 1,27,0.05 = 16 ,p = 0.000and there was also a main effect for time X groupinteraction, F 2,27,0.05 = 15.063, p = 0.000. However there was nomain effect for group F 2,27,0.05 = 0.050, p = 0.952. Tukey’s HSDanalysis showed that both the weight bearing and non weightbearing aerobic exercise group improved significantly comparedto the control group. However, there was no significant differencebetween the exercise groups.

RESTING HEART RATE: There was a main effect for time F1,27,0.05 = 95.184, p = 0.000 and there was a main effect for timeX group interaction F 2,27,0.05 = 32.423, p = 0.000. However themain effect for the group was also qualified, F 2,27,0.05 = 5.238, p= 0.012. Tukey’s HSD analysis showed that both the weightbearing and non weight bearing aerobic exercise group improvedsignificantly compared to the control group. However, there wasno significant difference between the exercise groups.

RESTING SYSTOLIC BLOOD PRESSURE: There was a maineffect for time, F 1,27,0.05 = 86.901, p = 0.000 and there was nomain effect for group, F 2,27,0.05 = 0.564, p = 0.575. However thismain effect was qualified by time X group interaction, F 2,27,0.05 =21.725, p = 0.000. Tukey’s HSD analysis showed that both theweight bearing and non weight bearing aerobic exercise groupimproved significantly compared to the control group. However,there was no significant difference between the exercise groups.

DiscussionThe overall results of the study showed reduction in

abdominal circumference, skin fold thickness, body mass, restingheart rate and resting systolic blood pressure in both weightbearing aerobic exercise group and non weight bearing aerobicexercise group compared to the control group. However therewas no statistically significant difference between theexperimental groups with regard to the above variables. Thisstudy suggests that the results obtained with non weight bearingexercise were as beneficial as those obtained with the weightbearing aerobic exercise in overweight and obese individuals.

ABDOMINAL CIRCUMFERENCE: The findings of the studyshowed significant reduction in abdominal circumferencemeasured at the level of umbilicus in both the exercise groupscompared with the control group. However there was nosignificant difference between the exercise groups. This issupported by the following studies. In 2001 Daniel W. Schmidtin his study of long versus short bout exercise on fitness andweight loss in female college students found significant reductionin abdominal girth measurement (at the level of umbilicus).Sojung Lee et al (2005) found significant reduction in waistcircumference (at the level of the last rib) in a 13 week aerobicexercise intervention program that consisted of either walkingor light jogging on a treadmill for 60 minutes, 5 times per weekat a moderate intensity (60% of peak oxygen uptake). Jakicicet al in 1999 conducted a randomized trial in sedentaryoverweight women evaluating the effects of intermittent withtraditional continuous exercise on weight loss, adherence andfitness in which there was significant reduction in the waistcircumference following 18 month program which includedexercise and behavioural weight control program. Hidekishimamoto in 1998 compared the effectiveness of low impactaerobic dance for 60 minutes for a total duration of 3 months,consisting of diet and exercise prescription found significantreduction in the waist circumference.The reduction in abdominalcircumference in this study can be attributed to reduction inabdominal fat, which is not reduced selectively from theexercised areas, but rather from total body fat reserves and isusually from the areas of greatest fat concentration. It is believedthat an increase in a muscle’s activity facilitates a relativelygreater fat mobilization from the storage areas. Excess fat in

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the abdominal area is more active metabolically than fat locatedin the other areas33. The lack of significant difference inabdominal circumference reduction between the weight bearingand non weight bearing aerobic exercise group may be attributedthat both the exercises had similar effects.

SKIN FOLD THICKNESS: This study demonstrated significantreduction in skin fold thickness in both the experimental groupscompared with the control group. However there was nosignificant difference between the experimental groups. Thesefindings are supported by the following studies. Slentz et al(2005) in a randomized controlled trial found significantdecreases in visceral, subcutaneous and total abdominal fat,without changes in caloric intake. Robert Ross et al (2005)reported significant reductions in subcutaneous adipose tissueand visceral adipose tissue. Robert Ross and Janssencolleagues (2004) conducted a 14 week intervention programreported greater reduction in total fat and abdominalsubcutaneous fat in the exercise group. Susan B Racette et al(1995) reported significant reduction in fat mass in the aerobicexercise group. Brocham CAG et al (2005) examined the effectof 8 weeks of stair climbing on blood lipids reported significantreduction in low density lipoprotein cholesterol. The reductionin skin fold thickness may be attributed to the mobilization oflipids from adipose tissue which plays a key role in the regulationof free fatty acid use as a energy substrate for skeletal musclemetabolism during endurance exercise, especially prolongedexercise of low to moderate intensity. The rate of mobilizationof free fatty acid from adipose tissue is largely dependent onthe rate of lipolysis. Rate of adipose tissue lipolysis increaseswith exercise duration. Adipose tissue lipolysis is under hormonal

regulation. The essential changes promoting increased lipolysisduring whole-body exercise are increased sympathoadrenal â-adrenergic stimulation and decreased circulating insulin levels.Upon their mobilization from adipose tissue, free fatty acidcirculate in plasma. The exercise – induced increase in plasmaFFA availability is important because it is a contributing factorfor the regulation of FFA use by muscle. During low to moderateexercise intensity in humans, the gradual increase in plasmaFFA concentration is associated with an increase in the FFAturnover and oxidation35. The main effect with time in both theweight bearing and non weight bearing aerobic exercise groupmay be attributed to the above fact. The lack of significantdifference between the weight bearing and non weight bearingexercise group reveals that both the exercise has contributedsimilar effects.

BODY MASS: The result of this study showed significantreduction in body mass in both the non weight bearing and weightbearing aerobic exercise group compared with the control group.However there was no significant difference between theexperimental groups. The findings are in accordance with thefollowing studies. In 2001 Daniel W. Schmidt et al evaluated theeffects of long versus short bout exercise on fitness and weightloss in females in 12 week duration at an intensity of 75% ofheart rate reserve using treadmill found significant reduction inbody mass. Robert Ross and Janssen Colleagues (2004)conducted a 14 week intervention program with brisk walkingand light jogging in treadmill and reported reduction in bodyweight in exercise weight loss group. Slentz et al (2005)conducted a randomized controlled study of exercise intensityand amount for duration of 8 months, reported significant

APPENDIXMASTER CHARTS. No Group Sex Age Abdominal Skin Fold Body mass Resting Resting

circumference Thickness Heart Rate Systolic BPPre Post Pret Post Pre Post Pre Post Pre PostTest Test Test Test Test Test Test Test Test Test

Group-I1 1 M 39.00 95.50 93.60 154.32 125.99 73.00 72.00 82.00 77.00 126.00 120.002 1 M 39.00 92.00 91.00 130.31 100.31 67.00 67.00 85.00 81.00 110.00 106.003 1 F 33.00 94.00 84.00 140.31 118.33 69.00 67.50 93.00 87.00 120.00 118.004 1 F 32.00 91.00 91.00 148.65 111.30 67.00 67.00 90.00 78.00 110.00 102.005 1 F 20.00 109.00 99.00 152.99 128.32 75.00 73.00 90.00 85.00 120.00 116.006 1 F 28.00 90.20 88.50 135.65 104.64 77.00 77.00 87.00 80.00 116.00 110.007 1 F 21.00 86.00 83.50 142.99 118.66 65.00 64.00 85.00 78.00 110.00 100.008 1 F 20.00 90.00 80.00 148.65 132.66 68.00 66.50 90.00 84.00 110.00 104.009 1 F 20.00 92.00 85.50 146.62 123.63 73.00 70.50 92.00 82.00 110.00 104.0010 1 M 28.00 86.00 85.00 147.89 110.90 70.00 69.50 88.00 88.00 120.00 118.00

Group-II11 2 M 20.00 96.00 91.00 68.65 140.32 66.00 66.00 78.00 72.00 120.00 116.0012 2 M 26.00 97.00 93.00 97.32 90.64 90.00 89.00 84.00 78.00 110.00 100.0013 2 M 38.00 94.00 88.50 111.32 103.32 77.00 76.00 89.00 83.00 120.00 116.005 2 F 20.00 104.50 100.30 206.98 181.98 86.00 85.00 88.00 82.00 110.00 106.0016 2 F 42.00 94.00 87.00 186.99 133.98 65.00 63.00 90.00 87.00 120.00 118.0017 2 F 20.00 76.00 73.00 124.32 99.99 55.00 55.00 89.00 82.00 110.00 100.0018 2 F 20.00 82.00 78.00 126.64 84.32 57.00 55.00 89.00 84.00 110.00 104.0019 2 M 28.00 89.00 87.00 146.32 133.65 65.00 63.00 85.00 80.00 120.00 114.0020 2 M 38.00 95.00 93.00 121.66 101.32 71.00 70.00 87.00 81.00 120.00 116.00

Group-III21 3 F 38.00 93.50 96.00 189.66 193.33 66.00 67.00 89.00 89.00 118.00 118.0022 3 F 32.00 90.00 90.00 151.98 152.00 52.00 52.00 88.00 90.00 110.00 110.0023 3 F 23.00 88.00 89.00 147.98 160.00 59.00 60.00 89.00 89.00 110.00 110.0024 3 F 22.00 90.00 90.00 147.99 147.33 65.00 65.00 90.00 90.00 110.00 110.0025 3 M 41.00 94.50 94.50 150.66 154.32 72.00 73.00 83.00 83.00 126.00 126.0026 3 M 26.00 96.00 98.00 153.31 156.00 79.00 80.00 86.00 89.00 120.00 120.0027 3 M 26.00 84.00 86.00 101.98 108.32 72.00 73.00 87.00 88.00 110.00 110.0028 3 M 36.00 92.00 92.00 114.65 116.65 67.00 67.00 88.00 88.00 120.00 120.0029 3 M 29.00 100.00 100.00 160.98 171.33 91.00 91.00 92.00 92.00 120.00 120.0030 3 M 28.00 96.00 96.00 150.99 152.66 84.50 84.50 88.00 88.00 110.00 110.00

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reduction in body weight with the exercise group. The significantreduction in body mass in both the weight bearing and non weightbearing aerobic exercise groups with time might be ascribed tounbalancing the energy balance equation by increasing caloricoutput through endurance-type exercise33. The lack ofsignificance difference between the weight bearing and nonweight bearing aerobic exercise group suggests that both theexercises has attributed similar effects on body mass. The resultof this study differ from the study of Sojung Lee et al (2005) whoexamined the effects of exercise without weight loss on obesityreduction in obese individuals and did not find any significantreduction in body weight following 13 week of aerobic exerciseas the subjects consumed the calories required to compensatefor the energy expended during the exercise session.

CARDIOVASCULAR ENDURANCE (RESTING HEART RATEAND RESTING SYSTOLIC BLOOD PRESSURE) : The currentstudy demonstrated significant improvement in thecardiovascular endurance (Resting heart rate and resting systolicblood pressure) in both the weight bearing and non weightbearing aerobic exercise group compared to the control group.However there was no significant difference between theexperimental groups. The findings are in accordance with thefollowing studies. Daniel Schmidt et al (2001) aimed to determineif three 10 minute bouts of exercise per day (3 X 10) and two 15minute bouts per day (2 X 15) were as effective as one 30 minutebout per day (1 X 30) for improving VO2max and weight lossand found significant improvement in the VO2max and reductionin the resting heart rate in the exercise groups, but not in thecontrol group. Marcia L. Stefanick (2000) examined the effectsof diet and exercise in men and menopausal women with lowlevels of HDL cholesterol and high levels of LDL cholesteroland found significant improvement in the maximal oxygenuptake. Johan M. Jakicic et al (1999) examined the effects ofintermittent exercise and use of home exercise equipment andfound significant improvement in the cardio respiratory fitness(resting heart rate, resting blood pressure). Anderson et al (1999)examined effects of lifestyle activity vs. structured aerobicexercise in obese women found significant improvement inmaximum oxygen capacity, reduction in resting heart rate andresting blood pressure. The reduction in the resting heart rate inthe weight bearing and non weight bearing aerobic exercisegroup over the control group in the present study can beattributed to the central adaptations. Stimulation of thesympathetic cardioaccelerator nerves releases epinephrine andnorepinephrine, which accelerate the depolarization of the sinusnode. Acetylcholine, the hormone of the parasympatheticnervous system, retards the rate of sinus discharge and slowsthe heart rate. The effect is largely mediated through the actionof the vagus nerve whose cell-bodies originate in the cardio-inhibitory centre in the medulla. Vagal stimulation has essentiallyno effect on myocardial contractility. Exercise training createsan imbalance between tonic activity of the sympatheticaccelerator and parasympathetic depressor neurons in favourof greater vagal dominance. This is mediated primarily by anincrease in parasympathetic activity perhaps a decrease insympathetic discharge. In addition, training may also decreasethe intrinsic rate of firing of SA node. The lack of significantdifference between the exercise groups attributes that both theexercises have similar effects. The mechanism for the exercise-lowering effect on blood pressure in weight bearing and nonweight bearing aerobic exercise may be due to the reduction ofthe catecholamines with training. This response would contributeto a decrease in peripheral resistance to blood flow and asubsequent reduction in blood pressure. Exercise training mayalso facilitate the elimination of sodium by the kidneys tosubsequently reduce fluid volume and blood pressure33, 36. Themain effect with time in both the weight bearing and non weightbearing aerobic exercise group may be attributed to the above

fact. The lack of significant difference between the exercisegroups attributes that both the exercises have similar effects.The lack of significant difference between the weight bearingand non weight bearing aerobic exercise groups in all thevariables may be due to the fact that both the weight bearingand non weight bearing aerobic exercises were performed atsame intensity, duration and frequency.

ConclusionThere is no difference between weight bearing aerobic

exercise and non weight bearing aerobic exercise performed atsimilar intensity, duration and frequency with regard to abdominalcircumference, skin fold thickness, body mass, resting heart rateand resting systolic blood pressure. This suggests that nonweight bearing aerobic exercise and weight bearing aerobicexercise are equally beneficial as a weight reduction program.The above findings suggests that non weight bearing aerobicexercise can be prescribed as a weight reduction program forthe individuals who should not carry out weight bearing activitiesas a prophylaxis measure and cannot perform weight bearingactivities owing to pain and other disabilities.

Limitations(i) Small sample size(ii) Carry over effect of the exercise group was not observed.(iii) Other aspects like visceral fat, lipid levels, cholesterol levels,

energy expenditure index and aerobic capacity which areclosely related to obesity program was not observed.

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14. Len Kravitz et al. energy expenditure in different modes ofexercise. American college of Sports Medicine. CurrentComment. June 2002.

15. Boreham CAG et al. Training effects of short bouts of stairclimbing on cardio-respiratory fitness, blood lipids andhomocysteine in sedentary young women. Br. J. SportsMedicine. 2005; 39; 590 – 593.

16. Sojung lee et al. Exercise without weight loss is an effectivestrategy for obesity reduction in obese individuals with andwithout type 2 diabetes. J. Appl. Physiol. 2005; 99; 1220 –1225.

17. Slentz et al. Inactivity, exercise and visceral fat. STRRIDE:A Randomized, Controlled study of exercise intensity andamount . J. Appl. Physiol. 2005, 99, 1613 – 1618.

18. Robert Ross and Ian Janssen et al: Exercise – Inducedreduction in obesity and insulin resistance in women: ARandomized Controlled Trial. Obesity Research: 2004; 12;789 – 798.

19. Robert W. Jeffery et al: Physical activity and weight loss:Does prescribing higher physical activity goals improveoutcome. Am. J. Clin. Nutr. 2003; 78; 684 – 9.

20. Cheung et al: An eight week exercise programme improvesphysical fitness of sedentary female adolescents.Physiotherapy. April 2003, 89, No.4, 249 – 255.

21. Van Aggel – Leijssen et al. The effect of low-intensityexercise training on fat metabolism of obese women.Obesity Research. Feb 2001; Vol. 9; No.2, 86 – 96.

22. Daniel w. Schmidt et al: Effects of long versus short boutexercise on fitness and weight loss in overweight females.J. of the Am. College of Nutrition. 2001; Vol. 20, No. 5, 494– 501.

23. Marcia L. Stefanick et al. Effects of diet and exercise nmen and postmenopausal women with low levels of HDLcholesterol and high levels of LDL cholesterol. N. Engl. J.Med. November1998; 339: 1552 – 1553.

24. John M. Jackicic et al. Effects of intermittent exercise anduse of home exercise equipment on adherence, weight lossand fitness in overweight women. A Randomized Trail.JAMA; 1999; 282; 1554 – 1560.

25. Ross E. Anderson et al. Effects of lifestyle activity Vs.Structured aerobic exercise in obese women. JAMA.1999;281; 335 – 340.

26. Hikdeki Shimamoto et al. Low impact aerobic dance as auseful exercise mode for reducing body mass in mildlyobese middle – aged women. Applied Human Science.Journal of physiological Anthropology. 1998; 17; 3; 109 –114.

27. Ruth S. Weinstock. Diet and exercise in the treatment ofobesity. Effect of 3 interventions on insulin resistance. Arch.Intern. Med. 1998; 158; 2477 – 2483.

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Effect of functional strength training on functional motorperformance in young children with cerebral palsyDharam Pani Pandey*, Vimal Tyagi***Head Department of Physiotherapy & Rehabilitation Sciences, Jaipur Golden Hospital, Rohini Delhi-110085, **Lecturer Physiotherapy,Imperial University, Lucknow, UP

Abstract

ObjectiveThe main objective of this study was to determine the effects

of task-specific strength training of lower limb on functional motorperformance in children with spastic cerebral palsy, and to assessthe feasibility of closed kinetic chain exercise on functionalmotor abilities in children with cerebral palsy.

Design of studyA single blinded randomized controlled intervention study

consisted of two groups and three measurements, preintervention, post intervention and follow up.

Participants18 children with spastic diplegia among them 11 were male

and 7 were female. All the subjects were received physiotherapypreviously and none were allowed to attend physiotherapy otherthan intervention protocol.

Main outcome MeasuresFunctional strength was assessed by Lateral step up test,

functional motor performance was assessed by minimum heightchair test, motor assessment scale( sit to stand item), 10 meterwalk test, 2- minute walk test.

ResultsThe lateral step up test of both, the left leg (p=0.002),

(F=22.57) and the right leg (p=0.001), (F=44.8) demonstratedthe significant improvement where as control group did notshowed any such significant improvement, left leg (p=0.502),(F=0.476) and right leg (p=0.332), (F=1). Motor assessmentscale – sit-to –stand item showed significant (p=0.041), (F=4.92)change pre to post training as compared to control group.Minimum height chair test score demonstrated significantimprovement in intervention group (p=0.001) post training. Incontrol group there was no such significant (p=0.88),) F=0.02)changes noted. All the gain in intervention group was maintainedat follow up without any significant decline.

ConclusionThe result of present randomized clinical study support the

view that a four week functional strength training programmeconsisting of weight bearing exercises functional strength ofmuscle of lower extremity and also improves functional motorperformance such as walking, running, stair climbing, sit to standin young children with spastic diplegic cerebral palsy, the findingare in agreement with other previous studies which have shownthat functional strength training in cerebral palsy is associatedwith improvement in motor functions. Results of this studyprovides the ground for future research with a larger samplesize and longer follow up and with more severe form of cerebralpalsy.

KeywordsFunctional strength training, Cerebral Palsy, Functional MotorPerformance.

Cerebral palsy is term for a range of non-progressivesyndrome of posture and motor impairment that results frominsult to developing central nervous system.1

Cerebral palsy is most common developmental disorder ofchildren first described by William little in 1861.2 being the mostcommon physical disability in childhood which results from anon progressive injury to the developing central nervous system.Cerebral palsy has many neurological disorders of which motorimpairment is most remarkable.These impairments include3

1) increased muscle tone2) impaired muscle control3) Decreased muscle strength.

The primary culprit of motor performance has beendebatable for long time.3 Muscle strength is a reflection of motorcontrol and evidence now strongly supports that increasedmuscle strength results in better performance.3,4,5,6. It is evidentthat muscle weakness has impact on motor performance andthat an increase in muscle strength could improve motorperformance. 6,10

Several studies in children provide evidence in support ofthis training and exercise approach. Investigations of effect ofexercises for lower limb muscles demonstrated the increase instrength and function in children with cerebral palsy, 10, 11 with noincrease in spasticity.14, 17, 21 These positive results are inagreement with several studies of adults following stroke also.

Many of previous study method were based on open chain(non-weight bearing) training. 6,9,10, 12,15,18,19 The gain in strengthmay enhance functional motor performance if strengtheningexercises are involves more practice of functionally relatedclosed kinetic chain (weight bearing) exercise.15

Our main objective of present study was1) To determine the effects of task-specific strength training

of lower limb on functional motor performance in childrenwith spastic cerebral palsy.

2) To determine the feasibility of closed kinetic chain exerciseon functional motor abilities in children with cerebral palsy.

Material and methodsSubjects: Invited subjects in the study were 18 children

with spastic diplegia among them 11 were male and 7 werefemale. All the subjects were received physiotherapy previouslyand none were allowed to attend physiotherapy other thanintervention protocol.

Inclusion criteria1. Spastic cerebral palsy children aged between 5-10 years.2. Able to walk with or without aids.3. Able to extend knee from 90 degree to 45 degree or more

in sitting position with full passive range of motion in supine.4. No known mental impairment (understand simple command

given by therapist.)

Dharam Pani Pandey / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1

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5. Able to flex knee to 90 degree in prone position withoutsimultaneous hip flexion.

6. Spasticity grade to or less than 2 on modified ashworthscale( Hip adductor/abdductor, knee flexor, ankle planterflexor)Subjects with known cognitive impairment, orthopedic/

medical condition that prevent from exercising, cerebellarsymptom, known visual, speech, hearing disorders, systemicmedical problem which prevent from exercising, lower limbsurgery within 12 months, on anticonvulsant. antispasticmedication and those non-ambulatory were excluded from study.

A convenience sample of twenty six children aged from 5to10 years were invited to participate in the study among them23 were male and 7 were female all the subjects had thediagnosis of spastic diplegia . After assessment only 18 childrenwere qualified the inclusion criteria. All the children and parentswere Informed about the purpose of study and gave written andverbal consent to participate in the study, All eligible subjectswere randomly assigned to intervention (n-9) group and controlgroup (n-9)

All eligible subjects were randomly assigned to interventiongroup and control group, through use of random numbergenerator with sealed envelopes.

The study employed a randomized single blind controlledtrial design consisting of two group and three measurement ,training was conducted in one-hour sessions twice a week forfour weeks

Outcome measuresLower extremity functional strength was tested with the

Lateral Step-up Test, using 22 cm height stable step13,20 thenumber of step-ups performed in 15 seconds was recorded usinga stop watch . Functional motor performance: Minimum heightchair-Test was done using draughtsman adjustable height chairwithout arm rest, lowest value of tree successive repetitions wasrecorded. Motor Assessment (sit-to-stand item) test was carriedout using motor assessment scale (developed by Carr andShepherd 1987). The stride length, cadence and speed werethen calculated from the score of 10 meter walk test. 2-minutewalk test was used to assessed the walking speed.

InterventionEach session started with warm-up stretches of major

muscle groups (hip flexors, adductors, knee flexors, extensorsplanter flexors). Children then move to practice functional trainingand exercises designed to strengthen lower limb muscles,improve segmental control of the lower limbs, and improvebalance which included bilateral heel raises, sit to stand, standingbalance exercises, step up, vestibular ball supported half squat.The therapist supervised the training, giving individual trainingwith assistance from parents each session.

Data analysisTo examine the effect of training on functional motor

performance and lower extremity functional strength .A repeatedmeasures of ANOVA were performed using data analysissoftware Biostat 2007 Professional.

ResultsFunctional strength test and functional performance score

both demonstrated the significant improvement following trainingand maintenance of the gains at follow up in intervention group,whereas control group did not showed such significant changes.

Functional Strength test: The lateral step up test of both,the left leg (p=0.002),(F=22.57) and the right leg(p=0.001),(F=44.8) demonstrated the significant improvement

where as control group did not showed any such significantimprovement, left leg (p=0.502), (F=0.476) and right leg(p=0.332),(F=1). Motor assessment scale – sit-to –stand itemshowed significant (p=0.041),(F=4.92) change pre to posttraining as compared to control group. Minimum height chairtest score demonstrated significant improvement in interventiongroup (p=0.001) post training. In control group there was nosuch significant (p=0.88),(F=0.02) changes noted. There wasalso significant improvement in intervention group in walkingspeed (p=.0015), children walked faster with improved stridelength (p=0.024), took less time to complete 10 meter walk test(p=0.0013) and also they walked more distance at 2-minute walktest (p=0.034).where in control group changes did not reachedsignificant level. All the gain in intervention group was maintainedat follow up without any significant decline.

DiscussionThe unstabelised motion against resistance, not only

improved balance and coordination but also helps nervoussystem and muscle to learn to operate more efficiently, increasesthe integrity of joints, connective tissue and improves theperformance of the central nervous system. Impairments

Dharam Pani Pandey / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1

Graph 1: showing comparison between interventions and controlgroup score of lateral step up test of left leg.(Mean value)

Graph 2: showing comparison between intervention and controlgroup score of lateral step up test of right leg.(Mean value)

Graph 3: showing comparison between intervention and controlgroup score of sit to stand test.(Mean value)

54 Dharam Pani Pandey / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1

Graph 4: showing comparison between intervention and controlgroup score of minimum height chair test.(Mean value)

Graph 5: showing comparison between intervention and controlgroup score of 2 minute walk test.(Mean value)

Table 1:Intervention Group

TEST Pre training Post training Follow up A-B Effect B-C Effect(A) (B) ©

M SD M SD M SD F p F pLSUT Lt (Reps) 3.11 0.72 5.9 1.5 5.55 1.24 22.51 *0.0002 0.0339 0.8562LSUT Rt (Reps) 3.2 0.8 6.3 1.12 6.44 1.01 44.8 *0.0001 0.0488 0.828

Table 2: The table reports the means and standard deviations at pre training, post training and follow up. F score and p values of pretraining to post training (A-B) effect and post training to follow up (B-C) effect comparisonsControl Group

TEST Pre training Post training Follow up A-B Effect B-C Effect(A) (B) ©

M SD M SD M SD F p F pLSUT Lt (Reps) 3.22 0.83 3 0.6 2.8 0.463 0.476 0.5025 1 0.332LSUT Rt (Reps) 2.9 0.6 2.67 0.53 2.56 0.74 1 0.332 0.1081 0.746

Table 3: The table reports the means and standard deviations at pre training, post training and follow up. F score and p values of pretraining to post training (A-B) effect and post training to follow up (B-C) effect comparisons.Result of fst - intervention group

TEST Pre training Post training Follow up A-B Effect B-C Effect(A) (B) ©

M SD M SD M SD F p F PLSUT Lt (Reps) 3.11 0.72 5.9 1.5 5.55 1.24 22.51 *0.0002 0.0339 0.8562LSUT Rt (Reps) 3.2 0.8 6.3 1.12 6.44 1.01 44.8 *0.0001 0.0488 0.828MST-STS Score 2.22 1.56 3.3 0.9 3.3 0.7 3.4783 0.0806 0.3459 0.5646Min.chair height(cm) 21 7.1 17 1.8 16.7 1.39 46.623 *0.001 3459 0.5646Walking speed (m/s) 0.54 0.08 0.7 0.1 0.71 0.13 14.6269 *0.0015 0.0431 0.8382Stride length (m) 0.63 0.16 0.63 0.1 0.63 0.059 6.1762 0.0244 0.02221 0.6438Cadence (steps/min) 111 10 127 11 132 17.8 6.7121 0.0197 0.5541 0.467410-m walk test (m) 19.7 3.12 15.1 1.72 14.4 2.34 15.0517 *0.0013 0.5067 0.48682-m walk test (s) 66.4 9.58 87.1 13.1 85.8 16.4 13.6386 *0.002 0.0348 0.8544

Graph 6: showing comparison between intervention and controlgroup score of 10 m walk test.(Mean value)

Graph 7: showing comparison between intervention and controlgroup score of walking speed.(Mean value)

55Dharam Pani Pandey / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1

Table 4: The table reports the means and standard deviations at pre training, post training and follow up. F score and p values of pretraining to post training (A-B) effect and post training to follow up (B-C) effect comparisons. (Result of functional test Control group)

TEST Pre training Post training Follow up A-B Effect B-C Effect(A) (B) ©M SD M SD M SD F p F p

LSUT Lt (Reps) 3.22 0.83 3 0.6 2.8 0.463 0.476 0.5025 1 0.332LSUT Rt (Reps) 2.9 0.6 2.67 0.53 2.56 0.74 1 0.332 0.1081 0.746MAS-STS Score 1075 0.71 2 1 2 1 0.6667 0.4262 0 1Min.chair height(cm) 23 1.7 23 1.6 22.67 1.3 0.0209 0.8867 0.0237 0.8797Walking speed (m/s) 0.59 0.09 0.6 0.1 0.62 0.08 0.0008 0.9784 0.4124 0.5298Stride length (m) 0.58 0.14 0.6 0.1 0.67 0.1 0.0084 0.9282 0.3255 0.8591Cadence (steps/min) 125 27 127 26 126 24.7 0.0179 0.8953 0.0008 0.977910-m walk test (m) 20.4 3.15 16.7 2.92 17.3 2.82 0.1113 0.743 0.0025 0.94042-m walk test (s) 74 11.7 74 10.4 75.2 9.82 0.0056 0.9415 0.2944 0.5949

affecting muscle strength and motor control are major causesof motor performance deficit in children with cerebral palsy. 6,7,10,11

Non weight bearing exercises may have limitedtransferability as compared to weight bearing exercises as weightbearing training involves different and more complex pattern ofmuscle activation, the gain in strength may transfer better in toimprovements of functional motor performance if strengtheningexercises involves the practice of more functionally relatedclosed kinetic chain exercises.16,18

The present study examined the repetitive practice of weightbearing (closed kinetic chain) exercises with similarcharacteristics to those normally found in many functionalactivities that involves lower extremity in support, balance.

Exercises included in this study have the potential to trainthe motor performance such as coordination, balance, strength,endurance and physical conditioning. The practice these taskrelated exercises are expected to refine the efficient motorpatterns.

ConclusionThe present study examined the repetitive practice of weight

bearing (closed kinetic chain) exercises with similarcharacteristics to those normally found in many functionalactivities that involves lower extremity in support, balance, andresults suggests that a four week functional strength trainingprogramme should be considered in clinical practice whiledealing with pediatric population.

Limitations: This study has limitation in smaller sample sizeand only one follow up post training. Never the less the findingare in agreement with other previous studies which have shownthat functional strength training in cerebral palsy is associatedwith improvement in motor functions.

References1. L A Koman Cerebral palsy, THE LANCET • Vol 363 • May

15, 20042. Cerebral Palsy: An overview Wajid Ali et.al Curr Pediatr

Res 2006; 10 (1 & 2): 1-73. K.Tammic el.al. Neuromuscular function in children with

spastic cerebral palsy Brain and development2007,29(9):553-558

4. K.J Dodd et al.A randomized clinical trial of strength trainingin young people with cerebral palsy. Dev Med & Child Neu2003, 45: 652–657

5. C.Andersson et al. Adults with cerebral palsy: walking abilityafter progressive strength training ,Dev Med & Child Neu2003, 45: 220–228

6. Damiano D et.al Effect of quadriceps femoris musclestrengthening on crouch gait in children with spasticdiplegia. Phys Ther. 1995; 75:658- 671.

7. Giuliani CA. Dorsal rhizotomy for children with cerebralpalsy: support for concepts of motor control. Phys Ther1991; 71: 248–59.

8. Engsberg JR, et al. Hip spasticity and strength in childrenwith spastic diplegia cerebral palsy. J Appl Biomech 2000;16: 221–33.

9. MacPhail HE, Kramer JF. Effect of isokinetic strengthtraining on functional ability and walking efficiency inadolescents with cerebral palsy. Dev Med Child Neurol1995; 37: 763–75.

10. Damiano DL, et.al Muscle response to heavy resistanceexercise in children with spastic cerebral palsy. Dev MedChild Neurol 1995; 37: 731–39.

11. Jack R Engsberg et.al. Ankle spasticity and strength inchildren with spastic diplegic cerebral palsy DevMedicine& Child Neurology 2000, 42: 42–47

12. Damiano DL, Kelly LE, Vaughan CL. Effects of quadricepsfemoris muscle strengthening on crouch gait in childrenwith spastic diplegia. Phys Ther 1995; 75: 658–71.

13. Worrell TW, Borchert B, Erner K. Effect of a lateral step-upexercise protocol on quadriceps and lower extremityperformance. J Orthop Sports Phys Ther 1993; 18: 646–53.

14. Fowler EG, Ho TW, Nwigwe AI et al. The effects ofquadriceps femoris muscle strengthening exercises onspasticity in children with cerebral palsy. Phys Ther 2001;81: 1215–23.

15. Diane L Damiano et.al. Should we be testing and trainingmuscle strength in cerebral palsy? Developmental Medicine& Child Neurology 2002, 44: 68–72

16. SW Blundell, RB Shepherd, CM Dean, RD Adams,Functional strength training in cerebral palsy: a pilot studyof a group circuit training class for children aged 4–8 yearsClinical Rehabilitation 2003; 1 7: 48–57

17. Fowler EG, Kolobe THA, Damiano DL, et al DevelopmentalMedicine & Child Neurology 2004, 46: 580–589 Promotionof physical fitness and prevention of secondary conditionsfor children with cerebral palsy: Section on PediatricsResearch Summit Proceedings. Phys Ther. 2007;87:1495–1510.

18. Shepherd RB. Physiotherapy in pediatrics, third edition.Oxford: Butterworth-Heinemann, 1995.

19. Damiano DL.et.al. Activity, activity, activity: rethinking ourphysical therapy approach to cerebral palsy. Phys.Ther.2006; 86:1534 –1540.

20. Ross M. Test–retest reliability of the Lateral Step-up Test inyoung adult healthy subjects. J Orthop Sports Phys.Ther1997; 25: 128–32.

21. Fowler EG,Ho TW, Nwigwe AI, Dorey F. The effect ofquadriceps femoris muscle strengthening exercises onspasticity in children with cerebral palsy. Phys.Ther.2001;81:1215–1223.

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Effect of post isometric relaxation on pain intensity, functionaldisability and cervical range of motion in myofacial pain of uppertrapeziusDheeraj Lamba*, Satish Pant***Incharge, Physiotherapy IAHSET, Medical College Haldwani, **(B.P.T. Final Year) IAHSET, Haldwani.

IntroductionMPS is the most common overlooked cause of chronic

disability. Chronic pain leads to depression, physicaldeconditioning due to sleep disturbances, lack of exercise andother psychological and behavioral disturbances. A recentepidemiological study of young women (age 20-40 years)revealed that MFP occurs in about 30% of this population, with6% having symptoms severe enough to require treatment. Foremuscles trapezius, levator scapulae, infraspinatus and scalenusaccounted for 84.7% of the trigger points. Out of these fourtrapezius account for 34.7% and levator scapulae constitute19.7% of trigger points .Upper trapezius is the most commonmuscle for development of Myofascial trigger point.

“Myofascial pain” is the pain that drives from Myofascialtrigger points which are small highly sensitive areas in muscles.Trigger points are characterized by hypersensitive palpable, tautbands of muscles that are painful on palpation and reproducepatient’s symptoms and cause referred pain. Myofascial painsyndrome has been termed Myofascial pain, myofibrositis,myogelosis, myalgia and Myofascial pain dysfunction when it isassociated with temporomandibular joint dysfunction. There area lot of perpetuating factors for it like postural, mechanical,environmental stresses emotional stresses and externalcompression.

Purpose1. To find out the effectiveness of post isometric relaxation

technique on pain intensity, functional, disability, cervicalrange of motion in patients with myofascial pain of uppertrapezius.

2. To find out effectiveness of five treatment sessions.

MethodologySample30 subjects (19 females, 11 males) with myofascial pain of

upper trapezius participated in this study. The subjects wererecruited from the Sushila Tiwari Hospital, Haldwani. Subjectswere of mean age 28.2 years and all subjects were diagnosedby orthopedics surgeons of Sushila Tiwari Hospital. The subjectswere selected on the basis of inclusion and exclusion criteriaand were recruited to the group randomly.

Instruments1. Moist hot pack2. Measuring tape3. VAS4. N.D.I.

ProtocolBased on inclusion and exclusion criteria, subjects were

included in the study. Convenient sampling with randomallocation to the two groups. Group A (control group) standardtherapy i.e. hot pack, ischemic compression, auto stretch andergonomic advices were given. Group B (experimental group)received standard therapy and post isometric relaxation.

Procedure

Group a (control group)All Patients in this group received hot pack for 15 min

followed by ischemic compression for upper trapezius muscle.They were advised to perform auto stretches for upper trapeziusat home. The stretches were performed in 3 sets, 3 times a dayfor a total duration of 5 days. Before starting the treatmenttherapist palpated patient’s upper trapezius muscle for the triggerpoint with the help of pincher grip and flat palpation. Then localtwitch response and jump sign were recorded in the assessmentform. In subject having more than one active trigger point, themost hypersensitive point was selected and marked by usingthe permanent marker. Before starting the treatment on zeroday, patients were made to fill VAS, N.D.I.Hot Pack

Subject was made to lie down in prone lying position with apillow under his legs for relaxation and his head resting on hispalm. Then hot pack wrapped in 4layers of towel was appliedon upper trapezius of the side to be treated for 15 minutes. Itwas followed by ischemic compression.Ischemic compression

After hot pack treatment, therapist placed his thumb on thetrigger point. Thumb was pressed against the trigger point tillnail bed blenching took place and then pressure was furtherincreased up to subject’s tolerance. Subject was instructed toraise hand when he could not beat pain anymore. It was heldfor 30 second. After compression, band- aid was applied on thetrigger point to avoid confusion on next therapy session.Auto stretch

Following this treatment subject was taught auto- stretchesfor upper trapezius as home program. Subject was made to fixhis right arm (if right side trigger point) by hooking the seat ofchair on which he was sitting and then was asked to vend theneck away from the side on which shoulder was fixed. Whilemaintaining this position he was instructed to move his neckforward and finally to rotate their neck to side of pain. If he feltenough stretch in this position only then the stretch wasconsidered to be effective. Otherwise he was made to increasethe stretch by keeping his left hand on the head and stretch wasimposed by the hanging weight of the arm. The stretch wassustained for 30 second followed by relaxation for 30 seconds.

Inclusion Criteria Exclusion Criteria1.Both male and females. 1.History of trauma to the neck.2.Age groups 18-35 years. 2.Sprain/ strains in cervical

spine3.Active trigger point of 3.Malignanciesupper trapezius. 4.Congenital anomalies

5.Upper quarter surgery6.Neurological deficit7.Generalized inflammatorydiseases8.No known cardiac conditions

DesignThis is an experimental design.

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Subject was instructed to do stretching 3 times per sitting and 3times a day.Ergonomic advice1. Sit on a chair with armrest not on without armrest.2. Avoid static posture for prolonged period.3. Do not sit too long in a position when watching T.V., or at a

mover theater. At interval move your head from side to sideand rotate your shoulder.

4. Do not try to lift heavy piece of furniture by yourself or tocarry anything on your head.

5. Sleeping posture- For patients who preferred side lying wereinstructed to tuck the corner of pillow around between thelower most shoulder and chin. For subjects who preferredsupine lying were instructed to use only on pillow underthe head. Patients were instructed to avoid prone lying.

6. Reading- always read with neck properly supported andarm resting on arms of chair and try to keep book at thelevel of eyes and avoid prolong bending of neck.

7. Women’s were advised to avoid carrying bags on oneshoulder. A wide strap is helpful when it is want across thebody.

8. Females were instructed to use handbags with short slingsand were instructed to hang them on the acromion.

9. Women were advised to avoid tight strap bra and wereadvised to use elastic strap bra.

10. Driving – while driving they were instructed to hold steeringwheel with one hand atbottom and with the forearm supinated and rested on thigh.

Group B (Experimental group)All subject in this group received above described standard

therapy i.e. hot pack for 15 minutes followed by ischemiccompression as given for group A. In addition to this postisometric relaxation (Lewit) was given for upper trapezius. Beforestarting the treatment on first day, patients were made to fillVAS, N.D.I. and their range of motion was measured by usingtape method.

After getting ischemic compression, subject was made tolie down on plinth in supine lying. A pillow was given under hisknees to relax hamstring muscles. Then therapist’s one handwas placed on the ipsilateral shoulder (affected side shoulder)and cupped the mastoid area of the same side of the head withother hand. Then neck and head were moved away (side bend)maximum from the affected shoulder till the restriction was met.Subject was instructed to move the ear towards the shoulder ofthe affected side and the same shoulder towards the ear, againstthe resistance of the therapist’s hands with minimum force (only20%of there total force). For this he was firstly asked to wastheir maximum force and with reference to this he was instructedto was only20% of their force. No movement was allowed tooccur at neck so that it resulted in the isometric contraction ofupper trapezius. During this procedure he was instructed to see

towards the side away from which head was bent and hold theirbreath. He was made to hold this position for 10 seconds subjectwas instructed to exhale completely and relax. During thisrelaxation phase head and neck were taken further away fromipsilateral shoulder and ipsilateral shoulder was pusheddownward until next restriction is met. Stretch was stopped atthe slightest resistance. From this new position the procedurewas repeated. care was taken that the range of motion gainedwas not lost during isometric contraction. This procedure wasrepeated 3 times. After this, subject was taught auto stretchingprocedure like group A and were given ergonomic advices.

He was made to demonstrated for the first time and thenhe was instructed to repeat 3 times per set and 3 times per dayfor 5 days.

Data analysisIt was done by using SPSS software version 11.0. All the

variables of age, VAS,NDI, right lateral flexion, left lateral flexion,right lateral rotation and left lateral rotation were analyses byusing paired t test within group A and group B.

Variable of VAS, NDI, right lateral flexion, lateral flexion,right lateral rotation and left lateral rotation were analyzed byusing independent t test between group A and group B.

Data analysis of rate of improvement between group A andgroup B was done for variable of VAS, NDI, tight lateral flexionleft lateral flexion, tight lateral rotation and left lateral rotation byusing independent t test.

Statistical significance was set at (p<0.05) level.

ResultsAnalysis of age of Group A and Group B was done but on

comparison no significant difference gas been observed. (table5.1)

Analysis of VAS, NDI ,and cervical range of motion (Rightand left lateral flexion and lateral rotation) was done betweengroup A and group B on 0 day 5th day. The results showed nosignificant difference in VAS,NDI and Cervical range of motion (right and left lateral flexion and lateral rotation) on 0 day. Butthere was a significant difference in NDI on 5th day. (Table5.2)

On analyzing the data within group A and group B resultsshowed significant difference in VAS, NDI cervical range ofmotion (right and left lateral flexion and lateral rotation) on 5th

day. (table5.3)

Table 5.1: Demographic DataVariable Group AMeant. Group BMeant t p

+ S.D + S.D value valueAge 28.2 + 2.5 27.3 + 2.7 0.973 0.339

Table 5.2: Comparison of VAS, NDI, Cervical Range of motion between. Group A and Group B on 0 day to 5th day.Variable Days Group A Group B t value p value

Mean+S.D. Mean+S.D.VAS 0 6 + 1.1 6.27+ 1.2 0.619 0.541

5 4 +1.1 3.2+ 1.3 1.824 0.079NDI 0 49.9 +12.4 51.02+14.8 0.215 0.831

5 35.6+ 9.6 26.3+ 13 2.210 0.035Right lateral flexion 0 5.1+ 0.9 5.09 +1.1 0.018 0.086

5 5.83+ 0.90 6.41+ 1.2 1.528 0.138Left lateral flexion 0 5.65+0.9 5.1+1.0 0.202 0.84

5 5.65+0.9 5.35+1.0 1.914 0.066Right lateral rotation 0 7.64+1.3 7.84+1.8 0.452 0.655

5 8.27+1.4 8.6+1.0 0.815 0.423Left lateral rotation 0 7.66+1.3 7.82+1.2 0.351 0.728

5 8.23+13 8.71+1.1 1.078 0.290VSA: - Visual Analog ScaleNDI: - Neck Disability Index

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Table 5.3: Comparison of the VAS, NDI, Cervical range of motion within. Group A and Group B on 0 to 5th day.Variable Group 0day 5th day t value p value

Mean+S.D. Mean+S.D.VAS Group A 6+1.0 4+1.1 14.491 .000

Group B 6.2+1.2 3.20+1.2 4.869 .00NDI Group A 49.9+12.4 35.6+9.6 11.23 .000

Group B 51.0+14.8 26.3+13.0 8.04 .000Right lateral flexion Group A 5.1+0.9 5.8+0.9 14.83 .000

Group B 5.1+1.1 6.4+1.1 23.12 .000Left lateral flexion Group A 5.0+0.9 5.6+0.9 15.31 .000

Group B 5.1+1.0 5.3+1.1 20.94 .000Right lateral rotation Group A 7.6+1.3 8.2+1.4 4.09 00.1

Group B 7.8+1.0 8.6+1.0 7.37 .000Left lateral rotation Group A 7.6+1.2 8.23+1.3 11.76 .000

Group B 7.8+1.2 8.7+1.1 8.708 .000VSA: - Visual Analog ScaleNDI: - Neck Disability Index

Table 5.4: Comparison of the rate of improvement in VAS, NDI,Cervical range if motion between Group A and Group B from 0 dayto 5th day

Variable Group A Group B t value p valueVAS 2+.53 3.06+.79 4.2 .000NDI 14.28+4.9 24.62+11.85 3.1 .004Right lateral flexion .733+1.9 1.32+.22 7.7 .000Left lateral flexion .62+.15 1.2+.22 8.6 .000Right lateral rotation .63+.59 .80+.42 28 .368Left lateral rotation .56+.18 .88+.39 28 .007

VSA: - Visual Analog ScaleNDI: - Neck Disability Index.

Fig 5.3: Graphical representation of right lateral flexion in GraphA and Graph B on 0 day to 5th day

Fig 5.4: Graphical representation of left lateral flexion in GroupA and Group B on 0 day to 5th day

Fig 5.1: Graphical representation of VAS in graph A and GroupB on 0 day and 5th day.

Fig 5.2: Graphical representation of Neck disability index inGroup A and Group B on 0 day to 5th day.

Table 5.4 explains the comparison of rate o improvementin pain intensity, neck disability and cervical range of motion(right and left lateral flexion and rotation) from 0 day to 5th day.The results show significant improvement in both the group.But on comparison, Group B is giving more significant results.

Discussion

The result showed that both the treatment method i.e.ischemic compression and post isometric relaxation are effectivein reducing pain, functional disability and improving cervicalrange of motion. But the rate of improvement in group B whichreceived both therapies is more.

The significant results of ischemic compression treatmentexplained the effectiveness of this treatment due to ischemia

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followed by hyperemia of the muscle. The skin first balancedand then shows reactive hyperemia. The changes in perfusionof the skin likely corresponds to the circulatory changes in themuscle beneath, which was subjected to the same pressure.This may inactivate the trigger points as ischemia is removedfrom flushing the blood into the vessels Similarly Chuen –Ru-Heu et. L. reported that hot pack followed by ischemiacompression for 30 sec is most effective in decreasing pain. Itwas suggested that it may result from reactive hyperemia in theMyofascial trigger points, counter- irritation effects or spinal reflexmechanism for the relief of muscle spasm. Another theory for itseffectiveness is the Melzack and Wall “Pain Gate theory”, ongiving ischemic compression mechanoreceptors ate stimulated,initiating an interference with pain messages teaching the brain.

This 5 days study did not produced any significant resultsbut the rate of improvement was more in-group B who receivedpost isometric relaxation in combination with ischemiccompression. According to literature upper trapezius gas threefibers anterior, middle and posterior and the stretching maneuverfor each fiber is different. With the neck side bent and not rotatedonly anterior fibers are being treated. So, this might be the causefor significant results. The study might have shown significantresults if isolated treatment to each fiber would have given. Butrate of improvement was more in-group which received postisometric relaxation in combination with ischemic compression.But the time period over which accumulation or rate ofimprovement took place was small (5 days). So it might beanother cause for non significant result at the end.

The significant increase in rate of improvement in group Bcan be due to post isometric relaxation. It is in consistence withdifferent studies.

ConclusionResult of present study reported no significant difference

in the effects of post isometric relaxation with ischemiccompression when compared to ischemic compression on painintensity, cervical range of motion (lateral flexion and lateralrotation.) But this study does not conclude by stating that postisometric relaxation is an ineffective intervention as significantdifference in rate of improvement was found in group whichreceived post isometric relaxation with ischemic compression.Since the duration over which accumulation of rate of

Fig 5.6: Graphical representation of left lateral rotation in GroupA and Group B on 0 day 5th day

Fig 5.5: Graphical representation of right lateral rotation in GraphA and Graph B on 0 day to 5th day

improvement took place was small thus it could not produceany significant difference at end. Secondly, the results mighthave come significant if all the fibers of upper trapezius woundhave been treated.

References1. Rosen NB , Myofascial pain syndrome.Phy.Med.Rehabil

North Am..4 feb,41-63,19932. Edward S.Rachlin , Myofascial pain and fibromyalgia,

1nded,Moshy, 19943. Stein J.B.,Simsons,David G, Myofascial pain : Foccused

review, Arch Of Phys Med and Rehab,83 supple 1,S 40-47, 2002

4. James R. Friction, Clinical care for myofascial pain. Dentalclinical of North America.35, 1-27. 1991

5. Friction J.R., Kroening R., Haley D., Siegert R., Myofascialpain syndrome the head and neck : A review of clinicalcharacterstics of 164 patients. Oral Surgery Oral Med.Pathol. 60, 615-623 , 1985.

6. Skootsy S. A.. Jaeger B ., Oye R. K., Prevalence ofmyofascial pain in general internal medicine practice. WestJournal of Medicine. 151 , 157-160 ,1989

7. Bendtsen L., Jensen R., and Olsen J . , Qualitativelyaltered nociception in chronic myofascial pain . Pain 65, 259-264, 1996

8. Kraft G. H., Johnson E. W., Laban M ., The fibrositissyndrome. Archives of Physical medicine and rehabilitation9, 155-162, 1968

9. Simon DG, Travell JG, Myofascial pain and dysfunction ,the trigger point manual vol. 1 , upper half of body , 2nd ed.Baltimore , Wiliam and Wilkins, 1991

10. Tes- chieh, Hseuch,ta-shen et. Al., The immediateeffectiveness of electrical nerve stimulation on myofascialtrigger points. Am J Phy Med Rehab 76,471-476, 1997

11. Lewit K., SIMSONS D.G., Myofascial pain : relief bypost-isometric relaxation Archives of Physical Medicine& Rehabilitation 65, 45-57, 1984

12. Kraus H, Fischer A.A. , Diagnosis and treatment ofmyofascial pain. The Mount Sinai Journal of Medicine 58 ,235-249, 1991

13. Mense, Simsons MD, Muscle pain, 2nd ed, Lippincoi,Williams and Wilkins, 1990.

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The effect of foot orthoses on energy consumption in runnerswith flat footF.Farmani1, M.Sadeghi2, H.Saeedi3, M.Kamali3

1MSc in Orthotics and Prosthetics, Iran University of Medical Sciences, Tehran, Iran. 2PhD student of physical therapy, TehranUniversity of Medical Sciences. 3Academic staff of Faculty of Rehabilitation Sciences, Mohseni Square, Tehran University of MedicalSciences, Iran.

AbstractFoot orthosis uses as conservative treatment in subjects

with flatfoot. This study aimed at assessing the effects of Footorthosis on Energy consumption in 20 runner subjects with Flatfoot. In this study treadmill and Quark b2 oxygen consumptiondevice were used. In the first stage patients did not wear Footorthoses.Then in the second stage for each patient prepared apair of suitable foot orthosis and they wore orthoses. Themaximum running Heart rate, vo2 max and vo2 of the patientswith Flat foot were measured and calculated with and withoutFoot orthoses. statistical analysis indicated significantly less HR,VO2, VO2 max in before and after use of foot orthoses on runnerswith flat foot. (P-Value <0.05). Foot orthoses result in realignmentof lower extremity Joints in patient with flat foot, thus length-Tension Relationship of muscles improves. this prevent of fatigueon this muscles, when he run in long- distance. Finally, whensuitable Foot orthoses was applied energy consumption duringrunning decreased.

Key wordsEnergy consumption, Foot orthoses , Flat Foot

IntroductionFoot is changed more than other parts of body. One of the

most important and changeable structural characteristics of footis height of medial longitudinal arch on bearing the weight (1).Flat foot is a trouble in which the height of medial longitudinalarch is lost or reduced. Flat foot can be flexible or rigid. Thepeople who suffered from flat foot have a lot of biomechanicalinefficiencies in foot and ankle and they also become involvedin unusual walking. (2). Flat foot can cause biomechanicalirregularities in running of athlete and this leads to pain of Achillestendon, pain of shank, pain of heel, hamstring strain, quadricepsstrain, knee pain, backache and premature fatigue (3,4). In thepeople who suffered from flat foot, muscular activity of lowerlimb is changed because of biomechanical changes. Mostly,these people express premature fatigue while walking and thisproblem is due to high activities of their muscles (5). In treatingthe flat foot, using usual shoes which have supporters of medialarch or medical shoes is common (6). The main function oforthosis in flat foot which is flexible is improving the direction offoot bones and returning them back to normal direction. Runnersuse foot orthoses in order to avoid injuries, rehabilitation ofinjuries, enhancing the comfort and improving the efficiency (7).Most of these bony-muscular injuries are accompanied withkinematic alterations of muscular activity due to structural andabnormal direction of foot. One of the advantages of usingorthosis is related to reducing muscular activity which is requiredfor stability or axial control of lower limb rotations and guidingfoot alignment. Primary studies showed considerable changesin activity of foot muscles with using insoles. To describe thesechanges, it is noted that orthosis reduces muscular activity withcontrolling abnormal movement of joint (5).

It is assumed that biomechanical imbalances is expressed

more in runners who suffered from flat foot because of enhancingthe forces which are sustained by body and this will causemuscular fatigue and increasing the energy consumption inrunners (5)Amount of energy consumption is very important forrunners because of individual and collective competitions, speedand endurance running races and it can be considered bymedicine society. So in this way, compensating flat foot whichhas been done by insoles would be very important. The aim ofthis research is to investigate and compare the effect of footorthoses on energy consumption in runners who suffered fromflat foot.

Material and methodsThis research was done pseudo empirically with the type

of simple improbable on 20 athletic men who affected by flexibleflatness on two sides of foot. These persons are selected amongrunners who have referred Enqelab Sports Complex of Tehranthat didn’t have any cardiovascular and pulmonary diseases oroperation surgery in lower limbs, deformity in lower limbs andpsychological diseases. Average age of these persons is 23and average BMI (body mass index) of them is 21.99 kg/m2 andthe place of performing the research was physical educationassessment center which is located on National Academy ofOlympic. First, testable person completed questionnairecontained required information after filling consent form forparticipating in the study. Then foot of patient was assessed inorder to determine and diagnose flat foot based on arch ratiowhich is obtained by dividing posterior surface of foot middlepoint up to land level on the length of area which is extendedfrom behind the heel to the internal middle of firstmetatarsophalangeal joint. For this, testable person asked standup barefooted with equal distribution of weight on two feet. Inthese conditions, height of posterior surface of foot to land levelis measured in parallel with foot,s middle point. Moreover, thefigure of foot was drawn on a paper which was placed under thefoot. Then the length of that foot area which was extended frombehind the heel to medial middle of the first metatarsophalangealjoint was measured and finally, height of foot is divided on targetlength (8 ).

If the presence of flat foot is diagnosed, patient should beplaced in the mode with not bearing the weight in order to finalizeabout the presence of flexible flat foot. In the event that flexibleflat foot is observed, patient has been provided for molding.Then the patient should be lied down on his stomach and moldingplaster with type of negative mold was prepared from the feet ofpatient and then a pair of insoles made of leather and supportivefoam of longitudinal arch was made. Testable person receivedthe insole and placed it in his shoes and he came to the testplace after two weeks of using the insoles. A pair of sneakerswas given to each participant in a way that all snickers were thesame. Test has been done in two stages. Firstly, the personwears sneakers with insoles while he was standing up on anergometer device and he fastened oral mask of oxygenconsumption measurement device with commercial name ofQuark b2 with its vest to face and body of himself. In fact, Quarkb2 device was used near an ergometer so that in this test, all

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information related to respiratory and cardiovascular system wascalculated and was given to us by device; this information aremaximum heart rate in a minute, total volume of consumedoxygen with the unit of ml/minute and maximum of oxygenconsumption by the person with unit of ml/minute for onekilogram of his weight.

Tests have been performed by the protocol of ProducerCompany of device (COSMED). Onset of person’s movementis considered 6 km in an hour in a way that speed of device isincreased one kilometer in an hour for each minute. In this way,order of running speed for each person is gradually increased.Display screen of device showed a graph which indicatedconsumed oxygen of the person. Speed of device was increasinguntil the volume of oxygen consumption reached to maximumvolume therefore the increasing graph of oxygen consumptionreached to a linear form and actually, maximum volume ofoxygen consumption was identified.

After 24 hours, testable person would be come to test placefor the second stage of test. Again, the first stage conditionswere performed. Choice of being first or second in the stage ofusing insole in th0e test was done randomly. All obtainedinformation of device was recorded in the questionnaire of eachperson. Analysis of the results in this research has been doneby SPSS in 11th version. Since k.s test showed the overlap ofvariables with theoretical normal distribution, t test has beenused for comparing the results before and after the intervention.

ResultsThe results of this test showed that volume of consumed

oxygen has a significant difference before and after using insole(P-value: 0.035) in a way that after using insole, volume ofconsumed oxygen has been decreased for each person (Table1).Maximum rate of consumed oxygen showed a significantdifference before and after using of insole (P-value: 0.029) in away that after using insole, maximum volume of consumedoxygen was decreased for each person (Table 1). Maximumheart rate showed a significant difference before and after usingof insole (P-value: 0.031) in a way that maximum heart rate hasbeen decreased after using insole (Table 1).

DiscussionThe results of this research showed that using Foot orthosis

in runners who suffered from flat foot can decrease the volumeof consumed oxygen, maximum consumed oxygen andmaximum heart rate in running. Change in stability of ankle andover pronation can lead to change in muscle activity which finallycaused muscular fatigue and the injuries due to extremely highactivity. Reason of these injuries and fatigues are several factorsbut over pronation imposed a force on muscles which leads toinju(5). Increasing muscles’ activity is necessarily accompaniedwith increase in oxygen consumption and carbohydrate as mainmetabolic factor of muscles (9).

One of the consequences of flat foot is premature fatigue

in runners (4) and it could be said that this problem has a directrelation with change in muscular activity and subsequently,increase in oxygen consumption of them (10). Change in footstability with abnormal pronation can be along with change inmuscular activity (5 ). One of considerable advantages of Footorthoses is that they cause to decrease required muscular activityin order to stabilize in sole and to control axial rotation of lowerlimb and guiding the foot alignment. Additionally, decrease inmuscle’s activities which is controller of maximum pronation ofankle in first half of stance phase of gai, are of main results inusing medical insoles.( 5)

Base of this research was that if Foot orthosis can properlyguide and support the movement of ankle joint, then activity ofmuscles will be decreased. Trend of the research is such a waythat participants were investigated in two stages with and withoutusing insoles and in the stage of using insole, reduction in theactivity of muscles was showed. In these studies, it is expressedthat increase of level and speed in the activity of muscular fiberscaused premature fatigue (11).

In fact, it is assumed that with prescribing and wearing anappropriate insole in the shoes of runners who affected by flatfoot, abnormal alignment of their ankles can be improved andas a result, level of muscular activity which play an importantrole in controlling this improper direction can be modified and inthis way, total level of energy consumption and also maximumoxygen consumption for each kilogram of body weight and usingtotal oxygen of body can be decreased. As mentioned earlier,one of the consequences of flat foot is premature fatigue andthe reason of this is that person passes aerobic respiration rangewith lower activity.

In related works such as the study which has been done byHennacy RH. in 1973, consumed oxygen is investigated in thepersons who suffered from flat foot before and after using insoles.The results were in a way that all participants had a primaryincrease in oxygen consumption which showed negative effectof orthosis. Nevertheless, oxygen consumption has beenshowed after 3 months (12). The reason of obtained results inthat research is that the authors investigated immediate effectof insole on oxygen consumption and there was no changebecause the persons didn’t get used to insoles. It was reportedthat after a time period of using insoles, a significant decreasewas observed in oxygen consumption which are consistent withobtained results of the present study.

In another research which has been done by Bergg andSady in 1985, volume of consumed oxygen in healthy studentswith using orthosis is investigated with comparing without usingorthosis. The persons were run on a treadmill equipped withmeasurement mask of oxygen consumption in two stages withusing shoes and insole and with using shoes solely. Theresearchers haven’t observed any considerable variable in thevolume of oxygen consumption in these persons with and withoutusing medical insoles (13). As mentioned before, medical insoleswere given to healthy runners in this research and the result ofresearch showed any change in volume of oxygen consumptionbefore and after using orthosis. But in the present research,

Table 1: Comparison among the volume of consumed oxygen, maximum consumed oxygen and maximum heart rate before andafter using the insole in runners.

P-value SD(standard deviation) Mean Description0.035 467.83436 4504.6 VO2 before using Foot orthosis (Ml/minute)

478.31295 4488.3 VO2 after using Foot orthosis (Ml/minute)0.029 6.53850 63.6040 VO2 Max before using Foot orthosis (Ml/minute

for each kilogram of body weight)6.62031 63.3715 VO2 Max after using Foot orthosis (Ml/minute

for each kilogram of body weight)0.031 6.15673 168.7 Max Heart Rate before using Foot orthosis

based on number of heart rate6.29118 168 Max Heart Rate after using Foot orthosis based

on number of heart rate

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participants have two-side and flexible flat foot. According tobiomechanical direction of their lower limbs especially in ankleand knee joints, insole was effective on muscular activity andso on oxygen consumption with improving this direction.

Also in a similar research which has been done by Otmanet al. in 1988, the effect of supporter orthosis in the sole arch isinvestigated on energy consumption in the patients who sufferedfrom flat foot. He measured Heart Rate and volume of oxygenconsumption in patients in the time of resting and walking on atreadmill device. His research has been done in two stages; inthe first stage: the measurement was done without using insoleand in the second stage: a pair of insoles was given to patient.In that research, in the first stage, while resting, there is nosignificant difference in Heart Rate and oxygen consumptionwith and without using insole but in the second stage, walking;there are significant differences in volume of oxygenconsumption and Heat Rate in two situations of with and withoutusing insoles. The results of the research showed that anappropriate insole can decrease volume of oxygen consumptionwhile walking. As mentioned before, in the present study, in usinginsole, volume of oxygen consumption and Heart Rate weredecreased (14) Twenty persons were assessed in two studieswho suffered from flat foot and the same results were obtained.

ConclusionIn runners who affected by flat foot, biomechanical

imbalance leads to muscular fatigue and increase in energyconsumption in these persons. So compensating the flat footwith using medical insoles can improve biomechanical directionof lower limbs, improve the muscular performance andconsequently, reduce in energy consumption and this issue isvery important for runners in speed and endurance running racesin sport fields. Using insoles caused to returning normal walkingback and lower energy consumption in persons who sufferedfrom flat foot and this subject can be considered by physiciansand experts and sports teams.

AcknowledgementThe work was supported by National Olympic Academy of

Iran.We would like to thank Mrs Behshid Farahmand and Drmorteza bahrami nejad for assisting with performing this study.

References1. Cavangh PR, Rodgers MM. The arch index is useful

measures from foot prints. J Biomech 1987; 20 (5): 547 –51.

2. Van Boerum DH, Sangeorzan BJ. Biomechanics andpathophysiology of flat foot. foot ankle clin 2003 sep,8(3),419-30.

3. Michael S.Lee. Diagnosis and treatment of adult flatfoot,Journal of foot and Ankle surgery, 2005 p. 78.

4. Sokhangoei Y,Asgari Ashtyani AR.MedicalShoe.tehran.sarmadi pub.2005 p 47,51.

5. Deborah A. Nawoczenski. Paula M. Ludwig.Electromyographic Effects of foot orthotics on SelectedLower Extremity Muscles During Running. Arch phys MedRehabil 1999; 80: 540- 344.

6. Noll KH. The use of orthotic devices in adult acquied flatfootdeformity. foot ankle clin 2001,mar,6(1) 25-36.

7. Anne M. James MW and et al. Foot orthoses affectfrequency components of muscle. Activitiy in the Lowerextremity – Gait & posture, 2006; 23(3): 295-302.

8. Williams DS,Mcclay IS. Measurement used to characterizethe foot and medial Longitudinal arch: Reliability and validity.physical Therapy. 2000; 80(9): 864-71.

9. Gottschall. J.s. Kram R. Energy cost and muscular activityrequired for propulsion during walking. Appl physiol, 2003;94: 1766-1772.

10. Fax LF,Matias LK.Exercise Physiology.translated to Persianby Khaledan A.tehran.tehran university pub.2000.p82-84,90-97.

11. Taylor JH,kastil DL.sport injuries. .translated to Persian by:Rahmaninia F,Moeeni Z,Salami F.2005.mobtakeran pub.p 70-95.

12. Hennacy Rl. Metabolic Efficiency of orthotic AppliancesMeasured by oxygen consumption, Journal of the AmericanPediatric Association, 1973, 63 (10): 481- 490.

13. Bergg K. Sady S. Oxygen cost of running at sub maximalSpeeds while wearing shoe inserts. Research Quarterlyfor Exercise and sports, 1987, 56 (1): 86- 89.

14. Otman S, Basgoze O, Gokee- kustal y. Energy cost ofwalking with flat feet,Prosthet Orthot Int, 1988, 12(2): 37-6.

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A study of prevalence of Developmental Coordination Disorder(DCD) at Kattankulathur, ChennaiGanapathy Sankar U*, S. Saritha***M.O.T. (Paediatrics), Research Scholar, Vice Principal, SRM College of Occupational Therapy, SRM University, Chennai. **B.O.T.,Occupational Therapist, SRM College of Occupational Therapy, Chennai.

Abstract

ObjectiveTo find out the prevalence rate of Developmental CoordinationDisorder (DCD) at Kattankulathur among 5 – 10 years of agegroup.

MethodTwo hundred and ninety one subjects (Mean age = 7.5 years ,S.D = 1.39) participated in this study. The DevelopmentalCoordination Disorder Questionnaire (DCDQ) was distributedto parents and filled Questionnaires were collected. Data wasanalyzed by descriptive statistics.

ResultsFour children were screened as Developmental CoordinationDisorder. It shows that the prevalence rate was 1.37%. DCDwas more prevalent in boys than girls.

ConclusionThe study concluded that there is prevailing (Prevalencerate=1.37%) of Developmental Coordination Disorder amongthe age group of 5-10 years at Kattankulathur. The prevalenceof the disorder suggests a need for program to educate parents,caretakers, teachers and professionals about DCD.

KeywordsPrevalence, Developmental Coordination Disorder,DCDQ

IntroductionDevelopmental Coordination Disorder (DCD) is a motor skill

disorder that often becomes evident in school-aged children.Children with DCD lack the motor co-ordination necessary toperform tasks considered appropriate for their age, given normalintellectual ability and the absence of other neurological disorders1.For the last 100 years, poor motor coordination in children hasbeen recognized as a developmental problem. As early as 1937,these children were classified as “clumsy”2. Since then, otherterms such as “motorically awkward,” “motor impaired,” and”physically awkward” have been used to describe these children,and the terms “developmental apraxia” and “perceptual motordifficulties” have been used to characterize this developmentalproblem 3,4. These terms does not distinguish the specificdifficulties experienced by the children in any meaningful wayAs a result, an international consensus meeting was held in1994 to debate the usage of different terms and to streamlineresearch in this field; Researchers and clinicians from aroundthe world agreed to accept the diagnostic term DevelopmentalCoordination Disorder (DCD) as an umbrella term to describethese children5.

Children with DCD demonstrate significant difficulty withself care tasks (eg. dressing, using utensils, toileting); academictasks (eg. copying, organizing seat work, gym class ); leisure

activities (eg. sports, playground activities); or a combination ofthe above6. Difficulties in any one of these areas can benegatively affect the child’s social integration and developingsense of self concept 7.This can be lead to repeated experiencesof failure for the child causing a significant negative impact ontheir self – esteem, socialization, behavior and academicperformance 8.Children with DCD may therefore be sociallyexcluded 9 because they engage in passive, solitary activitiesand they rate themselves as particularly low in social acceptance10.The prevalence of DCD are estimated to represent 5% to 6 %of the school aged population11. Although some estimates ofthe prevalence of DCD ranges from 5 to 15 %. Of the primaryschool population12, the widely accepted rate is 5 to 6 % orapproximately 1 in 20 children13. Given these rates there is likelyto be at at least one child with DCD in every class room.Prevalence of DCD in children has been reported as high as19%.However two studies undertaken in the U.K reported aprevalence of 5 to 8.5 % respectively 14. The prevalence ofDCD in India has not been reported. Since the prevalence ofthis disorder is unknown at Kattankulathur,Chennai. It isappropriate to conduct a study, as this will ascertain theprevalence of DCD at Kattankulathur, therefore the major thrustof this study was to find out the prevalence of DCD atKattankulathur,Chennai.

Material and methodology

SampleThis study employed the survey design, cross sectional

study. Two ninety one children (n =291) were participated in thisstudy. The samples were selected by means of conveniencesampling Procedure at Kattankulathur area. The sampleincluded boys and girls between the ages of 5 -10 years (Meanage = 7.5 years + = 1.39)

Instrument

Developmental coordination disorderquestionnaire (DCDQ)

The Developmental Coordination Questionnaire (DCDQ)is a parent report measure developed to assist in the identificationof Developmental Coordination Disorder (DCD) in children.Parents are asked to compare their child’s motor performanceto that of his/her peers using a 5 point Likert scale. It provides astandard method to measure a child’s coordination in everydayfunctional activities. The DCDQ consists of 15 items, which groupinto three distinct factors. The first factor contains a number ofitems related to motor control while the child was moving, orwhile an object was in motion, and is labelled “Control duringMovement”. The second factor contains “Fine Motor andHandwriting” items and the third factor relates to “GeneralCoordination”. The DCDQ usually takes parents about 10-15minutes to complete.

The alpha coefficient for the total test was .88. The alphaof each item, if that item was deleted, measured greater than.87 (range of .87 to .88). The total score of the DCDQ was

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significantly correlated with each of the items of the test, anothermeasure of internal consistency. These item – total correlationsranged from r = .40 to r = .76, with all significant at the probabilitylevel of .0001.The total score of the DCDQ was significantlycorrelated with the four complete scores of the BOTMP ( r = .46to .54 , p<.0001). The DCDQ was also significantly correlatedwith the total Impairment score of the movement ABC ( r =.59,p<.0001).

Data collection procedureThe Purpose of the study was explained to panchayat union

leader. Door to door survey was conducted at Kattankulathurarea,Chennai and consent forms were obtained from concernedparents. The Developmental Coordination DisorderQuestionnaire (DCDQ) was distributed to parents andinvestigator explains the DCDQ in details and clarify the parentsdoubts. The filled Questionnaires were collected. The data wasanalyzed using descriptive statistics.

ResultsThis study investigated the prevalence Developmental

Coordination Disorder (DCD) at kattankulathur. Two hundredand ninty one children (291) were studied.126 were Boys and165 were girls. The age range was 5 to 10 years with mean ageof 7.5 years. Descriptive statistics was used to analyse the data.The result showed that 4 out of the 291 children had scores thatmet the criteria for a diagnosis of Developmental CoordinationDisorder (DCD), giving a prevalence rate of 1.37% (Table I).

that four children (1.37%) were screened positive for DCD.Prevalence of DCD in children has been reported as high as19%. But prospective data of prevalence of DCD in India is notavailable. The prevalence rate was comparatively low compareto previous studies. Culture difference influences the DCDprevalence rates. Increasing level of physical activity may assistin reducing prevalence rate of DCD in children 15 (Tsiotra, Flouris,Koutedakis, Faught, Nevill, Lane, and Skenteris 2006). Thisstudy was done in village which might be influence the results.

The comparison of prevalence of DCD in both gendersshows that 4 subjects were identified with DCD in boys and notin girls. The results indicate that DCD was more prevalent inboys than girls. This may be due to behavior of boys with motorincoordination may be more difficult to manage at home and inthe classroom. This result was supported by 16 Smyth,1992.Certain limitations of the research need to be taken intoaccount when relating to the findings. One is the possibility ofpotential bias since the results are based only on parent’s reports,which, by their very nature, are subjective and may be influencedby factors such as denial, over anxiety or wishful thinking. Thequestionnaire was translated in Tamil, the most of the parentsare illiterate and some of the parents hesitate to clarify theirdoubts in questionnaire. This may influence the results of thestudy. The data in this study are based on a screening surveyinstrument. The intensive follow up diagnostic assessments orconfirmatory test of those identified as positive for theDevelopmental Coordination disorder was not done.

ConclusionThe study concluded that there is prevailing (PR=1.37) of

Developmental Coordination Disorder among the age group of5-10 years at Kattankulathur. The prevalence of DCD was highin Boys than girls. The prevalence of the disorder suggests aneed for program to educate parents, caretakers, teachers andprofessionals about DCD.

AcknowledgementsI pay my sincere thanks to the chairman of SRM group of

institutions and SRM University. I express my sincere thanks toall the participants who have been the real pillars of this study.Last but not least, I thank all of them whose names haveinadvertently fails my memory and who in their own unique wayhave made this project a reality.

References1. Barnhart, R.C., Davenport, M.J., Epps and Nordquist, V.M.

Developmental Coordination Disorder. Physical Therapy,2003; 83, (8) : 639 - 651.

2. Coleman, R., Piek J.P., Livesey D.J.. A longitudinal studyof motor ability kinesthetic acuity in young children at riskof developmental coordination disorder. Human MovementScience, 2001; 20, (1–2): 95–110.

3. Miyahara, M., Register, C. Perception of three terms todescribe physical awkwardness in children. Res DevDisabil, , 2001; 21: 367- 376.

4. Miyahara, M., Mobs, I. Developmental dyspraxia anddevelopmental coordination disorder. Neuropsychol Rev,1995; 5: 245–268.

5. Polatjko, H., Fox, M., and Missiuna, C. An internationalconsensus on children with Developmental CoordinationDisorder. Canadian Journal of Occupational Therapy, 1995;62: 3 – 6.

6. Miller, L.T., Missiuna, C.A., Macnab, J.J., Malloy – Miller,T., and Polatjko, H.J. Clinical Description of children withDevelopmental Coordination Disorder. Canadian Journalof Occupational Therapy, 2001;68: 5 – 15.

Table 2: The Prevalence of Developmental CoordinationDisorder (DCD) in both gender

Gender Total sample Prevalence rate %Boys 126 0Girls 165 1.37

This confirms the existence of Developmental CoordinationDisorder (DCD) among 5-10 years at Kattankulathur. From therespondents the percentage of children who were screened ashaving the symptoms of Developmental Coordination Disorder(DCD) was computed using simple percentages. The percentageof children studied that suffer from this disorder is presented(Table II) as follows; Girls - 1.37% (4 girls were screened asDCD) and Boys – 0 (No one screened as DCD in boys.)

Table 1: The Prevalence of Developmental CoordinationDisorder (DCD) at Kattankulathur

Age interval Total sample Prevalence rate %5.0-5.11 49 06.0-6.11 55 07.0-7.11 65 0.688.0-8.11 58 0.349.0-9.11 64 0.35Total 291 1.37

DiscussionDevelopmental Coordination Disorder (DCD) is common

disorder which affects well being of children and their families.There are strong associations with learning disabilities andpsychiatric illness in adolescence. The family physician andpediatrician frequently do not recognize the DCD or dismiss itas transient and unimportant. The present study was carriedout to identify prevalence rate of DCD at Kattankulathur.

In this study 291 parents were participated. Result shows

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7. Skinner, R.A., and Piek, J.P. Psychosocial Implications ofPoor Motor Coordination in Children and Adolescents.Human Movement Science, 2001; 20: 73 – 94.

8. Parnmenter , T.R., & Knox, M.. The post – schoolexperiences of young people with a disability . internationalJournal of rehabilitation research, 1991; 14: 281 – 291.

9. Hallum, A. Disability and the transition to adult hood : Issuesfor the disabled child,The family and pediatrician. CurrentProblems in Pediatrics, 1995; 12 – 50.

10. King, G.A., Shitz, I.Z., Steel, K., Gilpin, M., & Cathers, T.Self – concept of adolescents with physical disabilities.American Journal of Ocupational Therapy, 1993; 4: 132 –140.

11. Sugden, D., and Keogh, J.F. Problems in movement skilldevelopment. Columbia, SC: University of South CarolinaPress; 1990.

12. Wilson, P.H.Practitioner review: Approaches to assessmentand treatment of children with DCD: An evaluative review.

Journal of Child Psychology and Psychiatry, 2005;46: 806– 823.

13. American Psychiatric Association . Diagnostic StatisticalManual of Mental Disorders (DSM) 4th ed, Washington;2001.

14. Michelle & Miller. Develpomental Coordination Disorder :A review of evidence and models of practice employed byallied health professionals in Scotland. DyspraxiaFoundation; 2008.

15. Tistoria, G.D., Flouris, A.d., Koutedakis, Y., Faught, B.E.,Nevill, A.M., Lane, A.M., and Skenteris, N. A comparison ofDevelopmental Coordination Disorder Prevalence Ratesin Canadian and Greek children. Journal of AdolescentHealth, 2006; 39: 125 – 127.

16. Smyth, T. R.Impaired motor skill (clumsiness) in otherwisenormal children : a review. Child Care, Health andDevelopment, 1992; 18: 283 – 300.

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Dynamic standing balance in individuals with osteoarthritis knee-a comparison with matched controlsR.HariHaranSenior Lecturer, M.M College of Physiotherapy & Rehabilitation, M.M University, Mullana, Ambala, Haryana

Abstract

Objectives(i) To compare the dynamic standing balance in individuals

with osteoarthritis Knee and in age, gender, body massmatched controls using simple functional tests

(ii) To find the agreement between two functional dynamicstanding balance tests

Study designNon-experimental designCase- control (cross-sectional), Agreement between two clinicalmeasures

ParticipantsThirty-four patients with Osteoarthritis Knee and Thirty-four age,gender, BMI matched Controls participated in the study

InterventionsNot applicable

Outcome measuresDynamic Standing balance is assessed through Step Test andFunctional Reach Test

Data analysisPaired “T” test & Spearman “P” Coefficient were used to analyzethe data

ResultsPoor dynamic standing balance is evident in OA group(P<0.0001) than the controls when assessed through step testand functional reach test. Step test and functional reach testagreed with each other in assessing dynamic standing balance.

ConclusionDynamic standing balance is impaired in individuals with OAKnee when compared with age, gender and BMI matchedcontrols. There is good agreement between the step test andfunctional reach test in assessing dynamic standing balance inOA Knee.

KeywordsDynamic standing balance, Osteoarthritis Knee (OA knee), steptest, functional reach test, Body mass index (BMI)

IntroductionOsteoarthritis knee (OA) is one of the most prevalent

musculoskeletal complaint worldwide. It is a major cause ofimpairment and disability among the elderly. Individuals with OAknee suffer progressive loss of function, displaying increasingdependency in walking, stair climbing and other lower extremitytasks. (1,2)

Balance is a complex function involving numerous neuromuscular mechanisms.

Control of balance is dependent upon sensory input fromthe vestibular, visual and somatosensory (proprioception)systems. Central processing of this information results incoordinated neuromuscular responses that ensure the centerof mass remains with in the base of support (BOS) in situationswhen balance is disturbed. Effective control of balance thus reliesnot only on accurate sensory input but also on timely responseof strong muscles. Balance is an integral component of activitiesof daily living. Balance impairment is associated with anincreased risk of falls and poorer mobility in the elderlypopulation. (2)

Age related impairments in balance and postural stabilityare well documented. (3,4,6) Ageing is associated with a declinein the integrity of neurophysiological systems that contribute tothe control of balance. The presence of OA knee may result inchanges that accelerate the deterioration of these systems orcompound the effects of ageing. Individuals with OA knee displayreductions in quadriceps strength and activation as well asimpairments in knee joint proprioception. (8,9,10,11,12) Thesedeficits, in combination with the ageing process, may culminatein greater impairments in balance in this patient population,compared with healthy counter parts.

Falls and loss of balance most commonly occur duringmovement-related tasks such as walking and less frequentlyduring static activities. (5,6,7) It is therefore important that theevaluation of balance incorporates testing procedures that reflectthe dynamic nature of locomotor tasks. Simple, inexpensive andeasy to administer clinical tests are required to allow the clinicianto assess balance readily and quickly in patients with OA Knee.

Limited research has evaluated the impact of OA Knee onbalance. Few studies, all utilizing force platform to identifybalance deficits in this patient population have revealed deficitsin balance compared with asymptomatic subjects. Simple,Clinically practical measures to assess dynamic standingbalance in individuals with OA Knee were not used in any of thestudies. The effect of OA Knee on functional dynamic tests ofbalance remains unknown.

Methodology

ParticipantsThirty-four participants (19 male, 15 female) with

osteoarthritis knee (primary, both unilateral and bilateral) andequal number of controls (19 male, 15 female) aged between45 to 55 years were included in the study. Both groups i.e.,osteoarthritic group and the control group were similar in age,weight and BMI (table-1). Orthopaedician and or physiatristdiagnosed OA knee

Participants in OA group were excluded if they had anyknee surgery, past history of lower limb joint replacement,systematic arthritic condition, severe medical condition

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precluding safe testing, vertigo. Control participants wereexcluded if they reported any lower limb pathology, joint disorder,injury to (or) pain in either knee in the past year, displayedabnormality on physical examination of knees, vertigo and othermusculo skeletal disorders.

Materials used:• 15 cm foot stool• tape measure• stop watch• Weighing machineThe two tests step test and functional reach test were used

to assess the dynamic standing balance in both groups.Step test:The step test is functional, dynamic test of standing balance

with known reliability and validity. (17,18,19) Participants wereinstructed to maintain balance on one leg, while stepping thecontralateral limb on and off a 15 cm step as quickly as possibleby utilizing footstool. The number of times the participant placesthe foot up on to the step and return it to the floor over 15 secondinterval was recorded by using stopwatch. Participants performedthe test with bare feet, and no hand support was permitted. ForOA knee participants, the test was performed while standing onthe osteo arthritic limb. For those with bilateral symptoms, themost symptomatic limb was deemed the osteo arthritic limb forthe purpose of study. In all participants, the test was performedonce only, with two to three practice steps permitted before thetest. If loss of balance occurred, the test was ceased and thenumber of steps up completed until this point was recorded.

Forward reach test (or) functional reach test:Functional reach test, developed by Duncan et al is a test

of dynamic standing balance. (21,22,26) Functional reach testis defined as the maximal distance one can reach forward beyondarm’s length while maintaining fixed base of support (BOS) instanding position. The participants, relaxely stands next to the

wall (without touching) with the shoulders flexed to 90 degreeand elbows extended. Both hands are fisted. The initial markingswere made on the wall at shoulder level and fist level. The patientis then instructed to lean as for forward as possible without losingbalance (or) taking a step. Again the marking was made at thefist level in forward reach position. The difference between themarkings in the two positions were noted and documented forboth groups.

Statistical analysisIndependent group t test for means was used compare the

characteristics (Age, Height, Weight, BMI) of OA group andControl group

Paired “T” Test was used to compare the difference betweenthe control group and osteoarthritic group. P values< 0.05 (5%)were regarded statistically significant.

In order to determine the relationship between the step testand the functional reach test spearman ‘P’ coefficient was used.

The data were analyzed using statistical package for socialsciences (SPSS)

ResultThere is no significant difference in age, height, weight,

BMI between the OA group and Control group (Table: 1)Compared with controls, participants in the OA group took

approximately eight fewer steps (table 2) in 15 seconds testperiod while standing on their osteoarthritic leg. The p value isless than 0.001 indicating poorer balance under dynamic testingcondition.

Ho: Let there be no significant difference between theobservations of control group and OA group in step test

According to the table values

Table 4: ‘t’ values of step test and forward reach test (Comparison of means between control group and OA group)Paired differencesMean Standard deviation Standard error mean ‘t’ values df

Step test 8.88 5.61 0.96 -9.237 33Forward reach test 6.34 4.68 0.80 -7.891 33

Table 3: Mean Values of functional reach test with standard deviation for both groupsForward reach TestGroups Mean (cms) Number of Subjects Standard deviation Standard error meanOA Group 17.44 34 3.19 0.55Control Group 23.78 34 4.00 0.69

Table 2: Mean Values of step test with standard deviation for both groupsStep TestGroups Mean(number of steps Number of Standard Standard

in 15 seconds) Subjects deviation error meanOA Group 12.91 34 3.47 0.59Control Group 21.79 34 3.64 0.62

Table 1: Presenting characteristics of OA and control participantsCharacteristics OA group (N=34) Control group (N= 34) Significance (Confidence

Mean S.D Mean S.D Level- 95%)Age (Years) 49 ±3.44 48.79 ±3.13 NSHeight (meters) 1.58 ±0.08 1.57 0.07 NSWeight (Kgs) 60.55 ±9.78 58.94 ±8.3 NSBMI 24.26 ±3.70 25.47 ±3.31 NSPain (NPRS) 6.85 -Duration of 8 -symptoms (months)

NPRS- Numerical Pain Rating ScaleNS- Not SignificantSD- Standard deviation

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t 0.05, 33 = 2.00t = 9.237 (according to the calculation; table 4)t > t 0.05, 33Ho is rejected at 5% level. Hence there is significant

difference between the control group and OA group in the steptest.

The mean results of the functional reach test is presentedin fig (2)

Compared with the controls, participants in the OA groupwas 6 cms (table 2) low in functional reach test.

Ho: Let there be no significant difference between theobservations of control group and OA group in functional reachtest.

According to the table values,t 0.05, 33 = 2.00t = 7.891 (According to the calculation; table 4)t > t 0.05,33Ho is rejected at 5% level. Hence there is significant

difference between the control groups and OA groups infunctional reach test.

Agreement between balance measuresThe two tests step test and functional reach test were

correlated. Spearman ‘P’ coefficient is 0.79 between step testand forward reach test.

t-test for the significance of the correlation coefficient =10.4795 > (95% C.I for slope 0.5291 to 0.8038)

Two-tailed probability = 0.0000Total number of subjects was sixty-eight. There is good

agreement between two tests. The means of step test andfunctional reach test are positively correlated. When the valuesof step test increases (or) decreases the values of functionalreach test increases (or) decreases respectively.

DiscussionUsing simple clinical measures, the result of the study

demonstrate that individual with OA knee display impairment inpostural control, mostly under the dynamic resting condition.This reflects a reduced ability to maintain standing balance whileperforming a potentially destabilizing activity.

Deficits in lower limb proprioception and muscle strengtharte associated with OA knee and thus may be postulated as acause of impaired balance. (3,4,8-12) However studies ofbalance in this population are yet to establish a relationshipbetween these parameters, rendering this hypothesis open toquestion. Pain associated with the OA knee may play a role inbalance impairments. (1,3) The presence of pain may reflexivelyinhibit the muscles around the knee, which could compromiseeffective and timely motor responses in postural control.Furthermore pain, may result in reduced loading of the affectedjoint, potentially jeopardizing an individuals ability to maintain

their center of mass within the base of support. Further researchis required to determine the impact of OA knee on the systemsresponsible for postural control before mechanisms behindbalance deficits can be understood.

Four other studies evaluated balance in people with OAknee. (9,14,15,16) Three of the studies have utilized forceplatforms and one utilized postural swaymeter. Hassan et aland wegner et al demonstrated increased postural sway insubjects with OA knee when standing on a firm surface, witheyes opened and closed, in both AP and lateral directions. Incontrast Hurley and colleagues were unable to detect a deficitin body sway in individuals with OA knee despite the OA Groupbeing more unsteady as a whole compared with controls. Hinmanet al found there is increased postural sway in subjects with OAknee on postural sway meter when compared with the controls.

The close matching of control participants in this studycompared with the published investigations, supports thehypothesis that observed balance deficits are due to thepresence of OA knee, and not to inherent differences betweengroups with regard to age, gender (or) BMI.

Simple, inexpensive tests of balance are necessary for usein clinical setting. The step test and functional reach test is veryquick to perform, requires minimal apparatus and does not needanalysis (or) manipulation of results. Since our study revealsthat there is good agreement between functional reach test andstep test, either functional reach test or step test can be used toassess balance. Limitations to the interpretation of results ofthis study exist. The results of this study shows statisticallysignificant balance impairments with the OA group, the functionalimpact of such deficits remains unknown. Further research iswarranted to determine the magnitude of balance deficit (asassessed by functional reach, step test) is required beforefunction is impaired.

The findings of this study have important clinical implicationsfor the understanding and management of patients with OA knee.Balance deficits in this population can be identified easily andquickly in the clinical setting by the use of step test and functionalreach test, however the clinical and functional implications ofsuch deficits are unknown. Treatment strategies directed atimproving balance in these people may be warranted and requirefuture investigation.

ConclusionDynamic standing balance in individuals with osteoarthritis

knee is impaired when compared with age, gender and BMImatched controls. There is good agreement between the steptest and forward reach test. Either the step test or the forwardreach test can be used to assess the dynamic standing balancein individuals with Osteoarthritic knee.

Fig 1: Mean results of the step test for OA and control groupparticipants

The mean results of the functional reach test is presented in fig(2).

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References1. Guccione AA, Felson DT, Anderson JJ et al. The effects of

specific medical conditions on functional limitations of eldersin the Framingham study. Am j public health 1994; 84:351-358.

2. Carrie M. hall, Lori Theinbrody. Therapeutic exercisemoving toward function; 112-117

3. Hurley MV, Rees J, Newhem J. Quadriceps function,proprioceptive acuity and functional performance in healthyyoung, middle aged and elderly subjects. Age ageing 1998;27:55-62

4. Whipple R, Wolfson L, Derby C, Singh D, Tobin J. Alteredsensory function and balance in older persons. J gerontol1993; 48:71-76

5. Shumway - cook A, Brauer S, Woollacott M. Predicting theprobability of falls in community - dwelling older adults usingthe timed up and go test. Phys ther 2000; 80:896-903

6. Campbell AJ, Borne MJ, Spear GF, Jakson SL et al.Circumstances and consequences of falls experienced bya community population of 70 yrs and over during aprospective study. Age ageing 1990; 19:136-141

7. Niino N, Tsuzuku S et al. Frequencies and circumstancesof falls in the national institute for longevity sciences,longitudinal study of aging. J Epidemiol 2000; 10: S 90-94.

8. Fisher NM, Pendergast DR. Reduced muscle function inpatients with osteo arthritis. Scand J rehabil Med 1997;29:213-221

9. Hurley MV, Scott DL, Rees J, Newham DJ. Sensorimotorchanges and functional performance in patients with kneeosteoarthritis. Ann Rhem dis 1997; 56:641-648

10. Reilly SC et al. Quadriceps weakness in knee osteo arthritis:the effect on pain and disability. Ann rhem dis 1998; 51:588-594.

11. Pai Y-C, Rymer WZ et al. Effect of age and osteo arthritison knee proprioception. Arthritis rheum 1997; 40:2260-2265

12. Sharma C et al. Is knee joint proprioception worse in thearthritic knee versus the unaffected knee in unilateralosteoarthritis? Arthritis rheum 1997; 40: 1518-1525.

13. Harrison AL. The influence of pathology, pain, balance, andself-efficacy on function in women with osteoarthritis of theknee. Phys ther 2004 sep; 84(9): 822-831

14. Ekdahl et al. Standing balance in rheumatoid arthritis. Acomparitive study with healthy subjects. Scand J rhemotal1989; 18:33-42

15. Wegener L et al. Static and dynamic balance responses inpersons with bilateral knee osteo arthritis. J orthop sportsphys ther 1997; 25:13-18

16. Hassan B et al. Static postural sway, proprioception, andmaximal voluntary quadriceps contraction in patients withknee osteo arthritis and normal control subjects. Am rheumDis 2001; 60:612-618

17. R.S.Hinman et al. Balance impairments in individuals withsymptomatic knee osteo arthritis: a comparison withmatched controls using clinical tests. Rheumatology 2002;41:1388-1394.

18. Hill K et al. A new test of dynamic standing balance forstroke patients: Reliability, validity and comparison withhealthy elderly. Physiother can 1996; 48:257-262

19. K.L Benell et al. Efficacy of physiotherapy management ofknee joint osteoarthritis a randomized double blind, placebocontrolled trial. Ann Rheum Dis 2005;64:906-912

20. Sarch F Tyson et al. Reliability and validity of functionalbalance test post stroke. Clinical rehabilitation 2004;18:916-923.

21. Koralewicz LM, Engh GA. Comparison of proprioception inarthritic and age- matched normal knees. J bone joint surgAm 2003 Nov; 82-A (11): 1582-1588.

22. Duncan PW et al. Functional reach: a new clinical measureof balance. J. gerontol 1990 Nov; 45 (6):M 192-197.

23. Duncan PW et al. Functional reach: a predictive validity ina sample of elderly male veterans. J. gerontol 1992 May;47(3): M 93-98

24. Karinkanta S et al. Factors predicting dynamic balance andquality of life in home dwelling elderly women. Gerontology2005 Mar- Apr; 51(2): 116-121

25. Smith PS et al. Berg Balance scale and functional reach:determining the best clinical tool for individuals post acutestroke. Clin Rehabil 2004 Nov: 18(7): 811-818

26. Karin Ringsberg et al. Is there a relationship betweenbalance, gait performance and muscular strength in 75 yearold women? Age and Ageing 1999:28:289-293.

27. Susan B.O’Sullivan, Thomas J.Schmitz. PhysicalRehabilitation: Assessment and Treatment. 2001 (Fourthedition); 196.

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Effect of play therapy in children with attention deficit hyperactivitydisorder - a single blinded randomized controlled studyJagatheesan Alagesan1, Sardesai A. Shradha2, Sankar B. Mani3

1Associate Professor, K J Pandya College of Physiotherapy, Sumandeep University, Vadodara, 2Pediatric Physiotherapist, AshadeepSpecial School, Vasco Da Gama, Goa, 3Professor, K J Pandya College of Physiotherapy, Sumandeep University, Vadodara

Address for correspondence:Dr. A. Jagatheesan, MPT, M.Sc, M.Phil, MIAP,Associate Professor, Kashiba Jayashanker Pandya College ofPhysiotherapy, Sumandeep Vidyapeeth, Piparia, Waghodia,Vadodara, India-391760. Mobile: +91 9725837903; Email:jagatheesanmpt@yahoo.com

Abstract

ObjectiveThe current study is proposed for incorporating play therapy

in the treatment of children with attention deficit hyperactivitydisorder with the Objective being to determine the beneficialeffects of play therapy on Attention in attention deficithyperactivity disorder.

Method50 children diagnosed with Attention deficit hyperactivity

disorder between the age group of 5 to 12 years satisfying theselection criteria were included in the study. A routine pediatricassessment was done and attention was assessed usingConners’ Abbreviated Teacher Rating Scale. Children were thendivided in to 2 groups. Group-A was experimental group receivingplay therapy along with medications. Group-B was control groupreceiving only medications. Play therapy was given for one hourdaily for one month and post intervention values were assessed.

ResultThe statistical analysis of the data supports the beneficial

effect of play therapy on attention component of childrendiagnosed with Attention Deficit Hyperactivity Disorder. Theobjective improvement in the majority of the subjects wasstatistically significant with p value <0.001, i.e. decrease in thescore on Conners’ Abbreviated Teacher Rating Scale.

ConclusionFrom the study it has been observed that play therapy

intervention is effective and beneficial in Attention DeficitHyperactivity Disorder rehabilitation.

KeywordsAttention Deficit Hyperactivity Disorder, Play therapy,

Conners’ Abbreviated Teacher Rating Scale.

IntroductionAttention Deficit Hyperactivity Disorder has many faces and

remains one of the most talked about and controversial subjectsin education, hanging in the balance of heated debates overmedication, diagnostic methods and treatment approaches arechildren, adolescents and adults who must manage the conditionand lead productive lives on daily bases.01

The childhood cognitive and behavioural difficulties

categorized as problems of inattention, impulsivity andhyperactivity have presented a clinical challenge over the past50 years.02 Attention Deficit Hyperactivity Disorder refers to afamily of related chronic neurobiological disorders that interferewith an individual’s capacity to regulate activity level(hyperactivity), inhibit behavior (impulsivity) and attend to tasks(inattention) in developmentally appropriate ways.03

According to Diagnostic and Statistical Manual of Mentaldisorder (DSM-IV, APA, 1994) the essential feature of ADHD is“.....a persistent of inattention and/or hyperactivity, impulsivitywhich is more frequent and severe than is typically observed inindividuals at a comparable level of development. Symptoms ofADHD must be present before the age seven years and mustinterfere with developmentally appropriate social, academic oroccupational functioning in at least two settings (for example athome and at school).04

The world wide prevalence of attention deficit hyperactivitydisorder is in the range of 7 to 17 % of school aged children.04 InIndia prevalence of the disorder in the age group of 5 to12 yearsin pediatric clinic was 15.5%, the inattention sub type waspredominant. The mean age of boys and girls was 8.49 and6.82 years respectively also male: female was 6.4:1. Majority ofpatients were from middle socio-economic status belonging toHindu families.05

The management of Attention Deficit Hyperactivity Disordermust be multidisciplinary, multimodal and maintained over a longperiod. By far the most effective short term interventions forAttention Deficit Hyperactivity Disorder are combination ofMedical, Behavioral and Environmental techniques.02 Theoriessuggesting the mechanism of increasing attention are that thebrain reorganizes itself allowing the undamaged areas to takeover the responsibilities of the damaged areas. Another theorysuggests that recovery of function occurs when the brain usesits remaining functional capacities to achieve behavioral goalsby different routes.06 In the recent years a growing number ofnoted health professionals have observed that play is importantto human happiness and well being as love and work.

Play therapy may be directive that is the therapist mayassume responsibility for guidance and interpretation or maybe non directive where the therapist may leave responsibilityand direction to the child. In non directive play therapy the childis given the opportunity to play out his accumulated feelings oftension, frustration, insecurity, aggression, fear, bewildermentand confusion.

Objective of the studyObjective of this study is to determine the beneficial effects

of play therapy on attention in Attention Deficit HyperactivityDisorder.

MethodologyResearch DesignSingle Blinded Randomized Controlled TrailSource of Data & SettingSubjects with ADHD from a Special School in Bangalore,KarnatakaSample Size50 subjects of both genders fulfilling selection criteria were

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selected from the population and randomly (lottery methodwithout replacement) divided into 2 groups.GROUP A: Experimental group received play therapy along withmedications [25 subjects]GROUP B: Control group received only medications [25 subjects]Selection Criteria• Subjects diagnosed as Attention Deficit Hyperactivity

Disorder by neuropsychiatrist based on DSM-IV andundergoing drug therapy

• 5 -12 years of age• Both male and female children• No other medical or psychiatric disorder

Therapy DurationPlay therapy was given for one hour daily for one month.Outcome Measure & TesterConners’ Abbreviated Teacher Rating Scale (ATRS) 07,08 wasused as outcome measure and the special educator of the studysetting was the blinded tester for the study.ProcedureSelected subjects were included in the study after gettinginformed consent from parents. The study was approved byinstitutional ethical committee. Subjects in both groups werereceiving their routine medications; experimental group inaddition was given with following play therapy. Steps that werefollowed during play therapy are,• A connection was made with the subject by shine

acceptance, embracing, joining him/her with his/herinterests, giving him/her control, not manipulating him/herphysically, staying at his/her eye level and not being in theteacher mode.

• Getting delighted in the connection that had beenestablished so a difference was made. The feeling of joyand fun was expressed to the child.

• A game was started by use of fairly basic toys and gamesin number of different ways. The process of treating wasas much fun as getting into the play therapy room. Gamesin which the subject was interested were made moreinteractive. The ongoing activity was not changed, butinterspersed with another variety. Thus making the childstay in the activity by having energy, excitement andenthusiasm.

• Getting the subject excited and motivated for an activity.• By making a request the following task was made to do by

the subject.• Tasks that required prolonged attention such as solving a

jigsaw puzzle.• Playing with building blocks was performed by the subject.• Tasks were performed in the presence of distraction.• Child played computer exercise that aimed at increasing

attention.

Data analysis and resultsThe Statistical software SPSS 11.5 for windows was used

for the analysis of the data. The results were tabulated in termsof Mean, Standard Deviation, Effect size, Z- Value, and P- Valueby using Wilcoxon Signed Rank test.

(36 %) were female children and in the Control Group 17 subjectsthat is 68 % were male children and 8 subjects (32 %) werefemales. The Experimental and the control groups were assignedrandomly so the homogeneity of the groups was not checked.Graph-1&2 shows the age and sex distribution of experimentaland control group respectively.

Table 1: Age and Sex Distribution of subjects in both groupsAge Experimental group Control group

Males Females Total Males Females Total5-8 13 7 20 11 5 169-12 3 2 5 6 3 9Total 16 9 25 17 8 25

Table-1 shows the age and sex distribution of 50 subjectsparticipated. In the study 36 (72 %) subjects belonged to 5- 8years age group and 14 (28%) belonged to 9-12 years age group.In the experimental group 16 (64%) were male children and 9

Graph 1: Age and Sex Distribution of Experimental Group

Graph 2: Age and Sex Distribution of Control Group

The table-2 and graph-3 shows the comparison of beforeintervention and after intervention values within the Experimentaland Control Group by Wilcoxon Signed Rank Test. In the studyit is observed that the Mean±SD of the experimental group duringPre therapy is 11.80±4.06 and during Post therapy is 8.24±5.04with an effect size of 0.78. Hence there is a difference from Pretherapy to Post therapy and is statistically significant with p valuebeing <0.001.

In control group the Pre therapy Mean±SD is 8.80±4.00and during Post therapy is 8.88±4.81 with a negligible effectsize of 0.02. Hence there is no statistically significantimprovement from Pre therapy to Post therapy with p value being>0.903.

The Pre treatment and Post treatment values betweengroups were not compared since there is no statisticallysignificant improvement in the Post treatment values of thecontrol group.

This statistical analysis of the data supports the beneficialeffect of Play therapy on attention component of childrendiagnosed with Attention Deficit Hyperactivity Disorder. Theobjective improvement in the majority of the subjects wasstatistically significant i.e. decrease in the score on Conners’Abbreviated Teacher Rating Scale. So play therapy interventionis effective on children with Attention Deficit HyperactivityDisorder.

DiscussionThe study showed inattention component was significantly

decreased in experimental group which had received playtherapy intervention along with medications and there was noimprovement in the control group which had received onlymedications.

In the support of this study, Susan Hansen, Karen Meisslerand Ovens in the study of group Play therapy model for children

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with ADHD symptomology had concluded that a significantincrease in self esteem was seen which ultimately allows forheightened level of functioning and overall increased ability toengage in social acceptable behaviour.09

Also Marcus D in his study emphasized that Play therapyhelps the child not only at home but also helps in the schoolenvironment.10

But Jerker Ronnberg in his review concluded that executive,central functions (e.g. attention) are negatively affected. Thus itis ventured that this type of theoretical analysis of consequencesare prerequisites and are important for the future developmentof physiotherapy in research and practice.11

The current study has opened doors for physiotherapy toexplore the role of a pediatric physiotherapist while treatingchildren with Attention Deficit Hyperactivity Disorder. We cansay Play therapy intervention is a boon for children sufferingwith Attention Deficit Hyperactivity Disorder. Thus on the basesof the result Play therapy with medication is very effective in thisparticular disorder.

Limitations– Treatment was given for a short duration and long term

carry over effects were not calculated.– The study was conducted on a small population from one

special school.– The experimental and control groups were assigned

randomly from population and they were heterogeneousbefore treatment in terms of inattention component.

– Only Conners’ Abbreviated Teacher Rating Scale was usedas an outcome measure other test batteries could act asadjuncts for more conclusive results.

– Effect of Play therapy was found with medications, the effectof only play therapy without any other treatment was notfound.

Table 2: Comparison within the Experimental and Control Group by Wilcoxon Signed Rank TestGroup Pre treatment Post treatment Effect size z-value p-value

Mean±SD Mean±SDExperimental 11.80±4.06 8.24±5.04 0.78 3.365 <0.001

Graph 3: Comparison of Pre & Post treatment values ofExperimental & Control Group

ConclusionPlay therapy intervention along with medications is effective

in enhancing attention in children diagnosed with Attention DeficitHyperactivity Disorder. Play therapy intervention can be includedas an essential measure in the rehabilitation of children withAttention Deficit Hyperactivity Disorder.

Bibliography01. Kelly Henderson, Identifying and treating Attention Deficit

Hyperactivity Disorder: A resource for School and home;2003:1.

02. Sam Goldstein and Cecil R. Reynolds. Handbook ofNeurodevelopment and genetic disorder in children;1999:154-184.

03. Matthew Cordes and T.F.Mchaughlin. Attention DeficitHyperactivity Disorder and Rating scales with a brief reviewof the Conners teacher rating scale. International journalof special education, 2004; vol19: No.2.

04. Michael Martin et al. Report on attention Deficit HyperactivityDisorder (ADHD).Connecticut ADHD task Force; 2005, 3rd

Edition: 10.05. Mukhopadhyay M, Misra T, Niyogi P. Attention deficit

hyperactivity disorder. Indian J Pediatrics; 2003Oct, 70(10):789-92.

06. Rachel S Tappan. Rehabilitation for balance and ambulationin a patient with attention impairment due to intracranialhemorrhage. Physical therapy; 2002 May, volume 82 No.5:473-484.

07. C. Keith Conners, Gill Sitarenion, James D.A.Parker andJeffery N.Epstein. Revision and Restandardization of theConners’ teacher rating scale (CTRS-R): factor structure,reliability and criterion validity.Journal of abnormal childpsychology; 1998 Aug, vol 26 No.4: 279-291.

08. Farre-Riba A, Narbona J. Conners’ rating scales in theassessment of attention deficit disorder with hyperactivity(ADHD). A new validation and factor analysis in Spanishchildren. Journal of abnormal child psychology; 1997 Feb,25(138): 20.

09. Susan Hansen, Karen Meissler and Richard ovens. KidsTogether: A group play Therapy model for children withADHD symptomalogy. Journal of child and AdolescentGroup Therapy; Dec 2000, Volume 10, no. 4:191-211.

10. Marcus D. Play therapy with young children. Indian journalpediatric; 1992 Jan-Feb, 59(1): 53-60.

11. Jerker Ronnberg. Cognitive and comminicative perspectiveon physiotherapy: A review. Advances in physiotherapy;1999, vol1 No.1:37-44.

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A study of effectiveness of wheelchair skill training program(WSTP) in teaching wheelie to occupational therapy studentsKamal Narayan AryaSenior Occupational Therapist, Pt.DDU Institute for the Physically Handicapped, 4 Vishnu Digamber Marg, New Delhi - 2

Abstract

IntroductionThe “wheelie” is a useful skill that enables the wheelchair userto overcome a number of environmental obstacles. The inabilityof most wheelchair users to perform wheelies is due to lack offormalized training. The Wheelchair Skills Training Program(WSTP) is a structured protocol which is used to test and trainwheelchair users and/or their caregivers and clinicians.

ObjectiveTo test the hypothesis that formalized training based on WSTPguidelines given to Occupational therapy students would improvetheir skills of doing Wheelie.

MethodologyResearch Design – Pretest Post-test single group design15 Students of Occupational therapy(BOT III /BOT IV) weretaken.Setting – College/Lab settingMaterials/equipment – Wheelchair, wooden blocks/bricks,Spotters strap, stopwatch, measuring tape, WSTPOutcome Measures – Height of Castors rise, Time in secondsfor maintaining wheelie position, Safety perception on VisualAnalog ScaleProcedure - Subjects were trained for wheelie by using WSTPguidelines. They were assessed by using the outcome measures

ResultsThere was significant difference (p<0.05) between pre and

post training measure

ConclusionFormalized training based on WSTP guidelines given to

Occupational given to Occupational Therapy students improvedtheir skills of doing wheelie.

IntroductionWheelchair is the most important therapeutic devices in

rehabilitation.1 The fundamental purpose of a wheelchair is topromote mobility, inclusion and enhanced quality of life of theuser. It is a mobility device to promote inclusion and participation(WHO definition)2

The “wheelie” is a useful skill that enables the wheelchairusers to alter their position in space and to overcome a numberof environmental obstacles (e.g., rough ground curbs) that mayotherwise limit mobility. To perform a wheelie, the wheelchair usermust lift the casters off the ground to the point where the combinedcenter of mass (COM) of the users and wheelchair can bebalanced over the rear axles.3, 4 It is surprising that the wheeliehas received little attention in the scientific literature and that onlya minority of wheelchair users ever learn to perform them4.

Usually in Occupational Therapy curriculum such trainingis not given in formalized manner to the students. As a resultOccupational Therapist lacks skills and ability to become experttrainer for their clients.

The Wheelchair Skills Training Program (WSTP) is astructured protocol that incorporates several principles of motorlearning. Evidence has shown that learning wheelchair skills ina formal setting is better than learning through trial and error,and that improvement in wheelchair skills can be retained. TheWSTP has been shown to be a practical, safe, and effectiveway to improve wheelchair skills performance and knowledge.5,

6, 7, & 8

The primary purpose of this study was to test the hypothesisthat formalized training based on WSTP guidelines given toOccupational therapy students would improve their skills of doingWheelie.

Review of literatureKirby RL, Mifflen NJ, Thibault DL, Smith C, Best KL,Thompson KJ, MacLeod DA (2004) studied Wheelchair SkillsTraining Program (WSTP) version 2.4 effectiveness in improvingthe wheelchair-handling skills of untrained caregivers. Twenty-four caregivers of manual wheelchair users were taken.Caregiver participants underwent the WSTP, adapted forcaregivers. The greatest improvements were at the advancedskill level. The WSTP was found to be a safe, practical, andeffective method of improving the wheelchair-handling skills ofuntrained caregivers.7

MacPhee AH, Kirby RL, Coolen AL, Smith C, MacLeod DA,Dupuis DJ (2004) conducted a study to test the hypothesis thata brief, formalized period of additional wheelchair skills trainingwas safe and results in significantly greater improvements inwheelchair skills performance than a standard rehabilitationprogram. Thirty-five wheelchair users participated in theWheelchair Skills Training Program (WSTP). The WSTP groupshowed significantly greater improvements than the controlgroup. programs. 5

Coolen AL, Kirby RL, Landry J, MacPhee AH, Dupuis D,Smith C, Best KL, Mackenzie DE, MacLeod DA (2004) testedthe hypothesis that a brief formalized period of wheelchair skillstraining, added to the standard curriculum, results in significantlygreater overall improvements in wheelchair skills than a standardundergraduate occupational therapy (OT) curriculum alone. The22 second-year students, randomly allocated to the WheelchairSkills Training Program (WSTP) group, on the 50 skills that makeup the WSTP. The WSTP was found to be an effective way toimprove the wheelchair-skills performance of OT students. Thishas implications for the education of all rehabilitation clinicians.6

Best KL, Kirby RL, Smith C, MacLeod DA (2005) tested thehypotheses that wheelchair skills training of community-basedmanual wheelchair users was efficacious, safe, and practical.Twenty community-based manual wheelchair users were taken.Participants were randomly allocated to the Wheelchair SkillsTraining Program (WSTP) or control groups. The WSTP grouphad clinically significant pre and post training improvements inthe success rates of 25 of the 57 individual WST skills, comparedwith only 5 skills for the control group.8

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MethodologyResearch Design – Pretest Post-test single group designSample size – 15 (6 male & 9 female)Sample characteristics – Subjects were students ofOccupational therapy who have been taught ‘Wheelchair’ asper their curriculum. Students were selected from two differentcolleges.Setting – College/Lab settingMaterials/equipment – Wheelchair, wooden blocks/bricks,Spotters strap, stop watch, measuring tape, WSTPDuration of study – 5 months (May 2007 to October 2007)Time of training for each subject – 1 month, 12 to 15 sessionsof 10-15 minutes each, total of 3 hours, in a group of 3-4 students (but individual practice session was also encouraged)

Construction of spotter strap 9 & 10

• Qualitative Video analysis of Wheelie related functionalactivity

Procedure1. Familiarization with wheelchair skills and parts All the

subjects were assessed for their knowledge of wheelchairparts and their basic skills for wheelchair propulsion suchas rolling forward, turning etc. Subjects had been taughtabout wheelchair parts and basic skills wherever required.

2. Testing of Wheelie with safety measures Ability to dowheelie was tested for every subject by taking proper safetymeasure

3. About Concept of Wheelie & its application Followingconcepts had been explained to all subjects in group/individually - It is very useful for crossing thresholds, curbs,uneven terrain steps, obstacles. They are of two types Static& Dynamic, static is useful for crossing levels, steps etcwhile dynamic wheelie is helpful in descending inclinedwithout which risk of rolling over is always there. In staticwheelie effort is done to do wheelie so as to cross aparticular height after that position of wheelie is releasedto further propel the wheelchair. While in dynamic wheelieuser propels the wheelchair in wheelie position.

4. Biomechanics of wheelie Following biomechanics conceptsof wheelie had been explained to subjects either in groupor individually - Wheelie, balancing of wheelchair on rearwheels is achieved when COG of wheelchair & usercombined lies vertically over the rear axle. Initiated byaccelerating and transferring weight rearward, inertial effectresist the acceleration, causes a turning moment about theaxle Balance wheelie position by propelling rear wheel infront and back so that base of support comes undercombined COG of user and wheelchair

5. Video demonstration clips of wheelie and its application invarious activities Video clips of various steps related towheelie skill training and its application in daily activitieswere shown to all subjects in group/individually10

6. Use of bricks/blocks Four bricks/wooden blocks were usedto block the both rear wheels of wheelchair to create aposition of wheelie passively by the trainer. This positionwas tried to be balanced till the subject achieve few secondsof hold by shifting his Centre of Gravity (COG) through trunkmovements.

7. Use of spotters strap Spotters strap was used through outthe training as and when required.

8. Use of Motor learning principles Basic principles of motorlearning were applied during learning the skills such asvideo/practical demonstration, drill practice, variedenvironment, mass/distributed practice, feedback (visualthrough mirror & auditory by trainer).

9. Post training assessment Post assessment was done byusing the same outcome measures as for pre training

Data analysis & resultsSample characteristics – 15 subjects, 6 males & 9 females

with mean age of 20.57 years and standard deviation (SD) of+1.55.

Data was analyzed for following variables –• Height of castor wheel rise (vertical)• Safety perception on Visual Analog Scale (ten points)• Time in seconds for maintenance of wheelie position –

static& dynamic• Total time of training (in minutes)

Main findings of the data analysis are summarized in table &graph (1 to 5)

Fig 1: Spotter strap

• A simple webbing strap that can be attached to thewheelchair at one end and held by a spotter at the otherwas constructed. It reduced the likelihood of injury due torear-tipping accidents at the time of training without makingthe spotter to bend forward to catch a tipping wheelchair.

Outcome measures• Height of Castors rise (vertical) – in inches, measured for

maximum safe and successful performance, subject wasinstructed for minimal wheelchair displacement.

• Time in seconds for maintaining wheelie position, both forStatic & Dynamic – stop watch was used to measure themaximum time for which subject could maintain wheelchairafter training

• Safety perception on Visual Analog Scale (ten points)4Subjects were asked to perceive their feeling of safety whiledoing wheelie pre and post training on visual analogue scaleof 10.

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Fig 2: Measurement of vertical height rise

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DiscussionWheelie, an important wheelchair skill to perform various

daily activities always seems to be difficult to do and far moredifficult to teach to clients. The following study used WSTPguidelines to teach wheelie to Occupational therapy studentwhich showed positive results of learning. None of the subjectshad ability to do wheelie before training though they haveundergone their usual curriculum of theory and practical classes.

Post training, significant results were found for doing wheelie interms of height of castor rise (vertical), time for maintainingwheelie position (Static) & safety perception. No adverseincidents were recorded. Similar results were found in a studydone by Coolen AL et al (2004) 6.

Mean vertical rise of castors was 12.78 inches, p <0.0005(significant), which was also clinically significant and hadfunctional implication for crossing levels of appropriate height,descending ramps etc.

Kirby and et al (2001) proposed 14 wheelie specific skillssuch as wheelie rest, stationary, move forward, turn, inclinedescent etc.4 In the present study implication of learning wheeliecould not be checked quantitatively for all specific skills.Qualitative video analysis was done on few subjects pre & posttraining to see the change and its implication.

All the subjects had 0 (zero) score for perceived safety onVisual analogue scale (VAS) of 10 points pre training. Posttraining mean VAS was 7.46, p< 0.05(significant).

Post training mean time in seconds for maintenance ofstatic wheelie was 185.33 seconds, p < 0.05(significant). Thistime of static wheelie is enough to perform wheelie relatedactivity. A L Coolen & et al (2004) reported mean time of 30minutes (180 seconds) for teaching stationary wheelie tooccupational therapy students.6

Though post training mean time for maintenance of dynamicwheelie was 149 seconds, not found statistically significant buthad functional significance and more time could be achieved bypractice. There were some subjects who could do either of thestatic or dynamic wheelie for infinite seconds or till they get tired.Personal factors such as motivation to learn, fear to fall couldbe probable explanation for this.

Table 5: Relation between training time (in seconds) &maintenance of dynamic wheelie (in seconds)

Test value r = 0.927p < 0.0005 (significant)

Table 2: Post training VAS score for perceived safetyMean 7.46SD + 1.34Test value t = - 1.962p < 0.05 (significant)

Graph 2:

Graph 5:

Kamal Narayan Arya / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1

Graph 1:

Table 1: Post training height rise (inches) of castorsMean 12.78SD + 2.59Test value t = - 8.128p < 0.0005 (significant)

Table 4: Relation between training time (in seconds) & heightof castors rise (inches)

Test value r = 0.79p < 0.0005 (significant)

Graph 4:

Table 3: Post training maintenance of static wheelie (in seconds)Mean 185.33SD + 80.36Test value t = - 1.857p < 0.05 (significant)

Graph 3:

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Qualitative educational usefulness was felt among all thesubjects for such type of practical training

There was strong positive correlation found betweentraining time and rise of castors wheel, r = 0.79, p < 0.0005.With practice more rise could be achieved but up to a certainlevel where COG just lies above the axle of rear wheels. Themore rise could be achieved by using strategies such as trunkforward flexion, propelling wheelchair in forward and backwarddirection. Safe and successful maximum rise also depends ontype of wheelchair. Wheelchair with more anterior axle in relationto backrest improves one’s ability to perform ability but at thecost of stability. Most of the imported wheelchair has moreanterior axle as compared to Indian one.

There was no statistical relation found between trainingtime and perceived safety on VAS but clinically it was found thatwith practice all the subjects felt more confident and safe. Thestatistical insignificance could be attributed to small sample sizeand large standard deviation. This could also be the probablereason for statistical insignificance relation between training timeand maintenance of static wheelie. Though very strong positivecorrelation was found between training time and maintenanceof dynamic wheelie(r = 0.927, p < 0.0005). Also clinically subjectcould perform better static wheelie with more practice session.Limitations- Long term retention of skill could not be checked- Functional implication of wheelie skill in daily activity was not tested- Randomized Controlled Trial could not be conducted- Sample size was small- Teaching was performed in lab setting onlyRecommendations –• Use of video analysis for feed back of learning to the

subjects• Students from more different colleges• Use of high technological aids such as Smart wheelchair,

motion analyzer etc.• More in depth study to study the variables such as visual

feedback, use of spotters strap, specific motor learning &biomechanical principles, training sessions & time, groupvs individual training etc. on learning wheelie.

• Effect of such skill on improvement in activity, participationand over all quality of life.

ConclusionFormalized training based on WSTP guidelines given to

Occupational therapy students made them skillful in doingwheelie. This has implications for the education of Occupational

Therapy clinicians which would improve their practice skillleading to better service for their clients. Such formalizedstructured training program should be incorporated inOccupational Therapy curriculum.

References1. Kirby RL Principle of W/c design & prescriptionin : Lazar

RB editor, Principle of Neurorehabilitation, Mc graw hillnewYork 465-81

2. ISPO consensus conference on wheelchairs for developingcountries: Conclusions and recommendations., ProsthetOrthot Int. 2007 Jun;31(2):217-23

3. JP Bonaparte et al, Learning to perform WheelchairWheelies: comparison of 2 strategies, Archives of PMR,May 2004, V 85, 785-793.

4. RL Kirby et al, New Wheelie Aid for Wheelchairs: ControlledTrial of Safety and Efficacy Archives of PMR, March 2001,V 82, 380-390.

5. Mac Phee AH et al, Wheelchair skills training program: Arandomized clinical trial of wheelchair users undergoinginitial rehabilitation; Arch Phys Med Rehabil. 2004Jan;85(1):41-50

6. Coolen et al, Wheelchair skills training program forclinicians: A randomized clinical trial with Occ therapystudents; Arch Phys Med Rehabil. 2004 Jul;85(7):1160-7

7. Kirby RL et al, The manual wheelchair-handling skills ofcaregivers and the effect of training, Arch Phys Med Rehabil.2004 Dec;85(12):2011-9

8. Best KL, Wheel skills training for community-based manualwheelchair users: a RCT, Arch Phys Med Rehabil. 2005Dec;86(12):2316-23

9. Kirby RL et al, Spotter strap for the prevention of wheelchairtipping Arch Phys Med Rehabil. 1999 Oct;80(10):1354-6.

10. www.wheelchairskillsprogram.ca

AcknowledgementI would like to thank-Dr. Dharmendra Kumar, Director PDU IPH, New DelhiDr. Anoop Agarwal, HOD (OT), PDU IPH, New DelhiDr Manish Samnani, Demonstrator (OT), PDU IPH, NewDelhiDr. Kirby, Faculty of Medicine, Dalhousie University, CanadaDr. Roory Cooper, University of Pittsburg, USABOT IV(2007) students of PDDU Institute for the PhysicallyHandicapped & BOT III students(2007) of Jamia Hamdardfor their support and cooperation as subjects.

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Perception and functional wellbeing of patients receivingphysiotherapy services in a multispecialty hospital – prospectiveobservational trialT. Lavinia Marwein1, Baskaran Chandrasekaran2, Bidhan Chandra Sharma3

1Physiotherapy Intern, College of Physiotherapy and Medical Sciences, Guwahati, 2 Lecturer in Physiotherapy, Sikkim ManipalCollege of Physiotherapy, SMU, Sikkim, 3 Assistant Professor in Physiotherapy, Sikkim Manipal College of Physiotherapy, SMU,Sikkim

IntroductionPhysiotherapy plays a vital role in the recovery of physical,

emotional illness of the various functionally impaired and re -integration into their family and community. Physiotherapy mayadd life to years of the patients and increases their physical,emotional and social wellbeing1.

The physical, social and psychological wellbeing afterrehabilitation is well established in well planned, statisticallystrong earlier studies2-6. The wellbeing, an abstract thinking ismainly relied on the patient perception which is highly subjectiveand non reproducible. Hence these studies are questioned fortheir validity and reliability2-7.

Very few reliable and valid scales have been developed tomeasure patient satisfaction of patients receiving out-patientphysiotherapy3, 5, and 7. Recent patient satisfaction questionnairedeveloped by American Physical therapy Association (APTA)claims high validity and reliability in their application5 but it hasnot been used in India so far and the patient’s quality of life afterphysiotherapy remains unknown.

Objectives of study1. To find the efficiency of physiotherapy services in outpatient

set-up.2. To qualitatively evaluate and document the satisfaction and

the quality of life in physiotherapy out patients.

MethodologyStudy Design: Prospective observational trial .Study Setting: Central Referral Hospital, Gangtok.Sample Size: 50 patients required to find minimum effect sizeof 50% improvement in the functional scores and at power of80% and level of significance of 90%.Patients: The study was approved by Sikkim Manipal InstituteEthics Committee. The patients enrolled for outpatientphysiotherapy without the due consideration to their ailmentsand are willing to participate are explained about the study. Thesubjects whose compliance was questioned are excluded fromthe study. It was assumed to have 100% compliance to thephysiotherapy treatment. They are recruited after the informedconsent. They were asked to fill the functional assessmentquestionnaire prior to the physiotherapy treatment. The patientsare then assigned to the clinical physiotherapists of similardemographics, professional qualification and experiencesblinded to the research question and procedure.

Procedure

AssessmentThe routine assessment was taken based upon the

individual differences in the problems, pain pattern andintellectual context, reasoning skills and the rationale of diagnosisof the physiotherapists performing the assessment.

Physiotherapy treatment

The treatment was based on the assessment by the clinicalphysiotherapists who are blinded to the current study. Thephysiotherapists recruited to the study were assessed for soundclinical knowledge, judgment and prioritizing the treatmenttechniques. We found that inter - rater reliability in theassessment techniques was high since stratified on the basisof qualification and experience.

Functional assessment questionnaireThe questionnaire consists of 18 components was given in

which the patient have to circle according to the functionalrestriction and impairments. However, a higher scorecorresponds to greater activity response and the lowest scorecorresponds to lower activity status or greater impairment.

Statistical analysisThe individual components of functional assessment

questionnaire between pre and post physiotherapy interventionis compared by paired sample t test. The rest of the data isdescribed by descriptive analysis.

ResultsTotally 50 patients screened and analyzed. Only 37 patients

completed the overall physiotherapy treatment sittings. The dataare presented in the table: 1.Satisfaction: the average satisfaction score from the APTAquestionnaire is 85.3 which are depicted in percentage in thefig: 2.The Functional Assessments:The t test showed that all the functional components reachedsignificant level except driving and is presented in table. 2.(To be significant, observed t value should be greater that ofcalculated t value 2.042 for 36 degrees of freedom with CI of95% and á = 95%)

Discussion1. Satisfaction:

We have observed that the 85% of the patients havesatisfied with the present physiotherapy services. The currenttherapists rationalistic knowledge, inter therapist relationship inassessment and the management, patient friendly environmentand accessibility and availability of the physiotherapeuticequipments might be the reason for the satisfaction.

We agree to the previous literature claims2-7 thatphysiotherapy services might give an excellent satisfaction ifthe services were easily accessible, excellent based on theavailability of modalities and therapists, therapist’s knowledgeand treatment planning, timing of the treatment, improvementin lifestyles and patient friendly.

No previous reports have reported a satisfaction statisticsof this high magnitude. This satisfaction may be due to chancebecause of the low sample size.2. Functional capacities evaluation:

We have proved that almost all the aspects of the functional

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evaluation scale were reported to reach significance levels aftertheir comparison among pre and post physiotherapy (graph. 3and table 2). This definitely implicates that Physiotherapy broughtimprovements in their quality of life by improving functionalabilities.

We had an assumption that any precise physiotherapyassessment and treatment pertained to the condition mightdecrease the above impairments and restore wellbeing. We haveobserved from our study that all the common functionalimpairment components improved with higher levels ofsignificance in ADL activities like bathing, functional activities

Table 2: paired t test analysis of the pre intervention and post intervention functional capacities of the individualsComponents of the functional assessment questionnaire 95% CI t Sig. (2

Mean SD SEM Lower Upper -tailed)Pre PT sleep disturbances - Post PT sleep disturbances 1.08108 1.03758 .17058 .73513 1.42703 6.338 .000Pre PT up and down stair climbing – Post PT stair climbing .97297 .95703 .15734 .65388 1.29206 6.184 .000Pre PT cooking,eating - Post PT cooking, eating food 1.05405 1.26811 .20848 .63124 1.47686 5.056 .000Pre PT walking - Post PT walking .64865 1.08567 .17848 .28667 1.01063 3.634 .001Pre PT grooming (bath, comb, shave) - Post PT 1.24324 1.49825 .24631 .74370 1.74278 5.047 .000Pre PT transfer - Post PT getting up and down(chair,bed) 1.10811 1.14949 .18897 .72485 1.49137 5.864 .000Pre PT dressing - Post PT normal dressing .97297 .86559 .14230 .68437 1.26158 6.837 .000Pre PT tie shoes, button shirt - Post PT tie shoes, button shirt .81081 1.32995 .21864 .36738 1.25424 3.708 .001Pre PTlifting, carrying - Post PTlifting, carrying 1.40541 1.03975 .17093 1.05874 1.75208 8.222 .000Pre PT sitting - Post PT sitting .81081 1.41102 .23197 .34035 1.28127 3.495 .001Pre PT standing - Post PT standing normal period 1.75676 4.65717 .76563 .20398 3.30953 2.295 .028Pre PT reaching - Post PT reaching 1.67568 3.63665 .59786 .46316 2.88820 2.803 .008Pre PT leisure, recreational - Post PT leisure, recreational 1.18919 1.30890 .21518 .75278 1.62560 5.526 .000Pre inter squat to pickup - Post intersquat to pickup items 1.18919 1.30890 .21518 .75278 1.62560 5.526 .000Pre inter running, jogging - Post inter running, jogging .94595 1.50824 .24795 .44308 1.44882 3.815 .001Pre intervention driving - Post intervention driving .37838 1.38145 .22711 -.08222 .83898 1.666 .104Pre PT job requirements - Post PT job requirements .91892 1.08981 .17916 .55556 1.28228 5.129 .000Pre intervention VAS - Post intervention VAS 3.78378 1.98795 .32682 3.12097 4.44660 11.578 .000

Table 1: Table explain the individual components of functional assessment questionnaire and satisfaction of the patients

like carrying and lifting and recreational activities like sports.We agree to the earlier literature8, 9 proving that the planned

and structured physiotherapeutic assessment and treatmentbring about improvement in their ADL activities (Basic,instrumental and recreational activities).

ConclusionPhysiotherapy improves quality of life of the patients

receiving outpatient rehabilitation services inspite of the ailmentsand the therapists. More than 2/3rd of the total patients receiving

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physiotherapy satisfy with the available physiotherapy servicesin the outpatient rehabilitation

References1. Crosbie J, Naylor J, Harmer A, Russell T. Predictors of

functional ambulation and patient perception following totalknee replacement and short-term rehabilitation. DisabilRehabil. 2009 Oct 28.

2. Deutscher D, Horn SD, Dickstein R, Hart DL, Smout RJ,Gutvirtz M, Ariel I. Associations between treatmentprocesses, patient characteristics, and outcomes inoutpatient physical therapy practice. Arch Phys MedRehabil. 2009 Aug;90(8):1349-63.

3. Marc S Goldstein, Steven D Elliott and Andrew A Guccione.The Development of an Instrument to Measure Satisfactionwith Physical Therapy. Phys Ther Vol. 80, No. 9, September2000, pp. 853-863

4. P.F Beattie, M. B. Pinto, and M. K Nelson and R. Nelson;Patient Satisfaction With Outpatient Physical Therapy:Instrument Validation; Physical Therapy, June 1, 2002;82(6): 557 - 565.

Fig. 2: Mean satisfaction of the patients attending Physiotherapydepartment of SMIMS

Graph 3: Bar diagram, showing a pre and post interventiondifference in functional activities

5. Longitudinal Continuity of Care Is Associated With HighPatient Satisfaction with Physical Therapy; PhysicalTherapy, October 1, 2005; 85(10): 1046 - 1052.

6. P.F Beattie ,R.M Nelson and A.Lis; Spanish-LanguageVersion of the MedRisk Instrument for Measuring PatientSatisfaction With Physical Therapy Care(MRPS):Preliminary Validation. Physical Therapy,June 1, 2007; 87(6): 793

7. Roush SE, Sonstroem RJ.Development of the physicaltherapy outpatient satisfaction survey (PTOPS). Phys Ther.1999 Feb;79(2):159-70.

8. Adamsen L, Quist M, Andersen C, Møller T, Herrstedt J,Kronborg D, Baadsgaard MT, Vistisen K, Midtgaard J,Christiansen B, Stage M, Kronborg MT, Rørth M. Effect ofa multimodal high intensity exercise intervention in cancerpatients undergoing chemotherapy: randomised controlledtrial. BMJ. 2009

9. R P. Van Peppen, G Kwakkel, S Wood-Dauphinee, H J.Hendriks, P. J Van der Wees, andJDekker. The impact ofphysical therapy on functional outcomes after stroke: what’sthe evidence? Clinical Rehabilitation, August 1, 2004; 18(8):833 – 862.

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Effect of concurrent quantitative feedback training on intra-raterand inter-rater reliability of grade III mobilization over fourthlumbar spinous processNidhi Gautam*, Shallu Sharma***Research Student, ISIC Institute of Rehabilitation Sciences, New Delhi, **Research Guide, M.P.T. Manual Therapy, Lectrurer, ISICInstitute of Rehabilitation Sciences, New Delhi

AbstractPostero-anterior mobilization of spine have been found to havequite beneficial effects in various musculoskeletal conditions,yet, the reliability of various parameters of grade, dosage (force,amplitude, acceleration, deceleration, etc) have not beenconcluded so far. Feedback training has positive impact on motorskill acquisition. The purpose of the present study was toinvestigate whether intra-rater & inter-rater reliability of grade IIImobilization over L4 spinous process can be improvedsecondary to feedback training using pressure algometer ?

Subjects & method200 asymptomatic, healthy subjects participated in the study.Two equally qualified & skilled raters were recruited & wereprovided with four week of feedback training in applying gradeIII mobilization over L4 spinous process over 200 healthysubjects, by the same mentor. Posts training intra-rater & inter-rater reliability of grade III mobilization force over L4 spinousprocess in 193 healthy asymptomatic subjects were calculated.

ResultsExcellent intra-rater & high inter-rater reliability values (ICC =.9434* & .8019* respectively, pd” 0.01) of grade III mobilizationover L4 spinous process were obtained.

Discussion & conclusionMobilization procedures are motor skills which require practiceto be learnt properly. Feedback training has established positiverole in facilitating motor skill acquisitition. Improved values ofintra-rater & inter-rater reliability of grade III mobilization overL4 spinous process secondary to feedback training usingpressure algometer, obtained in the present study can beexplained in consensus with the positive impact of feedbacktraining on acquisitition of motor skills.

Key wordsfeedback training, algometer, reliability, motor skill acquisition

IntroductionManual therapy is the mainstay of modern physiotherapy

which includes a wide range of interventions such as jointmobilization, manipulation, traction, soft tissue techniques, etc.It requires expertise in skillfully applying these different manualtechniques, thus, maximizing their effectiveness.1,2,3,4

Mobilization refers to gentle, repetitive, rhythmic movementsforming the mainstay of manual therapy assessment & treatmenttechniques. The outcomes of spinal manual therapy have mostcommonly been described in terms of biomechanical responseto application of treatment technique. Majority of these studieson applied manual forces relates to

the posterior to anterior (PA) spinal mobilization techniquethat was described by Maitland et al in book that is Maitland’svertebral manipulation (seventh edition)5 - four grades ofmobilization were defined with Grade I & II to be primarily used

for treating pain while grade III & IV to be used forstretching.6,7,8,9,10

Reliability forms an important basic question addressingthe fact that a test (a tool of measurement or scale) shouldmeasure exactly the same quality or attribute each time it isused. Intra-rater reliability is the similarity in the measurementsof a quality or an attribute taken by a same individual on specificintervals of time whereas inter-rater reliability is the similarity inthe measurements of same attribute or quality taken by two ormore individuals taken on specific intervals of time.

A large amount of literature investigating these variousparameters of applied forces along with the concept of reliability,in relation to various therapist’s & patient’s related factors, alreadyexists. Most of these studies were teemed with various flaws &limitations like testing over mechanical simulating models otherthan living subjects, inappropriate inclusion criteria of raters,lack of proper pre-training and feedback for acquired skill, andabsence of trials, etc, thus, making results of these differentstudies incomparable & incoherent.

A study on manual forces applied during cervicalmobilization by Suzanne et al in 2007 provided preliminaryevidence that cervical mobilization forces vary considerablybetween therapists, but intra-therapist repeatability was high.11

Suzanne et al in 2009 re-established the variability betweentherapists, but, intra-therapist reliability was good (intraclasscorrelation coefficient [2,1] for different force parameters, 0.84-0.93). Mean peak forces increase from grades I to IV, rangingfrom 22 to 92 N for resultant forces.12 Mc Harms et al foundinconsistency between experienced therapists in applying lumbarmobilization.13

On the other hand, J Keating et al in their study on effect oftraining on physical therapists ability to apply specified forces ofpalpation, concluded that training improves accuracy in forceapplication during various manual techniques.14 Similarly,Michael et al in 1990 established significant improvement inaccuracy & consistency in the application of the mobilizationforce with the use of feedback training during learning sessionof vertebral joint mobilization skill.15 B J Downney et al in 1999indicated training in spinal therapy enhances the palpatory skillsof physiotherapists in palpating nominated lumbar spinal levels.16

In the present study, pressure algometer which has beencommonly used in clinical settings, was used as a feedbacktool to facilitate teaching & learning of graded mobilization duringpre-training sessions.

Various sophisticated devices like force plates, speciallydesigned instrumented plinths, or more complicated deviceshave been used to quantify various parameters of forces appliedduring manual therapy techniques. Most of these instrumentsare very sophisticated, expansive with complex functioningmechanism which is more useful for research purpose inlaboratory settings rather than clinical purposes. There is needof a simple, easy to use, economical, easily accessible, but,accurate and reliable device which can be used in laboratory aswell as clinical settings easily for quantification of forceparameters during various manual therapy techniques.

Pressure algometer is one such simple device fulfilling theserequirements with good intra-rater & inter-rater reliability for forceapplication in various pathological conditions.17

In the light of these various inconclusive, equivocal studiesleading to lack of proper documentation of vital parameters of

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mobilization forces, there is a need of well organized, systematicstudy keeping various limitations in mind, thus, addressing thevery important basic question of reliability of mobilization forcesapplied by different therapists. A study aiming at finding somepractically effective method to find whether these mobilizationtechniques application can be improved or not, is needed.

Thus, the present study, using a conventional spring loadedpressure algometer to provide feedback training during learningsession of graded mobilization, is an effort towards overcomingvarious flaws & limitations of these previous studies to reach amore reliable & meaningful conclusion in the field of manualtherapy.

MethodsSubjects: A total sample of 230 healthy asymptomatic

subjects collected by displaying of advertisement on variousnotice boards of ISIC hospital & academic section of ISICInstitute of Rehabilitation Sciences. Out of 230 volunteer subjectswho satisfied inclusion criteria were selected. A detailedexplanation about the procedure and purpose of the study wasprovided to the subjects. Informed consent was duly signed byall the subjects after they agreed on participating in the study.Simultaneously two physical therapists with similar age, clinicalexperience and theoretical background, were randomly recruitedas raters for the study from a group of therapists specializing inthe field of musculoskeletal physiotherapy.

A mechanical Force dial TM FDK/FDN model algometerby Wagners was used for the study. These models are calibratedin the factory prior to the delivery to the customer, so no furthercalibration was required prior to commencement of the study.The instrument has 10 kg/cm2 marked scale with a 1 cm2 rubberfoot plate with an accuracy of two grades (± 2) through 5 lbf/2500gf [ (±1) one grade over 5 lbf/2500gf)]. A standard error ofthree grades was present in the model used in the present studywhich was considered subsequently during the whole dataanalysis.

A four week training session aiming at adequateunderstanding and learning of grade III mobilization techniqueover radial styloid process followed by over L4 spinous processmanually & later by using pressure algometer over L4 spinousprocess provided by a skilled mentor preceded the data collectionperiod. The mentor recruited for the purpose was an experiencedclinical physiotherapist having five years of experience withspecialization in neuro-musculoskeletal physiotherapy.

First, both the raters were only provided with theoreticalknowledge of grade III mobilization to be applied over L4 spinousprocess which was pre-marked by an independent rater. Properthumb grip was attained. Following this, raters were trained forapplying grade III mobilization force using thumb grip over thesuperior surface of algometer dial placed vertically on a hardtable with the styloid facing downward. The same placement ofalgometer and grasp was used over L4 spinous process markedby an independent rater as described before. All these volunteerswere dealt in this way within three days with no concurrentquantitative feedback given to raters. Readings of force appliedby two raters on same day and rater 1 on three consecutivedays, were recorded by the third rater independently. The raterswere asked to perform three to five oscillation over L4 spinousprocess and mean of last two readings was taken on day 1 andtwo consecutive days for data analysis to find pre-training forcemagnitude and intra-rater and inter-rater reliability.

After the first leg of study, the second leg commencedwith progression of the study towards four week training sessionin which each rater was trained to acquire the feel of grade IIImobilization force by direct application using thumb grip oversoft skin of forearm, followed by bony prominence of radial styloidprocess and finally over spinous processs of fourth lumbarvertebra. Mentor affirmed the correctness of technique of gradeIII force application. They were progressed further to application

of grade III mobilization force using pressure algometer over L4spinous process. The L4 spinous process was marked by thirdindependent rater using iliac crests and posterior superior iliacspines as reference landmarks. Rater perform grade IIImobilization and concurrently feedback regarding forcemagnitude was provided by the mentor for facilitating theirlearning of correct technique of graded III mobilization. Duringthis training period, range of force applied by the mentor recordedwith pressure algometer was used as a reference for learningamount of force to be applied in grade III mobilization over L4spinous

Once both raters became confident of acquired skill &consistency of their technique was re-evaluated by the mentor,these raters were upgraded to perform the same procedureover study sample of 193 healthy subjects over the period offive months. Now, these force readings were noted for dataanalysis to calculate intra-rater and inter-rater reliability of gradeIII mobilization over L4 spinous process.

A total of 193 subjects could be re-contacted. The third legof the study started with brief introduction of study explained toevery subject using forearm as demonstrating media. Subjectswere positioned in prone lying on a firm plinth with a small pillowunder hips to allow slight flexion of hip joints thus, making lumbarlordosis neutral, allowing easy palpation of L4 spinous process.Rest spine was made to lie in neutral relaxed position withoutany lateral bending or rotation with the arms relaxed by the sideof the trunk and head rotated comfortably to one side as persubject comfort. Now, palpation & marking of L4 spinous processwas done by third independent rater using highest points of iliaccrest as well as PSISs (Posterior superior iliac spines) asreference points chosen randomly for reconfirmation.

Subject was instructed to exhale normally at forceapplication by the raters. First grade III mobilization was appliedusing thumb grip directly on L4 spinous process & subjects wereasked to remember the amount of force as far as possiblethrough the perception felt at the end of procedure, immediatelythumb grip application was switched on to algometer forceapplication. Grade III mobilization force was applied 3-5 timeswith an interval of 30 seconds between each trial, using pressurealgometer over L4 spinous process & three readings which werealso in consensus with subject perception of force applied, wereused for data collection.

Rater 2 performed similar method of force application oneach subject for testing inter-rater reliability after five minutesof force application by rater 1, during which subject was notallowed to change his/ her position. Rater 1 used same methodfor two more consecutive days over same 193 subjects for intra-rater reliability testing. All the readings were recorded by thethird rater who had no knowledge about the purpose andobjective of the study. The average of last two of these threereadings was taken as the amount of force applied by eachrater during different trials for calculating post-training intra-raterand inter-rater reliability of grade III mobilization over L4 spinousprocess. These values were further taken for data analysis tocalculate intra-rater and inter-rater reliability of grade IIImobilization over L4 spinous process using suitable statisticaltools.

ResultsResults of the current study showed post –training

improvement in intra-rater and inter-rater reliability of grade IIImobilization forces from ICC values of .8344* (intra-rater); .7044*(inter-rater) to ICC values of .9434*(intra-rater); .8091* (inter-rater) respectively.

DiscussionOver the past two decades (1985-2009), with growing

understanding of various parameters of mobilization forces,

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Table 1: Demographic details of the subjects (pre-training period)N=200 (F=102,M=98)

VARIABLES MIN. MAX. MEAN±SDAGE 20.00 44.00 30.01±8.44

WEIGHT 45.00 79.00 64.19±8.10HEIGHT 1.07 1.80 1.66±9.04

BMI 18.5 25.00 23.07±1.80Ra1 2.30 6.65 4.40±0.81Rb1 2.50 6.85 4.74±0.77Ra2 2.85 6.45 4.46±0.70Ra3 2.85 6.45 4.56±0.74

Abbreviations:BMI- Body Mass IndexRa1 – force readings (in Kgf) of rater 1 on first dayRb1 – force readings (in Kgf) of rater 2 on first dayRa2 - force readings (in Kgf) of rater 1 on second dayRa3 - force readings (in Kgf) of rater 1 on third day

Table 2: Pre-training Intra-rater and inter-rater reliability valuesobtained in 200 healthy subjects

VARIABLES AVERAGE ICCFORCE

APPLIED (kgf)INTRA Ra1 4.40RATER Ra2 4.46 .8344*

Ra3 4.56INTER Ra1 4.40RATER Rb1 4.74 .7044*

Results showing high intra-rater and moderate inter-raterreliability of grade III mobilization during pre- training session

Table 4: Post-training Intra-rater and inter-rater reliability valuesobtained in 193 healthy subjects

VARIABLE AVERAGE ICCFORCE VALUEAPPLIED (kgf)

INTRA Ra1 4.37RATER Ra2 4.49 .9434*

Ra3 4.57INTER Ra1 4.37 .8019*RATER Rb1 4.72

Results showing excellent intra-rater reliability & high inter-raterreliability between two raters post-training

Figure 1: Pre-training force variation of rater1 on threeconsecutive days without feedback training

Figure 2: Pre-training force variation between two raters withoutfeedback training

Table 3: Demographic details of the subjects (post-trainingperiod)N=193 (F=102,M=91)VARIABLES MIN. MAX. MEAN±SDAGE 20.00 44.00 29.86±6.41WEIGHT 45.00 79.00 63.96±8.10HEIGHT 1.07 1.80 1.66±9.08BMI 18.5 25.00 23.03±1.81Ra1 2.65 6.75 4.37±0.78Rb1 2.75 6.85 4.72±0.80Ra2 2.85 6.45 4.49±0.75

Figure 5: Post-training force variation of rater1 on threeconsecutive days

Figure 6: Post-training force variation between two raters

various modifications have occurred suggesting improvisedreliability & reproducibility [poor to fair ranging from k=-.20 to.26; p=0.001].11,12,14,15,18, 19, 20,21,22,23,24,25,26,27 Since, these studieswere based on dimensions of parameters like stiffness; it is anongoing process. The current study focuses on investigatingforce related parameters & theoretical construct of grade III forcetesting.

In the present study, asymptomatic healthy subjects havebeen selected to assess grade of mobilization as symptomatic

subjects have been found to have varying amount of inter-examiner reliability in palpation and examination of inter-segmental mobility suggesting an unexplained variabilitybetween candidates.20,22,24,25,26,29,30,31,32,,33 In the present study, L4vertebra was targeted as this level simulates normal spinalkinematics to application of postero-anterior force. Moreover,L4 vertebra has better comparative values for intra-rater andinter-rater reliability for palpation than other lumbar vertebrallevels (L2, L3, L5) 21,34. Therefore, use of L4 in the current studystrengthens the internal validity of the study, as L4 is assumedto follow normal kinematic principles to poster-anterior forceapplication.35

Subjects falling in the normal range of BMI (18.5-25) hasbeen selected in the present study, to address another sourceof variation i.e. obesity, thus limiting the variations in force

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parameter due to excess fat tissue deposition (subcutaneousand inter-vertebral space). G.D.Maitland has suggested twotypes of grips- the thumb grip & the pisiform grip. He suggestedthe “loss of feel” as source of bias in perceived magnitude &reduction in stimulus discriminability. Since, both type of griphave equal stimulus discriminability, the therapist can use eitherof these grips, but, should ensure use of same grip each timefor test & retest.36 ,thus, justifying use of thumb grip in the presentstudy.

The results of the present study supports the experimentalhypothesis. Living human subjects have been used in the presentstudy, suggesting better expected values of perceived stiffnessthan on simulating mechanical models employed in earlierstudies.17,31,37

As the study by NJ Petty et al in 2002 suggested thatpatterns of stiffness observed in movement diagrams of spinalor peripheral joints are not analogous to normal tissue load-displacement curve, depicting the first point of resistance felt byexaminer (R1) at the beginning of the range, as early as thebeginning of the range (at point A), the choice of resistance-defined treatment grades of movement would, as aconsequence, be limited to grade III (III-,III,III+) and grade IV(IV-,IV,IV+) only.38,39,40 Therefore, grade III mobilization with muchlesser variability as suggested in line with these previous studies,was taken as part of the present study.

Mobilization procedures are motor skills that require practiceand correction in order to be learnt and repeated. Practice of amotor act is necessary for it to transpire into the skill.41 In thepresent study, two equally qualified and skilled physiotherapistswere recruited as raters who were provided with a four weeks oftraining aiming at acquisition of motor skill of grade III mobilizationprior to the start of the study.

It has been shown that concurrent qualitative andquantitative feedback in the form of real-time ultrasound imagingand pressure feedback training improves the learning of correcttechnique of abdominal drawing-in maneuver.28

Table 3 shows high values of inter-rater & intra-raterreliability( .8019* & .9434* respectively) of grade III mobilizationpost motor skill acquisitition using pressure algometer ascompare to moderate inter-rater reliability( ICC= .7044*) valuesobtained during initial pre-training phases without use ofconcurrent quantitative feedback ( algometer), in consensus withvarious behavioral studies emphasizing beneficial effect offeedback training. 28

These results from the current study are in accordance withprior studies using sophisticated instruments showing highreliability values.14,15,16,31 They suggests the advantage of relyingnot only on perception of resistance/ force which was taught inaccordance of theoretical concepts, but also referring quantitativemeasurement of amount of forces applied in the present studyIn the study under investigation, the focus was on studying theeffect of concurrent quantitative feedback training on improvingreproducibility & repeatability of grade III mobilization forces overL4 spinous process, having taken care of substantial patient aswell as therapist related variables, we conclude that results areapplicable to normal clinical settings.

Clinical significanceImproved reliability & accuracy of force application in grade

III mobilization over L4 spinous process was supported by thehigh inter-rater reliability values obtained in the present study,highlighting the beneficial use of concurrent quantitativefeedback training using pressure algometer while training gradeIII mobilization over L4 spinous process.In light of the comparableresults of the current study to previous literature, it isrecommended to be used in clinical and educational set ups.Encouragement for its use can contribute to homogeneity andobjectification of the teaching methods of manual mobilization.Itwould improve method of data collection for patient records as

well as research purposes in turn, it could help in improvisinginter-therapist communication and skills.

Future researchesStudies to adjudge force with respect to graded application

in a holistic view (that is force acceleration, deceleration,amplitude, etc) using advanced instrumentation are required.Effect of feedback training and its long term retention usingalgometer can be tested on diverse group of population &therapists.

Potential limitations of the studyA random choice from a group of suited raters would have

better addressed the therapist related variables. Abovementioned condition, though was not feasible for the presentstudy, is considered as a potential limitation.

ConclusionAfter addressing deficiencies of relevant previous studies

from the review of literature, the present study concludes thatconcurrent quantitative feedback training using pressurealgometer plays a significant role in improving reproducibilityand repeatability of grade III mobilization over L4 spinousprocess. Hence, feedback training and use of force magnitudeas a form of concurrent quantitative feedback is recommendedfor use in educational and clinical settings.

Acknowledgement I wish to thank my guide Ms. Shallu Sharma. Also I would

like to thank my HOD (Ms. Chitra Kataria) & all faculty membersof ISIC Institute of Rehabilitation Sciences. Lastly my thanks toall the participants of my study & my family & friends withoutwhom this study would not have been successfully completed.

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Efficacy of deep transverse friction massage in treatment ofchronic ankle sprainPooja K Arora*, Sujata Yardi**, Kunal Pathak****Lecturer, Dept. of Physiotherapy, Pad, Dr. D.Y Patil University, Nerul, Navi Mumbai, **Professor & Head, Dept. of Physiotherapy,Pad. Dr.D.Y Patil University, Nerul, Navi Mumbai, ***Intern, Dept. of Physiotherapy, DY Patil University, Nerul Navi Mumbai

Address for Communication:Dr Pooja AroraLecturer, Dept of Physiotherapy, Pad. Dr.D.Y Patil University,Nerul, Navi Mumbai. Mobile.: 9869672223

Abstract

IntroductionAnkle sprains of lateral ligaments are extremely common injuriesin athletic and physically active population and recurrenceremains a common problem accounting for as high as 80% withankle instability. Neuromuscular and proprioceptive deficits arethought to be related to chronic ankle instability, includingfunctional and mechanical insufficiencies. Physical therapy is atreatment modality for patients who have suffered moderate tosevere ankle sprains, especially persons who have chronicinstability and recurring symptoms. Deep Transverse FrictionMassage (DTFM) is a special type of connective tissue massageused after an injury or mechanical overuse in muscles, tendonsand ligaments is evaluated as a method of treatment in Anklesprains.

MethodologyAims & objectives

To evaluate and compare the short term therapeutic effects ofPulsed Ultrasound and Deep Friction Massage withStrengthening in Treatment of Recurrent Ankle Sprain

Study designHospital based, single blind, Randomized ControlledEquivalence Trial

Study populationThe study population were patients clinically and radio logicallydiagnosed by Consultant Orthopaedic surgeon in OrthopaedicOPD as recurrent ankle sprain and referred to physiotherapyfor treatment. TheInclusion Criteria

Patients >15 years age, of both genders with ankle sprainwith previous history of minimum two episodes of ankle sprainin the same foot and who had suffered from last ankle sprainwithin two months.Exclusion Criteria

Acute inflammation and swelling(less than 48 hours),Anklefractures and unstable ankles, Neurological disorders likeneuropathy, Musculoskeletal condition of the lower limbs likelimb shortening, foot deformities (Congenital or acquired)A total of 30 patients who were fulfilling the inclusion criteriawere enrolled in this study.

Study factors

Intervention: UltrasoundGroup was treated with Ultrasound and Strengthening

exercises. TheDeep Friction Massage

Group was treated with Deep Friction Massage andStrengthening exercises. Allocation to Intervention was by blockrandomization of 6 done by chit method.

Outcome factorsA blinded observer recorded pain scores on rest and onmovements before treatment, than on 3rd, 7th, and 10th day aftercompletion of therapy using visual analog scale (VAS). Rangeof movement at ankle namely Dorsi flexion, Plantar flexion,Eversion, Inversion at ankle joint was measured by Goniometerand. Foot and ankle disability scale score was recorded pre-treatment and post treatment.

ResultsOf 30 patients, 19 were females (63.33%) suggesting femalepreponderance. The mean age of the patient was24.63years.Twenty One patients had right side ankleinvolvement. Two groups were comparable for age, gender andside of sprain. On comparing the results of two therapies therewas no statistically significant difference noted in reliefparameters suggesting that the two studies were givingequivalent short term relief to patients of chronic ankle sprains.Overall analysis of Ankle disability score recorded pre-treatmentand post treatment in both modalities showed statisticallysignificant improvements in Ankle disability scores.

ConclusionDTFM is an efficacious tool for short term treatment of chronicankle sprains. Its efficacy is equivalent to standard ultrasoundtherapy.

KeywordsChronic Ankle Sprain, Ultrasound therapy, Deep Transverse

Friction Massage, Ankle Disability Scores

IntroductionAnkle sprains especially of lateral ligaments are extremely

common injuries in athletic and physically active population.Despite vast amount of research in management of anklesprains, recurrence remains a common problem accounting foras high as 80%.1 The possible causes of recurrence could behealing of ligament in lengthened position, persistent peronealweakness, 2 hereditary hyper mobility of joints, loss ofproprioception of the foot, 3 impairment of reflex stabilization offoot, 4 dysfunction of peroneal nerve and impingement by distalfascicle of antero-inferior tibio-fibular ligament. The incidenceof developing chronic ankle instability is 20-40% of those whohad previously sustained an acute ankle sprain.5 Neuromuscularand proprioceptive deficits are thought to be related to chronic

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ankle instability, including functional and mechanicalinsufficiencies.6 The functional limitations and disability are mostimportant to the patient and is essential that clinicians quantifydysfunction at this level. The Foot and Ankle Disability Index(FADI) was designed to assess functional limitations related tofoot and ankle conditions7 and is used as a tool of assessmentin present study.

Physical therapy is a treatment modality for patients whohave suffered moderate to severe ankle sprains,especially persons who have chronic instability and recurringsymptoms.8 The goals of Physiotherapy treatment are to regainthe full range of motion (ROM), improve strength and stability ofthe ankle joint.9, 10

Amongst treatment modalities in physiotherapy, Pulsedultrasound therapy is traditionally used to facilitate soft tissuehealing. It acts on cell membrane destabilization which is thoughtto enhance the inflammatory response from the inflammatoryphase to the proliferative phase. Deep Transverse FrictionMassage (DTFM) is a special type of connective tissue massageused after an injury or mechanical overuse in muscles, tendonsand ligaments. The technique is often used in conjunction withmobilization techniques. Proper case selection and effectiveexecution of massage at exact site give good results.11 There ispaucity of data on effectiveness of DTFM in recurrent anklesprains and no scientific study is documented in the literatureon the use of DTFM in the treatment of recurrent ankle sprains.Hence present study looks at effectiveness of DTFM in recurrentankle sprains and its comparison to standard pulsed Ultrasoundtherapy.

MethodologyAims & objectivesTo evaluate the short term therapeutic effects of PulsedUltrasound and Deep Friction Massage with Strengthening inTreatment of Recurrent Ankle Sprain and to compare theeffectiveness of both the modalities.Study designHospital based, single blind, Randomized ControlledEquivalence TrialStudy setupThe study was carried out at Department of Physiotherapy, Pad.Dr.D.Y.Patil Medical College and Hospital, Nerul, Navi Mumbai.Study populationThe study population were patients clinically and radiologicallydiagnosed by Consultant Orthopaedic surgeon in OrthopaedicOPD as recurrent ankle sprain and referred to physiotherapyfor treatment.

Subjects

Inclusion CriteriaPatients of more than 15 years age, of both gendersPatients having ankle sprain with previous history of minimumtwo episodes of ankle sprain in the same foot and who hadsuffered from last ankle sprain within two months.Exclusion CriteriaAcute inflammation and swelling(less than 48 hours)Clinically and radio logically diagnosed Ankle fractures andunstable ankles.Neurological disorders like neuropathy.Musculoskeletal condition of the lower limbs like limb shortening,foot deformities (Congenital or acquired)Sample sizeA total of 30 patients who were fulfilling the inclusion criteriawere enrolled in this study.Study factorsBasic demographic and clinical data was recordedFoot and Ankle Disability Scale were administered to record thepre training data.

Allocation to InterventionPatients were divided into two treatment groups i.e. UltrasoundGroup & Deep Friction Massage Group by block randomizationof 6 done by chit method.InterventionUltrasound Group was treated with Ultrasound andStrengthening exercises. 1 MHz ultrasound machine was usedto deliver the treatment for 10 min using a pulsed mode at anintensity of 1W/cm2. The Deep Friction Massage Group weretreated with Deep Friction Massage and Strengtheningexercises. The patient was placed in a comfortable position.After locating the ligament through proper palpation, deep frictionmassage was given transversely across the affected fibres for10 minutes in such a way that the therapist finger and thepatient’s skin moved as one.Strengthening was given with the help of a Theraband for all thegroups of muscles around the ankle in both the groups.Outcome factorsA blinded observer unaware of treatment status was asked torecord the following outcomes:1. Record pain scores on rest and on movements before

treatment, than on 3rd, 7th, and 10th day after completion oftherapy using visual analog scale (VAS).

2. Range of movement at ankle namely Dorsi flexion, Plantarflexion, Eversion, Inversion at ankle joint was measured byGoniometer before starting treatment and than aftercompletion of treatment on 10th day.

3. Foot and ankle disability scale score was recorded pre-treatment and post treatment.

Statistical analysis

Analytical Statistics:A Comparison of basic features of two groups was done i.e.age, sex and side of sprain to confirm that the two groups werecomparable and random allocation was adequate.The mean Pre test scores of Pain were compared with scoresof day 3, 7, and 10 in both groups. Similarly Pre-test scores ofrange of motion and ankle disability were compared with scoreof day 10 using unpaired Student t test.In order to find out equivalence of two therapeutic regimes allpre treatment and post treatment scores and range of movementwere analyzed using paired t test.

ResultsOf 30 patients, 19 were females (63.33%) suggesting

female preponderance. The mean age of the patient was24.63years.Twenty One patients had right side ankleinvolvement. On comparing two treatment modalities groupswere comparable for age, gender and side of sprain.

In Ultrasound group the pain scores of both pain at restand pain on motion showed statistically significant reduction from3rd day onwards and scores continued to improve till 10th day.(Table I and II) Similar improvements in range of movementwere also observed (Table III) These results imply thatUltrasound treatment cause pain relief and improved range ofmotion. DFM group results also showed statistically significantscore improvements and range of movement improvement by10th day starting from 3rd day. (Table IV, V, VI)

On comparing the results of two therapies there was nostatistically significant difference noted in relief parameterssuggesting that the two studies were giving equivalent shortterm relief to patients of chronic ankle sprains.

Overall analysis of Ankle disability score recorded pre-treatment and post treatment in both modalities showedstatistically significant improvements in Ankle disabilityscores.(Table X) On comparing the two treatment modality theimprovement in score was not significantly different suggestingequivalence of both treatment modalities.(Table XI)

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Table I: Showing Pain Scores at rest in Ultrasound groupPain score n Mean Std. Dev. 95% CI p ValueBefore Treatment 15 3.23 0.99 2.68 – 3.78 -3rd day after Treatment 15 0.4 0.51 0.119 – 0.68 0.00 HS7th day after Treatment 15 0.26 0.457 0.013 – 0.052 0.00 HS

Table II: Showing Pain relief Scores with movements in Ultrasound groupPain Score on movement n Mean Pain Score Std. Dev. 95% CI p valuePreTreatment 15 5.766 0.98 0.97 – 5.2 -3rd day after Treatment 15 3.266 1.162 2.62 – 3.91 0.00 HS7th day after Treatment 15 1.466 1.407 0.68 – 2.24 0.00 HS10th day after Treatment 15 0.66 0.259 -0.076 – -0.2 0.00 HS

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Table III: Showing improvement in range of movements in Ultrasound groupMovement n Mean range Std. Dev. 95% CI p ValuePre Treatment Dorsi flexion 15 5.33 1.29 4.6 – 6 0.00 HSPost treatment Dorsi flexion 14 1.36 13.24 – 14.75Pre Treatment Planter flexion 15 16.4 0.73 2.82 – 14.83 0.00 HSPost Treatment Planter flexion 46 1.3 5.07 – 43.19Pre Treatment Inversion 15 5 3.7 2.93 – 7.06 0.000 HSPost treatment Inversion 11 12.1 4.2 – 17.15Pre treatment Eversion 15 0.93 1.7 -0.01 – 1.88 0.000 HSPost Treatment Eversion 12.66 2.58 11.23 – 14.09

Table IV: Showing Pain relief score at rest and after Deep friction massagePain score n Mean score Std. Dev. 95% CI p ValuePre Treatment 15 3.4 1.19 2.73 – 4.0 -3rd day after Treatment 15 0 0 0 0.00 HS7th day after Treatment 15 0.26 0.2 0.79 – 0.175 0.00 HS10th day after Treatment 15 0 0 0 0.00 HS

Table V: Showing Pain relief Scores with movements in Deep friction massagePain Score on movement n Mean Pain Score Std. Dev. 95% CI p valuePreTreatment 15 6.2 0.94 5.64 – 6.68 -3rd day after Treatment 15 2.4 1.3 1.74 – 3.18 0.00 HS7th day after Treatment 15 1.26 1.03 0.69 – 1.83 0.00 HS10th day after Treatment 15 0.13 0.35 -0.06 – 0.32 0.00 HS

Table VI: Showing improvement in range of movements after Deep friction massageMovement n Mean range Std. Dev. 95% CI p ValuePre Treatment Dorsi flexion 15 5.8 2.07 4.64 – 6.95 0.000 HSPost Treatment Dorsi flexion 13.66 2.2 12.4 – 14.9Pre Teatment Planter flexion 15 17.86 5.02 15 – 206 0.000 HSPost Teatment Planter flexion 48.66 2.96 47 – 50Pre Treatment Inversion 15 5.53 3.9 3.37 – 7.7 0.000 HSPost Treatment Inversion 32.66 2.6 31.7 – 34Pre Treatment Eversion 15 5.93 3.12 4.2 – 7.66 0.000 HSPost Treatment Eversion 13.13 2.9 11.5 – 14.74

Table VII: Comparison of Pain Relief in 2 modalities of treatmentPain Score at rest Mean Ultrasound Mean Deep St. Dev. 95% CI p value

friction therapyPre Treatment at rest 3.23 3.4 1.08 29 – 3.72 0.68 NS3rd day 0.4 0 - 0.13 – 0.66 0.05 S7th day 0.26 0.26 0.64 0.27 – 0.5 0.30 NS10th day 0.26 0 0.34 0.004 – 0.26 0.03 NS

Table VIII: Comparison of Pain relief on movement in two modalities of treatmentPain Score Mean Ultrasound Mean Deep St. Dev. 95% CI p value

friction therapyPre Treatment 5.76 6.16 0.964 5.6 – 6.32 0.26 NS3rd day 3.26 2.46 1.27 2.31 – 3.3 0.08 NS7th day 1.46 1.26 1.21 0.91 – 1.8 0.66 NS10th day 0.066 0.133 0.30 0.013 – 0.21 0.55 NS

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DiscussionDTFM is a special type of connective tissue massage

applied by fingers directly to the lesion and transverse to thedirection of fibres.12 It is used for injury or mechanical overuseof muscles, tendons and ligaments. It was used as an alternativeto steroid infiltration, but had slower effects with physically morefundamental resolutions resulting in more permanent cure andless recurrence. This was the rational for selection of DTFM asa modality of treatment. It is important to note that massageshould be performed at exact site of lesion in the right directionby a trained therapist to obtain best results, which is usuallynoted in 6-10 sessions. Lack of scientific evidence on DTFM onrecurrent ankle sprains was another rational for selecting thismodality for research. Ankle sprain was selected formanagement because of high incidence of recurrence inspiteof best therapy. Here DTFM could give relief of pain and help ineffective connective tissue repair by stimulating phagocytosisand regenerating connective tissue and also prevent adhesionformation and ruptures unwanted adhesions.

The Improvements in pain scores and ROM observedDTFM group could be due to post massage analgesic effect,modulation of non-nociceptive impulses at spinal cord level (Gatecontrol theory) and inhibition of mechanoreceptors by rhythmicalmovements over the affected area, just closing the gate forafferents. Friction also leads to increase destruction of painprovoking metabolites (Levis’s substances) whose presence inhigh concentration provokes ischemia and pain. Another reasonfor pain relief after prolonged deep friction to a localized areacould be lasting peripheral nerve disturbance with localanaesthetic effects.13,14 The ROM improvement could be due toreduction in pain.

The present study was for short term effect only for 10 daysand looked at mainly pain relief and improvement in range ofmotion. So the long-term effect of DTFM and Ultrasound onconnective tissue repair was not evaluated. On comparing the2 modalities of treatment namely Ultrasound and DTFM, DTFMwas equally efficacious in reducing the pain and restoring themovements when compared with standard Ultrasound therapy.It should be kept in mind that the results of DTFM are based onproper case selection and is therapist dependent. Similar resultswere seen in Cochrane review 2002 which showed efficacy ofDTFM in treating patients with ITBFS and ECRT15. No specificstudy showing utility of DTFM in chronic ankle sprain was found

in literature. Hence present study is first to take up suchevaluation. However a study using pulsed electromagnetic fieldtherapy and interferential treatment showed significantimprovement in pain relief in ankle sprains.16

The weakness of present study could be non calculation ofsample size considering this to be an equivalence trial whichmight require larger samples. But considering this to be anexpedition study a larger trial could be taken up at a later date.Another drawback was that the study looked at only pain reliefand ROM evaluated only till 10th day, thus missing an opportunityto look at the long term effects on healing and prevention ofrecurrence which is an important complication of ankle sprains.

ConclusionDTFM is an efficacious tool for short term treatment of

chronic ankle sprains. Its efficacy is equivalent to standardultrasound therapy. Important point to remember is that DTFMis operator dependant procedure and results could vary fromtherapist to therapist. More randomized trials are necessary tocollect enough evidence to establish DTFM as standardtreatment modality for chronic ankle sprains and long-term follow-up studies are required for assessing its role in maintaining theankle stability and preventing recurrence.

References1. Hertel J. Functional instability following lateral ankle

sprain. Sports Med. May 2000;29(5):361-71. [Medline].2. Bosien WR, Staples OS, Russell SW. Residual disability

following acute ankle sprains. J Bone Joint SurgAm. Dec 1955;37-A(6):1237-43. [Medline]. [Full Text].

3. Freeman MA, Dean MR, Hanham IW. The etiology andprevention of functional instability of the foot. J Bone JointSurg Br. Nov 1965;47(4):678-85. [Medline]. [Full Text]

4. Freeman MAR, Wyke BD. An experimental study of articularneurology. J Bone Joint Surg. 1967;49B:185.

5. Valderrabano V, Wiewiorski M, Frigg A, Hintermann B,Leumann A. [Chronic ankle instability][German]. Unfallchirurg. Aug 2007;110(8):691-9; quiz700. [Medline].

6. Hubbard TJ, Kramer LC, Denegar CR, HertelJ. Contributing factors to chronic ankle instability. Foot AnkleInt. Mar 2007;28(3):343-54. [Medline].

Table XI: Showing comparison in Ankle Disability Scores between 2 modalities of TreatmentScores N Ultrasound Deep Friction Massage P valuePre-treatment 15 28.2 30.13 0.4(NS)Post-treatment 15 63.26 70.866 0.002(HS)

Table X: Showing improvement in ankle disability scoresModality of Treatment N Pre-test scores Post-test Scores p ValueUltrasound 15 28.2 63.26 0.00(HS)Deep Friction Massage 15 30.13 70.866 0.00(HS)

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Table IX: Comparison of changes in range of movements in two modalities of treatmentRange of movement Mean I Mean II Std. Dev. 95% CI p valueDorsi flexion pre Treatment 5.33 5.8 1.715 4.9 – 6.2 0.466Dorsi flexion post Treatment 14 13.66 1.85 13.13 – 14.52 0.6317Planter flexion pre Treatment 16.4 17.86 4.07 15.6 – 18.65 0.3329Planter flexion post Treatment 46 48.66 4.3 45.7 – 48.93 0.089Inversion pre Treatment 5 5.53 3.75 3.86 – 6.67 0.704Inversion post Treatment 11 32.66 13.98 16.61 – 27 0.00 HSEversion pre treatment 0.93 5.93 3.54 2.1 – 4.75 0.00 HSEversion post treatment 12.66 13.13 2.72 11.88 – 13.9 0.646

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7. Brown C, Padua D, Marshall SW, et al. Individuals withmechanical ankle instability exhibit different motion patternsthan those with functional ankle instability and ankle spraincopers. Clin Biomech (Bristol, Avon). Jul 2008;23(6):822-31. [Medline].

8. Hubbard TJ, Denegar CR. Does cryotherapy improveoutcomes with soft tissue injury?. J AthlTrain. Sep 2004;39(3):278-9. [Medline]. [Full Text].

9. Laufer Y, Rotem-Lehrer N, Ronen Z, et al. Effect of attentionfocus on acquisition and retention of postural controlfollowing ankle sprain. Arch Phys MedRehabil. Jan 2007;88(1):105-8. [Medline]

10. Van der Windt DAWM, Van der Heijden GJMG, Van denBerg SGM, Ter Riet G, De Winter AF, Bouter LM.Therapeutic ultrasound for acute ankle sprains. (CochraneReview). In: The Cochrane Library, Issue 1, 2006. Oxford:Update Software.

11. This text is an Abstract of the chapter ‘ Deep TransverseFriction’ from the book “A System of Orthopaedic Medicine”.This book is available on Amazon.com.

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12. Carreck A. “The effect of massage on pain perceptionthreshold”, Manipulative Physiotherapist. 1994, 26:10-16

13. Kaada B,Torsteino O Increased plasma beta-endorphinsin connective tissuemassage.Gen.Pharmacol.1989;20(4):487-9

14. Goats GC. Massage Therap effects. AmPsychol.1998;53(12):1270-81

15. Brosseau L, Casimiro L, Milne S, Robinson V, Shea B,Tugwell P, Wells G. Deep transverse friction massage fortreating tendonitis Cochrane Database Syst Rev.2002;(4):CD003528.

16. Sharma Bhakti ,Yadav Vikram Singh,Sandhu Jaspal Singh.A comparative study on the efficacy of pulsedelectromagnetic field therapy and interferential therapy inthe management of ankle sprains. Indian Journal ofPhysiotherapy and Occupational Therapy.2007(1):4:

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Comparative analysis of 12 minute walk test and modified shuttlewalk test in normal subjectsRicha Rai*, Sujata Yardi*M.P.Th Cardiovascular, Mumbai, **Prof and Head, Department of Physiotherapy, Padmashree Dr D.Y. Patil University Navi Mumbai.

Objective measures of functional limitations and impairedexercise are essential for assessment and clinical managementof patients with cardiopulmonary limitations. The traditionalincremental maximal treadmill testing and cycle ergo meterrequires sophisticated instruments and is expensive and maynot be relevant to usual exercise patterns and thus provesdifficult.

Certain performance and predictive tests, which do notrequire such expensive sophisticated instruments, are thereforedevised to know and predict VO2 max, to assess functionallimitations, to assess outcome of interventions such as exerciseprograms and to examine effects of recovery strategy on exerciseprograms. Subsequently, sub maximal tests like 12 Minute WalkTest (MWT) and 6MWT were devised which measure responsesto standardized physical activities that are typically encounteredin everyday life, like walking. In 1976 Mc Gavin et al [10]introduced 12 MWT to evaluate the disability in patients withchronic obstructive pulmonary disease. In 1982, Butland andco-workers [11] had compared the validity of different walk testsas exercise test protocols in predicting maximal ventilatoryfunctions to determine if a shorter length test could be used.They found 2-,6- and 12 MWT to be comparable. But in thesefields walking tests the subject are asked to walk as fast aspossible and the test is not graded with respect to speed.

This prompted the development of a standardized andexternally paced field walking test-MSWT –Modified shuttle walktest, incorporating an incremental and progressive structure, toassess functional capacity of an individual.

Leger and Lambert devised the original shuttle walk test[6] for athletes. However later in 1992, Sally J. Singh et almodified the protocol for chronic obstructive pulmonary diseasesgroup of population and compared the modified protocol to 6-MWT and proved MSWT to be an effective means in comparisonto 6-MWT [6]. MSWT has also been validated on individual otherthan lung diseases as compared to 10 MWT, in patients withcardiac pacemakers by Payne GE et al [9].

However in 1994 Singh N.P et al [13] compared 6MWT,4MWT and 2MWT to 12 MWT and observed that 12 MWT issuperior because changes in VO2 /kg in 12 MWT correlated betterwith changes in the maximal exercise tests than in other walkingtests of shorter duration.

No attempt was made as yet to compare 12MWT withMSWT, as to know how an individual would respond whensubjected to both the tests in terms of physiological variables.So the aim of this study is “To assess and comparecardiopulmonary responses of the 12 MWT and modified shuttlewalk test in asymptomatic adults of different age groups.”

Material and method used wereSphygmomanometer and stethoscopePolar digital heart rate leadsTape measureRPE Scale2 stoolsWatchPre recorded audiotapeCassette PlayerCounterConsent Form and Case Report Form (CRF)

A uniform tile terrain, 10 meters in length with 2 stools placed10 meters apart and 0.5 meters from the ends to prevent abruptchanges in direction. Thus 20 meters marked on the terrain.

Exercise test procedure75 subjects of age group 20-59 years volunteered for the

study out of which 44 were males and rest 31 were females.Theywere screened for entry into this study on the basis of normalphysical examination i.e. no recent major history of any medical/surgical condition, pregnancy or any neuromotor or locomotordisorder. Obese, alcoholics and smokers were all excluded.Volunteered subjects were asked to get clearance from aphysician.Patients with absolute contraindications like

Resting ECG abnormalitiesRecent MIUnstable AnginaVentricular ArrhythmiasHeart Blocks and pacemakersCCF with Cor PulmonaleAortic Stenosis or any other rheumatic heart disordersAcute infectionsPulmonary embolism were all excluded.

Others with relative contraindications likeDBP > 115,SBP >200PregnancyElectrolyte abnormalitiesPVCsVentricular aneurysmUncontrolled Metabolic Disorders (diabetes)Chronic Infectious disease (hepatitis, AIDS ) etcSilent ECG abnormalities ruled out on GXT were alsoexcluded.Before starting each test, all volunteered subjects were

asked to sign a consent form ,complete a medical historyquestionnaire- PAR-Q and describe personal details to be notedon Case Report Form(CRF) .After this the CRF for the individualwas numbered and his MHR and THR calculated by Karvonen’sformulae as follows:

MHR=220-AgeTHR= [60-70%(MHR-RHR)]+RHRWhere RHR= Basal ‘Resting Heart Rate”MHR= Maximal Heart RateTHR = Target Heart RateTesting sessions were scheduled at 1-week interval and

the subjects were asked to keep their living and activity habitsconstant for the course of the study. Avoid strenuous activity 24hours prior to testing and heavy meals 2- hours prior testing.Visitone comprised of one practice trial of each test spaced at atleast45 minutes interval.For visit 2, a randomized balanced design(with random no. table) was used with one Shuttle walking testfollowed approximately one week later by a 12MWT or viceversa.Basal Parameters of the subjects were noted on CRF anda warm up session of calisthenics and stretching given. Subjectswere continuously monitored for H.R. with polar leads For 12MWT, individuals walked bare footed on the 20 meters terrain,with standard instructions to all “to cover as much ground aspossible on foot in 12 minutes by walking as fast as possible sothat at the end of the test he should feel that he could not havecovered more ground in the same amount of time.”

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The instructor stood in the mid of the 20 meters courseand boosted him at every 30 seconds, giving the subjects afeedback on time progression and encouraging him to keep onwalking as fast as possible (standard for each person)[2] H.R.was monitored and noted at every 2 minutes.

The subjects who stopped because of pain, fatigue,breathlessness or any other limiting factor and could notcomplete the 12MWT were excluded from the study. For theones who completed the following outcomes were measured.

Subjective level of exertion was qualified using Borg 6-20scale [16]Peak Heart Rate (H.R.)B.P (by auscultation method)Respiratory Rate (R.R)Total number of rounds i.e. distance covered in metersReason for stoppingFinally subject was made to sit for a cool down and recovery

pattern was taken at 3 minutes and later at every minute till theparameters were near basal and recovery time was noted.

For MSWT, at the same place and almost the same time aweek later the subject’s basal parameters were noted and aftera warm up the test started with the standard instructions of howmuch time an individual should take to cover the 10 metersdistance, of one round, at each level.

By the end of the counts of seconds on the audio, theindividual should be walking around the stool and should startonly when the next count starts. i.e. if he covered the distanceearlier than required he had to wait for the next beginning countto start a new round. The accuracy of the timed signal wasensured by the inclusion on the tape of a calibration period of 1minute. (The cassette available)Individuals were thus instructed“walk or may be run, if required, at a steady pace, aiming to turnaround when you hear the instruction. You should continue towalk until you feel that you are unable to maintain the requiredspeed, without becoming unduly breathless or fatigue and orwhen instructed to stop.”The instructor stood along side the 20meters course and no encouragement was given. Only advicegiven each minute was to increase the walking speed slightly.

All subjects found it easy to pace themselves and no

Table 2.2AGE(40-59 years) H.R Peak H.R

(Mean + SD)Age predicted MHR = PMHR 172.35 + 5Peak H.R on 12MWT (PHR) 129.6 + 10.2Peak H.R on MSWT (PHR) 151.8 + 8.4% Adequacy of PHR on 12MWT to PMHR 74.3 + 5.8 %% Adequacy of PHR on MSWT to PMHR 88+ 3.6 %

The above tables reveal that % adequacy of PHR on MSWT toage predicted MHR is 88 % and that of 12MWT is 73 % in 20-39years of age and 74 % in 40-59 years of age.

Table 1: Profile of heart rateAGE (years) H.R. (mean+ SD)12 MWT MSWT20-39 139.84 + 7.7 169.71+ 10.6340-59 129.37 + 10.15 151.86 + 8.5

P < 0.05 significant

Profile of respiratory rateTable 5:AGE (years) R.R (Mean + SD)

12MWT MSWT20-39 28.55 + 4.89 36.68 + 5.2840-59 30.21 + 2.61 38.45 + 2.42

P< 0.05 significant

Table 3.2 AGE (40-59)H.R THR (Mean + SD)PHR on 12 MWT 129.6 + 10.2PHR on MSWT 151.8 + 8.4Target heart rate zone 136.5 + 3.6(from Karvonen’s formulae) 145.7 + 3.7

The above table shows that peak heart rate of 12 MWT fallsapproximately near the lower limit of THR zone and that of MSWTis higher than the upper limit of THR zone.

Profile of heart rate with the target heart rate (thr)Table 3.1 AGE (20-39)H.R THR (Mean + SD)PHR on 12MWT 139.8 + 7.6PHR on MSWT 169.7 + 10.4Target Heart Rate Zone 148.7 + 3.5(from Karvonen’s formulae) 159.1 + 4.1

The above data shows that peak heart rate obtained on 12 MWTfalls approximately near the lower limit of THR and that of MSWTis higher than the upper limit of THR zone.

Table 2.1AGE(20-39 years) H.R Peak H.R

(Mean + SD)Age predicted MHR = PMHR 191.8 + 5.9Peak H.R on 12MWT (PHR) 139.8 + 7.6Peak H.R on 12MSWT (PHR) 169.7 + 10.4% Adequacy of PHR on 12MWT to PMHR 72.8 + 4.0 %% Adequacy of PHR on MSWT to PMHR 88.2 + 4.4 %

Profile of peak heart rate

The above data reveals mean peak heart rates obtained inMSWT was significantly higher when compared to 12MWT inboth age groups. Also within the test, heart rate showed asignificantly lower response in subjects of 40-59 years of ageas compared to 20-39 years of age.

Comparison of heart rate between 12mwt & mswt Grap. 1:

HEA

RT

RAT

E

difficulty was encountered in administrating the test.The modifiedshuttle walk test (MSWT) starts at 0.50meters/second speedfor level 1, each level lasts for a minute and speed is increasedeach minute by 0.17meters/second for 12 minutes to a finalspeed of 2.37 meters/second (Appendix-A)

The individual continued until a) He or she was breathlessor showed any signs and symptoms of exertion beyond whichhe or she was unable to carry on the test.b)He or she was 0.50meters away from the stool, kept at each end of the course,when the count for that particular level was over.

The same outcome measures were noted as in 12MWTand the distance was noted as the number of shuttles wasknown. Subject was then allowed to sit comfortably and therecovery pattern was noted.

Results

Profile of systolic b.p.Table 4:AGE (years ) S.B.P (Mean + SD)12 MWT MSWT20-39 143.05 + 15.05 163.42 + 13.240-59 150.45+ 13.48 169.45 + 11.33

P< 0.05 significant

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Graph 4: Comparison of s.b.p. Between 12mwt & mswt

The above data reveals that mean systolic B.P. showedsignificant increase after both the tests, among which the S.B.P.in MSWT was significantly more than 12MWT for both the agegroups.

SBP

Graph 5: Comparison of r.r. Between 12mwt & mswt

Respiratory rate shows a statistically significant higher value inMSWT as compared to 12MWT for both age groups. Howeverwithin the protocol higher age group showed a significantly higherrespiratory rate as compared to the lower age group

R.R

The above data reveals that when the rate of perceived exertion(RPE) was compared across the groups, MSWT showedstatistically significant higher values in both the age group ascompared to 12 MWT.

Graph 6: Comparison of rpe between 12mwt & mswt

MET

ERS

The distance traveled in 12 MWT was significantly greater forboth age groups as compared to MSWT.

Graph 7: Graph 4: Comparison of rpe between 12mwt &mswt

RPE

Profile of distance covered (meters)Table 7AGE (years ) Distance (Mean + SD )

12MWT MSWT20-39 1305.78 + 106.45 974.21 + 9040-59 1090 + 70.4 726 + 181.6

P < 0.05 significant

Profile of rate of perceived exertion (rpe)Table 6:AGE (years) RPE (Mean + SD)12MWT MSWT20-39 10.26 + 2.34 13.86 + 1.8

Graph 1.2

Exercise duration vs heart rate for 20-39years and 40-59years (graph 1.1,1.2)

Pink -MSWT and Blue -12MWTGraph 1.1

DiscussionLaboratory assessment of functional capacity of an

individual is not widely available and may be expensive andintimidating to the patient. As questions regarding the need forfurther diagnostic studies, therapeutic decisions and prognosiscan often be resolved by knowing the functional capacity, thewillingness for exercise testing is catching demand.

Therefore, field walking tests are often used in absence ofsophisticated instruments. They comprise a self paced test in

which the subject walks as fast as possible in 12 minutes [1]. Tomaintain the pace of the subject however becomes the limitationof the test, which can be overcomed by regular motivation andencouragement as validated by Guyatt et al [2].

Review of literature [6] of our study shows that MSWT is of12 minutes duration therefore 12 MWT was an ideal test withwhich the former could be compared. Normal adults of two agegroup 20-39 years and 40-59 years were included in the test. Apractice trial was administered for both the test to make theresults valid [15].As we have seen; both the 12 MWT and MSWT

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are simple and require no sophisticated instruments. Moreover,act of walking used in the test is familiar to all. Both the tests areof 12 minute duration and are being used for stress testing andto evaluate cardio-pulmonary system.

However, MSWT is an externally paced test in which thesubject walks to the audio signal dictated to him. As the testcontinues, he slowly increases his speed by 0.17 meters/second,every minute, as guided by the audio signal, whereas in 12 MWTthe subject has to walk as fast as possible from the verybeginning.

On viewing these differences in both the tests, it seemedessential to know as to how these would reflect in the cardio-pulmonary responses of an individual. Therefore, the study wasinitiated to compare the physiological responses, in both thetests, as the same individual was subjected to them.

Consequently, the results show that the average peak heartrates obtained in both the age groups, were significantly higherin MSWT as compared to 12MWT.(table 1, graph 1)

Also seen in graph 1.1, 1.2 the peak heart rate responsewhich was achieved at 12 minutes duration in 12 MWT wasreached in a graduated manner and at duration much earlier inMSWT.

On comparing the average heart rate for both the tests toage predicted MHR (PMHR) of the two age groups, we foundthat percentage adequacy of the peak H.R. response obtainedin MSWT to predicted MHR is 88% whereas even though thesubject performed for longer duration in 12 MWT as seen ingraph 1.1, 1.2 they reached to only 74% of their predicted MHR(table 2.1,2.2)

Moreover the mean peak H.R. obtained in MSWT is higherthan the upper limit of THR zone whereas that of 12 MWT fallsapproximately near the lower limit of THR zone (table 3.1, 3.2)Aclose look at the graph 1.1, 1.2 shows that in MSWT, in theinitial stages, the H.R. is even lower than that achieved in 12MWT. This could be attributed to the person’s maximal effortright from the start in 12MWT as compared to the initial veryslow ‘defined’ speed of walking in case of MSWT. Moreover,these defined speeds ensure that work load increases in amanner that provides an incremental stress and a gradedcardiovascular pulmonary response, as seen for heart rateachieved in MSWT in the graph 1.1, 1.2.However, the steeperincrease in heart rate observed in the end stages of MSWTmay increase the sensitivity of the test but it also means that thesubject should be able to cope up with the stress induced.

The other physiological variables like systolic B.P,respiratory rate and rate of perceived exertion (RPE) were alsosignificantly higher for both the age groups at the end of MSWTas compared to 12MWT. (Table 4, 5, 6 and graph 4, 5, 6). Thisdemonstrates a greater and graded stress imposed oncardiopulmonary system as compared to 12 MWT.

The average distance covered in MSWT for the age groups20-39 years is 794.21-1154.21 meters as compared to 1092-1518 meters in 12 MWT. Similarly for age group 40-59 years,average group distance for MSWT was 362-1089 meters ascompared to 949-1130 meters on MSWT. (Table 7- Graph 7).The distance covered in MSWT, for both the age groups weresignificantly lower in shorter duration in comparison to 12 MWTbut maximal physiological variables were achieved.

Thus, MSWT reveals cardiopulmonary limitations toexercise and the initial slow and subsequently increasing speedsused in the modified protocol in comparison to that of Leger andLambert [6] makes it an objective measure for exercise testingfor a wider variety of subject population.

However, the steeper increase in exercise intensity in thelater stages is a disadvantage for the elderly cardiopulmonarycompromised subjects but it’s a potential measure for evaluatingyoung active group of population.

For the subject population, for whom it is very easy toperform on 12 MWT, this 12MWT might not be effective enoughto stress the cardiopulmonary system and evaluate the reserve

capacity.As the graph 1.1, 1.2 shows the longer duration and an

almost steady heart rate response on 12 MWT as compared toMSWT, it could be used as a exercise test for endurance trainingand to evaluate the “functional capacity” of normal sedentaryand elderly deconditioned individuals with cardiopulmonarycompromised state.[14]

For this group, walking being an activity of daily living (ADL),12MWT evaluates the person’s ability to walk continuously forover a period of time and thus to know the factors which limit hisfunctional capacity and endurance. MSWT can be used as aprogression or as an additional test to check the reserve capacityin such cases.

External pacing in MSWT allows valid inter subject andintra subject comparison and can yield a precise end point anda specific outcome measure that can easily be applied toexercise rehabilitation for different groups of people, bycalibrating an individual’s physiological responses to the test;also a suitable walking speed can be judged for a trainingprogram. This being an objective measure may enable moreeffective comparison of different approaches to patientmanagement and treatment than has previously been possiblewith other field exercise tests.

Thus, quantitative methods of assigning exercise likeMSWT may improve exercise prescription specificity andprecision in comparison to 12MWT. However, clinical decisionregarding the prescription of a proper performance test shouldbe made according to the age, health status and the initial levelof fitness of the population to be studied.

Conclusion12MWT and MSWT both are easily administrable, simple,

non-invasive and cost effective exercise testing protocols.MSWTstresses cardiopulmonary system more in terms of H.R, B.P.,R.R and RPE than 12MWT.However, to evaluate an individual,clinical decision should help to individualize the test accordingto the subject’s age, health status, initial fitness and objective ofthe testing.

(Appendix) MODIFIED SHUTTLE WALK TESTLEVEL SPEED IN NO OF NO OF

shuttles 2/shuttleM/s Km/h mph

1 0.50 1.72 1.12 3 202 0.67 2.40 1.50 4 153 0.84 3.00 1.88 5 124 1.06 3.61 2.26 6 105 1.18 4.22 2.64 7 8.56 1.35 4.83 3.02 8 7.57 1.52 5.44 3.40 9 6.68 1.69 6.04 3.78 10 69 1.86 6.65 4.16 11 5.4510 2.03 7.26 4.54 12 511 2.20 7.87 4.92 13 4.612 2.37 8.48 5.30 14 4.2

References1. Swinburn CR, Wakefield J M Janes

PW……Performance,ventilation and O2 consumption inthree different types of exercise test in patients with chronicobstructive lung disease…..Thorax 1985; 40; 581-6.

2. Guyatt GH, Pugsley So, Sullivan MJ, Thompson PJ,Berman LB, Jones NL et al…… Effect of encouragementon walking test performance…..Thorax 1984; 39; 818-22.

3. Beaumont A, Cockeroft A, Guz A……A Self paced treadmillwalking test for breathless patients….Thorax 1985;40; 459-64.

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4. Jwerts PMJ, Mosert R, Wonters EFM….Comparison ofcorridor and Treadmill walking in patients with severechronic obstructive pulmonary disease….Physical Therapy1990; 70; 439-42

5. Mc Gavin CR, Artvinli M, Nooe H, Mc HardyGJR…..Dyspnea disability and distance walked;comparison of estimates of exercise performance inrespiratory disease……BMJ 1978; 11; 241-3.

6. Sally J Singh, Michael DJ Morgan, Shona Scott, DeniseWalters, Adrianne E Hardman…..Development of a shuttlewalking test of disability in patients with chronic airwayobstrucution…Thorax 1992; 47; 1019-1024.

7. CA & Dyer, SJ Singh, RA Stockley, A.J.Sinclair,S.L.Hill…The Incremental shuttle walking test in elderlypeople with chronic airflow limitation…Thorax 2002; 57; 34-38.

8. Singh SJ, Morgan MDI, Hardman AE et al…..Comparisonof O2 uptake during a conventional treadmill test and theshuttle walking test in chronic airflow limitation…..EuropeanRespiratory Journal; 1994; 7; 2016-2020.

9. Payne GE, Skehan ID…..Shuttle walking test; a newapproach for evaluation of patients with pacemakers…Heart1996; 75; 414-418.

10. Mc Gavin CR, Gupta SP, Mc Hardy GJR….Twelve minutewalking test for assessing disability in chronicbronchitis….BMJ 1976; 1;822-823.

11. Butland RJA, Pang J, Gross ER, Woodcock A.A, GeddesDM….Two, six and twelve minute walking test in respiratorydiseases. BMJ 1982; 284; 1607-1608.

12. T Troosters, R Gosselink, M Decramer….6 minute walkdistances in healthy elderly subjects….EuropeanRespiratory Journal 1999; 14; 270-274.

13. Bernstein ML, Despars JA, Singh NP et al….Reanalysis ofthe 12MWT in patients with chronic obstructive pulmonarydisease…..Chest 1994; 105; 163-167.

14. Judy Larson-Saps ford; Osteoporosis; 43915. V Noonan….. Sub maximal exercise testing overcomes

many of the limitations of maximal exercisetesting….Physical Therapy Vol 80. No.8 August 2000.

16. Borg GAV, Psychophysical basis of perceivedexertion…Med. Science sports Exercise 1982; 14; 377-381.

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Cervical spinal mobilization versus TENS in the management ofcervical radiculopathy: A comparative, experimental andrandomized controlled trialRonald Prabhakar*, G. J. Ramteke***B.P.T., M.P.Th., **Professor & Principal (B.Ph.T, M.Ph.T.), Datta Meghe Institute of Medical Science’s, Ravi Nair PhysiotherapyCollege, Sawangi (M), Wardha, Maharashta

Abstract

Purpose of studyThe need of study was to find out whether a movement basedapproach along with exercises is beneficial than a non-movement based electrotherapeutic approach along withexercises for relieving upper limb radiculopathy arising due tocervical spondylosis

Materials & methodology75 subjects were randomly allocated into three groups i.e. GroupA: (Hot fomentation, Cervical contralateral lateral flexionmobilization and Isometric neck exercises), Group B: (Hotfomentation, Transcutaneous electrical nerve stimulation andIsometric neck exercises), Group C: (Control group: Hotfomentation and Isometric neck exercises).The duration ofintervention was 3 weeks and treatment was given on Theoutcome measures were VAS pain score, Elbow extension rangeof motion measured in upper limb tension test-1 position,Northwick Park neck pain questionnaire, Neuropathic pain scale,Short form of Mc Gill pain questionnaire. Pre and postintervention values of outcome measures were recorded andalso after a follow-up of 6 weeks.

ResultsThe participants treated within groups showed a statisticallysignificant decrease in pain, increase in elbow extension ROM,and an improvement in the functional outcome scores as perNPQ score, NPPS and SF- MPQ score with p<0.001. But therewas no statistically significant difference in pain scores whencompared between the experimental groups (p= 0.075), increasein amount of elbow extension ROM (p=0.024) was significant,and a significant improvement in functional outcome level asper NPQ (p=0.034) and a non-significant improvement in NPPSand SF-MPQ score (p>0.05), after 3 weeks of intervention.

ConclusionCervical mobilization when compared to Transcutaneouselectrical nerve stimulation is equally effective in relieving pain,reducing the radicular pain in upper limb and improving thefunctional outcome.

Key wordsNeck pain, Cervical radiculopathy, Cervical lateral flexionmobilization, TENS, Isometric neck Exercises, ULTT-1.

IntroductionNeck disorders affect 13% of adults at any one time and up

to 30% of men and 50% of women in the course of a lifetime1,2.Some studies have stressed the importance of physical factorslike faulty posture, monotonous work and unsuitable workingpositions1. Cervical spondylosis is a common degenerative

condition of the cervical spine that most likely is caused by age-related changes in the intervertebral disks3. Cervicalradiculopathy has an incidence rate of 83 per 100,000 populationand a prevalence of 3.3 cases per 1000 people4. Theradiculopathy is a result of mechanical pressure on the nerveroot exerted by disk protrusion or spondylotic spurring or acombination associated with an inflammatory component5.

Testing of nerve reaction indicates the sensory nerve rootas a prominent site of pain production in a dermatomicdistribution6. Pain of aching nature is felt proximally and aparasthesia or sensation of numbness is felt distally, pain moredistal in radiation is dermatomal in distribution, whereas painproximal to the interscapular area is more likely from posteriorprimary division radicular pain7. The recognition of the origin ofthe referred pain is important for both the indication andcontraindication of specific physiotherapy treatment techniques8.

Clinical practice guidelines recommend the use of manualtherapy along with exercise therapy for managing mechanicalneck disorders9. Cervical mobilization reduces pain and disabilityand, more specifically, with studies illustrating the benefits of amovement-based treatment approach of patients with peripheralNeurogenic pain10. Both manual therapy interventions combinedwith home exercises are effective in improving pain intensity,pain quality scores and functional disability levels11. Cervicallateral flexion mobilization is used in patients whose symptomsof cervical origin are unilaterally distributed, either cranially or inthe neck, scapula or arm 12. The main aim of this technique is toproduce lateral flexion so as to direct the mechanism towardopening of the intervertebral foramen12. Release of pressure inthis situation may help venous return, improve resolution ofinflammatory process, reduce tissue fluid pressure and improveintraneural circulation13.

In a survey of physicians about attitudes on treatment ofmusculoskeletal disease, active exercise, traction, TENS, andultrasound were perceived to be the best methods for thetreatment of neck pain14.. In the past decade, a number of studieshave indicated that strengthening of the neck muscles in patientswith chronic neck pain results in reduced pain and decrease indisability15. Nordemar and Thorner reported that TENSsignificantly increased neck mobility compared with wearing aneck collar in patients with neck pain16

Materials and methodology

Materials used1. Single channel TENS Kit. (Galtron electromedical

equipments, 20E620, 100 Hz)2. Universal Half circle plastic goniometer.3. Hot moist pack.

Study settingDatta Meghe Institute of Medical science’s Ravi Nair

Physiotherapy College, Musculoskeletal physiotherapy OPD.

Inclusion criteria1. Subjects between 20 to 50 years of age.

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2. Subjects having neck pain and tingling numbnessunilaterally in upper limb for more than one week.

3. Diagnosed cases of Cervical spondylosis.4. Participants who gave informed consent to participate in

the study.

Exclusion criteria1. Presence of VBI syndrome2. History of fracture cervical vertebrae3. Cervical hypermobility4. Bone disease: tumors or infection.5. Diabetic neuropathy6. Acute intervertebral disc prolapse7. Osteoporosis8. Rheumatoid arthritis/ inflammatory arthropathies

MethodologySubject Recruitment: 75 subjects which were diagnosed casesof Cervical Spondylosis with history of subacute unilateral upperlimb radiating pain of cervical origin in the age group of 20 - 50years of age were referred from Department of Orthopedics toMusculoskeletal physiotherapy OPD. The subjects were thenrandomly assigned to three study groups. Then subject’s consentwas taken for their willingness to participate. All the rights of theparticipants were protected.Assessment : The subjects were assessed using theassessment proforma. The testing for reduced intervertebralforaminal opening dysfunction or reduced closing dysfunctionwere then performed for conforming the mechanical diagnosisof the disorder.Application of Hydrocollator packs: The part to be treatedwas properly exposed covering rest of the body. The subjectwas asked to lie prone on the treatment plinth in prone positionwith one pillow under the chest. The hot pack was then appliedto the posterior aspect of neck.

Group A: Cervical contralateral lateral flexion mobilization(Dynamic Opener):

Depending upon the dermatomal involvement and therelevant upper limb neural tissue provocation test, the level/

permitting any lateral flexion of the subjects head or allowingany movements of the heel of hand away from the subject’s ear,the therapist moved around alongside the subject’s contralateralshoulder to face diagonally across his head.

Fig1: Application of hot moist pack to neck.

levels of mobilization was/were determined14. Irrespective ofthe type of dysfunction diagnosed while performing the specifictests mentioned above, dynamic opener technique applied forthe opening of intervertebral foramen was used.

Stage 1: Subject lied on his back with his head and neckbeyond the end of couch supported by the therapist.

Stage 2: Initially the therapist stood at the head end of couchand took up the head and arm position i.e. the head of the subjectsupported by the therapist arm. The position was then alteredso that the ipsilateral forearm lied behind the subject’s ear almostunder the occiput and the contralateral hand was broughtforwards so that the palm covered the whole of ear. Without

Fig 2: Taking up the head and arm position

Stage 3: The final stage involved crouching to hug thesubjects head while adopting the required degree of lateralflexion by displacing his neck to affected side with thecontralateral hand and laterally flexing the head on the oppositeside The movement was localized to particular intervertebrallevel by the pressure of the palmar surface of the index finger,just distal to MCP joint on the relevant level of articular pillar.

Fig3: Adopting the initial stage of mobilization

The oscillatory movement was then produced by bodymotion. The body movements generated a force which wastransmitted to subject’s neck by a much localized pressureagainst the articular pillar which displaced the neck away causingthe intervertebral foramen to open up on to the affected side.

Amplitude: Grade II: Large-amplitude movement withoutmoving into resistance / Grade III: Large-amplitude movementupto the limit of the range.

Frequency of oscillations: 1 repetition / 5 seconds.No of repetitions: 10-15 oscillations.

Group B: Application of Transcutaneous electrical nervestimulation

Preparation of apparatus: All the apparatus and equipmentneeded were assembled and suitably positioned.

Preparation of the subject: Area to be treated was properlyexposed covering rest of body.

Application: Silicone rubber electrodes were fixed to theskin with adhesive tape. The dermatomal placement methodwas used: One electrode was placed at the corresponding spinalnerve root level and other at the distal end of dermatome.

Type of TENS: ConventionalPulse duration: 50 µsFrequency: 100 Hz.Mode of application: ContinuousDuration of treatment: 30 minutes

Isometric neck exercises: (Figure.)

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Isometric neck exercises began with isometric contractionsfor neck flexors, lateral flexors, rotators, and extensors. Thesecontractions were maintained for a period of 6-8 seconds.Subjects were asked to perform 5 repetitions in each direction.

Group C (Control group):

Subjects allocated to this group received hot fomentation appliedto posterior aspect of neck region for 20-25 minutes. After theapplication of hot pack, they were taught the Isometric neckexercises and were asked to perform it under supervision. Theprocedures were the same as mentioned above.

Intervention:

10 treatment sessions were given to the subjects, on alternatedays for a period of 3 weeks. They were called after period of 6weeks for follow-up.

Outcome measurement toolsProcedure: Assessment on the outcome parameters was

performed as follows.1. Visual Analogue Scale: Pain was rated by the subject

placing a mark in one location on the line.2. Elbow extension range of motion measured in the upper

limb tension test 1 position: The recording of the range ofmotion was done by a therapist using a half circle plasticgoniometer, who was blinded from the nature and expectedoutcomes of the study.

3. Northwick Park Neck pain questionnaire (NPNQ): Thereare 4 points given to each question for e.g. no pain =0 andworst pain=4. The subject is asked to select only one optionin each question according to the present status

4. Neuropathic pain scale (NPPS): The scale measuresseveral different aspects of pain Each pain descriptor wasbeen given 10 points for e.g. 0= No pain and 10= the mostintense pain sensation imaginable. The subjects wereasked to put an ‘X’ through the number which best describedthe type of pain.

5. Short form of Mc Gill pain questionnaire (SF-MPQ): Themain component of the SF-MPQ consists of 15 descriptors(11 sensory; 4 affective) which are rated on an intensityscale as 0 = none, 1 = mild, 2 = moderate or 3 = severe.The subjects were asked to rate their symptoms.

Results

Statistical analysisStatistical analysis was done by the statistical package of

social science (SPSS) version 14.0. The results are expressedby means and SD, confidence interval & p value for significance.Chi-squared tests were used for nominal data comparison. Alsostatistically three groups were compared by ANOVA & Post hoctest. Within group comparison was done by using paired t-test.

Demographic profile- The mean age of subjects ingroup A was 36.33±9.4 years, in group B was 37.25±9.8 yearsand in group C was 39.33±8.6 years. There were 52% femalesand 48% males. As a result all groups were found to behomogenous regarding age; body mass index and duration ofsymptoms.

Within group analysis- Mean±sd reduction in VAS scorein Group A was after intervention of 3 weeks was 4.49±0.76which was statistically significant (p=0.000) and a similar resultat 6th week follow-up. Improvement in the Elbow extension rangeof motion after intervention was 14.6º±5.94º which wasstatistically significant (p=0.000). Improvement in the NorthwickNeck pain questionnaire score was 9.15±1.96 and this resultwas statistically significant (p=0.000). Mean improvement inNPPS scores after the intervention was 19.43±5.14 which wasfound to be statistically significant (p=0.003). Reduction in theSF-MPQ score was 14.40±5.44 which was statistically significant(p=0.000).

Mean±sd reduction in VAS score in Group B afterintervention of 3 weeks was 3.53± 0.76 which was statisticallysignificant (p=0.000). Improvement in the Elbow extension rangeof motion after intervention was 10.17º±4.36º which wasstatistically significant (p=0.011). Improvement in the score was7.65±1.81and this result was statistically significant (p=0.006).Mean improvement in neuropathic pain scale scores after theintervention was 19.2±4.14 which was found to be statisticallysignificant (p=0.007). Reduction in the Short-form McGill painquestionnaire score was 11±2.16 which was statisticallysignificant (p=0.006).

The mean±sd reduction in VAS score in Group C (controlgroup) was 2.16± 0.8 which was statistically significant (p=0.042).The improvements in the scores of other parameters in i.e.NPNQ, NPPS and SF-MPQ were non-significant (p>0.05).

Between group analysis- All the outcome parameters ofthe Groups A, B & C were compared at various intervals i.e.Pre-intervention, Post-intervention (3weeks) and Follow up (6thweek) using One-way analysis of variance (ANOVA) and PostHOC Tukey-HSD test.1. Visual analogue scale score:

Fig5: Application of TENS to subject.

There was insignificant difference between the VAS scoresof Group A&B (F= 18.49, p=0.075) and a significant differencebetween group A&C and group B&C (p<0.005)2. Elbow extension ROM limitation measured in ULTT1position:

Graph 1:

Graph 2:

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There was non significant difference in the ranges ofGroup A&B (F=12.01, p=0.024). But between Group B&C inwhich there was a significant difference (p=0.005), and alsobetween Group A&C (p=0.000) showed a significant difference.3. Northwick Park neck pain questionnaire score:

significant differences could be observed between the effectsof cervical mobilization and TENS when compared using acontrol group. The results of the study have demonstrated thatthe manipulative physiotherapy treatment for cervical spine andexercise protocol is capable of producing beneficial effects onpain, functional disability in subjects with lower cervicalradiculopathy associated with cervical spondylosis.

In a comparative group study done by Nordemar R andThorner C16, neck collar, neck collar plus transcutaneouselectrical nerve stimulation and neck collar plus mobilization werecompared in the treatment of sub-acute cervical pain. Themobilization group exhibited greater improvements in short formMcGill (SF-MPQ) score at 1 week, but no significant differenceswere noted at 8 weeks and 3 months. Our results of betweengroup analyses revealed that there was a significant differencein the score of the two experimental groups were compared(p=0.001). In the study done by Michel W. Coppieters et al17,analyzing the treatment effects between the 2 groups i.e. onegroup of subjects receiving cervical mobilization and the otherreceiving therapeutic ultrasound for the management ofcervicobrachial pain, significant differences could be observedin the increase in the elbow extension range of motion (P=.0306).Our results of between group analyses revealed that there wasa significant difference in the elbow extension range of motionbetween ranges of the two experimental groups (p=0.024).

In a study done by Cowelland IM18, whereby they hadobtained 55% improvement in the Northwick neck painquestionnaire score of the subject receiving cervical mobilization.This result is similar to the result of our study, where in thesubjects receiving cervical spinal mobilization had a significantimprovement (62%; p=0.000) in the NPPQ score.

Also in the study group, where the subjects received TENSthere was a significant improvement (53%; p=0.000). A similarresult was found in a randomized clinical trial done by ThomasTW chiu et.al19 in which they investigated the effect oftranscutaneous electrical nerve stimulation(TENS) and neckexercise in chronic neck pain patients where there was asignificant reduction(p=0.034) in the Northwick park neck painquestionnaire score of subjects receiving TENS. The mechanismof the analgesia produced by transcutaneous electrical nervestimulation is explained by the gate control theory of painmodulation proposed by Melzack and Wall20.

Rationale of the treatment by cervical spinal mobilizationtechnique: According to classical work on neurodymamics byMichael Shacklock(2005)13, treatment for different nerve rootsproblems often gravitate towards similar technique, that initiallyfocus on reduction of pressure on the nerve root. Release ofpressure in this situation may help venous return, improveresolution of inflammatory process, reduce tissue fluid pressureand improve intraneural circulation. In the case of cervicalradiculopathy, the key concern is to take pressure off the nerveroot and improve its blood flow and oxygenation. Thus Cervicallateral flexion mobilization was used in patients whose symptomsof cervical origin are unilaterally distributed, either cranially or inthe neck, scapula or arm20. In such cases, when this mobilizationwas being used for the first time it was done with the patientshead laterally flexed away from the painful side. The direction ofmovement, particularly of a mobilization technique, is guidedby the purpose of the technique21. Thus the aim was to openintervertebral space of the affected side.

It is also hypothesized that with enhanced intersegmentalmotion, the introduction of home exercises also enabled thesubject to have a physiological and remedial influence on thepathological neural tissue. In a study done by AIlison GT et.al22,the subjects receiving passive technique for mobilizing neuraltissue structures and the cervical spine, showed greaterimprovements in pain intensity, pain quality scores and functionaldisability levels at 2 weeks. In the present study, where in thesubjects receiving cervical spine mobilization had a significantimprovement (57%; p=0.000) in the score.

Graph 3:

When the scores of Group A&B were compared there wasstatistically significant difference (F=39.28, p=0.015) betweenthem. When scores of Group A&C was compared there was asignificant difference (p=0.000) and also a similar result whengroups B&C were compared (p=0.001).4. Neuropathic pain scale scores:Graph 4:

When the Group A&B were analyzed there was non-significant difference between the scores (F=15.93, p=0.953)and significant difference between the groups A&C and GroupsB&C (p<0.05).5. Short form-McGill pain questionnaire score:Graph 5:

A comparison of all the 3 groups demonstrated a significantdifference in the functional outcome score subsequent to thetreatment (F=28.23, p= 0.000). When the scores of Group A&Bwere compared there was statistically significant difference(p=0.001) between them. When scores of Group A&C andgroups B&C were compared there was a significant difference(p=0.000)

DiscussionThe analysis of the treatment effects revealed that

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ConclusionThe randomized control trial showed that Cervical

mobilization when compared to Transcutaneous electrical nervestimulation was more effective in relieving pain, reducing theradicular pain in upper limb and improving the functional outcomefor a short term duration of 3 weeks. However in long termduration the results remained equivocal as subjects in bothexperimental groups had similar scores in the functionalquestionnaires.

Limitations of Study1. Relatively smaller sample size.2. The motor weakness present/absent in the muscles of the

upper limb associated with cervical radiculopathy was nottaken into consideration while comparing the effectivenessof cervical mobilization and TENS in the managing cervicalradiculopathy.

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management of mechanical neck pain: systematic overviewand meta-analysis. BMJ 1996; 313:1291–6.

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3. Horwitz T. Degenerative lesions in the cervical portion ofspine. Achieves of Internal medicine, 65, 1178-1191, 1940

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6. Elvey RL: Pathophysiology of radiculopathy: A clinicalinterpretation. In: Dalziel BA, Snowsill JC , ProceedingsFifth Biennial M.T.A.A. Conference, Melbourne: Australia,1987

7. Eaton LM, Pain caused by disease involving the sensorynerve roots. Journal of the American Medical Association,(1941), 117(17), 1435-1439.

8. Rush PJ, Shore A. Physician perceptions of the value ofphysical modalities in the treatment of musculoskeletaldisease. Br J Rheumatol 1994;33:566-8.

9. Ingeborg B C Korthals-de Bos, Jan L Hoving, Maurits Wvan Tulder Cost effectiveness of physiotherapy, manual

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10. krysia dziedzic, jonathan hill, martyn lewis, julius sim,1 janedaniels, and elaine m. hay. effectiveness of manual therapyor pulsed shortwave diathermy in addition to advice andexercise for neck disorders. physical therapy clinics: arthritis& rheumatism vol. 53, no. 2, april 15, 2005, pp 214–222

11. Jordan A, Bendix T, Nielsen H, Hansen FR, Host D, WinkleA. Intensive training, physiotherapy, or manipulation forpatients with chronic neck pain: a prospective, single-blinded, randomized clinical trial. Spine 1998; 23: 311_/19.

12. Bronfort G, Nelson B, Aker PD, Goldsmith CH, Vernon H. Arandomized clinical trial of exercise and spinal manipulationfor subjects with chronic neck pain. Spine 2001; 26: 788_/97.

13. Michael Shacklock 2005, Clinical Neurodynamics ,Butterworth Heinemann, London.

14. Jull G, Bogduk N, Marsland A. The accuracy of manualdiagnosis for cervical zygapophyseal joint painsyndromes.Med J Aust. 1988;148(5):233–236.

15. Cleland JA, Whitman JM Fritz JM, Palmer JA. Manualphysical therapy, cervical traction, and strengtheningexercise in patients with cervical radiculopathy: a casesereies, J Orthop Sports Phys Ther. 2005;35:802-811.

16. Nordemar R, Thorner C. Treatment of acute cervical pain_/a comparative group study. Pain 1981; 10: 93_/101.

17. Michel W. Coppieters, Karel H. Stappaerts, Leo L. Wouters,Koen Janssens. The Immediate Effects of a Cervical LateralGlide Treatment Technique in Patients With NeurogenicCervicobrachial Pain :J Orthop Sports Phys Ther • Volume33 • Number 7 • July 2003

18. I M. Cowelland D. R. Phillips. Effectiveness of manipulativephysiotherapy for the treatment of a neurogeniccervicobrachial pain syndrome: Manual Therapy Volume7, Issue 1, February 2002, Pages 31-38

19. Thomas TW Chiu, Christina WY Hui-Chan.A randomizedclinical trial of TENS and exercise for patients with chronicneck pain. Clinical Rehabilitation 2005; 19: 850_/860

20. Elver RL 1986 Treatment of arm pain associated withabnormal brachial plexus tension. Australian Journal ofPhysiotherapy 32: 225–23.

21. Maitland GD, Vertebral Manipulation, 5th edition,Butterworths, London 2006.

22. Allison GT, Nagy BM, Hall T. A randomized clinical trial ofmanual therapy for cervico-brachial pain syndrome- a pilotstudy. Man Ther. 2002;7(2):95–102

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Home based constraint-induced therapy for children withhemiplegic cerebral palsy: A pilot studySaleh AL-Oraibi*, Hashem Abu Tariah***Assistant Professor, Physical Therapy Department, Faculty of Allied health Sciences, Hashemite University, Jordan, **AssistantProfessor, Department of Occupational Therapy, Hashemite University, Jordan

Abstract

Background Constraint induced movement therapy (CIMT) has been

documented to improve motor function in children withhemiplegic cerebral palsy. Most of CIMT previous studies werecarried out by therapists at laboratory or clinical-basedenvironment.

PurposeThe purpose of this pilot study was to evaluate the possibility

of using CIMT in children with hemiplegic cerebral palsy by theirmothers at their homes.

MethodsThree children with hemiplegic cerebral palsy participated

in CIMT training and completed the evaluation. Children’sfunctional upper-extremity activities were assessed at homeusing the Pediatric Motor Activity Log (PMAL) (parent ratings)at baseline, after, and at 4 weeks post-treatment. The CIMTinvolved promoting increased use of the more-affected arm andhand by intensive training of the more-impaired upper extremityfor six hours/ day for 21 consecutive days coupled with bivalvelong arm casting of the child’s less-affected upper extremity.

ResultsConstraint-induced movement therapy as implemented in

this study was acceptable to mothers and their children but withsome difficulties. Over the intervention period, participantsexperienced improvements in the performance of important dailyactivities as determined by parents rating.

ConclusionsModified constraint-induced therapy which is family-focused

is sufficiently promising to justify additional studies with largersample size in the form of a randomized control trails usingdifferent types of splints.

Key wordsPhysical therapy, Occupational therapy, Constraint Induced

Movement Therapy, Children with Hemiplegic Cerebral Palsy,Home based therapy

IntroductionConstraint Induced Movement Therapy (CIMT), a new

rehabilitative therapeutic approach to improve affected handfunction was emerged and it has been used with stroke patientswith upper extremity (UE) dysfunction (Taub et al., 1993; Taub& Wolf ,1997). The CIMT studies in adult stroke patients showedpromising outcomes for reducing impairment and improvingfunctional use of the affected UE (Weinstein, Miller , et al., 2001;Pierce, Daly , Gallagher , Gershkoff , & Schaumburg , 2002).

When an individual experiences a dysfunction in an UE, he/shetends to depend more on the unaffected UE and neglecting theuse of the affected one. This observation is called “learned- nonuse” and it is the base of the CIMT approach (Taub, et al., 1993).

The CIMT includes constraining the movement of theunaffected hand and at the same time encouraging the use ofthe affected hand by presenting different UE functional skills forthe patient to perform (Taub, et al., 1993; Taub & Uswatte , 2003).Following promising outcomes in adult stroke patients, CIMThas been introduced for children with hemiplegic cerebral palsy.However, limited studies have evaluated the use of CIMT inchildren with hemiplegic cerebral palsy to improve their handfunctions and all these studies have indicated positive outcomes(Charles, Lavinder, & Gordon, 2001; Willis et al., 2002; Karmanet al., 2003; DeLuca, Echols, Ramey, & Taub, 2003; Taub,Ramey, DeLuca, & Echols, 2004).

There are some concerns related to the CIMT trainingprograms, such as it is mainly conducted in clinical/laboratory-based environments which questioning the possibility oftransferring the approach into usual rehabilitation program.Additionally, CIMT requires concentrated period of therapist’stime with limited studies looking at the applicability of CIMT innatural environments where children spent most of their normallives with their families. Moreover, family involvement inimplementing CIMT has not been evaluated. For all thesereasons and other methodological reasons (Grotta, et al., 2004),CIMT is not yet become part of routine children rehabilitationprogram and the approach still under investigation. To strengthenthe evidence of the CIMT approach and validate the applicabilityof CIMT in children who have had hemiplegia across variouscultures and environments, additional studies are needed tounderstand better whether the CIMT would be carried out inchildren’s homes by their mothers. The aim of this study was toevaluate the possibility of using CIMT in children with hemiplegiccerebral palsy in their homes.

Method

SubjectsParticipants were recruited with the help of therapists who

work at the Cerebral Palsy Foundation (CPF) in Amman-Jordan.For practical reasons children and their mothers were selectedpurposively. Four children were recruited initially; one child wasdropped out at an early stage resulting in three children whocompleted the CIMT program. The reason for the drop out wasrelated to the child’s rejecting the cast and it was difficult for thefamily to cope with the situation.

The children included in the study had a diagnosis ofcongenital spastic hemiplegic cerebral palsy made by aconsultant neuro- pediatrician. Parents were able and willing tocommit to the time required for the daily procedure and the follow-up care after the program completed (see Table 1).

InterventionThe Hashemite University of Jordan Research Review

Board approved the study protocol, and parents signed informed-consent statement. Prior to therapeutic intervention, families had

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received proper training to enhance their abilities to carry outthe treatment sessions at home. The training was conducted bytwo therapists (a physiotherapist and occupational therapist). Athree-days parents’ training program included: orientation aboutthe CIMT approach, the important of mother’s commitment tothe success of training activities and detailed information abouttraining activities to be carried out at homes during theintervention and the follow-up period. The follow-up period lastedfor four weeks post intervention. Mothers were allowed to askquestions and express their concerns during the trainingsessions. Examples from previous CIMT studies were discussed.Mothers were also provided with detailed instructions aboutcasting procedures and cast handling at home.

A lightweight, fiberglass cast was applied to the less affectedUE from shoulder to fingertips (DeLuca et al., 2003). The castwas applied to the UE in 90 degrees of elbow flexion and in aneutral position of wrist and fingers. The cast was bivalved sothat it could be removed once a week to wash the arm, permitactive range of motion and to check skin integrity. The cast wasworn for 24 hours a day for the three-week intervention period.In order to avoid any risk of skin breakdown or discomfort, thecast was fabricated by hand therapists. Mothers were giveninstructions about how to manage the cast and to report anyproblem.

The daily hand training program was provided by children’smother with a once a week visit by therapist and follow up phonecalls three times a week. The six-hour daily training took placein the child’s home for 21 days. All three mothers were housewives and have no commitment outside their homes. Trainingagenda was based on sensorimotor activities, encouragementof gross motor movements training and behavioral techniques.All these activities were shown to mothers and mothers wereprovided with written training guideline. Training was based onmotivating the child to use the impaired hand to play, selectingactivities of an appropriate level of difficulty to develop new skillsand to provide opportunities for repetition.

Outcome measurement toolThe Pediatric Motor Activity Log (PMAL) and parents open

interview were used. The PMAL test was used to assesschildren’s upper limbs performance before and after interventionperiod and it was based on the Motor Activity Log (MAL) measureused for adults (DeLuca et al., 2003). The PMAL is a 22-itemparental interview used to measure the child’s upper-extremityfunctioning in different activities at home. Upper-limb use isscored on two ordinal scales, “How Often” and “How Well”. The“How Often” scale ranges from 0 (never uses the affected armfor task completion) to 5 (uses affected arm on almost alloccasions for task completion); the “How Well” scale ranges

from 0 (unable to use affected arm for task completion) to 5(uses affected arm in a way that is normal for child’s age). Scoringfor both scales involved averaging across the 22 items, with ahigher score indicating a better performance. The mothers’perceptions of quantity and quality of their children upperextremity function were recorded by one of the therapists oncea week totaling three assessments of PMAL throughout theintervention period. The assessment of PMAL was repeated atfollow up period once a week. The validity and reliability of themeasure still not yet established.

An open interview was performed with children’s mothersto evaluate their experiences with the CIMT. Interviews wereconducted by the researchers after the intervention period wascompleted. Families were also provided with diaries to recordchild’s daily upper arms functional activities.

Data analysisData were managed and analyzed using the Statistical

Package for Social Sciences (SPSS) version 16 (SPSS Inc.,Chicago, IL., USA). Because of the small number of data points,only descriptive statistics were used. The PMAL scores for thethree children were calculated at the baseline, post-intervention,and at four weeks post-intervention. Authors of the studyseparately reviewed mothers’ interviews. Qualitative data fromthe mothers’ interviews was coded into initial categories. Initialcategories compared, contrasted, and refined to come out withmajor categories of the study (Bogdan and Biklen, 1992).Consensus was reached by the two authors about thecategories.

ResultsTable 2 presents scores of PMAL means and change scores

for the three children at baseline, post treatment and at the endof four weeks follow up. The analysis revealed pronouncedtrends of improvements in the PMAL amount of use and qualityof use scales for all three children.

All of the three mothers completed the CIMT interventionwith their children as expected in the study design. Complianceof the families with CIMT intervention was varies. Familiesreported satisfaction with carrying CIMT intervention at home.There were no transportation arrangement, transportation cost,clinic waiting time, arrangement of baby sitter or somebody todo house work during their absence from home as reported bymothers. Additionally, mothers reported that being at homesreduced their worries about other siblings and allow them to dotheir daily home-management activities.

The mothers reported that their children used the full bivalvelong arm cast in their home environment during the three weeksperiod. Mothers reported that children were not happy with

Table 1: Demographic data of cerebral palsy children with hemiplegia (n= 3)Child Age (months) Gender Gestational Parents’ level Age at Therapy

week of education diagnosis of CP services at enrollment(hr/week)

1 18 Female Preterm College 4 months ½ hour/week ofphysiotherapy (regular)

2 26 Male Full term College 6 months ½ hour/week ofphysiotherapy plus ½hour/week ofoccupational therapy(regular)

3 24 Male Preterm HighSchool 5 months ½ hour /week ofphysiotherapy (regular)

Table 2: PMAL means and change scores for 3 children at baseline, post treatment and at 4 weeks follow upTime of assessment Mean ChangesHow often(0-5)Pre-treatmentPost treatment4 weeks follow up 0.71.51.3 +0.8+0.6How well (0-5)Pre-treatmentPost treatment4 weeks follow up 0.31.91.7 +1.6+1.4

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casting procedures, especially when the “cast saw” was usedto bivalve the cast. The mothers also reported that in the firstthree days of donning the cast children had experienced somesleep disruption.

In terms of the increased treatment intensity, mothers findit difficult to manage time for the treatment at the beginning,especially in the first week of intervention period. During thefirst week, mothers also reported that children were crying duringtraining sessions and felt slowness of using their both hands,slow movement in the lower limbs and muscle soreness butthese consequences improved in the next two weeks of theintervention period.

According to their reports all mothers were pleased withthe observable improvement in their children’s functional use ofthe affect arm and hand. Mothers reported various functionalimprovements including bimanual activities, using the affectedhands during play activities, less need for assistance, andimproved reaching activities especially during the last two weeksof the intervention and on the follow up period. All motherswere pleased with the results and with the overall treatmentapproach. During interviews, mothers suggested readymadecast with lighter materials, less training intensity, and morefrequent visits by therapists might enhance their futureparticipation.

DiscussionThe purpose of this study was to evaluate the possibility of

using CIMT in children with hemiplegic cerebral palsy in theirhomes. Results from this study are consistent with other studiesin showing improvement in upper limb function after CIMT inyoung children with hemiplegic cerebral palsy (Willis et al., 2002;Eliasson, et al., 2005). Unlike other studies, the CIMTimprovements in this study were completed by children’smothers. Mothers reported various functional improvementsincluding bimanual activities, using the affected hands duringplay activities, less need of assistance, reaching activitiesespecially during the last two weeks of the intervention and atthe four week follow-up period. Similar to other CIMT studies,the improvement of these functional activities may be due tothe intensity of training and the type of training (Taub & Uswatte,2003). However, other factors such as the mother’s commitmentto attend the three days workshop, to carry out the training bythemselves with weekly regular visits and follow up phone callsby therapists might contribute positively to the improvement ofupper limb function.

In this study, despite difficulties to adapt long arm cast inthe first week of the intervention, all three children used the armcast as expected. Similarly, these difficulties have been recordedin previous children CIMT studies (Charles, Lavinder, & Gordon,2001). Other consequences such as muscle soreness, lowerlimb slow movement especially in the first week of interventionreported in this study were also reported in other studies (Glover,Mateer, & Yoell, 2002; Crocker, et al., 1997). The possibleexplanation for these consequences following casting might bedue to restraint type, restraint duration and intensity of training.In regards to restraint type, other studies using similar restrainttype recorded similar difficulties (DeLuca, et al., 2003). Sideeffects of prolonged restraint duration in this study were inagreement with other studies (Willis et al., 2002; Yasukawa,1990). The possible explanation for these side effects that theCIMT used in adults may be not appropriate to children as itmay affect their interaction with the environment around them.It has been suggested that the CIMT used in adults should bemodified when used with children (Crocker et al., 1997).

In this study mothers were committed to complete thetraining intensity at home beside their other house hold task.These mothers were housewives and the training was integratedin children’s routine daily activities, but one could argue thatthis type of intervention may not be appropriate for mothers whohave commitment outside their homes.

Limitations of the studyThis home-based study found positive effects of pediatric

CIMT for hemiplegic cerebral palsy. However, the findings ofthis study must be interpreted with caution for the followingreasons: purposive sampling was used, where mothers whowere able to attend the workshop training and had commitmentto complete the program at home were selected. A further studyinvolving a sample of participants selected randomly might leadto different findings. The sample size in the current study wasalso small (Three children only) raising concerns about thegeneralizability of the study. Other limitation was that the PMALmeasurements used in the study lacked reliability and validity,which brings the results into question.

ReferencesBogdan, R., & Biklen, S. (1992). Qualitative Research for

Education: An Introduction to Theory And Methods (2ndedn). Needham Heights, MA: Allyn and Bacon

Charles, J., Lavinder, G., & Gordon, AM. (2001). Effects ofconstraint-induced therapy on hand function in children withhemiplegic cerebral palsy. Pediatr Phys Ther , 13, 68–76.

Crocker, MD., MacKay-Lyons, M., & McDonnell, E. (1997).Forced use of the upper extremity in cerebral palsy: asingle-case design. American Journal of OccupationalTherapy, 51(10), 824-833

DeLuca, SC., Echols, K., Ramey, SL., & Taub, E. ( 2003).Pediatric constraint-induced movement therapy for a youngchild with cerebral palsy: two episodes of care. Phys Ther, 83,1003–1013.

Glover, J. E., Mateer, C. A., Yoell, C., & Speed, S.(2002). Theeffectiveness of constraint induced movement therapy intwo young children with hemiplegia. Pediatr Rehabil , 5(3), 125-31.

Grotta, J., Noser, E., Ro, T., Boake, C., Levin, H., Aronowski,J., & Schallert,T.(2004). Constraint-Induced MovementTherapy. Stroke, 35 [suppl I], 2699-2701.

Karman, N., Maryles, J., Baker, RW., Simpser, E., & Berger-Gross P.(2003). Constraint-induced movement therapy forhemiplegic children with acquired brain injuries. J HeadTrauma Rehabil, 18, 259-267.

Pierce, SR., Daly, K., Gallagher, KG., Gershkoff, AM., &Schaumburg, SW. (2002).Constraint-induced therapy fora child with hemiplegic cerebral palsy” a case report. ArchPhys Med Rehabil , 83,1462-1463.

Taub, E., & Uswatte, G. (2003). Constraint-induced movementtherapy: bridging from the primate laboratory to the strokerehabilitation laboratory. J Rehabil Med , 41 (suppl), 34–40.

Taub, E., Miller, N.E., Novack, T.A., Cook, E.W. , Fleming, W.C.,Nepomuceno, C.S., Connell, J.S., & Crago, J.E. (1993).Technique to improve chronic motor deficit after stroke. ArchPhys Med Rehabil, 74, 347–354.

Taub, E., & Wolf, SL. (1997).Constraint induction techniques tofacilitate upper extremity use in stroke patients. Top RehabTop Stroke Rehab, 3, 38-61.

Weinstein, CJ., Miller, JP., Blanton, S., Taub, E., Uswatte, G.,Morris, D., et al (2003). Methods for a multisite randomizedtrial to investigate the effect of constraint-induced movementtherapy in improving upper extremity function among adultsrecovering from a cerebrovascular stroke. NeurorehabNeural Repair , 17, 137-152.

Willis, JK., Morello, A., Davie, A., et al (2002). Forced usetreatment of childhood hemiparesis. Pediatrics,110 ,94–96.

Yasukawa, A.(1990). Upper extremity casting: adjunct treatmentfor a child with cerebral palsy hemiplegia. American Journalof Occupational Therapy, 44 (9), 840-84

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Taping and OKC exercises versus taping and CKC exercises intreating patients with patellofemoral pain syndromeYehia N. Abd Elhafz 1, Mohammed S. Abd El Salam 2, Samiha M. Abd Elkader3

1Department of Musculoskeletal Physical Therapy, Faculty of Physical Therapy, Cairo University, Giza, Egypt, 2Department of PhysicalTherapy, College of Applied Medical Sciences, King Saud University, Riyadh, KSA, 3Department of Physical Therapy, College ofApplied Medical Sciences, University of Dammam, Eastern Province, Dammam, KSA.

AbstractThis study aimed to compare the combined effect (s) of

taping and open kinetic chain (OKC) versus taping and closedkinetic chain (CKC) exercises in patients with patellofemoral painsyndrome (PFPS). Thirty patients with PFPS were randomlyassigned to group A (tape, OKC), or group B (tape, CKC). Tapewas applied, for both groups A and B using medial glide. Patientsin both groups practiced exercises three times weekly for fourweeks. A 10 cm visual analogue scale (VAS) was used forassessment pain. Q- angle, and congruence angle were usedfor assessment of patellar maltracking. Both OKC and CKCexercises combined with taping were significant in reducing painand improving patellar alignment. However, neither interventionwas significantly more efficient in reducing pain and improvingpatellar alignment compared to the other. Combined patellartaping and either OKC or CKC exercises were consideredequally effective in treating PFPS.

Key wordsOpen kinetic chain (OKC), closed kinetic chain (CKC),

patellar taping, patellofemoral pain syndrome (PFPS).Patellofemoral pain syndrome (PFPS) is a common problem

in third and fourth decades of life, characterized by retropatellarpain or peripatellar pain when ascending or descending stairs,squatting or sitting with flexed knees 1.

Weakness of vastus medialis obliquus (VMO) wassuggested to cause abnormal patellar tracking in PFPS2. It wasproposed that PFPS results from muscle imbalance betweenVMO and vastus lateralis (VL) 3. Patellar mal-alignment may berelated to tightness of soft tissues around patella 4, 5.

Increased Q-angle is a biomechanical factor observed inPFPS. Q-angle creates a lateral force vector on patella andexposes it to lateral displacement during activation of Quadriceps6. Tendency for lateral displacement of patella are believed toincrease as Q-angle increases. This will contribute to increasedpatellar contact pressure 7. An increase in Q angle (more than150) may increase patella lateral pull, causing patella to glide onthe lateral ridge of femoral groove and produce pain 8, 9.

Among commonly used plain radiographic measures ofpatellar mal tracking is patellar congruence angle (CA), whichmeasures relationship of patella to intercondylar sulcus . If apexof patellar articular ridge is lateral to the zero line, CA is positive.If it is medial, CA is negative 10.

One main objective of rehabilitation is to strengthen VMOto counterbalance VL action during activities 8. It is debatablewhether it is better to apply OKC or CKC exercises for quadricepsstrengthening in such conditions. However, there is strongevidence that both modes are equally effective11, 12.

Taping is utilized in managing PFPS to improve pain andfunction. Some authors suggested that mechanical advantageof quadriceps is maximized because of increased leverage bypatella via a medial shift as it returns to trochlear groove of thefemur 13, 14, 15, 16. Others hypothesized that patellar taping reduceneural inhibition of quadriceps and modulate pain via largeafferent fiber input 14, 15, 17.

Under influence of patellar taping, altered afferent input inand around patellofemoral joint may improve proprioceptivefunctions in patients with PFPS 2, 13, 18. Studies showed significant

improvement of VMO initiation timing under taping condition 19,

20.Since application of OKC and CKC exercises under taping

conditions takes place under modified mechanical andneuromuscular conditions compared to non- taping condition,we expected effects of both exercises modes might differ. Sincecomparison of combined effects of taping and OKC versus tapingand CKC has not been done yet, so, purpose of this study wasto compare those combined effects on pain and patellaralignment in patients with PFPS. It was hypothesized that therewould be no significant difference in pain and patellar alignmentfollowing application of taping/ OKC or taping/ CKC in patientswith PFPS.

MethodsThirty patients (19 males and 11 females), age 35.83(+ 5.36)

years with PFPS were randomly selected, from patients files ofphysiotherapy clinic. They were randomly assigned to group A(n=15) received patellar taping and OKC exercises, and groupB (n=15) received patellar taping and CKC (Fig. 1).

Patients were included if they presented with diffuse,unilateral anterior knee pain for at least 8 weeks, exacerbatedby activity and isometric quadriceps contraction 21, 22. Patientswere excluded if they had a history of lower limb surgery,deformities, or patellar fractures or dislocations 23.

Before the study began each subject signed a writtenconsent form after they got full explanation of evaluation andintervention procedures that conforms to Helsinki Declaration.

Evaluation proceduresA physical therapist carried out; pain assessment using a10-

cm visual analog scale (VAS) 16, and Q- angle measures clinicallyby identifying center of patella, tibial tuberosity, and ASIS. Then,assessor connected center of patella with ASIS, and center ofpatella to tibial tuberosity, and measured angle between themusing universal goniometer 8.

A radiologist carried out radiological evaluation to assessCA measured by X-ray

(Toshiba radiographic machine, Toshiba co, Japan, and X-ray film, Fuji film type 20 x 25cm), applying Merchant view 17.

Both assessors and Patients were blinded; unaware aboutnumber of groups, randomization technique, or interventionsfor each group.

Treatment proceduresPatients in both groups received 3 sessions per week for 4

weeks. Patients in group A received OKC exercises; Patients ingroup B received OKC exercises; and medial taping was appliedfor both groups.

Taping techniqueTherapist applied medial patellar taping before exercises.

Patients were instructed to maintain tape in-between sessions.Therapist applied a 15-cm cover-roll tape directly onto the skin,then a 12-cm Leukotape P (BSN-JOBST, Inc) 24.

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ExercisesPrior to onset of experiment several recommended OKC

and CKC exercises were revised in previous studies 25, 26,27,28 toselect exercises applied in this study.

Patients in group A applied OKC exercises including;1- Flexion SLR from supine.2- Isometric exercise of the quadriceps from supine.3- Short arc knee extension from sitting position, 30o flexion

to full extension.Patients in group B applied CKC exercises including25

1- leg press machine2- Mini squats

3- Squat-to-stand and stand-to-squat tasks4- Forward step up exercise on stairs.

SPSS version 12.0 was used for data analysis. Significancelevel (P < 0.05)

ResultsPain assessment within groups’ analysis showed significant

improvement in pain in groups A and B. (Table 1 and Fig 2).

Table 1: Comparison of mean VAS, Q-angle, and CA within groups A and B at pretest versus posttest evaluations.Evaluations Mean SD 95% Confidence Interval t value Sig.

of the DifferenceLower Upper

Group A Pre 6.51 1.52 1.45 1.85 17.60 0.00(VAS) Post 4.87 1.43Group B Pre 6.97 1.28 1.17 1.78 10.43 0.00(VAS) Post 5.50 0.85Group A pre 15.20 0.94 1.18 1.89 9.28 0.00(Q-angle) Post 13.67 1.05Group B Pre 15.53 0.83 1.53 2.47 9.17 0.00(Q-angle)Post 13.53 1.06GroupA Pre 3.13 1.85 1.20 2.39 6.44 0.00(CA) Post 1.33 0.98Group B Pre 3.367 1.53 1.16 2.84 5.12 0.00(CA) Post 1.367 1.08

P<0.05

Fig. 1:

Fig. 2: Within groups comparison between mean VAS at pretestversus posttest evaluations

Comparing within groups means at pretest- posttestevaluations showed a significant reduction of Q- angle in groupsA and B. Within group mean values for groups A and B shouldsignificant reduction in CA post-test (Fig. 3).

Fig. 3: Within groups comparison between mean Q-angle andCA at pretest versus posttest evaluations.

In-between groups analysis showed non-significantdifferences between groups A and B at both pretest and posttestevaluations for pain, Q-angle and CA values (Table 2 and Figs.4&5).

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DiscussionAnalysis of data showed within groups’ reduction of pain,

besides reduced Q-angle and CA angles in both interventiongroups A and B.

There is general agreement among all reviewedliterature that taping and exercises program, produces reductionof pain at pretest- post-test comparisons 15, 16, 19, 29, 30, 31, 32 .However, capacity of patellar taping to provide correction ofpatellar alignment had been debatable. Christou19

demonstratedthat patellar taping reduce pain and enhance activity of VMOduring CKC movement, however, author reported that thisoutcome was equivocal when taping was applied with medialglide or in neutral position which reflected no taping effect onpatellar position. In the contrary, the current study patellar maltracking was measured as indicated by Q- angle and CA. Bothshowed improved patellar positioning with both interventions.We suggest differences in those outcomes was due to lack ofpatellar alignment measures in Christou’s study. Whittinghamet al31, suggested improved pain and function in patients withPFPS when therapeutic taping is combined with exercisescompared to placebo taping and exercises, and exercises aloneconditions. These findings indirectly supported our findingsconcerning efficiency of combination of tape and exercises. Wewould not claim direct relativity of these findings to ours as currentstudy did not included placebo tape or exercise only groups.

Reduced Q- angle and CA was reported in literature forcombined taping and exercises. However, reduced CA withpatellar taping has been reported by Worrell et al. 33. It was notcomparable to this study as measurement of CA was done duringtaping using MRI, and no exercises were involved. Other authors17, 34 reported non- significant difference in patellar alignmentwith taping. Bockrath et al.17 had subjects who applied taperegularly well before assessment that might caused some biasto occur, while Gigante et al. 34 applied assessment of CA in CTscan rather than plain radiographs applied in this study, and noexercises intervention has been applied. However, it can besuggested that the combined effect of taping and exercises, ofeither modes, had enhanced onset of VMO activation, increasedVMO activity, and VMO/VL ratio, as supported by several authorsthus, reducing lateral patellar shift, and adjusting patellaralignment 19, 20, 26.

Post experimental In-between groups analysis had beenour target. So that we would conclude which combination would

be better in managing patients with PFPS. Results achievedsuggested that there was no significant difference betweenoutcomes in either interventions. Unfortunately, to our bestknowledge, no previous existing literature that would help inexplaining this finding. It seemed that whatever effects suggestedto occur with patellar taping with medial glide, it did not modulatedand/ or enhanced the effects of either OKC or CKC exerciseson pain and patellar alignment. However, the effect of combinedtaping and OKC compared to combined taping and CKCexercises should be further studied to identify the effects of eithercombinations in improving function, VMO strength, and VMO/VL timing compared to one another.

ConclusionApplication of patellar taping combined with either OKC or

CKC exercises showed to be beneficial in reducing pain andpatellar mal tracking in patients with PFPS. Despite this, nosignificant differences were detected in combining taping witheither OKC or CKC exercises in pain values, Q- angles, and CAvalues in patients with PFPS.

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Hietaniemi K, Seitsalo S., Malmivaara. A., Kujala UM.Knee arthroscopy and exercise versus exercise only forchronic patellofemoral pain syndrome: a randomizedcontrolled trial. BMC Med 2007; 13: 5- 38.

2. Ng GY, Zhang AQ, Li CK. Biofeedback exercise improvedthe EMG activity ratio of the medial and lateral vasti musclesin subjects with patellofemoral pain syndrome.

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Table 2: Comparison of mean VAS , Q-angle, and (CA), In-between groups A and B at pretest versus posttest evaluations.Groups Mean SD 95% Confidence Interval t-value Sig.

of theDifferenceLower Upper

VAS Pre Group AGroup B 6.516.97 1.521.28 -1.51 0.59 -0.89 0.38VAS Post Group AGroup B 4.875.50 1.440.85 -1.51 0.24 -1.48 0.15Q-angle Pre Group AGroup B 15.2015.53 0.940.83 -0.99 0.33 -1.03 0.31Q-angle Post Group AGroup B 13.6713.53 1.051.06 -0.66 0.92 0.35 0.73CA Pre Group AGroup B 3.133.37 1.851.53 -1.50 1.04 -.38 0.71CA Post Group AGroup B 1.331.37 0.981.08 -0.80 0.74 -0.09 0.93

Fig. 4: In- between groups comparison between mean VAS atpretest and posttest evaluations.

Fig. 5: In- between groups comparison between mean Q- Angleand CA at pretest and post test evaluations.

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6. Grelsamer RP, Klein JR.”The Biomechanics of thePatellofemoral Joint”. J Orthop Sports Phys Ther 1998;28:276-98.

7. Schulthies S, Francis R, Fisher A and Van De Graaf K “Doesthe Q- angle reflect the force on the patella in the FrontalPlane?”. Phys Ther 1995;75 : 24-30.

8. Mizuno Y, Kumagai M, Mattessich SM, et al. Q-angleinfluences Tibiofemoral and patellofemoral kinematics. JOrthop Res 2001; 19:834– 40.

9. Powers CM. The influence of altered lower-extremitykinematics on patellofemoral joint dysfunction: a theoreticalperspective. J Orthop Sports Phys Ther.2003; 33: 639–46.

10. Katchburian MV, Bull AM, Shih YF, Heatley FW, Amis AA.Measurement of patellar Tracking: assessment and analysisof the literature. Clin Orthop Relat Res 2003; 412:241–59.

11. Heintjes E, Berger MY, Bierma-Zeinstra SM, Bernsen RM,Verhaar JA, Koes BW. Exercise therapy for patellofemoralpain syndrome. Cochran Database Syst Rev 2003.CD0034725.

12. Herrington L, Al-Sherhi A. A controlled trial of weight-bearingversus non weight-bearing exercises for patellofemoralpain. J Orthop Sports Phys Ther 2007; 37:155-60.

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15. Herrington L. The effect of patellar taping on quadricepspeak torque and perceived pain: a preliminary study. PhysTher Sport 2001;2: 23–28.

16. Ng GY, Cheng JMF. The effects of patellar taping on painand neuromuscular performance in subjects withpatellofemoral pain syndrome. Clin Rehabil 2002; 16: 821–27.

17. Bockrath K, Wooden C, Worrell T, Ingersoll CD, Farr J.Effects of Patellar taping on patella position and perceivedpain. Med Sci Sports Exerc 1993; 25: 989–92.

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19. Christou EA. Patellar taping increases vastus medialisoblique activity in the presence of patellofemoral pain. JElectromyogr Kinesiol 2004;14: 495–504.

20. Cowan SM, Bennell KL, Hodges PW .Therapeutic patellartaping changes the timing of vasti muscle activation inpeople with patellofemoral pain syndrome. Clin J SportMed 2002;

12(6):339- 47.21. Anderson G, Herrington L. A comparison of eccentric

isokinetic torque production and velocity of knee flexionangle during step down in patellofemoral pain syndromepatients and unaffected subjects. Clin Biomech (Bristol,Avon) 2003; 18: 500–4.

22. Baker V, Bennell KL, Stillman B, Cowan SM, Crossley KM.Abnormal knee joint position sense in individuals with

patellofemoral pain syn-drome J Orthop Res 2000; 20:208–14.

23. Livingston LA, Mandigo JL. Bilateral Q angle asymmetryand anterior knee pain syndrome. Clinical Biomechanics1999; 14: 7- 13.

24. Aminaka N, Gribble PA. Patellar Taping, Patellofemoral PainSyndrome, Lower Extremity Kinematics, and DynamicPostural Control. Journal of Athletic Training 2008;43:21–8.

25. Witvrouw DE, Cambier L. Danneels J. Bellemans S. WernerF. Almqvist R. The effect of Exercises regimens on reflexresponse time of the vasti muscles in patients with anteriorknee pain: a prospective randomized intervention study.Scandinavian Journal of Medicine &

Science in Sports, 2003; 13: 251-8.26. Boling MC, Bolgla LA, Mattacola CG, Uhl TL, Hosey RG.

Outcomes of a weight-bearing rehabilitation program forpatients diagnosed with patellofemoral pain syndrome. ArchPhys Med Rehabil 2006; 87:1428-35.

27. Liebensteiner MC, Szubski C, Raschner C, Krismer M,Burtscher M, Platzer HP, Deibl M, Dirnberger E. Frontalplane leg alignment and muscular activity during maximumeccentric contractions in individuals with and withoutpatellofemoral pain syndrome. Knee 2008; 15(3):180-86.

28. Tang SF, Chen CK, Hsu R, Chou SW, Hong WH, Lew HL.Vastus medialis obliquus and vastus lateralis activity in openand Closed kinetic chain exercises in patients withpatellofemoral pain syndrome: an electromyographic study.Arch Phys Med Rehabil 2001; 82:1441-5.

29. Clark DI, Downing N, Mitchell J, Coulson L, Syzpryt EP,Doherty M. Physiotherapy for anterior knee pain: arandomised controlled trial. Ann Rheum Dis 2000;59:700–4.

30. Boling MC, Bolgla LA, Mattacola CG, Uhl TL, Hosey RG.Outcomes of a Weight-Bearing Rehabilitation Program forPatients Diagnosed With Patellofemoral Pain Syndrome.Arch Phys Med Rehabil 2006; 87:1428-

31. Whittingham M, Palmer S, Macmillan F. Effects of tapingon pain and function in Patellofemoral pain syndrome: arandomized controlled trial. J Orthop Sports Phys Ther2004; 34: 504–10.

32. Salsich GB, Brechter JH, Farwell D, Powers CM. The effectsof patellar taping on knee kinetics, kinematics, and vastuslateralis muscle activity during stair ambulation in individualswith patellofemoral pain. J Orthop Sports Phys Ther 2002;32:3–10.

33. Worrell T, Ingersoll CD, Bockrath-Pugliese K, Minis P. Effectof patellar taping and bracing on patellar position asdetermined by MRI in patients with patellofemoral pain. JAthl Train 1998; 33:16-20.

34. Gigante A, Pasquinelli FM, Paladini P, Ulisse S, Greco F.The effect of patellar taping on patellofemoral incongruence:a computed tomography study. Am J Sports Med 2001; 29:88–92.

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Cardiovascular responses to McKenzie lumbar spine exercisesin hypertensive individualsPrabhu R1, Nambiar V.K2, Ravindra S3, Kommineni P4

1Dept. of Physiotherapy, KLE Hospital, Belgaum, 2, 3, 4Dept. of Physiotherapy, M.S.R.M.T.H, Bangalore

Abstract

BackgroundLow back pain (LBP) is one of the most common health

problems inthe society. Repetitive lumbar spine exercises which arerecommended by McKenzie such as flexion and extensionexercises in lying (FIL and EIL) and flexion and extensionexercises in standing (FIS and EIS), have been used in theassessment and management of low back pain since 20 years.Studies are done in normal individuals to see the cardiovascularchanges after repetitive McKenzie exercises. So, there is a needto study the effect of these exercises on cardiovascular systemin hypertensives, who are at risk to develop cardiovascularcomplications. Therefore, this study was undertaken to examinecardiovascular effects of McKenzie exercises in hypertensiveindividuals.

Objectives1. To measure the pattern of HR, SBP and RPP during flexion

McKenzie lumbar spine exercises in hypertensive individuals. 2. To measure the pattern of HR, SBP and RPP during

extensionMcKenzie lumbar spine exercises in hypertensiveindividuals.

3. To compare the changes in HR, SBP and RPP betweenflexion and extensionMcKenzie lumbar spine exercises in hypertensiveindividuals.

MethodsA convenience sample of 60 hypertensive individuals

between the age group 30 to 60 years was recruited from theM. S. Ramaiah teaching hospital, Bangalore. The subjects wereadministered flexion in lying (FIL), extension in lying (EIL), flexionin standing (FIS) and extension in standing (EIS) with a washout period of 30 minutes between each exercise. Cross overtrial was followed. Subjects performed 10 repetitions of assignedexercises. Blood pressure, Heart rate and rate pressure productwere recorded before and after each set of repetition.

ResultsPaired t test was used to compare the amount of change in

heart rate,systolic blood pressure and rate pressure product between

resting andFIL, EIL, FIS and EIS exercises. For comparison of FIL

with EIL and FIS with EIS, Paired t-test was used .Data analysishave shown that there is a significant change in blood pressure,heart rate and rate pressure product after 10 repetition of FIL,EIL, FIS and EIS exercises when compared with resting.Comparing FIL with EIL exercise and FIS with EIS showed asignificant change in BP, HR and RPP. The effect size of flexionexercise showed more change in SBP, HR and RPP than

Extension exercises.

Interpretation and Conclusion In hypertensive individuals, McKenzie flexion exercises put

a greater stress on the cardiovascular system than the extensionexercises. Therefore, in such individuals, flexion exercisesshould be given under close monitoring.

KeywordsCardiovascular responses, blood pressure, McKenzie

lumbar spine exercises, low back pain, Rate pressure product.

IntroductionLow back pain (LBP) is one of the most common health

problems in the society and causes considerable disability, workabsenteeism and use of health services.1 LBP is commonlyseen in people aged between the ages of 35 and 64yrs 2.

In 1981, Robin McKenzie proposed a classification systemfor LBP and a classification based treatment for the same labeledas mechanical diagnosis and therapy, or simply the McKenziemethod 3 . These exercises are used to classify patients, having1 of the 3 syndromes (postural, dysfunction and derangementsyndromes) and to guide the treatment 4.

McKenzie exercises include repeated flexion and extensionmovements performed in different body positions.5 Based onMcKenzie approach, the patient performing 10 to 15 repetitionsevery 2hrs in home program implies that end range exercisewill be attained 80 to 100 times a day. The number of repetitionsand type of exercise can affect the overall physiological demandof exercise 6 .

The McKenzie exercises involve muscle co-contraction tostabilize the trunk and some exercises involve arm exercises,both of which are associated with disproportionate cardiovasculardemand to a given load compared with leg work 7 , 8.

Non invasive measure of cardiovascular responses canbe obtained with HR, systolic BP and rate pressure product(RPP). RPP is a product of HR and systolic BP. The RPP isconsidered an excellent index of myocardial oxygen demandand therefore work of heart 9 . The increase in HR and SBP perunit increase in work is greater during upper extremity exercisethan during lower extremity exercises 10,11 .

Some risk factors for back pain are similar to thoseassociated with cardiovascular disease (eg, lack of physicalconditioning, obesity, smoking ) 12. This evidence suggest thatclinicians working with patients who have low back pain need toconsider that there can be an increased risk of an adversecardiovascular response.13 14

Spinal flexion exercise in lying position, involves work oflarge muscle mass of upper and lower extremities, abdominalmuscles and trunk muscles (acting as stabilizer). Therefore thedemand of oxygen to supply this contracting muscles isincreased and this leads to increase in HR, BP and thereforeRPP 15

In McKenzie extension exercise such as push up involvesstatic contraction of upper extremity muscle which increaseswork load on heart after 10-15 repetitions.

So understanding the cardiovascular responses to

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McKenzie exercises on hypertensive individuals, can be usefulfor clinicians in prescribing these exercises for treatmentpurpose. Little evidence is available on the cardiovascularchanges occurring in hypertensives during McKenzie lumbarspine exercises. Therefore there is a need to study the effect ofMcKenzie exercises (i.e. lumbar spinal flexion and extension instanding and lying, repeated at 10 times), on cardiovascularchanges in hypertensives, as a precautionary measure, beforeprescribing them the same.

Null Hypothesis McKenzie lumbar spine exercises will notbring about a change in HR, SBP and RPP in hypertensiveindividuals.

Alternate Hypothesis McKenzie lumbar spine exerciseswill bring about a change in HR, SBP and RPP in hypertensiveindividuals.

Aims and objectives1. To measure the pattern of HR, SBP and RPP during flexion

McKenzie lumbar spine exercises in hypertensive individuals.2. To measure the pattern of HR, SBP and RPP during

extension McKenzie lumbar spine exercises in hypertensive individuals.3. To compare the changes in HR, SBP and RPP between

flexion and extensionMcKenzie lumbar spine exercises in hypertensiveindividuals.

Review of literatureMcKenzie R A, in 1981 proposed a classification system

and a classification based treatment for LBP called as McKenziemethod 16 Donelson et al reported that, 4 sets of 10 repetitionsof McKenzie lumbar spine flexion and extension exercises with30 to 60 seconds rest in between each set of exercise wereused for treatment of LBP 17.

Leino-Arjas P et al. found that the increased LBP scorewas predicted by a high BMI, serum total cholesterol, triglyceride,SBP and DBP levels and smoking status at baseline. An overallscore of CVD risk factors showed a graded association withincreased LBP 18.

Nicholas U. Ahn et al. concluded that smoking, hypertensionand coronary artery disease (CAD) are all associated withdevelopment of LBP. These same factors as well ashypercholesterolemia, are associated with development ofdegenerative lumbar spondylosis and spondylolisthesis19.

It is known that in a healthy individual HR and SBPincreases during exercises. Increase in HR is a first physiologicalresponse of cardiovascular system to exercise, which is undercontrol of sympathetic system. Myocardial oxygen consumptionhas an other independent determinant, which is called ratepressure product (RPP). It has been well documented that RPPis a valid and reliable index to measure the myocardial oxygenconsumption 20

.Greer M et al. reported HR and BP responses to several

methods of strength training programs. The isometric, isotonicand isokinetic exercises are included in this study which showedthat there was a significant increase in SBP, HR and RPP in allexercises 21.

Liu Danhua et al. established that the repeated McKenzieexercises causes more cardiovascular stress, so there is needto monitor HR and BP in cardiovascular dysfunction patientswho are at risk 22. All the above studies in the literature reviewhave been done on cardiovascular changes in normal individualsduring McKenzie lumbar spine exercises, but little evidenceexists supporting the cardiovascular changes during McKenzieexercises in hypertensive individuals.

The present study was undertaken to determine the

difference in the amount of changes in HR, SBP and RPP duringMcKenzie lumbar spine exercises in hypertensive individuals.

Materials and methodology

Source of dataHypertensive individuals between the age group of 30 to

60 years visiting General Medicine OPD at M. S. RamaiahTeaching Hospitals, Bangalore, Karnataka, from March to August2007. The type of study was cross sectional and conveniencesampling method was used. Sixty hypertensive individuals wererecruited for the study.

Inclusion criteria: Controlled hypertensive (who are onmedications) of either sex in age group between 30-60 years

Exclusion criteria: History of low back ache, any spinaltrauma. any history of pulmonary conditions and patients withneurological deficit

Materials: Philips A 1 Monitor for HR and BP, Couch.

Procedure: An ethical clearance was obtained from ethicalcommittee of M. S. Ramaiah Medical College, Bangalore,Karnataka. Hypertensive individuals from M. S. RamaiahTeaching Hospital were taken up for the study throughconvenience sampling. The subjects were administered flexionin lying (FIL), extension in lying (EIL), flexion in standing (FIS),and extension in standing (EIS) with a wash out period of 30minutes between each exercise 23,24. Cross over trial wasfollowed. The experimental protocol was based on establishedclinical standards for performing repetitive exercises of thelumbar spine as advocated by McKenzie.

Subjects were made to relax for 5 minutes in the referenceposition (supine lying) prior to the test procedure, following whichHR and BP was measured. To begin with, FIL exercise wasperformed by all the subjects, in supine lying with hip and kneefully flexed and taking it towards the chest by clasping the handaround knees to apply maximum overpressure to the lumbarspine. After 30 min of washout period patient were made to doEIL exercise in prone lying with full extension of both the handsnear the shoulder (as traditional press-up exercise), to overcomethe weight of the upper trunk against gravity. After 30 min ofwashout period, subjects performed FIS exercise with feet apart(30cms) and bending forward, sliding the hands down the frontof the legs in order to have some support. Again after the washoutperiod of 30 min, they performed EIS exercise with feet apartand hands placed in small of back across the beltline and thenlean backwards as far as possible using hands as fulcrum. Thesubjects were made to perform 10 repetitions of each of theassigned exercise and then instructed to assume the restingposition. Subjects were instructed not to hold breath. After 10repetitions, they returned to the reference position. HR and BPwere recorded and RPP was calculated.

Statistical analysis: Statistical analysis has been doneusing the statistical software namely SPSS 11.0 and Systat 8.0and Microsoft word and Excel have been used to generate tablesetc.

ResultsA cross-sectional study consisting of 60 hypertensive

individuals including 34 males and 26 females between the agegroup of 30 to 60 years was taken for this study.

DiscussionThis study has been undertaken to study the effects of

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McKenzie exercises on the cardiovascular response in thehypertensive individuals.

The results as seen in Table 1 shows that in FIL, SBP, HRand RPP was increased significantly from resting. McKenzieFIL exercise involves supine lying with hip and knee activelygoing into flexion, this involves the work of large muscle massof lower extremities, the abdominal muscles and the trunkmuscles (acting as a stabilizer). Because of the raised positionof diaphragm and increased intra abdominal pressure there isan increase in vascular resistance bringing about an increasein HR and BP thereby increasing RPP. The demand for oxygento supply the contracting muscles is increased. Consequently,cardiac output (CO) and stroke volume (SV) are increased. Thereis increase in venous return and central blood volume whichincreases the demand on heart in lying because of the cephalicshift of the fluid in lying position 6.

The results as seen in Table 2 shows that in FIS showSBP, HR and RPP was increased significantly from resting. Thismay be because the upright bending position exercise causeskinking of large vessels situated in abdominal cavity namelyabdominal aorta and inferior vena cava which in turn increasesthe load on heart. FIS exercise, involves large range of motionwhich presumably increases the muscle work .This in turn

increases the SBP and HR, thereby increasing RPP. FIS requiresthat while returning to the upright position involves the concentriccontraction of the back muscles. This brings about greaterincrease in the SBP and HR.

McKenzie EIL exercise as seen in Table 3 shows that thereis significant increase in SBP, HR and RPP. EIL exercise involvesprone lying with the weight of the upper trunk has to be overcome,against gravity which is a closed chain exercise. This staticexercise causes the smaller arm muscle mass and vasculatureto offer greater resistance to blood flow than the larger leg musclemass which in turn increases SBP, HR and RPP. Palatini et aldescribed the mechanism of increase in BP and HR during staticexercises. During static exercises, the pressure within the muscleincreases and causes the small blood vessels (i.e arterioles andcapillaries) of these muscles to collapse 25. This reduces thesupply of oxygen rich blood to these working muscles. Thehypoxia (i.e. lack of oxygen) results in increase in SBP and DBPduring the contraction.

The results from Table 4 show that there is significantincrease in SBP, HR and RPP with EIS as compared to resting.EIS causes eccentric contraction of abdominal muscles but whilereturning to the upright position, there is concentric contractionof the same which may be responsible for changes in

Table 4: Comparison of SBP, HR and RPP between restingand EIS exercise

Mean SD t-value P-valueSBP Resting 137.12 6.62 19.529 <0.001

EIS 146.32 5.91HR Resting 77.13 6.13 18.316 <0.001

EIS 83.27 6.58RPP Resting 10587.90 1101.72 28.312 <0.001

EIS 12189.73 1102.57The above Table 4 shows that there was a significant change inSBP, HR and RPP after extension in standing (EIS) exercisewhen compared with resting (p<0.001).

Table 3: Comparison of SBP, HR and RPP between restingand EIL exercise

Mean SD t-value P-valueSBP Resting 137.27 7.38 22.935 <0.001

EIL 152.33 7.02HR Resting 76.87 5.99 23.021 <0.001

EIL 86.38 6.58RPP Resting 10567.30 1159.65 27.130 <0.001

EIL 13185.70 1446.04The above Table 3 shows that there was a significant change inSBP, HR and RPP after extension in lying (EIL) exercise whencompared with resting (p<0.001).

Table 2: Comparison of SBP, HR and RPP between restingand FIS exercise

Mean SD t-value P-valueSBP Resting 136.35 7.164 14.593 <0.001

FIS 150.68 8.550HR Resting 76.92 6.285 24.999 <0.001

FIS 85.77 6.500RPP Resting 10499.38 1138.578 23.281 <0.001

FIS 12990.77 1372.090The above Table 2 shows that there was a significant change inSBP, HR and RPP after flexion in standing (FIS) exercise whencompared with resting ( p<0.001)

Table 1: Comparison of SBP, HR and RPP between restingand FIL exercise

Mean SD t-value P-valueSBP Resting 138.00 7.67 18.383 <0.001

FIL 156.92 7.43HR Resting 77.97 6.43 23.203 <0.001

FIL 89.02 7.11RPP Resting 10778.70 1206.92 25.870 <0.001

FIL 14001.30 1652.71The above Table 1 shows that there was a significant change inSBP, HR and RPP after flexion in lying (FIL) exercise whencompared with resting (p<0.001

Table 6: Comparison of SBP, HR and RPP between FIS and EIS exercises.FIS EIS Mean diff. Effect size t-value P-value

Mean SD Mean SDSBP 150.68 8.55 146.32 5.90 4.37 0.59 5.330 <0.001HR 85.77 6.50 83.27 6.58 2.50 0.38 7.198 <0.001

RPP 12990.77 1372.09 12189.73 1102.57 801.03 0.64 10.547 <0.001The above Table 6 shows that there was a significant increase in SBP, HR and RPP i.e. P<0.001 when compared between FIS andEIS exercises. The effect size of SBP, HR and RPP shows that FIS exercise causes more haemodynamic changes i.e. SBP, HR andRPP than EIS exercise.

Table 5: Comparison of SBP, HR and RPP between FIL and EIL exercises.FIL EIL Mean diff. Effect size t-value P-value

Mean SD Mean SDSBP 156.92 7.43 152.33 7.02 4.58 0.63 4.968 <0.001HR 89.02 7.11 86.38 6.58 2.63 0.38 6.127 <0.001

RPP 14001.30 1652.71 13185.70 1446.04 815.60 0.53 6.901 <0.001The above Table 5 shows that there was a significant increase in SBP, HR and RPP i.e. P<0.001 when compared between FIL andEIL exercises. The effect size of SBP, HR and RPP shows that FIL exercise causes more haemodynamic changes i.e. SBP, HR andRPP than EIL exercise.

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cardiovascular responses.Analysing Table 5 it was found that, there was a significant

increase in SBP, HR and RPP in FIL exercise when comparedwith EIL exercise as seen by effect size. FIL exercise involveslarger range of motion and more muscle work than EIL whichindicates that FIL exercise is haemodynamically more stressfulthan EIL exercise.

The results as seen in Table 6 shows that there was asignificant increase in SBP, HR and RPP in FIS exercise whencompared with EIS exercise as seen by effect size. FIS exerciseinvolves larger range of motion and more muscle work than EISexercise. Biomechanically, it is known that the spinal extensionrange is less than the spinal flexion. In addition at the end ofextension the limitation of chest movement prevents furtheralteration in cardiovascular changes. In EIS exercise there isexpansion of thoracic cage which puts less stress on largervessels of heart reducing its workload.

The result of this study supports the idea that the McKenzieexercises typically performed within 1min represent a risk ofcardiovascular stress in the hypertensive individuals 25. Thus,absolute increase in RPP may constitute marked haemodynamicstrain in hypertensive individuals.

On comparison of haemodynamic parameters in restingwith FIL, EIL, FIS and EIS McKenzie exercises (Table 1, 2, 3, 4)it was found that there was a significant increase in SBP, HRand RPP. All these four McKenzie exercises showed a significantchange in SBP, HR and RPP (P<0.001). The comparison of FILwith EIL exercises showed a greater SBP, HR and RPP in FILas seen in effect size (Table 5). Similarly, FIS showed greaterSBP, HR and RPP than EIS as seen in effect size (Table 6).Thus we conclude that exercises in FIL and FIS are morestrenuous than EIL and EIS.

The study signifies that the physical therapists shouldconsider monitoring of the cardiovascular status of hypertensiveindividuals with spinal problems for which McKenzie exercisesare indicated. The standard McKenzie evaluation form shouldinclude assessment of baseline HR and BP. Patients should bewarned not to exceed the prescribed number of repetitions andsets for each exercise when prescribed as a home exerciseprogram, especially hypertensive patients.

Since the FIL and FIS puts more stress on thecardiovascular system, it is advisable to give extension exercisesprior to the McKenzie flexion exercises, especially inhypertensives.

Therefore, the routine monitoring of BP and HR is afundamental component of all physical therapist examinationsin hypertensive individuals. Monitoring is also an importantprecautionary measure during McKenzie lumbar spineassessment and management.

LimitationA larger sample size needs to be studied to be

representative of the population.

ConclusionIn hypertensive individuals, McKenzie flexion exercises put

a greater stress on the cardiovascular system than the extensionexercises. Therefore, in such individuals, flexion exercisesshould be given under close monitoring.

SummaryLow back pain (LBP) is one of the most common health

problems and it is more common in the age group of 35 to 65years. LBP affects approximately 80% of individuals, is thesecond most reason of activity limitation in individuals under 45years of age.

McKenzie are used for assessment and management of

LBP. McKenzie exercises include repeated flexion andextension exercises in lying and standing position which maycause cardiovascular stress in hypertensive individuals. Littleevidence is available on cardiovascular responses to repetitiveMcKenzie exercises in hypertensive individuals. Therefore,this study was undertaken to examine cardiovascular effects ofMcKenzie exercises in hypertensive individuals.

A convenience sample of 60 hypertensive individualsbetween the age group 30 to 60 years was recruited from the ofM. S. Ramaiah teaching hospital, Bangalore. Subjects whofulfilled the inclusion criteria were included into this study. Thesubjects were administered flexion in lying (FIL) , extension inlying (EIL), flexion in standing (FIS) and extension in standing(EIS) with a wash out period of 30 minutes between eachexercise. Cross over trial was followed. Subjects performed 10repetitions of assigned exercises. Blood pressure, Heart rateand rate pressure product were recorded before and after eachset of repetitions.

Results of this study showed a significant change in SBP,HR and RPP when compared FIL, EIL, FIS and EIS with resting.FIL and FIS McKenzie exercises cause greater haemodynamicstress when compared with EIL and EIS respectively.

In this study it was concluded that, in hypertensiveindividuals, McKenzie flexion exercises put a greater stress onthe cardiovascular system than the extension exercises.Therefore, in such individuals, flexion exercises should be givenunder close monitoring.

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21. Greer M et al. Heart rate and blood pressure response toseveral methods of strength training. Phys. Ther, Feb 1984; 64 (2) :179 – 83.

22. Liu Danhua et al. McKenzie repeat the exercise on thecardiovascular effects of lumbar spine: Foreign Medical,Physical medicine and rehabilitation, 2002 -03.

23. Andrew Sherwood et al. “Effect of aerobic exercise trainingon haemodynamic responses during psychosocial stressin normotensive and borderline hypertensive Type A Men:A preliminary report”, American Psychosomatic society ,1989 : 51:123-136.

24. Forjaz et al. “Post-exercise changes in blood pressure, heartrate and rate pressure product at different exerciseintensities in normotensive humans”. Brazilian Journal ofMedical and Biological Research ,1998 : 31:1247-1255

25. Palatini P, et al. Blood pressure changes during heavy-resistance exercise. J Hypertens Suppl , 1989 ; 7(6) : 72-3.

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Care allowance for people in need of care in Turkey: An ethicaland social evaluationSema OÐLAK *, Erdem ÖZKARA**

* PhD, Dokuz Eylül University Health Vocational of Training School 35300 Ýnciraltý-Izmir, Turkey, **Assoc. Prof. M.D, Dokuz EylülUniversity Medical Faculty, Department of Forensic Medicine 35300 Izmir, Turkey

Correspondence:Sema OðlakDokuz Eylül University Health Vocational of Training School,35300– Ýnciraltý-Ýzmir-TURKEYE-mail: sema.oglak@deu.edu.tr

ABSTRACTWith economical and social developments, population

structures of countries have changed and the rate of people inneed of care and demands for care services have increased.

People may need help of their relatives to activities of dailyliving in order to survive at one stage of life. Both the foresightthat the burden of care is too severe to cope with and the factthat all states have social responsibilities underlined theimportance of regulations to support families althoughtraditionally people are responsible for caring their ill relatives.In recent years, attempts to support people in need of care haveincreased in Turkey. The Disability Law was enacted in 2005and it was modified in 2006. The statutes regulating selection ofdisabled people in need of care were also issued in 2007. TheDisability Law and the statutes, for the first time, made it possiblefor people taken care of by formal and informal caregivers toreceive care allowance.

Care allowance for formal and informal care at home hasunderlined ethical principles. It provides formal and informalcaregivers with financial support. However, it is still debatablewhether caregivers should be paid by governments.

In this article, the scope and effects of the Disability Lawand the relevant statutes will be evaluated and ethical andmedico-legal problems likely to appear in practice will bediscussed.

KeywordsHome care, people in need of care, care allowance and

ethics.

Introduction and aimIn this article, recently enacted laws concerning being in

need of care and home care in Turkey will be evaluated andsocial effects and medico-legal and ethical aspects of homecare will be compared with those from other countries.

Being in need of carePeople may need help of their relatives to perform activities

of daily living (ADLs) necessary to lead a normal life at onestage of life (Seyyar., 2005). Traditionally, if one of the familymembers is ill, the rest of the family is responsible for the careof the ill member. However, the burden of care may become sosevere that family members may not cope with it. Both thisexcessive burden of care and social responsibilities of stateshave resulted in new laws concerning support for families ofpeople in need of care (Commonwealth of Australia., 2003).

Increased elderly and disabled population, changes in thefamily structure and increased care expenditures have forcedcountries to seek effective solutions to care for the elderly and

disabled people throughout the world. In many developing anddeveloped countries, home care services are financed by careinsurance systems and predominantly by government funds.The governments have shared the burden of care and startedto create care insurance systems which support families ofelderly and disabled people (Brodsky et al., 2000). In this setting,elderly and disabled people have been provided care at homeby either family members or professional and semi-professionalcaregivers. The care insurance systems require that difficultieswhich prevent people in need of care from leading a normal lifein their own places should be eliminated (Oðlak., 2007a). Careinsurance systems provide long-term care and short-termpreventive medicine, medical and social care and rehabilitationas well as professional health care either at home or in institutionsand financial support in cases of irreversible conditions (Seyyar,2005; Oðlak, 2006). Home care has been increasingly preferredin recent years in that it decreases health care costs, allowsdelivery of health care at home and offers an appropriateenvironment for maintenance of patient self-esteem.

Care allowance and ethicsHome care is offered by three types of organization: profit

organizations, public institutions and non-profit organizations.This naturally causes differences in duration, monitoring andquality of home care. Home care should have a high quality inthat a high quality home care increases quality of life and patientsatisfaction and is an indication of respect for patient rights(Francis & Netten, 2004). Ethical principles are of greatimportance particularly in home care. It is quite difficult to monitorhome care services compared to other health care and socialservices and care standards and ethical principles can beviolated by caregivers. Respect for preferences of people in needof care and neglect, abuse and bad behaviour likely to arise inhome care are the issues which attract attention at present(Garcia, 2006; Letizia&Casagrande., 2004).

So that patient rights are not violated, individuals receivingcare and treatment at home should participate in the decisionmaking processes for all interventions they undergo and shouldhave the right to decline interventions. In other words, patientautonomy should be respected. Care given by caregiversunaware of patient rights may have undesirable effects. Thereare ethical concerns about home care given by family caregiversin that it may not be qualified enough, can be difficult to monitorand may cause such risks as abuse and mistreatment(Kondratowitz et al., 2002; Picard et al., 2003; Brodsky et al.,2000; Gross., 1994; Penhale., 2006; Özkara.,2003 ).

Care allowance is money paid monthly either directly tocaregivers or to individuals in need of care depending on thedegree of care needs. The primary goal is to decrease financialburden on people taking care of their ill relatives. Care allowanceis preferable in that it offers the right to choose the person/institution which will provide care and flexibility in care plans(Stryckman & Nahmiash.,1994). In addition, it is agreed thatcare allowance encourages families to provide care for elderlyand disabled people, provides compensation for financial lossesresulting from work leaves of carers and is indicative of anappreciation of family caregivers’ efforts although the amountsof payment are not so high (Horfmarcher & Riedel., 2001).

However, it is argued that care allowance for the care of

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elderly and disabled people may increase the number ofcaregivers without relevant qualifications who workindependently and that care services may not be sufficientlymonitored. In addition, individuals may have difficulties inselecting caregivers and care providing institutions, caregiversmay abuse care allowance and elderly and disabled people canbe abused financially, exposed to violence and neglected ( Picardet al., 2003).

It is difficult to determine criteria for quality standards ofhome care, a complicated and multi-faceted process, since it isdifficult to monitor home care services, individuals offered homecare cannot easily assess or criticise the value and quality ofthe care and care providing institutions offer a wide variety ofcare services. In addition, there is concern that uneducated staffand lack of standards for home care may result in neglect andmistreatment (Merlis., 2000). In some situations, not onlyconcrete criteria but also moral values play an important role inhome care quality. Irrespective of education, lack of mercy andcompassion may cause neglect and maltreatment. In fact,American Bar Association reported that home care services maycause quality problems such as physical damages, insufficienttime for patients due to caregivers’ reluctance or incompetence,mistreatment, insufficient or inappropriate performance andbehavioural problems such as insensitivity, disrespect, threats,psychological abuse and financial abuse (The Quality of HomeCare., 2006). The fact that individuals who receive home careare usually old, disabled and alone and do not have strength todefend themselves makes the quality of home care important.In fact, if home care is not performed in accordance withpredetermined standards, abuse of individuals in need of careis inevitable (Penhale., 2006).

The quality of life is directly related to the quality of homecare among individuals who need home care. Therefore,determination of quality standards for home care is the primaryresponsibility of states. Netten et al. noted that there were sixaspects of home care quality: reliability, flexibility, continuity,communication, behaviour and attitude of caregivers andknowledge and skills of caregivers (Netten et al., 2003; Francis&Netten., 2004;).

The WHO made the following recommendations to improvethe quality of home care (Gibson et al., 2003):a) Regulatory systems should be created and regulations for

fulfilment of minimum standards should be adopted.b) Knowledge and skills of caregivers should be improved and

accordingly educational standards should be determined.c) Standard processes and substructure characteristics of

education should be clearly described.d) Measurements concerning educational outcomes should

be evaluated regularly.e) The obtained results should be used to improve the quality

of home care.It is important to monitor home care in order to assure the

quality of care. Abuse and neglect are social and forensicproblems (Wang et al., 2006; Penhale., 2006). Based on thestatistics, abuse of elderly and disabled people is widespread(Wang et al., 2006).

There is public awareness in these problems in manycountries. For example, many studies from Ireland have revealedthat caregivers suffer from heavy workload and psychologicalstress. Another issue which strikes attention is abuse ofindividuals in need of care. It has been reported that individualscared by family members are exposed to verbal and physicalviolence (Mc Cann &Evans., 2002). Ventura found in 1980 that115 caregivers who offered home care had negative attitudetowards the elderly and did not have sufficient knowledge aboutold age (The Quality of Home Care, 2005 ).

The WHO reported that 4-6% of the elderly were exposedto abuse in Europe. The highest rate of psychological abusewas reported to be 54.1% in the USA followed by 21% in Chinaand 5% in Britain and Holland (Tazuko et al., 2005).

A study from Japan revealed that home care relatedexcessive stress caused mistreatment and neglect, which causeelder abuse (Tazuko et al., 2005).

It has been reported that women and individuals aged over80 years are more frequently exposed to abuse and neglected.In Japan, it has been shown that women who look after theirspouses’ parents and disabled family members more frequentlyexhibited abuse and bad behaviour (Tazuko et al., 2005; TheAdministration for Children and Families and the Administrationon Aging; 1998).

The elderly with Alzheimer’s disease are more frequentlyexposed to abuse than the general elderly population. In fact,one study revealed that 33% of the caregivers who took care offamily members with Alzheimer’s disease abused and neglectedthe ill family members (Coyne et al., 1993).

Disabled people taken care of by family members such asmother, father, spouse, children and spouses’ wives are mostfrequently abused and neglected. Excessive workload relatedstress, lack of support from other family members, insufficienttime for personal things, insufficient knowledge and skills andconflict with the individuals who need care are factors whichincrease neglect, mistreatment and abuse (Tazuko et al., 2005).

In Turkey, the Disability Management Directorate affiliatingwith the Prime Minister (ÖZÝDA) has created programs to solvesocial problems of disabled people. These programs haveincreased sensitivity to and public awareness in abuse ofdisabled people. In fact, governments should give priority toprevention of abuse as much as solving social problems(Baþbakanlýk Özürlüler Ýdaresi Baþkanlýðý OZÝDA.,2006). InTurkey, the disability law numbered 5378 enacted on 1 July 2005requires that disabled people are taken care of at home bycaregivers authorized by Sosyal Hizmetler ve Çocuk EsirgemeKurumu (SHÇEK) (Social Services and Child Protection Agency)and by health staff working at public institutions (Özürlüler veBazý Kanun ve Kanun Hükmünde Kararnamelerde DeðiþiklikYapýlmasý Hakkýnda Kanun., 2005). The law, for the first time,provided poor disabled people with care free of charge either athome or in an institution (Oðlak., 2007b).

However, the law 5378, which stipulates that disabledpeople without health insurance should be provided with care,and the relevant statutes have created some inequalities inpractice. Therefore, the law was changed on 10 February 2007.The new law, numbered 5579, requires that if disabled peopleand their family members have a total monthly income of lessthan two thirds of the minimum wage, those disabled peopleshould be provided with care in public and profit organizationsor at home when they need it (Sosyal Hizmetler ve ÇocukEsirgeme Kurumu Kanununda Deðiþiklik Yapýlmasý HakkýndaKanun, 2007).

According to regulations numbered 26430 and dated 23October 2007 on determination of disabled people in need ofcare and the principles of care services:a- A two-month minimum net salary is paid when a disabled

person is cared in an institution for 24 hours.b- A one-month minimum net salary is paid when a disabled

person is offered care in an institution for 8 hours duringday time.

c- When a disabled person is offered home care by the staffof a care institution for 4 hours a day, a one-month minimumnet salary is paid to the institution.

d- When a disabled person is taken care of by his relatives, aone-month minimum net salary is paid to the relative takingcare of the disabled person.Despite its deficiencies, the law which requires that people

who provide home care for their disabled relatives for 24 hoursshould be paid a one-month minimum salary in Turkey seemspromising. This has improved care for the disabled people.However, there are concerns about neglect and abuse likely tobe caused by care allowance to people for caring their disabledfamily relatives. In fact, care strategies and goals which

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guarantee the quality of the given care and quality performancecriteria have not been described yet and it is not obligatory forfamily members to attend trainings and to get a certificate inorder to offer high quality care (Oðlak., 2007c).

High standards and monitoring which will prevent financial,verbal, psychological and physical violence towards vulnerabledisabled people taken care of by their family members orcaregivers who work for private care institutions should beformed. According to the results of many studies and news, thebelief that there are strong ties between family members andthat neglect and abuse are less frequently encountered in ourcountry has been weakened. For example, in a study on 3500elderly people from seven different regions of the country byUlusal Sosyal ve Uygulamalý Gerontoloji Derneði (TurkishGerontology Society), it has been noted that the number of theelderly exposed to various forms of physical and psychologicalviolence in family settings was striking and that out of 10 elderlypeople, 9 were exposed to psychological violence and 3 wereexposed to physical violence (Ulusal Sosyal ve UygulamalýGerontoloji Derneði., 2006).

In view of the literature, it can be suggested that bothÖZÝDA and SHÇEK shoulder great responsibilities for homecare which is in its infancy in Turkey. The things which shouldbe prioritized are as follows:a. Care quality standards should be determined.b. Individuals at a high risk of abuse and neglect should be

followed closely.c. Caregiver education should be supervised and caregivers

should be observed for neglect.d. Caregivers should be provided with emotional support.e. Caregivers should be offered training for communication

and problem solving skills.f. Training for moral values and compassion should be offered

and sensitivity to the care of elderly and disabled shouldbe increased.

g. Caregivers’ workload should be decreased. Attempts toprovide formal care should be increased.

ConclusionDespite its deficiencies and limitations, the recently enacted

law which requires the government should pay for the care ofthe disabled is an important and promising development andan indication of social welfare function of the state. Provision ofcare for disabled people and care allowance to caregivers takingcare of their disabled relatives seem to be promising; however,quality care assurance systems, performance indicators, homecare standards and grading systems for monitoring home careshould be formed. In addition, it is imperative that home careservices given in partly isolated places should be monitored andthat caregivers should be provided with appropriate educationand trained for communication and problem solving skills in orderto avoid malpractices likely to result from the home careenvironment and personal characteristics of caregivers and toprevent elderly abuse.

ReferencesAC Coyne, WE Reichman and LJ Berbig; (1993) The relationship

between dementia and elder abuse, American JournalPsychiatry, 150:pp.643-646

Baþbakanlýk Özürlüler Ýdaresi Baþkanlýðý, Ýstismarý ÖnlemekDevletin Önceliðidir.www.ozida.gov.tr

Brodsky Jenny, Habib Jack, Mizrahi Ilana; (2000), Long-TermCare Laws in Five Developed Countries, A Review, JDCBrookdale Institute of Gerontology and HumanDevelopment, Jerusalem, World Health Organization.

Commonwealth of Australia; (2003), Review of PricingArrangements in Residential Aged Care, Long Term Aged

Care, International Perspectives, Background Paper, No.3.p.127

Francis Jennifer, Netten Ann; (2004), “Raising the Quality ofHome Care: A Study of Service Users’ Views, Social Policyand Administration: 38:3;290-305, June.

Garcia Teresa; (2006), Ethics in Home Care, Home Health CareManagement & Practice Vol.18, Number 2, pp.133-137

Gibson Jo Marry; Gregory R.Steven; Pandya M.Sheel; (2003)“Long-Term Care in Developed Nations:A Brief Overview”,AARP Public Policy, October. pp. 25-26

Gross M. Arnold; (1994) “Payments for Care: The Case of Israel”,Payment For Care, A Comparative Overview, (Edit; EversA; Pijl M; Ungerson C), European Centre Vienna, Avebury,s.296

Horfmarcher M.Maria, Riedel Monika; (2001) “Development ofage structure in the EU: The EU is ageing: even whenexpanding eastward. Focus: Acute care and long-term care:An interface according to analysis or chance?, HealthSystem Watch, Supplement of the Journal Social Securityby the Institute for Advanced Studies, IHS Health Econ,Edited by the Federation of Austrian Social SecurityIntuitions.

J. Wang, J. Lin, F. Lee ; (2006) Psychologically Abusive Behaviorby Those Caring for the Elderly in a Domestic Context,Geriatric Nursing, Vol:27, Issue 5, pp. 284-291

Kondratowitz H.Joachim; Tesch Römer Clemens et al; (2002)“Establishing Systems of Care in Germany: A Long andWiding Road”, Aging Clinical and Experimental Research,14; 239-246

Letizia M.John; Casagrande Kate; (2004) The Importance ofImplementing a Code of Ethics for Home Health Agencies,Home Health Care Management & Practice, 16 (5), 412-413

Mc Cann S; Evans D.S; (2002) “Informal Care: He Views ofPeople Receiving Care”, Health and Social Care in theCommunity, 10 (4):221-228

Merlis Mark; (2000) “Caring for the Frail Elderly: An InternationalReview”, Health Affairs, May-June Volume 19, Number 3,pp.141-149

Netten Ann; Francis Jennifer; Bebbington Andrew; Curtis Lesley;(2003) “Costs, Quality and Outcomes”, PSSRU Bulletin 14,June, pp.12-13

Oðlak Sema; (2006) “Evde Bakým Hizmetleri ve BakýmSigortasý”, IV. Ulusal Saðlýk Kuruluþlarý Yönetimi KongresiBilimsel Kitabý, 13-16 Nisan 2006, Fethiye-Muðla, s.102-109

Oðlak Sema; (2007a) Evde Bakým Hizmetleri ve BakýmSigortasý (Ülke Örnekleri ve Türkiye), ÝskenderunBelediyesi Kültür Yayýnlarý No:6, Color Ofset Matbaasý,Ýskenderun, Hatay, 1. Basým

Oðlak Sema; (2007b) “Türkiye Evde Bakýma Hazýr mý?”Uluslararasý Saðlýk ve Hastane Yönetimi Kongresi ÖzetlerKitabý, 01-03 Haziran 2007, Yakýn Doðu ÜniversitesiLefkoþa-KTTC, pp.103-104

Oðlak Sema; (2007c)Uzun Süreli Evde Bakým Hizmetleri veBakým Sigortasý, Turkish Journal of Geriatrics, 10 (2): 100-108

Özkara Erdem, Yavuz Ý.C, (2003) “Acil Serviste ve genelhekimlik uygulamasýnda hasta otonomisi kavramýnýnyansýmalarý” , Acil Týp Dergisi, 3(2),32-37

Özürlüler Kanunu (Özürlüler ve Bazý Kanun ve KanunHükmünde Kararnamelerde Deðiþiklik YapýlmasýHakkýnda Kanun), Kanun No: 5378, Kabul Tarihi:01.07.2005, www.ozida.gov.tr

Penhale B. (2006) Elder Abuse in Europe: An Overview ofRecent Developments. J Elder Abuse Negl.;18(1):107-16.

Picard Linda, Comas-Herrera Adelina, Font Costa Joan et al;(2003) “Modelling an Entitlement to Long-Term Care inEurope: Projections for Long-Term Care Expenditure to2050” 6th. European Sociological Association Conference,

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Murcia, Spain, September 23-27, Research Network onAgeing in Europe.pp.1-52

Seyyar, Ali; (2005) “Yaþlýlýða Baðlý Bakým Sorunlarýna ÇözümOlarak Sosyal Politikalar”; T.C. Baþbakanlýk Aile ve SosyalAraþtýrmalar Genel Müdürlüðü ve ÝSAV (Ýslamî ÝlimlerAraþtýrma Vakfý); Aile Sempozyumu; Ýstanbul; 02.-04.12.2005

Stryckman Judith, Nahmiash Daphne; (1994) Payments for Care:The Case of Canada, Payment For Care, A CompartiveOverview, Edit; Evers A; Pijl M; Ungerson C), EuropeanCentre Vienna, Avebury. pp.311-318

Tazuko Shibusawa, Tazuko; Kodaka Manami; Iwano Shinji;Kaizo Kiyoko; (2005) Interventions for Elder Abuse and

Neglect With Frail Elders in Japan, Brief Treatment andCrisis Intervention 5:203–211

The Administration for Children and Families and theAdministration on Aging; (1998)The National Elder AbuseIncidence Study, Final Report, September, pp.18

The Quality of Home Care,http://www.nih.gov/ninr/research/vol3/HomeCare.html, 10.18.2006, p.12

Ulusal Sosyal ve Uygulamalý Gerontoloji Derneði, (2006) DünyaYaþlý Suistimali Farkýndalýk Günü Basýn

5579 Sayýlý; Sosyal Hizmetler ve Çocuk Esirgeme KurumuKanununda Deðiþiklik Yapýlmasý Hakkýnda Kanun, Kabultarihi: 01.02.2007, RG No: 26430, 10.02.2007

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Comparative study of anaerobic capacity in sprinters and football playersD.S. Sakthivelavan*, S. Sumathilatha***Associate Professor, Department of Physiology, Hi-tech Medical College, Bhubaneshwar, Orissa, ** Assistant Professor, Departmentof Anatomy, Sri Ramachandra University, Chennai.

Abstract

Purpose of the studyThis study was aimed at comparing the anaerobic capacity

in sprinters and foot ball players.

Methodology30 elite male sprinters who received extensive resistance

training and 30 male football players who received bothresistance and endurance training for a period of more than 1year were chosen for the study. Physical parameters weremeasured and exercise stress testing was done on a cycleergometer with a portable gas analyzing system. Maximal poweroutput and carbon dioxide production at peak exercise weremeasured as parameters to study anaerobic capacity.

ResultSignificant (P<0.05) difference existed in values of Maximal

power output and carbon dioxide production at peak exercisefor sprinters and football players.

ConclusionThe higher anaerobic capacity displayed by the sprinters

when compared with football players could be due to variationsin adaptations that happen in them due to different types oftraining.

Keywords

Resistance training, Maximal Power output, CO2 production at

peak exercise, Sprinters, Football players.

IntroductionThis study was conducted to analyze the variations in

anaerobic energy capacities in Indian male sprinters (shortdistance runners -100 m, 200 m, and 400 m) and foot ball playersas there were not many Indian studies in this field. The sprinterspredominantly underwent resistance training in the form of weightlifting. With this method exercises are designed to strengthenspecific muscles by causing them to overcome a fixed resistance,usually in the form of a dumbbell or weight plates on a pulley –or cam-type machine1. On the other hand the foot ball playersreceived both resistance and endurance training which involvedcontinuous steady paced prolonged exercise in moderateintensities for long distances. This is because the averageprofessional footballer is in motion almost constantly for 90

Corresponding Author:D. S. Sakthivelavan, MD.,(Physiology),No 8 A, Jai Balji Nagar, Nesapakkam, Chennai – 78.e-mail – iconsakthi@yahoo.com

minutes of play2. The resultant motor unit characteristics andthe muscle fiber groups of these athletes were also found to bedifferent1. Measurement of anaerobic energy transfer in thesemuscles required the evaluation of the immediate and short termenergy systems (the ATP-Creatine Phosphate, and the Lacticacid system). They were done by assessing the maximal poweroutput. Power in this context may be defined as the rate of doingwork. Sports that require brief all out activities, requiringinstantaneous tremendous force rely on energy from these shortterm systems. Greater the power, greater is the ability to deriveanaerobic energy. When anaerobic glycolysis predominates,large amount of lactic acid accumulate in the blood. The level ofblood lactate is the most common indicator for the short termenergy system1. As the lactic acid generated during musclemetabolism is buffered to release CO2, the measurement of CO2which exits through the lungs is used as an indicator of bloodlactate levels1.

MethodologySelection and preparation of Participants

Sixty elite male athletes were selected from Prime SportsAcademy - Chennai. Thirty of these were sprinters undergoingresistance training and the other thirty were football playersundergoing resistance and endurance training (apart from sportspecific exercises which included muscles stretching, posturecontrol, passing, ball control, kicking, heading, dribbling etc.)for more than one year at college grounds of Madras medicalcollege. All the subjects were between 19-25 years andprocedures followed were in accordance with the ethicalstandards set by the institution and as per the “Joint Statementof the American Thoracic Society (ATS) and the AmericanCollege of Chest Physicians (ACCP) on CardiopulmonaryExercise Testing4”. Every individual was informed about theobjective of the study and his consent was obtained. Respiratoryor cardiovascular disabilities and medications contraindicatingtheir participation in the exercise stress test were ruled out. Adetailed clinical examination was also done to any excludesystemic pathology. All participants did not involve in any kindof exercise for the 6 hours before the test. The subjects wereinstructed about the importance of the test and proper techniquewas demonstrated. Precautions like loosening of tight clothing,usage of nose clips and keeping the pneumotach clip in theupright (12 o’ clock) position were adequately taken care of.Determination of Anaerobic Capacity

The athlete’s physical parameters were recorded andexercise stress testing was done on a cycle ergometer in theCPX EXPRESS system, which is a portable breath-by-breathgas analyzing system. It measures the power out put, analysesthe gas concentration and determines the VCO2 at peakexercise. The gas analyzer module of the CPX express systemcontains O2 and the CO2 breath-by-breath analyzers3. The O2sensor consists of a zirconium cell and CO2 sensor is a dualpath infra red (IR) analyzer. The system was then calibratedand made ready for use4.Selecting Bike protocol

An incremental protocol where the wattage changed indiscrete steps was selected for the bike (cycle ergometer). The

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time increment was specified as 30 seconds and a workincrement of 15 watts, allowing a work rate increase by a single15 watt step every 30 seconds4.

The subjects were completely familiarized with the testprocedures before experimental data collection. Beforeadministration of each test, the seat handle bars and toe clipsof the cycle ergometer were adjusted to the needs of eachsubject. Resting data for CO2 production per unit time (VCO2)was collected for 3 minutes of rest, followed by 3 minutes ofunloaded pedaling, followed by the incremental phase ofexercise (with a single 15 watt step every 30 seconds) duringwhich the subject maintained the bike revolutions anywherebetween 40-60 revolutions/min. The power output required bythe athlete to overcome the resistance offered was displayedby the cycle ergometer. The VCO2 was displayed on the LCDscreen of the CPX system. As the wattage increased the subjectfound it more and more difficult to maintain revolutions between40-60 revolutions/min. Subjects were required to remain seatedthroughout the test and verbally encouraged to pedal maximally.Exercise was continued to his supra maximal limit, a stage afterwhich he would not be able to exercise. This was considered asthe subject’s point of peak exercise. The values of maximalpower output and VCO2 production at peak exercise wererecorded.

Thus greater the power, greater the force generated by themuscles put into contraction. Power is measured in watts. Thepower out put in our study was greater in sprinters whencompared with football players. This is due to the variousadaptations that occur in the sprinters.

Adaptations could include hypertrophy of existing fast twitchfibers and even conversion of type I to type II fibers for exertingmore force. These fast twitch fibers have high capacity forelectromechanical transmission of action potentials, a high levelof myosin ATP-ase, a rapid level of calcium release and uptakeby a highly developed sarcoplasmic reticulum., and a high rateof cross-bridge turn over, all of which are related to this fiber’sability to generate energy rapidly for quick, powerful actions.The fast twitch fiber’s intrinsic speed of shortening and tensiondevelopment is five times faster than slow twitch fibers. Thefast twitch fibers rely on their well developed short-term glycolyticsystems for energy transfer. This explains how these fiberssuccessfully recruited in the sprinters and are better equippedto overcome the rapid change in resistance to pedaling thatwas occurring at the end of every 30 second interval during theexercise stress test1.

Carbon dioxide production measured at the mouth afteranaerobic threshold was used for ventilatory detection of lacticacid production (lactic acid produced in the muscle is bufferedto CO2). The levels of lactate are most common indicator ofshort term energy system and the CO2 levels achieved bysprinters were significantly greater when compared to footballers.This is because when an all out effort is needed in the finalstages of the ‘graded exercise stress test’, the energy requiredto produce motion significantly exceeds the energy generatedby oxidation of hydrogen in the respiratory chain. Consequently,the anaerobic glycolysis predominates and the lactic acidproduction serves as a ‘sink’ for excess hydrogen end product.Continued release of anaerobic energy in glycolysis dependson the availability of NAD+ for oxidation of 3-phosphoglyceraldehyde. Otherwise, the rapid rate of glycolysiswould grind to a halt. NAD+ is generated as pairs of excesshydrogen combine with pyruvate catalyzed by lactatedehydrogenase. This forms lactic acid1.

The lower levels of power and VCO2 at peak exercise byfootball players could be explained by the fact that they undergoendurance training to develop their aerobic system along withresistance training. This could have converted their musclespartly into slow twitch fibers which produce less anaerobic powerand lower levels of lactate1. A comparison of maximal poweroutput achieved by athletes competing at the national andinternational level from India5,6 and foreign countries7,8,9 with thatof the current study revealed that the levels achieved by athletesin current study were much lower.

ConclusionHigher anaerobic capacity was displayed by the sprinters

when compared with football players and this could be due tovariations in adaptations that happen in them due to differenttypes of training.

References1. William D. McArdle, Frank I. Katch, Victor L. Katch, editors.

Exercise physiology energy, nutrition, and humanperformance. 6th ed. Baltimore (ML): Lippincott Williams &Wilkins; 2007. p. 521, 299, 383, 233-8, 539-47, 477-88.

2. Expert Foot ball [online]. [cited 2009 Oct 21]; Available from:URL http://www.expertfootball.com/training/

3. Beaver WL, Wasserman K, Whipp BJ. On-line computeranalysis and breath-by-breath graphical display of exercisefunction tests. J Appl Physiol. 1973;34:128–134.

4. Joint Statement of the American Thoracic Society (ATS)and the American College of Chest Physicians (ACCP)

Fig 1: A subject undergoing exercise stress test on CPX system

Then the subjects were allowed to recover from exerciseby continuing to pedal the bike without any resistance and therecovery data was colleted for 5-10 min4.Statistical analysis

The mean and standard deviation of maximal power output and VCO2 production at peak exercise for both the groupswere first calculated and the data was subjected to Student-ttest with a significance level of 0.05.

ResultsThe mean of maximal power output (in watts) for sprinters

was found to be 242.66 ± 35.18 and this was significantly higher(P<0.05) when compared with the football players where it wasfound to be 220.38 ± 30.12. The mean of VCO2 production atpeak exercise (in ml/min) for sprinters was found to be 4082 ±376 and this was significantly higher (P<0.05) when comparedwith the football players where it was found to be 3878 ± 332.

DiscussionPower is defined as the rate of doing work and work is said

to be done when force acts against resistance to produce motion.

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Cardiopulmonary Exercise Testing as adopted by the ATSBoard of Directors, March 1, 2002 and by the ACCP HealthScience Policy Committee, November 1, 2001. Am J RespirCrit Care Med 2003;167:211–277.

5. J. L. Bhanot and L. S. Sidhu. Maximal anaerobic power innational level Indian players. Br J Sports Med. 1981December;15(4):265–268.

6. Col SC Singh. Maj R Chengappa,Lt Col A Banerjee.Evaluation of Muscle Strength Among Different SportsDisciplines: Relevance for Improving Sports Performance.MJAFI. 2002 October;58(4):311-4.

7. Davis JA, Brewer J, Atkin D. Pre-season physiologicalcharacteristics of English first and second division soccerplayers. J Sports Sci. 1992 December;10(6):541-7.

8. Popadic Gacesa JZ, Barak OF, Grujic NG. Maximalanaerobic power test in athletes of different sport disciplines.J Strength Cond Res. 2009 May;23(3):751-5.

9. Ward-Smith AJ, Radford PF. Investigation of the kinetics ofanaerobic metabolism by analysis of the performance ofelite sprinters. J Biomech. 2000 Aug;33(8):997-1004.

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Effect of varying abdominal pressures on pulmonary function inseated tetraplegic patients: A case reportShweta Gore*, Sivakumar T.**Lecturer, Department of Physiotherapy Sancheti Institute College of Physiotherapy Pune, Maharashtra 411005, India

Abstract

BackgroundPurpose: This study was done to evaluate the effect of

varying pressures of abdominal binders on pulmonary functionin seated tetraplegic patients.

MethodsThree subjects with lower cervical spinal cord injury were

included in this case report. Forced Vital Capacity (FVC) andPeak Expiratory Flow Rate (PEF) were recorded first withoutthe binder (baseline) and then with the binder by graduallyincreasing the abdominal pressure till the measured FVC valuefell below baseline level. Values were then plotted on a graph tosee the trend.

DiscussionIt was observed that as compared to baseline, there was

linear increase in the FVC and PEF values in all the threesubjects with increase in the abdominal pressure with binders.The change in FVC was more linear when compared to PEFwith in the subjects

KeywordsAbdominal binder, abdominal pressure, Pulmonary

Functions, Tetraplegia

Background and purposeSpinal cord lesions cause motor and sensory alterations,

leading not only to physical dependency but also to social,psychological and professional dependency1. Traumatic lesionsof spinal cord produce paralysis of the skeletal muscles suppliedby the nerve from and below the level of the lesion1. The degreeof respiratory failure/insufficiency associated with spinal cordinjuries depends upon the level of injury and it is directly relatedto the paralysis / weakness of the muscles of respiratory pump2.

High cervical lesions cause paralysis of the diaphragm,intercostals and abdominal muscles, which might necessitatemechanical ventilation for survival. Lower cervical and upperthoracic lesions can lead to various degree of respiratoryinsufficiency loss of pulmonary volume and capacity due to poorrespiratory mechanics. However in these patients spontaneousventilation is possible and the respiratory functions will besubnormal2.

Various literatures have reported the changes in pulmonaryfunction following spinal cord injuries. A decrease in expiratoryreserve volume, vital capacity, total lung capacity, maximalinspiratory pressure, maximal expiratory pressure and anincrease in residual volume were reported following SCI1.

The abdominal wall in tetraplegic patients is twice ascompliant as in normal subjects due to paralysis of abdominals3,

4. In erect postures the abdominal contents fall forwardsunopposed by the abdominal muscles and results in flatteningof diaphragm, which is mechanically disadvantageous3. Airway

protection and bronchial hygiene are also compromised due topoor cough/forced expiratory maneuvers resulting fromabdominal weakness/paralysis5. Although patients withtetraplegia use accessory muscles (clavicular portion of thepectoralis major) to deflate the rib cage during cough and forcedexpiration5, 6,7,8

their ability to raise intra thoracic pressure ismarkedly reduced due to paralysis/weakness of the abdominaland expiratory rib cage muscles5, 8,9

.Use of abdominal binder to improve pulmonary function

and cough efforts has been studied extensively. Abdominalbinder supports the anterior abdominal wall and assists breathingand cough by increasing intra abdominal pressure in seatedtetraplegic patients 1,3.

However, the effect of varying abdominal pressure imposedby the abdominal binder is not reported. The amount of pressureapplied by the binder on the anterior abdominal wall would differdepending on how tight or loose the binder is fastened. Tootight binder might even restrict the respiratory pump hamperingrespiratory function.

This study was carried out to evaluate the effect of varyingabdominal pressure due to binders on pulmonary function inseated tetraplegic patients.

Case descriptionThree tetraplegic patients from university hospital, Manipal,

were selected for the study. Written informed consent was takenfrom the participants. All the patients were spontaneouslybreathing with out any assistance and with no pulmonarycomplications at the time of examination. Demographiccharacteristics of all three patients are presented in table 1.

Table 1: Demographic characteristics of three patientsPatient 1 Patient 2 Patient 3

Gender Male Male FemaleAge in years 29 38 36Height in cm 174 160 150Weight in Kg 48 65 48Abdominal girth in cm 67.5 82.5 80Level of lesion C6 C5 C5Cause RTA RTA DomesticDuration in months 25 11 7

ProcedurePrior to the study a pilot study was done on age and sex

matched individuals to find the maximal abdominal pressurewithin the comfort fit of abdominal binder. The comfort rangewas up to 80 mm Hg. And this was set as higher limit for studypopulation. Any respiratory medication, which might affect therespiratory function, was avoided six hours prior to the procedure.

The patients were made to sit upright with the backsupported fully ( Fig 3). The technique of spirometry wasexplained, demonstrated and familiarized to the patients.Baseline values of FVC and PEF were recorded without theabdominal binder using Schiller’s PFT machine (Fig 1). FVC

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and PEF techniques were done following the standard AARCguidelines for PFT. The Abdominal binder, (model 0604, MGRMmedical limited) with 9" elastic band, foam fused fabric panelsand Velcro closure was then applied to patients. A manometercuff was placed between the binder and abdomen to record thepressure (Fig. 2). It was assumed that change in the cuff pressurewould be directly proportional to the rise in the abdominalpressure due to fastening of abdominal binder. Initially the binderwas fastened to the pressure level of 20 mm Hg. The FVC andPEF values in this position were recorded. The pressure in thecuff was then increased at gradations of 10 mm Hg till 80 mmHg or till the FVC values fell below baseline value and FVC andPEF measures were taken. The total procedure was spread overtwo days. The time intervals between the each measurementwere not controlled due to time constraints and patientcompliance.

OutcomeThe data obtained is presented in table2.Table 2 depicts the changes in FVC and PEF values with

increase in abdominal pressure. FVC was observed to increasewith increase in the pressure until 60 mmHg after which there

was a decline. Similarly PEF values also showed increase till40 mm Hg followed by decline. The trend of measures withincreasing pressures followed same pattern for all three patients.The data were also represented in graphs.

Graph 1 depicts the trend of FVC with increasing abdominalpressure and graph 2 depicts the trend of PEF.

DiscussionThis study yields the changes in FVC and PEF values with

the application of abdominal binders at different pressures. Ascompared to without the binder, there is an increase in the FVCand PEF values in all the three cases with the application of thebinder. With binder application, there was an improvement of7.82% and 12.68% in FVC and PEF respectively. These valuesimproved with subsequent increments of pressure. The FVCincreased to 34.78% as compared to baseline at 60 mm Hg.PEF at 40 mmHg was 28.35%as compared to without the binder.

The graph shows the trend of pulmonary function measureswith increasing abdominal pressure with binders in all threetetraplegic patients. The FVC sows a linear rise till 60 mm Hgafter which the values started falling. PEF shows a linear rise till40mm Hg after which there was a fall in the values.

However, there are certain limitations to this study. A gradualraise in the PEF till 60 mm Hg follows the sudden dip in PEFafter 40 mm Hg. This could be possibly due to the fact that thetechnique was effort dependent and the values were subjectedto change with patient’s effort. Also, the rest period was notmaintained constant during the procedure because of timeconstraints and patient compliance. So, patient fatigue couldhave been a contributing factor to the sudden dip in PEF.

The length of time since injury was different for each patient.This study attempted to evaluate the changes in pulmonaryfunction values with one time application of abdominal binder.Continual use of the abdominal binder may vary the results andtrend of pulmonary function with increasing abdominal pressure.Observations of this study lay the foundation for control trials tosubstantiate the results. This study does show an improvementin the pulmonary function with increasing pressures. This shouldbe validated with further randomized trials.

Fig1: Schiller’s PFT machine

Fig 2: Technique of application of binder

Table 2: showing median values of FVC and PEF for case 1, 2 and 3.Baseline 20 mm 30 mm 40 mm 50 mm 60 mm 70mm 80 mm

Hg Hg Hg Hg Hg Hg HgFVC (L) 1.15 1.24 1.36 1.44 1.46 1.55 1.25 1.30% change from Baseline 7.82 18.26 25.21 26.95 34.78 8.69 13.04PEFR (L/m) 2.68 3.02 3.12 3.44 3.08 3.10 2.53 2.29% change from Baseline 12.68 16.41 28.35 14.92 15.67 -5.59 -14.55

Fig 3: Measurement in sitting

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References1. C M Boaventura, A C Gastaldi, J M Silveira, P R Santos, R

C Guimaraes, L C De Lima. Effect of an abdominal binderon the efficacy of respiratory muscles in seated and supinetetraplegic patients. Physiotherapy 2003; 89:290 – 295.

2. John C McMichan, Luc Michael, Philip R.Westbrook.Pulmonary dysfunction following traumatic quadriplegia.JAMA 1980; 243: 528 – 531.

3. J M Goldman, L S Rose, S J Williams, J R Silver, D MDenison. Effect of abdominal binders on breathing intetraplegic patients. Thorax 1986; 41: 940 – 945.

4. J M Goldman, L S Rose, M D L Morgan, D Denison.Measurement of abdominal wall compliance in normalsubjects and tetraplegic patients. Thorax 1986; 41: 513 –518

5. Estenne M, Pinet C, De Troyer A. Abdominal musclestrength in patients with tetraplegia. American J Respir CritCare Med 2000; 161:707 – 712.

Graph 2: Trend of PEF with increasing abdominal pressure.Graph 1: Trend of FVC with increasing abdominal pressure

6. Estenne M, Van Muylem, , Gorini M, Kinnear W. Effects ofabdominal strapping on forced expiration in tetraplegicpatients. Am J Respir Crit Care Med 1998; 157: 95 – 98

7. Marc Estenne, Andre De Troyer. Evidence of dynamicairway compression during cough in tetraplegic patients.American Journal of Respiratory and Critical care medicine1994;150:1081 -1085

8. Cees P. van der Schans, Alberta Piers, Gerdina A Mulder.Efficacy of coughing in tetraplegic patients. Spine 2000;25: 2200 - 2203

9. Andre De Troyer, Marc Estenne, Andre Heilporn.Mechanism of active expiration in tetraplegic patients. NewEng Journal of Medicine 1986; 314: 740 – 744.

AcknowledgementWe thank the Department of physiotherapy, Manipal, for

having given the opportunity to conduct the study. We thank Dr.Kavitha Raja (MPT, Ph.D.). for her expert opinion and constantsupport throughout the study.

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Stabilization exercises in postnatal low back painTarek A. Ammar*, Katy Mitchell**, Amir Saleh****Lecturer, Faculty of Physical Therapy, Cairo University, Cairo, Egypt, **Assistant Professor, School of Physical Therapy, TexasWoman’s University, Houston, Texas, ***Assistant Professor, Faculty of Physical Therapy, Cairo University, Cairo, Egypt

Corresponding author:Tarek Ammar, PT, PhDAddress: 3333 Cummins street, apt. 1403, Houston, Texas77027, Phone: 832-896-0554E-mail: tarekpt@windowslive.com

AbstractPostnatal low back pain is a frequent complication of

pregnancy. The purpose of this study was to evaluate the effectof McGill-based stabilization exercise program in reducing painand disability in patients with postnatal low back pain. Thirty-four female subjects with postnatal low back pain participated inthis study. Numerical rating scale and Oswestry disabilityquestionnaire were used to measure pain and disability,respectively. The first group (n=17, mean age= 29.5, SD=5.2)received a traditional intervention only (heat therapy, stretching,and strengthening exercises). The second group (n=17, meanage=26.4, SD=5.3) received McGill-based stabilizationexercises. The second group showed statistically significantdifferences in pain reduction (F1,31= 10.189, P<0.025) anddisability reduction (F1,31= 15.351, P<0.025). A program basedon McGill stabilization of the trunk was found to reduce painand disability in women with postnatal low back pain.

Key wordslow back pain, stabilization exercise, postnatal, females

IntroductionLow back pain (LBP) is a common pregnancy complication

affecting nearly 80% of women.1 Postnatal LBP may be acontinuation of antenatal LBP, faulty postures or may beprecipitated by excessive straining during the expulsive phaseof delivery.2, 3 Many factors contribute to back pain during andafter pregnancy, including the effects of the hormone Relaxinwhich causes relaxation of the support structure of the spineand pelvis. This may lead to overstretching of the ligamentoussupport and instability of the pelvis.2,3 Not only does the hormoneRelaxin affects the pelvic structures, but can affect other jointsin the body. LBP usually resolves in the first few weeks afterdelivery, but it may continue for several months or years. Posturalimbalances (increased sway in the low back, increased forwardhead and rounded shoulder) are important causative factor inlow back pain during and after pregnancy. 4 These changesmay get worsened by abdominal and back muscle weakness.In a Swedish survey, postnatal pain persisted for an average of18 months after delivery in a third of the women who experiencedLBP during pregnancy.5

Physical therapy methods used to treat LBP includeflexibility and strengthening exercises, postural training,modifying activities of daily living, massage, joint mobilization,manipulation traction, biofeedback, cryotherapy, deep andsuperficial thermal modalities.6-8 Various therapeutic exerciseshave been developed to reduce pain and disability, restorefunction, and prevent recurrence in patients with LBP.9

Lumbar stabilization exercises have been used for patientswith LBP.10-16 Richardson and Jull designed specific stabilization

exercises that focus on reeducating the motor control system toactivate the transversus abdominis and multifidus in patientswith LBP.17 In contrast, McGill designed stabilization exercisesthat achieve activation of some key abdominal and back muscles(rectus abdominis, quadratus lumborum, transversus abdominis,multifidus, and erector spinae) with minimal spinal loading toensure spinal stability in patients with LBP.18 Thus, stabilizationexercises aim at recruiting and strengthening various abdominaland back muscles safely, in a manner not to provoke the lowback pain with excessive loading.

This is the first study of stabilization exercises of McGillthat has been done in postnatal subjects with LBP. The purposeof this study was to determine the effect of McGill stabilizationexercises on reducing pain and disability in postnatal subjectswith LBP.

MethodsDesign: A randomized controlled trial was performed with

subjects randomly assigned to one of two treatment groups: (1)a group that received a traditional program only (heat therapy,stretching, and strengthening exercises) or (2) a group thatreceived stabilization exercises. The physical therapist thatperformed the outcome assessments and data analysis beforeand after treatment was unaware of group allocation. However,a second physical therapist, who administered the exerciseprograms, was aware of group allocation.

Subjects: Thirty-four subjects were recruited from CairoUniversity Hospital in Cairo, Egypt. They were outpatientsseeking treatment for LBP. Women of any race were allowed toparticipate in the study if they were at least 18 years old with acurrent complaint of postnatal LBP. Exclusion criteria includeda history of previous lumbar surgery, spinal stenosis,spondylolisthesis, neurological dysfunction, radiculopathy,systemic disease, carcinoma, injection therapy, or a reluctanceto participate in the study.

All subjects signed a consent form permitting the use oftheir data for research purposes. Confidentiality was assuredby the use of a coding system. The consent form also includeda clear explanation of the benefits and expected possible risksof the study. The rights of human subjects were protected at alltimes.

After informed consent was obtained, all subjects wereinterviewed and examined by a research physical therapist whowas unaware of the intervention assignments, to ensure thatthe inclusion and exclusion criteria were fulfilled. Subjects wererandomly assigned to one of the two intervention programs viaa computer generated random number list. Both groups receivedthree sessions per week for four weeks. Each session lastedfor 45 minutes. The treating physical therapists asked subjects(regardless of group assignment) to fill out weekly self reportlogs to monitor home adherence.

Outcome measures: The numerical rating scale was usedto measure pain intensity. The NRS is a valid and reliable scalein which 0 equals no pain and 10 equals worst possible pain.19

An Oswestry Disability Questionnaire (ODQ), a disease-specificpatient-completed questionnaire, was utilized as a reliable andvalid method to measure functional disability.20,21 Thequestionnaire includes 10 sections and each section containssix statements. Each section is scored on a 0-to-5 scale, with

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higher values representing greater disability.20,21

Intervention: Subjects in those with LBP in the first groupreceived infra-red heat (15 minutes), stretching andstrengthening exercises for the trunk and lower limbs.

Trunk stretching and strengthening exercises for the controlgroup included the following exercises:• trunk flexion: single and double knee to chest from supine• trunk extension: raising the upper trunk off the floor while

keeping forearm in contact with the plinth.• trunk rotation: lowering knees toward each side of the body

in supine• Hip extension strengthening: bridging exercises• Trunk lateral flexion: side bending of the trunk in standing

position with and without opposite arm lifting.• Piriformis, hip abductor and extensor stretching

For a home program, subjects also performed three to fiveexercises based on their needs. For instance, subjects who hadweak hip abductors and tight piriformis and hamstrings did threeto five exercises to recruit the hip abductors and stretch thehamstrings and the piriformis at home. Subjects performed twosets of 10 repetitions for each exercise, with a 30-second toone-minute rest between each set rest between each set.duringeaive ng scale in — Subjects were instructed to perform theirhome exercises for approximately 10 minutes, twice a day.

Subjects in the second group received a McGill-basedstabilization exercise programs. The therapist helped the patientfind the comfortable neutral spinal posture or the position ofleast pain prior to initiating the stabilization program and askedthe subject to maintain this position (as able) during theperformance of stabilization exercise. To determine the neutralposture, the subject put one hand on the abdomen and the otheron the lumbar region and then tilted the pelvis, which flexed andextended the lumbar spine, until achieving the least pain position.

The stabilization program consisted of the following:• cat-camel motion exercise: consisted of six-to-eight cycles

of spinal flexion and extension in a quadruped position.• curl-up exercises: the subject flexed one knee while keeping

the other straight. The therapist placed a rolled towel underthe lumbar region to maintain the neutral spine posture.The subject performed the curling up by raising just thehead and shoulders a short distance off the floor.

• side-support exercises: lying on the side supported on herelbow and hip, knees bent to 90º, free hand placed on theopposite shoulder. The subject then lifted her trunk untilthe body is supported on the elbow and the knee. If thesubject was not able to perform the side support exercise,the subject would assume the side lying position and initiatean isometric contraction of the quadratus lumborum bytrying to lift both lower limbs up towards the ceiling.

• single arm and/or leg lifting in the supine lying andquadruped positions For a home program, subjects in thesecond group performed three to five stabilization exercises.They did two sets of 10 repetitions for each exercise with a30-second to one minute rest between each set. Durationof each home program session lasted for 10 minutes twicea day. The average rate for home adherence was 70% inthe first group compared with 80% in the second group.This was based on weekly subject logs.Subjects of both groups received a series of progressive

exercises building up to a maximum of 10 to 12 exercises bythe final visit. The subjects were asked to complete one set of10 reps for each exercise, with a 30 second to one minute restbefore each set during each exercise session. Each sessionlasted for 45 minutes.

Data analysisSeparate univariate analyses of covariance, with the pretest

scores as the covariates, were performed to determine whetherthere was a difference between the two groups on the posttest

scores of pain as measured by a NRS and disability as measuredby an ODQ. A Bonferroni approach was used to maintain thealpha level at P< 0.05. The analysis of covariance adjusts thedependent variable to eliminate the influence of the pretest onthe post test. The analysis of covariance asks the question, ifyou hold constant the pretest scores is there a significantdifferences between the posttest scores for the two groups? 22

ResultsThirty nine subjects with postnatal LBP participated in this

study. However, two subjects in each group dropped out of thestudy due to time constraints. One subject in the first groupdropped out of the study due to travel. Age of patients rangedbetween 21 and 38 years old. Women of any race 4 to 28 weekspostpartum with a history of LBP were eligible for the study.Group 1 comprised 17 subjects, average age 26.4 (SD 5.3)years, height 157.7 (SD 22.6) cm, and weight 74.4 (SD 11.1)kg. In group 1, pretest and posttest pain scores were 7.1 (SD1.5) and 5.1 (SD 1.4). For disability, pretest and posttest scoreswere 15.4 (SD 2.8) and 10.7 (SD 2.4). In group 2, pretest andposttest pain scores were 7.6 (SD 1.3) and 4.9 (SD 1.5). Fordisability, pretest and posttest scores were 7.6 (SD 1.3) and 4.9(SD 1.5).

For pain intensity, the analysis of covariance revealed asignificant difference between the two groups (F1,37=6.97,P=0.01, table 1) in favor of the second group. For disability, theanalysis of covariance revealed a significant difference betweenthe two groups (F1,31=7.4, P=0.01, table 2), with group 2 havinga lower disability posttest mean.

DiscussionThis study found that there were statistically significant

differences in reduction of pain and disability between bothgroups, in favor of the second group. There have been severalstudies investigating the effects of stabilization exercises ofRichardson and Jull (1995) in different patient populations withLBP. 6-33 There have been contradictory results of these studies.For example, Hides et al. (1996), Borx et al. (2003), and Cairnset al. (2006) found that stabilization exercises did not reducepain or disability in patients with LBP.23-25 On the other hand,O’Sullivan et al. (1997), Sung et al. (2003), Stuge et al. (2004),Koumantakis et al. (2005), Rackwitz et al. (2007), Hides et al.(2008), Kofotolis et al (2008), Kumar et al. (2009), and Francaet al. (2010) reported that stabilization exercises reduced painor disability in patients with LBP.26-34

There has been no research about the effect ofMcGill=based stabilization exercises for postnatal women withLBP. However, Stuge et al. (2004) studied the effect ofstabilization exercises of Richardson and Jull for postnatalwomen with LBP.27 In their trial, 81 women with pelvic girdlepain were randomized to 20 weeks of treatment with physicaltherapy focused on stabilization exercises, or to an individualizedphysical therapy program without stabilization exercises. Thegroup that received stabilization exercises had decreased painintensity and disability and improved quality of life comparedwith the control group post- treatment and at one yearpostpartum. The authors reported that functional disability wasreduced by more than 50% in the group that received stabilizationexercises.

The major limitation of the present study is the lack ofmeasuring long-term outcomes that are needed to furthersubstantiate the present study findings. It is not known if thefrequency of the studied interventions (three times per week forfour weeks) is appropriate to produce demonstrable results. Thisstudy did not assess muscle recruitment during the performanceof either exercise program. Therefore, it is difficult to know if thetwo exercise regimens were different enough. Patients in theregular exercise group may have recruited the trunk muscles to

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hold the neutral spinal position during performance of thetraditional exercises. Therefore, patients in both groups mayhave been engaging the same muscles, making the two exercisegroups similar. There was also lack of observation of the homeexercise program.

There is a need to measure long-term outcomes to furthervalidate the results of the present study. Also, electromyographyshould be used to assess muscle recruitment during exerciseperformance. The present study findings suggest thatstabilization exercises as compared to a more general programof heat and stretching/strengthening may reduce pain anddisability in postnatal patients with LBP.

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18. McGill SM. Low back exercises: evidence for improvingexercise regimens. Phys Ther 1998; 78:754-65.

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29. Sung PS. Multifidi muscles median frequency before andafter spinal stabilization exercises. Archives of PhysicalMedicine and Rehabilitation 2003;

84:1313-8.30. Rackwitz B, Limm H, Wessels T, Ewert T, Stucki G.

Practicability of segmental stabilizing exercises in thecontext of a group program for the secondary preventionof low back pain. An explorative pilot study. EuraMedicophys 2007;43:359-67.

31. Hides JA, Stanton WR, McMahon S, Sims K, Richardson,CA Effect of stabilization training on multifidus muscle cross-sectional area among young elite cricketers with low backpain. J Orthop Sports Phys The 2007; 38:101-8.

32. Kofotolis ND, Vlachopoulos SP, Kellis E. sequentiallyallocated clinical trial of rhythmic stabilization exercises andTENS in women with chronic low back pain. Clin Rehabil2008; 22:99-111.

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Efficacy of neural mobilization in sciaticaSharma Vijay1, Sarkari E2, Multani N.K3

1Consultant Physiotherapist, Sharma Physiotherapy,Centre, Ambala Cantonment, 2Ex-Lecturer, M.M.I.P.R, Mullana (Ambala), 3Prof.and Head Department of Physiotherapy and Sports Science, PU, Patiala

AbstractThe study was conducted on 30 patients, between age

group of 40-65 years who were diagnosed cases of radiatinglow back pain. Subjects were randomly allocated to either groupA or B. The patients of group A ( n = 15 ) were treated withneural mobilization along with conventional treatment, whereasgroup B ( n = 15) was administered only conventional treatment.ROM and pain were assessed using goniometer and VisualAnalog Scale(VAS). Neural mobilization along with conventionaltreatment was found out to be more effective in relieving lowback pain (t = 7.643) as well as improving the range of SLR (t =5.848) than conventional treatment alone.

Key wordsNeural Mobilization, Low Back Pain, ROM, VAS

IntroductionSciatica is a symptom not a diagnosis. It is a non-specific

term commonly used to describe symptoms of pain radiatingdownward from the buttock over the posterior or lateral side ofthe lower limb. It is usually assumed to be caused bycompression of nerve. Due to the dynamics of human spine,lumbar disc syndrome and accompanying complaints of sciaticaare long standing afflictions of our species (Karampelus et al,2004). It was not until 1943, with land mark publication of Mixterand Barr that the herniated lumbar disc was shown to be a majorcause of sciatica(Karampelus et al, 2004). At some time, up to40 percent of people experience sciatic pain, which occurs whensciatic nerve is trapped or inflamed (Harvey Simon, 2003).Prevalence of sciatic symptoms did not differ between malesand females( Kelsey and Ostfeld, 1975). It was 5.1% for menand 3.7% for women aged 30 years or over(Heliovaara et al,1987 and AHCPR, 1994). It is occupation related also (Magora,1973,Videman Battie, 1999). Traditional exercise therapyprogram for sciatica primarily focuses on pain relief. Butler(1991)recommends that neural neural mobilization be viewed asanother form of manual therapy similar to joint mobilization. Inorder to pay heed to it manual methods should be used in orderto restore the mechanical function of impaired neural tissue (intra-and extra neural impairment) in the lumbar-pelvic-lower limbcomplex. The focus of this study is to see the effectiveness ofneural mobilization on individuals with sciatica and to judge itssuperiority over the conventional treatment.

Materials and methodsOnce the subjects registered themselves in the Out Patient

Department with the complaint of radiating low back pain, theywere assessed according to format. Andersson GB & Deyo RA(1996). Differential diagnosis with other back conditionsmimicking sciatica was established. If the subjects were foundto have sciatica, all inclusion and exclusion criteria were checked.The subjects were included in the study if all the inclusion criteriawere met and no exclusion criteria were found. 30 subjects wereselected between the age group 40 to 65 years of which 14were males and 16 were female, of these 20 had symptoms onright side and 10 had on left side. The subjects were told all

about intervention and procedural details to follow in study andthereafter consent was obtained.

Range of motion was measured using goniometer. A VisualAnalog Scale was used for assessing the pain. Patients wereconveniently allocated either to group A or to group BGroup A (n=15) Experimental Group• Sciatic Nerve Mobilization• Traction• TENS• MHPGroup B (n=15) Control Group• Traction• TENS• MHP

Before starting the intervention all the patients were checkedfor range of motion of SLR at the hip and pain with the help ofstandard goniometer and visual analogue scale respectively.The control group (Group B) participated in a standardrehabilitation program or conventional physical therapy treatment(Vroomen PC et al, 2000) for the disease which included MHPfor 10 min, Traction for 10 min(intermittent) with 1/3 of bodyweight with the patient in supine and hip and knee flexed to900.This was followed by High TENS for 10 min. Theexperimental group (Group A) participated in a standardrehabilitation program supplemented with neural mobilizationprogram for sciatic nerve.

Neural mobilization was given for approximately 10 minutesper session including 30 sec hold and 1 min rest. The straightleg raise is done for inducing longitudinal tension as the sciaticnerve runs posterior to hip and knee joints, first described byLeseague in 1864.The leg is lifted upward, as a solid lever, whilemaintaining extension at the knee. To induce dural motionthrough the sciatic nerve, the leg must be raised past 35 degreesin order to take up slack in the nerve. Since the sciatic nerve iscompletely stretched at 70 degrees, pain beyond that point isusually of hip, sacroiliac, or lumbar spine origin David J Magee(1997). The unilateral straight leg raise causes traction on thesciatic nerve, lumbosacral nerve roots, and dura mater. Adverseneural tension produces symptoms from the low back areaextending into the sciatic nerve distribution of the affected lowerlimb.

To introduce additional traction (i.e., sensitization) into theproximal aspect of the sciatic nerve, hip adduction is added tothe straight leg raise. The average total treatment time wasapproximately 30-40minutes per session and the wholetreatment was given for 9 sessions. Pain free ROM at hip andVAS was recorded at the end of every 3rd 6th and 9th sessions.The patients were instructed not to do any type of exercise athome or take any medications.

Data was analyzed using the SPSS version 14 for MicrosoftWindows. Independent T-Test was performed to compare theROM and pain on VAS scale between groups A&B at 0, 3, 6, 9sessions. Paired t test was also performed to compareimprovement on 0-3, 3-6, 6-9 and 0-9 sessions within the twogroups. The significance (Probability-P) was selected as 0.05.

ResultsFifteen subjects were taken in each group A and B with the

mean age of 56.1± 4.95, and 58.3 ± 4.37 respectively (Table 1).

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At zero session the mean of ROM of group A was 39.67and that of group B was 42.33.When comparison of mean ROMwas done between Group A and Group B at zero session the tvalue was found to be0 .794 which was insignificant. Thus therewas no disparity in ROM at the starting of the treatment sessionbetween the two groups. ( Table 2).

At the end of 3rd session mean of ROM of group A was53.00 and that of group B was50.00, the difference in meanwas insignificant. At the end of 6th session mean of ROM ofgroup A was 71.00 and that of group B was59.33 the t valuewas 3.38 and was significant. At the end of 9th session mean ofROM of group A was 86.33 and that of group B was 67.33 the tvalue was 5.85 and was significant ( Table 2).

Similarly the reduction in pain was noted through VAS scoreand was evaluated using independent t test. At zero sessionthe mean of VAS of group A was 7.4 and that of group B was7.13 and the t value was found to be 0 .587which wasinsignificant(Table 3).

P<0.05 = SignificantAt the end of 3rd session the mean ±SD of VAS of group A

was 5.27±1.22 and that of group B was 6.2±1.42 and the t valuewas found to be 1.926which was insignificant. At the end of 6thsession the mean ±SD of VAS of group A was 3.47±0.99 andthat of group B was 5.53±1.13 and the t value was found to be5.34 which was significant. At the end of 6th session the mean±SD of VAS of group A was 1.67±0.98 and that of group B was4.60±1.121 and the t value was found to be 7.64 which wassignificant. Thus ROM and VAS showed significant results onlyby the end of 6th and 9th sessions, whereas the results at theend of 3rd session were insignificant (Table 3).

Paired T test is done to compare the improvement between0-3, 3-6, 6-9 and 0-9 session. The mean difference of ROM ofgroup A between 0 to 3rd session was 13.33±4.87 whereas thatof group B was 7.67±4.17 and their t values were 4.82 and 4.32respectively. Thus group A showing more significantimprovement than group B from 0 to 3rd session. Similarly

between 3 and 6th session the mean difference of group A was18.00±2.50 whereas that of group B was 9.33±4.58 and the tvalues were 5.28 and 4.47 respectively. Between 6th to 9thsessions the mean difference of group A was 15.33±4.42 andthat of group B was 8.0±4.14 .The t values were 5.01 and 4.39respectively. Between 0 and 9th session the mean difference ofgroup A was 46.67±4.49 and of group B was 25.00±8.45.The tvalues were 5.33 and 4.89 respectively ( Table 4).

Comparison of improvement in VAS score was calculatedsimilarly using the paired t test. The mean difference of VAS forgroup A between 0 to 3rd session was 2.13±0.35 and that ofgroup B was 0.93±0.70, their t values were 5.25 and 3.75respectively. Thus group A showing more significantimprovement than group B. Similarly between 3 and 6th sessionsthe mean difference of group A was 1.8±0.56 whereas that ofgroup B was 0.67±0.82 and the t values were 4.96 and 0.76respectively. Between 6th and 9th sessions the mean differenceof group A was 1.8±0.41 whereas that of group B was 0.67±1.23and the t values were 5.14 and 1.98 respectively. Between 0and 9th session the mean difference of group A was 5.733±0.88and of group B was 2.27±1.58.The t values were 5.27 and 3.9respectively (Table 5).

DiscussionThe result of this study shows that neural mobilization

technique is effective in increasing range of motion at hip anddecreasing paint thus reducing the symptoms of sciatica. Themean value of group A where neural mobilization was givenshows more significant increase as compared to group B. Whenthe comparison of means of ROM and VAS was done betweengroup A and B by the end of 3rd session there was no significantincrease in the ROM (t= 0.863) and decrease in the VAS (t=1.926) scores. Thus we can conclude that the effectiveness ofour neural mobilization was only by the end of 6th session forROM (t=3.379), as well as pain (t= 5.339). By the end of 9th

session again there was a significant increase in ROM (t= 5.84)and decrease in VAS score (t= 7.634). Thus neural mobilizationtechnique given to group A proved more effective than theconventional treatment for sciatica administered to group B.

Effectivity of neural mobilization is thought to be due toneural “flossing”, effect, that is ,its ability to restore normal mobilityand length relationship, and consequently, blood flow and axonal

Table No 5: Comparision of mean difference of vas within groupa and bS.NO Session Group MEAN ± SD t VALUE1 0-3 A 2.13±0.35 5.25

B 0.93±0.70 3.752 3-6 A 1.80±0.56 4.96

B 0.67±0.82 0.763 6-9 A 1.80±0.41 5.14

B 0.67±1.23 1.984 0-9 A 5.73±0.88 5.27

B 2.27±1.58 3.9

Table No 4: Comparision of mean difference of rom within groupa and b

S.NO Session Group MEAN ± SD t VALUE1 0-3 A 13.33±4.87 4.82

B 7.67±4.17 4.322 3-6 A 18.00±2.50 5.28

B 9.33±4.58 4.473 6-9 A 15.33±4.42 5.01

B 8.0±4.14 4.394 0-9 A 46.67±4.49 5.33

B 25.00±8.45 4.89

Table 1: Subject informationSerial No. Group N Age,yrs(MEAN

+ S.D.)1 A 15 56.1 + 4.952 B 15 58.3 + 4.37

Table 2: Comparison of mean of rom between group a and group bS.No. Group N ROM MEAN ± SD

S 0 S 3 S 6 S 91 A 15 39.67±7.90 53.00±6.49 71.00±7.37 86.33±6.672 B 15 42.33±10.33 50.00±11.80 59.33±11.16 67.33±10.673 t value .79 .863 3.38 5.85

Table No 3: Comparison of mean of vas score between group a and group bS.NO Group N VAS MEAN ± SD

S 0 S 3 S 6 S 91 A 15 7.40±1.24 5.27±1.22 3.47±0.99 1.67±0.982 B 15 7.13±1.25 6.20±1.42 5.53±1.13 4.60±1.123 t value .59 1.926 5.34 7.64

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transport dynamics in compromised neural tissue. Neuralmobilization is very effective in breaking up the adhesions andbringing about mobility. The results of this study also depict thesame. The conventional treatment effectively reduces pain andincreases ROM at the joint but is unable to eliminate the rootcause of the problem. According to Carey TS et al(1995) , ithelps in providing symptomatic relief only.

Limitations• Lesser number of subjects• No group had similar patients with same degree of

involvement• Age variation from 40-50 years• Patient’s built was variable• Proper strengthening program was not followed after neural

mobilization sessions due to lack of time

Clinical implicationThis study provides some evidence for use of Neural

Mobilisation as an adjunct to conventional exercise therapyregime in Sciatica. This study suggests that Neural Mobilisationis effective in the treatment of Sciatica.

This study provides preliminary evidence that neuralmobilisation is effective in the treatment of Sciatica.

References1. Agency for Health Care Policy and Research (AHCPR),

1994. Acute low back problems in adults: Clinical PracticeGuidelines 14. U.S. Department of Health and HumanServices, Rockville, MD.

2. Andersson GB & Deyo RA.1996. History and physicalexamination in patients with herniated lumbar discs. Spine21: S10–18.

3. Bogduk N.1997a. Clinical anatomy of the lumbar spine andsacrum. New York: Churchill Livingstone.

4. Bogduk N. 1997b. Musculoskeletal pain: toward precisiondiagnosis. In: Jensen TS, Turner JA & Wiesenfeld-Hallin Z(eds.) Proceedings of the 8th world congress on pain,

progress on pain research and management, IASP Press,Seattle, p 507–525.

5. Butler D.1991. Mobilization of nervous system. ChurchillLivingstone, Edinburgh

6. Butler D.2000. The sensitive nervous system. Noigrouppublication

7. Carey TS, Garrett J, Jackman A, McLaughlin C, Fryer J &Smucker DR.1995. The outcomes and costs of care foracute low back pain among patients seen by primary carepractitioners, chiropractors, and orthopedic surgeons. TheNorth Carolina Back Pain Project. N Engl J Med 333: 913–917.

8. Colby and Kisner.1996. Therapeutic Exercises. JaypeeBrothers, New Delhi. 4th edition

9. Cyriax J. 1994. Textbook of Orthopedic Medicine. BailliereTindall, London, 7th Edn.

10. David J. Magee.1997.Orthopaedic PhysicalAssessment,W.B.Saunders Company London 3rd edn.

11. Froster and Palastanga 1996.Clayton’s electrotherapyBailliere Tindall, London 9th Edn

12. Heliövaara M.1987a. Body height, obesity, and risk ofherniated lumbar intervertebral disc. Spine 12: 469–472.

13. Ioannis Karampels, Angel N.Boev lll,M..,Kostas N.Fountas,M.D.,Ph.D., AND Joe Sam Robnson,Jr.,M.D.2004, Neurosurg.Focus.

14. Kelsey JL & Ostfeld AM.1975. Demographic characteristicsof persons with acute herniated lumbar intervertebral disc.J Chronic Dis 28: 37–50.

15. Magora A. 1973. Investigation of the Relation between LowBack Pain and Occupation. IV. Physical requirements:bending, rotation, reaching and sudden maximal effort.Scand J Rehabil Med 5: 186–190.

16. Maitland G.D.1986. VertebralManipulation,5thed.London:Butterworth.

17. Shacklock M 1995. Neurodynamics. Physiotherapy 81:9-16.

18. Videman T & Battie MC 1999. The influence of occupationon lumbar degeneration. Spine 24: 1164–1168.

19. Vroomen PC, de Krom MC, Slofstra PD & Knottnerus JA2000 Conservative treatment of sciatica: a systematicreview. J Spinal Disord 13: 463–469.

Sharma Vijay / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1

Abstract

BackgroundGoldsmiths are commonly renowned for possessing the

intricate art, skill & capability to mould the precious metal intoan aesthetic masterpiece.

However, these traditional goldsmiths are exposed tovarious occupational health hazards ranging frommusculoskeletal to respiratory to ocular and skin problems.Additionally very less is known & done about these issues. Ithas also been seen that these goldsmiths are not adequatelyaware of the safety measures which could be undertaken toprevent these adverse occurrences.

Objectives1. To find prevalence of common health problems in traditional

goldsmiths.2. To study their workplace environment.3. To make appropriate recommendations.

MethodDESIGN: Cross Sectional Survey StudySTUDY POPULATION: 58INCLUSION CRITERIA: Traditional Goldsmiths working sinceat least 3yrs & for more than 5 days a week.EXCLUSION CRITERIA: Working less than 3yrs and pain dueto trauma out of workplace.STUDY FACTORS: A questionnaire was made based on thereview of literature & a pilot study that was conducted. Thequestionnaire was then administered to goldsmiths belongingto different regions of Maharashtra. Data was collected by directmethod and represented through bar and pie diagram.

ResultsOur study shows that; The most common problems reported

by the goldsmiths were musculoskeletal problems 91.37%.Respiratory complaints were reported by 43.1%. Eye irritationwas reported by 77.58% subjects. Skin irritation was reportedby 13.79% subjects. Headache during work was reported72.41% subjects.

The commonest position assumed was Cross-leg sittingwith back unsupported (82.75%). None used a Nose mask.Majority of goldsmiths used a LPG burner which preventsexposure to smoke during work than a traditional keroseneburner.

ConclusionsMusculoskeletal pain, commonest being back, neck and

knee were reported among goldsmiths.. Eye and respiratoryproblems were also reported probably owing to exposure toharmful gases like NOx (NO+NO2) produced while goldpurification and also lack of protective gears like nose masks.Skin irritation in the form of allergies, itching and rashe werealso reported probably due to exposure to acids and alkalis.

Prevalence of various health problems in traditional goldsmithAnup Pednekar*, Anu Arora**, Sujata Yardi****Intern, **Asst. Lecturer, ***Prof. & H.O.D. Pad. Dr. D. Y. Patil College of Physiotherapy, Sector-7, Nerul, Navi Mumbai

Keywordsgoldsmiths, occupational hazards, health problems

IntroductionGoldsmiths are commonly renowned for possessing the

intricate art, skill & capability to mould the precious metal intoan aesthetic masterpiece.

Making jewelry from gold is essentially an art. An art, thatbasically intends to satisfy the human aesthetic sense. Thesemen work hard to cater this sense, by putting their heart in thecreations.

But as said by a British Play writer in the 15th century, ‘Amask of Gold hides all deformities’

Goldsmiths are exposed to various occupational healthhazards. They generally have to assume a posture for prolongedperiods along with repeated activity of upper limb with intricateprecision. This makes them prone to various musculoskeletalproblems.

The workers are also exposed to toxic chemicals & acidslike sulfuric, nitric acid NO & NO2, which might be detrimentalto their health.

The working area is often not well ventilated. Commonly,the workers suffer from minor accidents like burns, cuts &penetrating injuries at workplace. Negligence, improper handlingand storage of chemicals and gasoline sometimes may lead tofire which is difficult to contain, due to the nature of combustiblematerials in workplace which again poses a major health hazard.

It has been seen that these professionals are not adequatelyaware of safety measures against the issues mentioned above.

Recognizing these factors prompted me to take up this studyto find out the prevalence of common health problems intraditional goldsmiths.

A questionnaire was made based on a pilot studyencompassing domains like

Musculoskeletal, respiratory, eye and skinOther questions involved aspects like headache, posture

assumed, workplace environment, working hrs, type of lampused etc. The questionnaire was formulated to find out commonlyencountered health problems in goldsmiths & about the workingconditions.

Objectives1. To find out prevalence of common musculoskeletal,

respiratory, eye, skin & headache problems in traditionalgoldsmiths.

2. To study their workplace environment.

Material and methodology1. Research Approach: Retrospective2. Study Tool: Questionnaire3. Study Design: Cross Sectional4. Inclusion Criteria: Traditional Goldsmiths working for at

least 3yrs & more than 5 days a week.

Anup Pednekar / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1

5. Exclusion Criteria: Working less than 3yrs and pain dueto trauma out of workplace.

6. Study Setting: Rural Set up7. Sample Size: 58 subjects8. Duration of Study: December 2008 to March 20099. Methodology: A questionnaire was made based on the

review of literature & a pilot study that was conducted. Thequestionnaire was then administered to goldsmithsbelonging to different regions of Maharashtra.

Data presentation

GRAPH 7: Skin problems

GRAPH 8: Headache

GRAPH 1: Common Health Problems faced by traditionalgoldsmiths:

GRAPH 2: Musculoskeletal pain

GRAPH 3: Musculoskeletal injury

GRAPH 4: Joint pains

GRAPH 5: Respiratory problems

GRAPH 6: Eye problems

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Discussion

Musculoskeletal problemsThe most affected domain the traditional goldsmiths, was

musculoskeletal. This could be attributed to the nature of physical work which

requires sustained posture with repetitive activity of upperextremity like hammering, polishing, carving etc making themprone to musculoskeletal pain and minor soft tissue injuries.

Low back pain can be associated with prolonged sitting asrequired in this profession. The avg. time for which the subjectsworked at one stretch was 3.7 Hrs, while total working hrs on anAvg. was 7.72 Hrs.

Sitting by itself does not increase the risk of LBP (Low BackPain). However, sitting for more than half a workday, incombination with WBV and/or awkward postures, does increasethe likelihood of having LBP and/or sciatica, and it is thecombination of those risk factors, which leads to the greatestincrease in LBP .[4]

Awkward posture was also independently associated withthe presence of LBP and/or sciatica. [4]

It has been postulated that sustained awkward seatingposture (cordoned or kyphosed, overly arched, or slouched) canresult in higher intra-discal pressure and may be injurious tospinal postural health. Therefore, awkward postures while sittinghave been described as possible risk factors for the presenceof LBP [4]

The commonest position assumed during work was CrossLeg Sitting.

In cross leg sitting position which is unsupported sittingplaces more load on the lumbar spine than standing because itcreates a backward tilt, a flattening of the low back, and acorresponding forward shift in the Centre Of Gravity.

This places loads on the discs and the posterior structuresof the vertebral segment. Sitting long in the flexed position mayincrease the resting length of the erector spinae muscles andoverstretch the posterior ligamentous structures. [7]

Neck pain can be associated with the neck postureassumed during work.

Forward head posture during work, which involves anexcessive anterior position of the head in relation to thetheoretical plumb line perpendicular to the body’s center ofgravity, and can be considered similar to a protracted positionof the cervical spine in which the lower cervical vertebrae areflexed in a forward glide and the upper cervical vertebrae areextended.

This causes a shortening of the posterior cervical and sub-occipital muscles, lengthening and weakness of the anterior neckmuscles, weakness of the scapula retractor muscles andincreased stress on the ligaments. The imbalances created bythis position decrease muscular efficiency, and extra muscularaction is needed to hold the head and neck in a stable position.[3]

The association between forward head posture and neckpain has not been clearly defined, but a mechanism for thedevelopment of neck pain from habitual postures has beendemonstrated. Studies of the effect of sustained forces haveindicated that a single posture should not be sustained for longerthan 1 hr. McGill and Brown have shown that 20 min in a positionof sustained loading can induce creep in soft tissues, withrecovery taking longer than 40 min. [3]

Sustained forces produce time-dependent deformation andadaptations in soft tissue. Short-duration stretching producestemporary deformation of soft tissues, but 1 h of stretching mightbe sufficient for long-term soft-tissue adaptations. Therefore, along-term habitual posture can result in abnormal loading ofligaments and muscles that might ultimately contribute to areduction in the cervical ROM and to the development of neckpain. [3]

Knee and hip pains were also the next most commonlyreported complaints.

The probable reason would be age related degenerationin these joints which may be aggravated by positions of extremeknee flexion that are assumed in cross leg sitting wheremaximum joint compression occurs in knee joint. Also 22/25who complained of knee pain had assumed cross leg sittingposition.

The subjects who complained of upper extremity painappeared to be at risk for musculoskeletal pain probably becauseof following reason: [2]√ Speed and intensity of muscle effort√ Persistent Strain√ Overuse√ Change in equipment√ Poor Ergonomic Design of Furniture & Equipments√ Insufficient Rest Breaks.

Respiratory problemsRespiratory problems were also frequently reported by the

traditional goldsmiths.

GRAPH 9: Burns

GRAPH 10: breaks taken during work

GRAPH 11: Posture during work

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√ Among the subjects 8 reported poor ventilation at workplace(22.41%)

√ None used a nose mask during work.√ 9 out of 58 used Kerosene burners while others used LPG

burner.This underlines the fact that poor ventilation alone cannot

be a factor for respiratory ailments. The probable reason for therespiratory complaints lies in the processes used to purify gold.The process can be briefly explained as follows:

At the first stage pure gold was obtained by melting impuregold and mixing it with twice the amount of silver. Later, nitricacid was added and the mixture was heated up again. Gradually,pure gold settles down in the pan while other impurities getdissolved. The procedure is repeated twice or thrice to obtaingold. Later, copper is added to recover silver and iron to takeout copper.

The recovered pure gold is later mixed with silver, cadmiumor copper, this time according to goldsmith’s own requirements.

Gold, silver and copper, all have high melting points: 1,063Celsius, 961 Celsius and 1,083 Celsius, respectively.

The melting and mixing process with the help of nitric acidis carried out on coal fuel many times while sulphuric acid isneeded at the polishing stage.

The manufacturing item gets black after going throughdifferent stages. It regains brightness when dipped in sulphuricacid and heated up. The acid is used again at the final stage toenhance the shine.

NOx (a mixture of NO2 and NO gas) is a red brown toxicgas. When inhaled through the respiratory tract and absorbedthrough the skin, it causes various skin diseases and respiratoryproblems.

Based on in vitro studies, Beckett et al. postulated that theenvironmental concentration of HNO2 is formed within therespiratory system predominantly by hydrogen abstraction, withsubsequent conversion of HNO2 at physiologic pH, to H+ andNO2.

Victorin proposed that HNO2 formed in this way maycontribute to the bronchoconstricting effects of NO2 seen innormal subjects and asthmatics. [6]

Victorin also observed eye irritation just before, during, andimmediately after exposure of asthmatic patients to NOx .Moreover NO2 levels as low as 0.5 ppm increase susceptibilityto bacterial infection of lungs. [6]

Studies of nitrogen dioxide (NO2) inhalation, in both animalsand humans, have demonstrated that this agent can causeepithelial cell damage and inflammation of the airway epithelium[5]

Occupational Asthma is defined as a condition which occursafter a variable period of symptomless exposure to sensitizingagent at work. Other definitions have included agents thatproduce bronchoconstriction by mechanism other than immunesensitization. It has become increasingly clear that non-immunemechanisms are important particularly for highly reactivechemicals of low molecular wt. [1]

This may probably help us to explain the symptoms likeshortness of breath, frequent cough & rhinitis.

These problems may be further aggravated by factors likepoor ventilation at the workplace & reluctance to use the nosemask while working which was evident from the questionnairewhere none of the subjects used a nose mask during work.

Eye and skin problemsEye problems were in the form of eye irritation, reddening

& watering. However, only 1 out 58 reported poor lightingconditions at workplace.

Thus the probable causes for eye problems could be;√ Exposure to chemicals, gases & fumes at workplace as

mentioned above.√ Poor ventilation may aggravate the above problem.

√ Prolonged working hours & nature of intricate work puttingstrain on eyes.

√ Age related changes in eyes.Skin problems were in the form of rashes or irritation while

handling chemicals at workplace.The skin problems can be attributed to:

√ Chemicals used at workplace.√ Improper handling of chemicals

HeadacheHeadache was also commonly reported by by the traditional

goldsmiths during or after work.The probable causes for headache can be

√ Pain referred from Neck√ Congested workplace with poor ventilation√ Hot environment√ Exposure to various chemicals listed before.√ Environmental and job related stress.

BurnsThese injuries occur during usage of burners either LPG

or Kerosene while melting gold for purification purposes andother procedures.

Awareness of health problemsThe subjects that took breaks voluntarily were 35 while

those took because of pain or discomforts were 23.This indicates that around 60 % of the subjects were

probably aware of the harmful effects of prolonged posture whichcommonly present as musculoskeletal pain.

However none of the subjects used a Nose-Mask whileworking to avoid respiratory problems reporting as its usagebeing a discomfort while work.

ConclusionsBased on the findings of the study the occurrence of various

health problems were probably due to the lack of appropriateknowledge about the hazards and also precautions for the same.These problems are moreover largely preventable. Thus basedon this information certain recommendations can be made.

Recommendations:The nature of health problems faced by these traditional

goldsmiths is avertable to a large extent by properergonomic advice and some precautionary measuresundertaken during work.

Proper Ergonomic Advice can help reduce theincidence of Back pain.

While sitting√ Use a chair preferably while working.√ Adjust the height of furniture according the person’s height

so that he does not need to bend forward while working.√ Arm Rest should be provided√ If the chair does not provide proper back support, tuck a

small pillow or rolled up towel between the chair and yourlower back to maintain the lower – back curve.

Activity recommended√ An individual should briefly stretch, stand up, move around

or do a different task.

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√ Exercise Breaks: Perform Stretching and Gentle exercisesto help relieve muscle fatigue every 1-2 hours.

For pain in upper limbDuring Work

√ Take frequent breaks during work.√ Stop the work if you experience any pain to avoid further

injury.√ void positions of extreme joint bending(flexion or extension)√ Use adaptive devices that reduce pressure on the skin

during work.

Posture correction exercisesSimple posture correction exercises can be done which

include chin tucks and shoulder retraction.

Respiratory problems√ Use of personal protective gears like properly fitting Nose

Mask.√ Ensuring proper ventilation at the workplace.√ Prompt treatment of various respiratory symptoms.√ Periodic medical examination to detect cases early.

Eye problems√ Adequate lighting at workplace.√ Use of special eye & face protective gears.√ Good general ventilation to avert contact with dust & fumes.√ Proper First Aid Training should be provided to deal with

medical emergencies like chemical & acid splashes.√ Eye cup goggles with plastic or glass lenses or plastic eye

shields are used for protection against chemicals.

Skin problems√ Avoid direct contact of chemicals with skin.√ Maintain good personal & environmental hygiene.√ Repeated cleaning & frequent washing should be practiced.√ Personal protective clothing should be used whenever Use

of barrier creams like;1. Simple vanishing cream type containing zinc oxide which

fills the skin pores & prevents entry of irritants.2. Water repellent creams which form an insoluble film that

gives protection against substances like acids, alkalis,kerosene etc.

References

Bibliography1. A Practical Approach to Occupational and Environmental

Medicine-2nd Edition, Robert J. McCunney2. Ergonomics-The Physiotherapist in Workplace by Margaret

Bullock3. The relation between active cervical ROM and changes in

head and neck posture after continuous VDT work-IndustrialHealth 2009,47,188-183, Won-Gyu Yoo & Duk-Hyun AN

4. Association between Sitting and Prolonged LBP- Eur SpineJ. 2007 February; 16(2): 283–298.

5. Effect of nitrogen dioxide on synthesis of inflammatorycytokines expressed by human bronchial epithelial cells invitro- American Journal Of Respiratory Cell & MolecularBiology: Vol/Issue: 9:3

6. Effects of NOx on Somatic Chromosomes of Goldsmiths-Environmental Health Perspectives Volume 106, Number10, October 1998, - Joginder S. Yadav and Neena Seth

7. Biomechanical Basis of Human Movement, 2nd Edition-Joseph Hamill & Kathleen M. Knutzen

8. Occupational Health Hazards and Remedies- First edition2002-R Mohapatra

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Effect of 12-weeks posterior tibial nerve stimulation in treatmentof overactive bladderAnwar Abdelgayed EbidLecturer Physical Therapy for Surgery, Faculty of Physical Therapy, Cairo University, Egypt.

AbstractThe aim of this study is to investigate the effect of posterior

tibial nerve electrical stimulation (PTN) on urodynamicparameters and in treatment of overactive bladder. Sixty patientstheir ages ranged from 20-70 years were participated in thisstudy. They were randomly allocated into two groups. Group(A) received 12 weeks posterior tibial nerve electrical stimulationand group (B) received pelvic floor exercises for 12 weeks. Theresult revealed that, Bladder stability in group (A) showed a highlystatistical significant improvement while for group (B) is notsignificant , by comparing both groups post-treatment, there wasa statistical significant difference between groups with highpercentage of improvement of the bladder stability in group (A)more than group (B). Maximum flow rate was significantlyimproved post-treatment for group (A) as well as for group (B)and by comparing both groups post treatment there was astatistical significant improvement in (A) group more than ingroup (B) . The results demonstrated that, there is objectiveeffect of PTNS on urodynamic parameters; also PTNS is effectiveto suppress detrusor overactivity.

Key wordsPosterior Tibial Nerve, Electrical stimulation, Overactive

Bladder, Urgency.

IntroductionUrinary incontinence and overactive bladder are common

conditions in adult population, with impact on physical,psychological and social well-being, and represent an importantburden to the economy of health services (1).

Overactive bladder symptoms include (urgency, frequency,nocturia and urge incontinence) are frequent complaints ofpatients attending urology and gynecology clinics. In manypatients, the cause is idiopathic with no obvious underlyingneurological abnormality. Patients with overactive bladder alsosuffer from sleep disturbance, psychological distress fromembarrassment due to incontinence and disruption to social andwork life. Quality of life scores (QOL) are consistently reducedin this group of patients (2).

PTNS is a minimally invasive neuromodulation systemdesigned to deliver retrograde electrical stimulation to the sacralnerve plexus through percutaneous electrical stimulation of theposterior tibial nerve. The posterior tibial nerve contains mixedsensory and motor nerve fibers that originate from L4 throughS3, which modulate the innervation to the bladder, urinarysphincter, and pelvic floor. The specific mechanism of action ofneuromodulation is unclear,theories include improved blood flowand change in neurochemical balance along the neurons.neuromodulation may have a direct effect on the detrusor or acentral effect on the micturition centers of the brain (3) .

Neuromodulation had been reported to be effective for thetreatment of stress and urgency urinary incontinence. The cureand improvement rates of pelvic floor neuroodulation in urinaryincontinence are 30–50% and 60–90% respectively, pelvic floorexercise with adjunctive neuromodulation is the mainstay ofconservative management for the treatment of stressincontinence. For urgency and mixed stress plus urgency

incontinence, neuromodulation may therefore be the treatmentof choice as an alternative to drug therapy it can offerimprovement in patient quality of life (4).

Electrical stimulation therapy can be considered a passivephysiotherapy; there is a twofold action of electrical stimulationwhen applied to the pelvic floor: contraction of pelvic floormuscles and relaxation with inhibition of bladder overactivity (5).

Transcutaneous stimulation progressed to percutaneousstimulation and is known as posterior tibial nerve stimulation(PTNS) was initially known as Stoller afferent nervestimulation.Posterior tibial nerve stimulation look to be an easyand less expensive way to reach satisfactory results (3).

Urodynamic detrusor overactivity (UDO) is currently definedby the International Continence Society (ICS) as a condition inwhich the bladder is shown to contract either spontaneously orwith provocation to contraction during filling while the subject isattempting to inhibit micturition, Urodynamic investigations area functional assessment of the lower urinary tract, the purposebeing to try to reproduce the symptoms and obtain an objectiveexplanation for the dysfunction.

Materials and methodsSixty patients with overactive bladder (urge incontinence)

participated in this study, they were randomly selected from thedepartment of urodynamics of The National Institute of Urologyand Nephrology between years 2008-2010. Their ages wereranged from 20 to 70 years old (mean age 52.96 ±15.18), fromboth sexes. Weight ranged between 60-93 kg with a mean of74.4 ± 9.41 kg in group (A), while it ranged between 60-90 kgwith a mean of 76.36 ± 7.7 kg in group (B).Height rangedbetween 156-179 cm with a mean of 166.68 ± 5.9 cm in group(A), while it ranged between 155-176 cm with a mean of 166.2± 6.15 cm in group (B).Comparing age, weight, and heightrevealed no statistically significant differences (P>0.05) betweenthe two groups.

Patient Criteria: Inclusion Criteria: Patient age was > 19years old; patient had e� 6 month history of documentedoveractive bladder, patient had failed other conventional therapy,patient free from mechanical urethral obstruction, patientdemonstrate an understanding of neuromodulation therapy, itsbenefits, and its potential risks, patient had an intact peripheralneurosensory system, If the patient is/was on pharmacologictreatment for urgency/frequency syndrome, a 10-day washoutperiod prior to treatment must be completed.

Exclusion Criteria: Pregnant patient or intends to becomepregnant during the course of the study. (Patients becomingpregnant during the course of the study will immediately beterminated from the study.), patient had an active urinary tractinfection, patient had a bladder stone, patient had ankle injuryor surgery which results inability to stimulate the tibial nerve ordiscomfort in using the foot cradle, patient has a hyperreflexicneurogenic bladder or urodynamically proven instabilitysecondary to a known neurourologic cause (i.e. stroke,Parkinson’s, Multiple Sclerosis), patient had uncontrolleddiabetes, patient had diagnosed peripheral neuropathy such asdiabetes with peripheral nerve involvement,

Complete physical examination and a complete history wastaken for all patients, including previous urological symptoms

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as frequency, urgency, nocturnal, or incontinence. The physicalexamination included was neurological assessment of perianalsensation, anal sphincter tone, and a brief screening for anyneurological factors as, Parkinson’s disease, multiples sclerosis,stroke or previous operations (mainly pelvic surgeries). Detailedanalysis of the present overactive bladder symptoms had beencarried. Medical history including drugs in actual use especiallydiuretics, and anti-diabetic drugs had been considered. Urologicexamination carried by the staff of urology department of theNational Institute of Urology and Nephrology, to exclude anygenitourinary infection that might cause urinary incontinence.Laboratory investigations, mainly fasting and postprandial bloodglucose, complete urine analysis had been carried out to excludediabetes mellitus, urinary tract infection as well as renal infection.Urodynamic studies had been carried by the staff of urodynamicunit, to confirm the diagnosis of overactive bladder and urgency.

The patients were randomly divided into two equal groups.Group (A) include thirty patients suffer from overactive bladder(urge incontinence) ,they received posterior tibial nerve electricalstimulation of faradic type, biphasic continuous rectangular, withfrequency of 0-10 Hz, pulse width 200 µHZ, 15 minutes daily,three days/week, with maximum tolerable intensity, for 12 weeks,plus the routine pelvic floor exercise. Group (B) include thirtypatients who received the routine physical therapy program ofpelvic floor muscle through pelvic floor exercises 15 min threetimes a week for 12 weeks.

Electrical stimulation delivered to the posterior tibial nervevia a combination of electrode and generator components,including a small 34-gauge needle electrode, surface electrode,lead wires and hand held electrical generator. The low-voltagestimulator had adjustable pulse intensity according to patienttolerance, a fixed pulse width of 200 microseconds and afrequency of 10Hz. The device produces an adjustable electricalimpulse that travels to the sacral nerve plexus via the tibial nerve.

Urodynamic investigation system had been used to performthe urodynamic investigations as voiding cystometry .It iscomprised of a trolley-mounted unit with integral printer andmonitor, a mobile patient unit with built in H2O and CO2 pumps,a stand-mounted uroflow transducer and a stand-mounted pullermechanism. Measurement was done by the staff of theurodynamic. All patients had been subjected to multichannelcystometry before starting the study and at the end of the study(after 12 weeks).

The Measurement was done by Urodynamic EvaluationSystem This procedure was performed by using the DANTICUD5000/500 urodynamic investigation system. The urodynamicstudies are valid and reliable, by testing the multichannelcystometry.

The variables measured. (1st) First desire to voide whichreveals bladder sensation, (2nd) Bladder stability (number ofuninhibited detrusor contractility), and (3rd) Maximum flow rate.

Results

The result of this study includes (1st) Results of 1st desireto void in both groups and between Groups, (2nd) Results ofStability in both groups and between groups and (3rd) Results ofMaximum flow rate in both groups and between groups: Thecollected data presented as before (pre) and after 12 weeks oftreatment application (post), that to determine role of PTNS inpatients with overactive bladder (urgency).

(1st) Results of 1st desire to void. There was no statisticalsignificant difference (P>0.05) in 1st desire to void for bothgroups (A) and (B) , after 12 weeks (Post) when compared withthe corresponding mean value before initiation of treatment (Pre),with a percentage of improvement of 8.64% and 0.88% for group(A) and (B) respectively.

Comparative Analysis of Testing First Desire to voidbetween Groups.Un-paired t-test of 1st desire to void at pretreatment for group (A) and group (B) revealed no statisticalsignificant differences (p>0.05) of mean value of 1st desire tovoid among both groups at entry of the study.

Comparative Analysis of 1st desire to void at end ofthe study (Post-treatment): Un-paired t-test of 1st desire tovoid after application of treatment (Post) for both groups (A)and group (B), revealed no statistical significant differences(p>0.05) of mean value of 1st desire to void among both groupsafter application of treatment.

(2nd) Results of stability

1-Results of stability for group (A): The statistical analysisof the mean differences of stability by Wilcoxon matched pairssigned ranks test at pre-treatment and after application oftreatment (Post) of electrical stimulation group revealed that,there was a highly statistical significant difference (P<0.05) instability, after application of treatment (Post) of PTN electricalstimulation group when compared with the corresponding meanvalue before initiation of treatment (Pre).with a percentage ofimprovement of 48.69% after application of treatment (Post) ofelectrical stimulation group.

2-Results of stability for group (B): the statistical analysisof the mean differences of stability by Wilcoxon matched pairssigned ranks test at pre-treatment and after application oftreatment (Post) of exercise group revealed the following results:There was no statistical significant difference (P>0.05) in stability,after application of treatment (Post) of exercise group whencompared with the corresponding mean value before initiationof treatment (Pre).with a percentage of improvement of 4.25%after application of treatment (Post) of exercise group.

3-Comparative Analysis of testing stability betweenGroups of the Study:

Comparative Analysis of stability at entry of the study (Pre-treatment):

Mann-Whitney test of stability at pre treatment for PTNElectrical stimulation group (Group A) and Exercise group (GroupB) revealed no statistical significant differences (p>0.05) of meanvalue of stability among both groups at entry of the study.

Comparative Analysis of stability at end of the study(Post-treatment):

As observed in table (1) and figure (1), Mann-Whitney testof stability after application of treatment (Post) for PTN electricalstimulation group (Group A) and Exercise group (Group B)revealed statistical significant differences (p<0.05) of mean valueof stability among both groups after application of treatment.

Table (1): Comparative analysis of the mean value ofstability among Electrical stimulation group (Group A) andExercise group (Group B) after application of treatment (Post).

(3rd) Results of Maximum flow rate:

1-Results of maximum flow rate for group (A):As observed in table (2). There was statistical significant

difference (P<0.05) in maximum flow rate, after application oftreatment (Post) of electrical stimulation group when comparedwith the corresponding mean value before initiation of treatment(Pre).With a percentage of improvement of 25.2% afterapplication of treatment (Post) of electrical stimulation group.

Table (2): The statistical analysis of mean differences ofmaximum flow rate before initiation of treatment (Pre) and afterapplication of treatment (Post) of Electrical stimulation group(Group A).2-Results of maximum flow rate for group (B):

There was statistical significant difference (P<0.05) inmaximum flow rate, after application of treatment (Post) ofexercise group when compared with the corresponding mean

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value before initiation of treatment (Pre). With a percentage ofimprovement of 12.37% after application of treatment (Post) ofExercise group.3-Comparative Analysis of Testing Maximum flow ratebetween Groups of the Study:Comparative Analysis of maximum flow rate at entry of thestudy (Pre-treatment):

Un-paired t-test of maximum flow rate at pre treatment forElectrical stimulation group (Group A) and Exercise group (GroupB) revealed no statistical significant differences (p>0.05) of meanvalue of maximum flow rate among both groups at entry of thestudy.Comparative Analysis of maximum flow rate at end of thestudy (Post-treatment):

As observed in table (3) and figure (2), un-paired t-test ofmaximum flow rate after application of treatment (Post) forElectrical stimulation group (Group A) and Exercise group (GroupB) revealed statistical significant differences (p<0.05) of meanvalue of maximum flow rate among both groups after applicationof treatment.

Table (3): Comparative analysis of the mean value ofmaximum flow rate among Electrical stimulation group (GroupA) and Exercise group (Group B) after application of treatment(Post).

DiscussionPercutaneous tibial nerve stimulation is reliable and

effective for nonneurogenic, refractory lower urinary tractdysfunction. Electrical stimulation of the posterior tibial nervewith needle electrodes demonstrates an effect to suppressdetrusor contraction in patients with overactive bladder. Posteriortibial nerve electrical stimulation was chosen as thephysiotherapeutic method because it is an interesting alternativefor the treatment of overactive bladder, which is effective andwithout side effects, despite the fact that pharmacologicaltreatment is currently the first option for the treatment of patientswith clinical symptoms of overactive bladder, but adherence totreatment is low. Posterior tibial nerve electrical stimulation isconsidered to be a simpler, less invasive and easy to apply formof peripheral sacral stimulation that is well tolerated by patientsand more affordable (6).

PTNS offers a nondestructive alternative for patients withurge incontinence, the aim of this treatment modality is to achievedetrusor inhibition by electrical stimulation of somatic nerve fibersby means of PTNS. (3).

In a prospective observational study, the efficacy of a tibialnerve stimulation device in patients with overactive bladderunresponsive to pharmacotherapy, the result of initial successrate was 54%, with improvements seen in voiding diaryparameters, urodynamic parameters and quality of life scores(7).

Additional studies assessed patients treated with PTNS andconcluded that PTNS is an effective, minimally invasiveprocedure to treat urge incontinence and idiopathic voidingdysfunction ( 8).

There is little difference in outcomes in incontinent patientsrandomly assigned to PTNS weekly (group 1) versus 3 timesper week (group 2), the result showed 63% and 45% werecompletely cured after treatment for group 1 and 2 respectively(9). In our study we use 1-10 Hz pulse rate which did not lead tofatigue contraction of the leg muscles.

PTNS in patients with over active bladder symptoms(urgency ,frequency) had a good results and urodynamicsparameters were improved after treatment and proved

Table 1: Comparative analysis of the mean value of stabilityamong Electrical stimulation group (Group A) and Exercise group(Group B) after application of treatment (Post).

Statistics Stability after application of treatmentElectrical stimulation Exercisegroup (A) group (B)

Mean 1.933 1.633Standard Deviation 0.254 0.49Mann-Whitney 315 U-valueProbability value 0.0411Significance Significant

Table (3): Comparative analysis of the mean value of maximumflow rate among Electrical stimulation group (Group A) andExercise group (Group B) after application oftreatment (Post).

Statistics Maximum flow rate after applicationof treatment

Electrical stimulation Exercisegroup (A) group (B)

Mean 15.663 12.807Standard Deviation 3.861 4.693Un-Paired t-value 2.575Probability value 0.0126Significance Significant

Table 2: The statistical analysis of mean differences of maximumflow rate before initiation of treatment (Pre) and after applicationof treatment (Post) of Electrical stimulation group (Group A).Statistics Maximum flow rate

Pre PostMean 12.51 15.663Standard Deviation 6.263 3.861Mean Difference 3.153Paired t-value 3.277Probability value 0.0027Significance SignificantPercent of Change 25.2 %

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statistically significant decrease in leakage episodes ,frequencyand nocturea (10) .

Objective results based on frequency volume charts, voidedvolume, number of leakage episodes, incontinence severity,number of pads used and quality of life was reported afterapplication of PTNS ( 11).

PTNS had proved to be effective and well tolerated in adultsand produced modification in urodynamic pattern in patients withnonneurogenic bladder dysfunction (12).There was an objectiveeffect of PTNS on urodynamic parameters (significantimprovement in maximum cyctometric capacity and involuntarydetrusor contraction and this improved bladder over activity isan encouraging argument to PTNS as a non invasive treatmentin clinical practice (13) .

Peripheral nerve stimulation produce a statistical significantimprovement in lower urinary tract symptoms specially day timeand night time voiding frequency and volume, leakage episodes(10) .

PTNS is a minimally invasive technique that is effective tosuppress detrusor over activity, also it improve bladdercyctometric capacity.PTNS has a subjective efficacy of 63–64%and an objective efficacy of 46–54% in a non-neurogenic patientwith overactive bladder (3).

Our results inconsistent or unsupported by the studyconducted on patients with interstitial cystitis which revealedthat PTNS had no significant clinical effect and it may give someresponse but less than through sacral root itself (14).

PTNS had no effect or failed to suppress detrusorcontraction on neurological detrusal over activity patients butthe bladder volume during the first contraction and cyctometricbladder capacity was increase (15).

ConclusionThis study has demonstrated that PTNS, which is a

minimally invasive technique, is effective to suppress detrusoroveractivity. Also, demonstrated objective effect of PTNS onespecially bladder stability, and maximum flow rate, improvedurodynamic parameters with PTNS, which is observed in thisstudy, is an encouraging finding that further supports its use asan effective treatment modality in the clinical practice of detrusoroveractivity. No serious adverse events or side effects wereobserved during or after treatments, so posterior tibial nerveelectrical stimulation is a new trend in the treatment of overactivebladder and urgency.

AcknowledgementI would like sincerely to thank Dr.AboZeid A. Mansour,

Consultant urologist in Elmatarya institute for urology for histechnical assistance, and many grateful to Dr.Marwa M.Abd ElMotelb PT, D. for their generous assistance in sample collection.

References1. Sofia Correia, Paulo Dinis, Nuno Lunet.Urinary

Incontinence and Overactive Bladder A Review.ArquiMed2009; 23(1):13-21.

2. Susan Calvert M. Percutaneous Tibial Nerve Stimulationfor the Treatment of the Overactive Bladder. UROLOGYNEWS 2008; Vol (12).

3. Van Rey J.P.F.A.and Heesakkers. Applications ofNeurostimulation Urinary Storage and Voiding forDysfunction in Neurological Patients. Urol Int 2008; 81: 373–378.

4. Yamanishi T., Sakakibara R., Uchiyama T., and Yasuda K.Comparative Study of The Effects of Magnetic VersusElectrical Stimulation on Inhibition of Detrusor Overactivity.Urol 2000; 56: 777-781.

5. Moore KN, and Dorey G. Conservative Treatment of UrinaryIncontinence in Men. Physiotherapy 1999; 83:77-87.

6. Patricia O. Bellette, Paulo C. Rodrigues-Palma, VivianeHermann, Cássio Riccetto, MiguelBigozzi,Juan M. Olivares.Posterior tibial nerve stimulation in the management ofoveractive bladder: A prospective and controlled study”ACTAS UROLÓGICAS ESPAÑOLAS 2009; 33(1): 58-63.

7. Nuhoglu, B., Fidan, V., Ayyildiz, A., Ersoy, E., Germiyanoglu,C. Stoller afferent nerve stimulation in woman with therapyresistant over active bladder; a 1-year follow up. IntUrogynecol J Pelvic Floor Dysfunct 2006 May; 17(3):204-7.

8. Vandoninck, V., van Balken, MR., Finazzi Agro, E.,Heesakkers, JP., Debruyne, FM., Kiemeney,LA.,Bemelmans, BL. Posterior tibial nerve stimulation inthe treatment of voiding dysfunction: urodynamicdata.Neurourol Urodyn 2004; 23(3):246-51.

9. Van der Pal F, van Balken MR, Heesakkers JP, et al.Percutaneous tibial nerve stimulation in the treatment ofrefractory overactive bladder syndrome: is maintenancetreatment necessary? BJU Int 2006; 97(3):547-50.

10. Van-Blaken M.R., Vergunst H., and Bemelanans B.L. TheUse of Electrical Device for The Treatment of BladderDysfunction: A Review of Methods” Journal of Urology 2004;(172): 846-851.

11. Van Melick H,Gisolf KW,Eckhardt MD,vanVenrooijGE,Boon TA .one24- hour frequency volume chart inwomen with objective urinary motor urge incontinence issufficient . Urology 2001; 58:188-92.

12. Bower WF, Moor, KH. and Adams, RD. Apilot study of thehome application of transcutaneous neuromodulation inchildren with urgency or urge incontinence .J Urol 2001;166:2420.

13. Amarenco G., Sheikh I, Raibaut P., Kerdraon J. UrodynamicEffect of Acute Trasncutaneous Posterior Tibial NerveStimulation in Overactive Bladder.J Urol 2003; 169 :2210-2215.

14. Zhao J, and Nordling J. Posterior tibial nerve stimulation inpatients with intractable in- terstitial cystitis. BJU Int 2004;94:101–104.

15. Fjorback ML, Van Rey FS,van derpal F et al .acuteurodynamic effect of posterior tibial nerve stimulation onneurogenic detrusal over activity in patients with MS.EurUro 2006;51:464-470.

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Comparison of manual physical therapy and conventionalphysical therapy programs in osteoarthritis of kneeDheeraj Lamba*, Satish Chandra Pant***Incharge/Lecturer, Physiotherapy, Uttarakhand Forest Hospital, Trust & Medical College, Haldwani, **B.P.T. Final Year Student

IntroductionKnee Osteoarthritis is a prevalent condition that contributes

significantly to functional limitations & disability in older people.It is the most important cause of the pain & disability in the world.Defined by American College of Rheumatology (ACR) as aheterogeneous group of conditions which lead to joint symptoms& signs associated with defective integrity of the underlying bone& joint margins. 80% patients develop medial compartmentosteoarthritis & develop a varus or bowlegged deformity. Painis the most dominant symptom. The osteoarthiritic patient mayalso present with limitation of joint motion, muscle atrophy &weakness, joint instability & progressive functional limitation.Exercise & applied physiotherapy consisting of heat, instructionsin joint use, maintenance of joint range of motion is quite usefulin osteoarthritis knee.Fitness walking, aerobic exercises &strength training also result in functional improvement in patientswith OA knee. Manual therapy procedures are also used aspart of comprehensive rehabilitation programs to help patientsregain joint mobility & function.

Aims and objectivesTo compare between manual physical therapy program and

conventional physical therapy program in treating osteoarthritisknee.

HypothesisExperimental Hypothesis : Manual physical therapy

program is better than conventional physical therapy programin treating knee osteoarthiritic patients.

Null Hypothesis : Manual physical therapy program is notsignificantly better than conventional physical therapy programin treating knee osteoarthiritic patients.

MethodologySampling method: Convenient samplingSample size: 73 subjects were screened for the study. A

sample of convenience of 60 subjects (both male and female)with age range of 45 to 65 years who met the inclusion criteriawas taken

Sample design : Experimental designSample source : OPD Sushila Tiwari Memorial Hospital

Trust & Medical College, Haldwani.

VariablesIndependent variable

Manual Physical TherapyConventional Physical Therapy

Dependent variableRange of MotionPain on VASDistance covered in 6 Minutes

Inclusion criteria

1. Knee pain & Crepitus with active motion and morningstiffness in age group: 45-65 years.

2 Knee pain on most days of previous month (average pain,more than 5cm on a 10cm VAS).

3. Minimum available range of 0-100 degrees knee flexion.4. Experience pain or difficulty in getting up from sitting or

coming down on stairs.5. Difficulty in household activities due to pain and swelling.

Exclusion criteria1. Symptoms or signs of synovitis.2. Acute or chronic ligamentous insufficiency.3. Any history of recent injury to knee joint.4. Any history of knee surgery (previous 3 months).5. Any history of Physiotherapeutic treatment for the knee

(Previous 12 months).6. Systemic Arthritic conditions.

Fifty patients completed the study, while 4 of ManualPhysical Therapy group & 6 out of conventional physical therapygroup withdraw from the study due to various reasons.Preliminary measurements were taken at baseline prior tobeginning of the study, which included Range of motion, Painon VAS scale & Distance covered in 6 minutes. TreatmentProgram was limited to 3 weeks duration with 5 sessions a week.

PROCEDURE

73 subject screened

A sample of 60 patients selected

Explanation of procedure

Informed consent

Pre Intervention Reading

Manual Physical Therapy Concentional Physcal Therapy

Post Intervention reading Post Intervention Reading

Group 1• Initially Short wave diathermy were given.• Then Manual Physical Therapy program was given which

is as follows:• Manual Mobilization of Extension• Manual Mobilization of Flexion• Patellar Glides• Later on manual passive stretching for Calf, Hamstring &

Quadriceps is administered• Followed by supervised exercise program including

strengthening & mobility exercises.

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Group 2• Subjects were initially given Short wave diathermy for 20

minutes by covering whole aspect of knee and wrapping itwith a towel with medio -lateral placement of pads.

• This will be followed by supervised exercise programincluding strengthening & mobility exercises.

Data analysisStatistics were performed using an Excel spreadsheet &

Statistical Package for Social Sciences (SPSS) software wasused for data analysis.Student ‘t’ test was used to compare1. Unpaired ‘t’ test for between group comparisons.2. Paired t-test for within group comparisons.A significance level of p<0.05 was set

Results*Significant (pd” 0.05)• There is significant improvement in range of motion at the

end of week 3 from day 0 in both groups (pd”0.05)• There is an insignificant difference between Group 1 and

Group 2 at Day 0 with t value=0.68, p>0.05.• But there is a significant difference between Group 1 and

Group 2 at Week 3 with t value=1.67, p<0.05.

DiscussionThe results of the study showed a statistically significant

decrease in pain scores & improvement in six minute walk test

distances and range of motion over 3 week period. Subjects inthe manual physical therapy group appeared to be more satisfiedthan subjects in conventional physical therapy group. Thedifference between the two groups is likely attributable to theadditional effects of manual physical therapy program consistingof passive physiological and accessory movements and musclestretching that conventional group was not performing.

Deyle et al supported our results when they found nosignificant change in pain scores and six-minute walk testmeasurements in patients with knee OA who received a clinicallyapplied placebo treatment in comparison to those receivingmanual therapy in osteoarthritis knee. The possible mechanismfor better results are that the passive physiological joint motionstimulates biologic activity by moving the synovial fluid, whichbrings nutrients to the avascular articular cartilage of the joint. Italso helps in maintenance of extensibility and tensile strengthof the articular and periarticular tissues & thus helps inmaintenance of joint motion and general health

The manual therapy passive movement techniques werealso found to increase excursion in both intra-articular andperiarticular tissues when restricted mobility was judged to berelated to the reproduction of symptoms or functional limitation.

G D Maitland states that gentle passive physiologic andaccessory movements techniques stimulate neurophysiologicand mechanical effects thus can be used to treat painful joints,muscle spasm & joint hypomobility.

G. D. Maitland, Hoeksma et al, G D Deyle et al, Pamela A.Kovar et al, N E Henderson et al through various studies alsosupport the results of the study.

Future researchFurther studies can be carried out with a large sample size

with some radiographic support of OA knee.Future studies should also focus on correcting the

disarrangement due to osteoarthritis by use of manual therapycombined with exercises.

Future studies should also focus on various factors affectingthe outcome like articular factors, kinesiological factors andpsychological factors.

Clinical relevanceThis study establishes that manual therapy combined with

exercises helps to relieve pain and improve function in OA kneepatients.

This study will help the therapists to use a combinedapproach involving both manual therapy and a supervisedexercise program to improve function in better way. .

Table 1: Comparison of Basic characteristics (Age & Weight) between Manual & Conventional Physical Therapy GroupsSubject’s Manual Physical Conventional Physical t-valuecharacteristics Therapy Group Therapy Group

Mean ± S.D. Mean ± S.D.Age 50.6154 ± 6.38yrs 50.9167 ± 5.97yrs .17NSWeight 62.9615 ± 7.84Kg 62.6667 ± 7.18Kg .14NSHeight 162.65±5.08cm 162.34±5.14cm .14NS

Key wordsYrs-yearKg-kilogramcm- centimeters

Table 2: Comparison of Pre-intervention scores of Range of Motion with post-intervention scores for Group 1 and Group 2Days Range of Motion t-value p-value

MEAN S.DGroup Day 0 117.26 4.49 20.84* 0.001(N=26) Week 3 123.64 4.54Group Day 0 116.04 3.4 10.83* 0.002(N=24) Week 3 119.72 3.4

Graph 1:

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Ta ble : Comparison of Pre-intervention scores of 6 – min walk test with post-intervention scores for Group 1 and Group 2Days Distance Covered in 6 minutes t-value p-value

MEAN S.DGroup Day 0 235.73 15.2 13.39* 0.001(N=26) Week 3 252.32 12.94Group Day 0 239.42 12.63 5.46* 0.002(N=24) Week 3 245.54 11.08

* : Significant (pd”0.05)There is significant improvement in distance covered in six minutes at the end of week 3 from day 0 in both groups (pd”0.05)

Table : Comparison of Pre-intervention scores of Pain on VAS with post-intervention scores for Group 1 and Group 2Days VAS t-value p-value

MEAN S.DGroup Day 0 6.78 .96 9.42* 0.001(N=26) Week 3 4.77 .86Group 2 Day 0 6.46 .96 13.30*

(N=24) Week 3 5.74 .91 0.0* : Significant (pd” 0.05)

Graph 3Graph 2:

ConclusionThe result of this study shows that manual physical therapy

is found to be more effective.The dependent variables Range of Motion, pain score on

VAS and Distance covered in 6 minutes improved for both thegroups, but the results were better in Manual Physical TherapyGroup.

The study therefore concludes by accepting theExperimental hypothesis, “Manual physical therapy program isbetter than conventional physical therapy program in treatingknee osteoarthiritic patients”.

Refernces1. Altman R.D., Asch E, Block G, Bale G, Borenstein K & Brandt

K (1986) “Development of Criteria for classification ofOsteoarthritis”. Arthritis & Rheumatism; 29: 1039-1049

2. John M Walker, Antonie Helewa. Physical Therapy inArthritis: W.B. Saunders Company, 1996

3. S Brotzmann & K E Wilk. Clinical OrthopaedicRehabilitation, 2nd ed., Mosby, 2003.

4. J Bruce Moseley, Kimbertly O’Malley, Nancy J. Peterson,Terri J. Menke, David H. Kuykendall; Vol.37, (2002). “AControlled trial of arthroscopic surgery for osteoarthritis ofthe knee”. The NEW ENGLAND JOURNAL OF MEDICINE;Vol 347: 81-88.

5. Maitland GD. Vertebral Manipulation, 5th ed., London;Butterworths, 1986

6. Maitland GD. Peripheral Manipulation, 3rd ed., Boston;Butterworth Heinmann, 1991.

7. American College of Rheumatology (2000).Recommendations for the medical management ofosteoarthritis of the hip and knee. Arthritis & Rheumatism,Vol 43, No. 9, September 1905-1915.

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Efficacy of home based pulmonary rehabilitation program onpulmonary functions and quality of life in asthmatic childrenGanesan Kathiresan 1, Andrew J Newens 2

1Lecturer, Masterskill University College, Selangor, Malaysia, 2 Senior Lecturer, Institute of Rehabilitation, Faculty of Health, Universityof Hull, UK

Corresponding author:Ganesan KathiresanLECTURERMasterskill University College Of Health Sciences,G8, Jalan Kemacahaya 11, Taman Kemacahaya, Batu 9, Cheras43200, Selangor, Malaysia. EMAIL: gans_therapist@yahoo.co.inPHONE: 0060176033025

AbstractObjective: To Investigate The Efficacy Of Home Based -

Pulmonary Rehabilitation Program On Pulmonary Functions AndQuality Of Life In Asthmatic ChildrenMethology: 28 (twenty eight)children with mild persistent or moderate asthma were includedinto a double blind, randomised study. 16(Sixteen ) children (9girls , 7 boys) with the mean age of 10.8 ± 2.3 were assigned toreceive pulmonary rehabilitation program with their parents for30 days (group I). Control group included 12 children (6 girls, 6boys ) with the mean age of 10.2 ± 2.4 (group II). Symptom andmedication scores quality of life index and pulmonary functiontests were evaluated in rehabilitation and control group in thebeginning of the study and after the one month period.Results:the groups did not differ on all parameters before the study (p >0.05). Statistically significant decrease were found in symptomand medication scores in rehabilitation group (p < 0.05) andquality of life index was increased significantly in the same group(p < 0.05). Pulmonary function measures also significantlyimproved including vital capacity, forced vital capacity, FEV1,PEF and FEF25-75 in the rehabilitation group (p < 0.05). The bestimprovement were seen in FEF25-75 (10.09% increase) and PEF(7.81% increase) values. In control group no statisticallysignificant differences were found in all parameters.Conclusion:This study was shown that pulmonary rehabilitation at homecould improve quality of life and pulmonary functions. Sopulmonary rehabilitation should be placed as a component ofmanagement in childhood asthma.

KeywordsPulmonary rehabilitation, asthma, Pulmonary Functions And

Quality Of Life

IntroductionA number of patients with chronic obstructive pulmonary

diseases and asthma is on the rise over all the world. Education,environmental control and drug therapy are the corner stonesin the management of asthma. Nowadays pulmonaryrehabilitation is a recognised discipline for stabilisation andimprovement of asthma and chronic obstructive pulmonarydiseases. Pulmonary rehabilitation program (PRP) could improvethe quality of life, pulmonary functions, exercise tolerance, reducethe symptoms and anxiety of patients and decrease frequencyand duration of hospitalisation (1-6).

The aim of this study is to investigate the efficacy of Homebaesd pulmonary rehabilitation program in children with asthma.

Methodology

Twenty eight children with mild persistent or moderateasthma were included into a double blind, randomised study.Sixteen children (9 girls, 7 boys) with the mean age of 10.8 ±2.3 were assigned to receive pulmonary rehabilitation programwith their parents for 30 days (group I). Control group included12 children (6 girls, 6 boys ) with the mean age of 10.2 ± 2.4(group II). Children in both groups were comparable accordingto the stage of asthma and they had been using same drugs atleast for six months.

Pulmonary rehabilitation program consisted of relaxationexercises, endurance exercises, breathing exercises andrhythmic mobilisation exercises. Patients and their parents hadvisited Physical Medicine and Rehabilitation Department at thefirst visit and they were thought to perform this program at homefor 30 days. Symptom scores, medication scores (7), quality oflife index (8) and pulmonary function tests were evaluated inrehabilitation and control group in the beginning of the studyand after the one month period.

Statistical analysisThe results in both group were given as mean scores and

standard deviation. The findings indicated that non parametricmethods were appropriate so Wilcoxon matched pairs test wasused for difference between results at baseline and after thestudy. Mann-Whitney U test was used for comparing the groups.A p value of < 0.05 was regarded as statistically significant.

RESULTSSymptom and medication scores and quality of life index

of group I and group II were listed in table I. The groups did notdiffer on all parameters before the study (p > 0.05). Statisticallysignificant decrease were found in symptom and medicationscores in rehabilitation group (p < 0.05 ) and quality of life indexwas increased significantly in the same group (p < 0.05) (tableI). Pulmonary function measures also significantly improvedincluding vital capacity, forced vital capacity, forced expiratoryvolume in the first second of expiration, peak expiratory flowrate (PEF) and FEF25-75 in the rehabilitation group (p < 0.05). thebest improvement were seen in FEF25-75 (10.09 % increase) andPEF (7.81% increase) values (table II).

In control group no statistically significant differences werefound in symptom and medication scores, in quality of life index,even in pulmonary function tests (p > 0.05).

Table 1: Symptom and medication score and quality of life indexof group I (rehabilitation group) and control group

First visit Second visit pRehabilitationgroup (Group I)Symptom score 0.63 ± 0.71 0.19 ± 0.40 0.01

(median: 0.5) (median: 0)Medication score 4.40 ± 1.70 3.50 ± 0.80 0.007Quality of life Index 6.02 ± 0.5 6.40 ± 0.40 0.009Control GroupSymptom score 0.67 ± 0.57 0.49 ± 1.40 0.16

(median: 0)Medication score 4.09 ± 0.79 4.06 ± 0.93 0.32Quality of life Index 6.15 ± 0.29 6.27 ± 0.49 0.16

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DiscussionPulmonary rehabilitation program had both physiological

and psychological beneficial effects on patients with chronicobstructive pulmonary diseases. Pulmonary rehabilitationrelaxes the chest muscles, improves ventilation, decreases workof breathing and decreases the anxiety of patients and theirparents.

In this study it was shown that pulmonary rehabilitation couldimprove the quality of life and pulmonary functions. Similar toour results Cambach et al had reported that quality of life andexercise capacity improved after the rehabilitation program (2).Field et al also had demonstrated that children with asthma hadimproved pulmonary function after the daily relaxation andmassage therapy (4). They found best improvement in FEF25-75values like our finding which reflects the small airway obstruction.These results mean PRP could lead improvement in airwayobstruction and control of asthma.

In another study that were carried out by Cox et al it wasshown that pulmonary rehabilitation had beneficial effects onendurance, psychological variables, quality of life, skills,coordination, smoking habits, airway obstruction and dyspnea(6). However bronchial hyperresponsiveness, need of pulmonarydrugs and complaint of cough did not change. They followedpatients for two years and long term effects of PRP wereevaluated. Our study is a preliminary study and long term effectsof PRP is well not known.

The cost effectiveness of PRP is another point that coulddiscuss. In our group PRP was performed at home by parentsand it makes less cost. If we had enough data about the resultsof PRP performed by physiotherapists we could make acomparison for these both methods. Effects on psychologicalvariables and compliance could not be evaluated in this study.

In conclusion because of the beneficial effects on qualityof life and pulmonary functions pulmonary rehabilitation shouldbe placed as a component of management in childhood asthma.Further studies are needed to investigate the long term effects

and cost effectiveness of PRP.

Author’s StatementWith the submission of this manuscript I would like to

undertake that the above mentioned manuscript is original andhas not been published elsewhere, accepted for publicationelsewhere or under editorial review for publication elsewhere;and that my Institute’s representative is fully aware of thissubmission.

Competing interestsThere are no sources of funding used to assist in the

preparation of this manuscript.There are no potential conflicts of interest the authors may

have that are relevant to the contents of this manuscript

Open accessThis article is distributed under the terms of the Creative

Commons Attribution Noncommercial License which permits anynoncommercial use, distribution, and reproduction in anymedium, provided the original author(s) and source are credited.

References1. Donna L. Frownfelter. Chest Physical Therapy and

Pulmonary Rehabilitation, 2ª ed. Chicago: Year BookMedical Publishers; 1987.

2. Cambach W, Wagenaar RC, Koelman TW, et al. The longterm effects of pulmonary rehabilitation in patients withasthma and chronic obstructive pulmonary diseases: aresearch synthesis. Arch Phys Med Rehabil 1999;80:103-11.

3. Barandun J. Value and cost of pulmonary rehabilitation.Schweiz Rundsch Med Prax 1997; 86:1979-83.

4. Field T, Hanteleff BS, Reif MH, et al. Children with asthmahave improved pulmonary functions after massage therapy.J Pediatr 1998; 132:854-8.

5. Homnick DN, Marks JH. Exercises and sports inadolescents with chronic pulmonary diseases. Adolesc Med1998;9:467-81.

6. Cox NJ, Hendricks JC, Binkhorts RA, et al. A pulmonaryrehabilitation program for patients with asthma and chronicobstructive pulmonary diseases (COPD). Lung 1993;171:235-44.

7. Bousquet J, Guerrin B, Dotte A, et al. Comparison betweenrush immunotherapy with a standardised allergen and analum adjuved pyridine extracted material in grass pollenallergy. Allergy 1985; 15:82.

8. Juniper EF, Guyatt GH, Ferrie PJ, et al. Measuring qualityof life in asthma. Am Rev Respir Dis 1993; 147:832-8.

Table 2: Pulmonary functions (% prediced values for age andheight) of group I (rehabilitation group) and control group

First visit Second visit pRehabilitation groupVC 76.62 ± 8.64 83.12 ± 12.38 0.05FVC 78.00 ± 8.83 84.75 ± 10.76 0.02FEV1 74.23 ± 11.67 80.62 ± 12.27 0.009PEF 65.62 ± 8.50 73.43 ± 7.32 0.001FEF25-75 75.73 ± 11.12 85.31 ± 14.45 0.006Control groupVC 78.66 ± 10.39 80.25 ± 6.25 0.75FVC 79.67 ± 8.64 81.41 ± 7.07 0.36FEV1 73.75 ± 7.12 75.91 ± 5.43 0.15PEF 6.33 ± 7.22 68.91 ± 9.16 0.21FEF25-75 74.54 ± 11.96 76.66 ± 10.37 0.37

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The relative efficacy of mobilization with movement versus Cyriaxphysiotherapy in the treatment of lateral epicondylitisPooja Bhardwaj*, Amit Dhawan***Sr. Lecturer, D.A.V. Institute of Physiotherapy & Rehabilitation, Jalandhar, Punjab, India. **Sr. Lecturer, Department of Physiotherapy,Lovely School of Applied Medical Sciences, Lovely Professional University, Phagwara, Punjab, India

BackroundProposed mechanism for pain in tennis elbow as cited by

Mulligan (1995) is that a minor positional fault of joint may occurfollowing an injury or strain, resulting in movement restriction orpain. Paungmali A (2003) concluded that Mobilization withMovement (MWM) for lateral epicondyalgia is capable ofproducing concurrent hypoalgesic effects and altering CNSfunction.

PurposeTo investigate the effects of MWM and Cyriax physiotherapy

and to compare these techniques in reducing pain and improvinggrip strength in patients with lateral epicondyalgia.

Methods/designSixty subjects with a history and examination results

consistent with lateral epicondyalgia participated in the study.The subjects were randomly assigned to a group that receivedMWM + Ultrasound (Group I), Cyriax Physiotherapy + ultrasound(Group II) and Ultrasound (Group III). Follow-up was done afterone month. The primary outcome measures were NPRS, GripStrength and Patient Rated Forearm Evaluation Questionnaire(PRFEQ). Analysis was performed using post HOC test, oneway ANOVA, Paired and Unpaired t tests.

ResultsMeans and standard deviations were used as descriptive

statistics. It was revealed that MWM reduces pain and increasesgrip strength to a greater extent than Cyriax Physiotherapy.

Discussion and conclusionThe study finds evidence to support the use of both MWM

and Cyriax in lateral epicondylitis over ultrasound; howeverCyriax is inferior to MWM, although in post treatment they werevery similar in effect. The results after one month follow up wereclearly in favour of MWM as supported by the analysis.

KeywordsHypoalgesia, Grip Strength, MWM, Mill’s Manipulation,

Ultrasound.

IntroductionIt is a work related or sports related pain disorder with

macroscopic and microscopic tears in the Extensor CarpiRadialis Brevis1, usually caused by excessive quick,monotonous, repetitive eccentric contractions and grippingactivities of the wrist.2, 3 Recent studies showed sensory fibrescontaining substance – P & CGRP (calcitonine gene relatedpeptide) in the origin of ECRB.4,5 The presence of theseneuropeptides which is limited to a subgroup of small vessels,implies the possibility of neurogenic inflammation as a cause ofperceived pain.6 Proposed mechanism for pain in tennis elbow

as cited by Mulligan (1995) is that a minor positional fault ofjoint may occur following an injury or strain, resulting inmovement restriction or pain. Lewit (1985) has shown thatreduced joint mobility can often be a result of a “mechanicalblock” from inert structures within a joint. Joint movement canbe reduced as a result of reflex muscle splinting. It is suggestedthat treatment directed at the joint will have an effect on muscleactivity and vice-versa. Paungmali A (2003) concluded that MWMfor lateral epicondyalgia is capable of producing concurrenthypoalgesic effects during and following its application as wellas altering CNS functions, Vicenzino demonstrated beneficialeffects of applying MWM technique on pain and dysfunctionthat is classically associated with tennis elbow. They concludedimprovement in grip strength, function and reduction in painlevel.7 “Articular Neurology is one of the fundamental sciencesof manipulative therapy.” Manipulation activates type 2 (fastadapting, with dynamic response to increased or decreased jointmovement) and type 3 (high – threshold) mechanoreceptorsrespectively. Pain abates after manipulation due to the reflexinhibition of the muscle spasm. Spinal Manipulation on thecervical spine resulted in significant deviation in plasmaendorphins (natural pain killers) levels.8

Cyriax claimed substantial success in treating tennis elbowusing deep transverse friction (DTF) in combination with Mill’smanipulation, which is performed immediately after DTF. For itto be considered a Cyriax intervention, the two components mustbe used together in the order maintained. 9

Within the field of manual therapy for lateral epicondyalgia,there are several randomized controlled trials (RCTs) that arespecifically evaluated for Cyriax Manipulation, transverse frictionmassage, and mobilization with movement (MWM) in lateralepicondyalgia. Both techniques have reported efficiency inimproving pain and grip strength.

MethodsThe Institutional Review Boards at M.M.Medical College &

Hospital, Ambala, & Indira Gandhi Medical College & hospital,Shimla, India had granted approval for the study.

Study sample

60 patients with signs and symptoms of lateralepicondyalgia were involved in the study. Over a period of oneyear, patients were recruited from:

The Outpatient Department of Orthopaedics andPhysiotherapy of M.M. Medical College & Hospital, Mullana,Ambala & Indira Gandhi Medical College & Hospital, Shimla.

The study will include the patients who meet the followinginclusion criteria:• Patients with age between 45-54 years were included in

the study.• Both male and female patients were recruited.• Pain that increased on palpation of the lateral epicondyle.• Pain during gripping.• Pain on resisted wrist extension.• Pain on resisted middle finger extension.• Pain of at least 6 weeks of duration.

The following exclusion criterion was used for this study:• Age less than 45 and more than 54 years.

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• Bilateral elbow symptoms.• Cervical radiculopathy.• Any other elbow joint pathology.• Peripheral nerve involvement.• Previous surgery of the elbow.• History of dislocation• History of fracture of humerus, radius and ulna.• Systemic or neurological disease (stroke and head injury).• Shoulder, wrist and hand pathology.• ·History of rheumatoid disease.• Health conditions that would have precluded treatment (eg,

osteoporosis, malignancy, haemophila, diabetes)• Recent steroid injection• Using medications such as analgesic drugs.

Design of the study

Randomised controlled design60 subjects were divided randomly into 3 groups. 20

subjects were included in each group and treated as follows:• Group I – Ultrasound therapy+ MWM• Group II – Ultrasound therapy+ Cyriax physiotherapy.• Group III – Ultrasound therapy (Control Group)

All participants provided written consent prior toparticipation.

The instrumentation for data collection included:Numeric Pain Rating Scale (NPRS) 14

Patient Rated Forearm Evaluation Questionnaire (PRFEQ)12, Grip Strength 13

Equipments usedDynamometer`StopwatchMulligan’s BeltUltrasound modality (Phyaction)

group I and group II received ultrasound therapy for 10 minutes.The trial comprised a two week intervention period for group

I and four week intervention period for group II and III and onemonth follow up for each group.

Participants were assessed:• Before treatment (baseline)• Group I after two weeks of treatment (final assessment)• Group II and III after four weeks of treatment (final

assessment)• At 1 months after final assessment (follow up)

Mobilization with movement (mwm)—group i11

The patient was made to lie supine on the couch. Therapiststood by the involved side. Treatment was to make the patientexercise his forearm repeatedly in any way that was (on testing)painful, but, exercise when done with a sustained mobilisationwas painless. Patient elbow was in full extension and forearmin pronation. Belt was worn around the therapist’s waist andwas parallel to the ground. Lateral glide of the forearm relativeto the humerus was produced by the mobilisation belt, was painfree and now rendered strong resisted wrist extension pain freewhich was applied by the therapist’s hand. Mulligan describedthis technique as being effective as supported by early casestudy research.

The glide was painlessly applied and sustained forapproximately 6 seconds while the participant performed thepain free resisted wrist extension. Gliding pressure wasmaintained until participant brought the wrist back to neutral. 3sets of 10 pain free MWMs were performed against strongestpain free wrist extension resistance. Patients were warned thatno pain should be perceived during the procedure.

ProceduresPatients were screened according to the inclusion and

exclusion criteria. 60 patients who met the criteria were includedin the study. They were allocated into three groups by simplerandom sampling. Procedures were explained to the patientsand duly signed written consent was taken. All the patients of

Cyriax physiotherapy—group iiIt includes Deep Transverse Friction (DTF) in combination

with Mills Manipulation, which was performed immediately afterDTF. For it to be considered, a Cyriax Intervention, the twocomponents were used together in the order mentioned. Theprotocol was followed 3 times a week for 4 weeks.

Deep transverse friction 10

Patient was made to sit on the chair comfortably and exactsite of lesion was palpated. DTF was performed only at the exactside of lesion with depth of friction tolerable to the patient. It wasapplied transversely to the specific tissues involved. Thetherapist’s fingers and patients skin moved as a single unit. Itmust be applied for 10 minutes.

Mills manipulation 10

It was performed immediately after the DTF, provided thepatient had full range of passive elbow extension. Patient waspositioned on chair with backrest and therapist stood behindthe patient. Patient’s arm was supported under the crook of elbowwith shoulder joint abducted to 90º and medially rotated withforearm pronation. Patient’s wrist was fully flexed and forearm

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pronated by the therapist. Hand supporting the crook of elbowwas moved on to the posterior surface of the elbow joint andwhile maintaining full wrist flexion and pronation, patient’s elbowwas extended until all the slack has been taken up in the tendon.Therapist then stepped sideways to stand behind the patient’shead, taking care to prevent the patient from leaning away eitherforwards or sideways, which would reduce the tension on thetendon. Minimal amplitude, high velocity thrust was then appliedby simultaneously side flexing therapist’s body away from thearm and pushed smartly downwards with the hand over thepatients elbow.

Post hoc analysis for pain scoresAccording to Bonferroni, multiple comparisons, it was

revealed that there is no significant difference between GP 1 &2 and GP 2 & 3 in terms of pre pain scores, except in case ofGP 1 & GP 3.

There exists no significant difference when GP 1 wascompared with GP 2 but with GP 3 there was a significantdifference in terms of post pain scores.

A significant difference exists when GP 2 was comparedwith GP 3 in terms of post pain and follow up scores.

Paired sample test analysis for pain scoresThere was a significant difference between pre pain and

post pain measurements and pre pain and follow up painmeasurements in all 3 groups.

Post hoc analysis for prfeq scores:The results revealed that there was no significant difference

between GP 1, 2 & 3 in terms of pre PRFEQ scores.There exists no significant difference when GP 1 was

compared with GP 2 but with GP 3 a significant difference existsin terms of post PRFEQ scores.

No significant difference exists between GP 1 and GP 2 interms of follow up PRFEQ scores.

GP 2 and GP 3 showed a significant difference betweenthem in terms of follow up PRFEQ scores.

Paired sample test analysis for prfeq scores:There is a significant difference between pre PRFEQ and

post PRFEQ measurements and pre PRFEQ and follow upPRFEQ scores in all 3 groups.

Post hoc analysis for grip strength scoresThe results revealed that there exists no significant

difference between the 3 groups in terms of pre grip strengthscores.

In terms of post grip strength, no significant differenceexisted between GP 1 and GP 2 (p value = .977) but a significantdifference was there between GP 1 and GP 3 (p value =.002).GP 2 and GP 3 have a significant difference between them (pvalue = .034)

Paired sample test analysis for grip strengthscores:

There was a significant difference between pre grip strength- post grip strength and pre grip strength – follow up grip strengthscores in all the 3 groups, except in group 3 (.143).

The measured values for assessment of effectiveness arestandardised as per percentage of improvement, calculated by:

% improvement = data before treatment – data after

The subjects in both groups I and II would receiveUltrasound treatment before undergoing MWM and CyriaxPhysiotherapy.

Ultrasound therapy— group iii 24

The subjects were given pulsed ultrasound with an on tooff ratio of one to four and a frequency of 1MHz. The space-averaged intensity was set to 1w/cm2 and treatment time to 10minutes during the course of treatment. 12 treatments were given(three per week) over four weeks, except for MWM group whichreceived ultrasound as per the number of MWM sessions.

Data analysisMeans and standard deviations were used as descriptive

statistics. A within-subject and between subject design was usedto evaluate the effect of 2 independent variables: treatmentconditions (mobilisation with movement and cyriaxphysiotherapy) and a no treatment group/control group(ultrasound). Pain, PRFEQ and Grip Strength as dependentvariables of mobilisation with movement and cyriaxphysiotherapy. Significant interactions and main effects werefurther explained with post HOC (multiple comparisons,bonferroni) test of simple effects. SPSS software (version 13.0,SSPS. Inc, Chicago, Illinois, USA) was used in statisticalanalysis, and level of significance was set at p< .05.

ResultsNo statistically significant difference existed between the

groups in terms of age and gender. Before the application oftreatment, the mean and standard deviations of pre pain, prePRFEQ, pre Grip Strength scores for 3 groups were as follows:

Groups Follow up Follow up Follow upPain PRFEQ Grip Strength

GP 1 1.55±1.3 18.44±9.74 18.20±4.9GP 2 3.65±1.5 18.52±6.73 11.55±4.26GP 3 5.85±.81 35.04±4.43 7.20±3.1

Groups Mean pre Mean pre Mean pre pain PRFEQ Grip Strength

GP 1 7.05±.83 39.78±6.68 4.25±3.5GP 2 6.5±.946 36.30±5.12 6.15±3.8GP 3 6.3±.979 36.60±4.42 6.45±3.4

Groups Mean post Mean post Mean postpain PRFEQ Grip Strength

GP 1 2.75±1.3 21.77±9.05 12.25±4.3GP 2 3.5±1.27 17.88±6.75 11±4.5GP 3 5.6±1.14 33.24±6.03 7.70±2.86

After 1 month of treatment, the mean and standarddeviations of post pain, post PRFEQ and post grip strength wereas follows:

Following 3 weeks after treatment, Pain, PRFEQ scoresare again taken. The mean scores of follow up were as follows.

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treatment/data before treatmentMobilisation with Movement (MWM) reduced the pain by

61.28% after treatment sessions but when 3 weeks follow upwas done, the reduction in pain level was found to 78.42. Itshowed 46% increase in the PRFEQ and this gain in PRFEQwas increased to 54% after 3 weeks of treatment.

Cyriax Physiotherapy reduced the pain by 46.69% but after3 weeks of follow up the reduction level in pain was found to be44.03%. Cyriax physiotherapy reported 51.7% increase inPRFEQ and this gain was seen to reduce to 49.7 after 3 weeksof treatment.

Ultrasound reduced the pain by 10.22% but reduction inpain level after 3 weeks follow up was only 5.93%. The PRFEQwas increased by 9.21% and after 3 weeks of follow up it wasjust 4.14%.

patient if correctly applied.17

It has been hypothesised that DTF has local paindiminishing effect and results in better alignment of connectivetissue fibrils, therefore increasing the strength and mobility.18

According to Cyriax, DTF also leads to destruction of painprovoking metabolites like Lewi’s substances, which producesischemia and pain. 10 minutes of DTF give lasting peripheraldisturbance of nerve tissue with local anaesthetic effect.18 Diffusenoxious inhibitory controls is another pain suppressionmechanism that releases endogenous opiates which areinhibitory neurotransmitters diminishing the intensity of paintransmitted to higher centres.57 DTF produces breaking downof the cross links or adhesions that have been formed, softeningthe scar tissue and mobilising the cross links between the mutualcollagen fibres. 17, 18, 20, and 22

Cyriax stated that Mill’s Manipulation should be performedimmediately after DTF to elongate the scar tissue by rupturingthe adhesions within the teno-osseous junction making the areamobile and pain free.23

MWM and Cyriax both were initially superior to the controlgroup with no significant difference amongst themselves butthis effect was lost in the follow up period of one month, in whichthe follow up results showed reversal in all three outcomemeasures for Cyriax interventions. Furthermore, Ultrasound(control group) gave poor outcome both in post treatment andfollow up showing that it is not effective treatment strategy asare MWM or Cyriax.

Results of ultrasound as indicated by the analysis of controlgroup, failed to show any improvement in any of the outcomemeasures on the basis of therapeutic effects of ultrasound intennis elbow.

At one month follow up MWM is superior to Cyriaxintervention on global improvement in all 3 measures. Cyriax issuperior to ultrasound (control group) for all outcome measures.Long term results of the study were not evaluated but Smidt etal concluded that given appropriate advice, tennis elbow is aself-limiting condition at 52 weeks in most cases.25

The reported efficiency of MWM over Cyriax & ultrasoundand maintenance of its beneficial effects even afterdiscontinuation of treatment are substantiated by many theoriesand studies. Both Exelby and Wilson postulated aneurophysiological rationale for the success of this approach.26

Mulligan favours a biomechanical thesis citing a theoretical“positional fault”.27

Paungmali A et al concluded that MWM treatment exerteda physiological effect similar to that reported by spinalmanipulations and also that it is capable of concurrenthypoalgesic effects during and following its applications, as wellas altering somatic nervous system function.28

All the above mentioned theories and studies are very muchin accordance with the results of the present study proving thebeneficial effects of MWM over Cyriax and control group in posttreatment and follow up periods.

There are certain limitations of the study. 1.Discrepancy in the number of treatment sessions between theprotocols; the MWM protocol was administered for four treatmentsessions over a two week period, whereas Cyriax and ultrasoundwere administered for three sessions per week for four weeks.But the discrepancy taken into account, the results should havebeen in favour of Cyriax or control group for their longer treatmentsessions, which was not so.

2. The long term effects of all the 3 groups were notevaluated to encounter whether any difference would still prevailamongst the groups as is cited by Smidt et al after 52 weeks oftreatment.

3. Use of ultrasound in all the 3 groups which wouldfurther reduce the generalisibility of results purely to either ofthe two experimental conditions i.e. MWM or Cyriax.Furthermore, another purpose of using ultrasound was to softenthe fibrosed tissue before applying either form of mobilisation.

Graph I: Comparison of pain scores (NPRS)

Graph II: Comparison of PRFEQ scores

Graph III: Comparison of Grip Strength scores

DiscussionThe study finds evidence to support the use of both MWM

and Cyriax in lateral epicondylitis over ultrasound as used incontrol group during the post treatment session; however Cyriaxis inferior to MWM, although in post treatment they were verysimilar in effect. Cyriax had already claimed substantial successin treating tennis elbow using Deep Transverse Friction (DTF)in combination with Mill’s Manipulation, which is performedimmediately after DTF.

DTF produced a numbing effect.15,16 It quickly results inanalgesic effect over the treated area and is not at all painful for

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Therefore, it was administered for 4 sessions in mulligan groupand 12 sessions in cyriax group as per their recommendedprotocols. This led to the discrepancy among the number ofultrasound sessions in both mulligan and cyriax group. Thisdiscrepancy taken into account, the results should have been infavour of either cyriax or control group, which was not so. Hence,unequal ultrasound sessions did not lead to any significantdifferences in results, and the results were still better with lessernumber of ultrasound sessions in MWM group.

4. Last, but not the least, the amount of forcerecommended for MWM is not stated in mulligan’s text. Mc Leanet al (2002)29 did a study to demonstrate the amount of forceused, using hand held dynamometer and showed that 66% or100% resulted in significant gains but these parameters werenot included and force is purely guided by the comfort level ofpatient, which did not produce pain while performing themovement.

This study compared the effects of MWM and Cyriax ontennis elbow patients and found significant differences amongthe results at the end of one month of follow up period. Theeffects at the end of 52 weeks of treatment were not seen, toanalyse whether any significant differences will exist at the periodof time or not as indicated by Smidt vet al, therefore the futureresearch is warranted. The sample size could be enlarged infuture research for better generalisibility of results. Thediscrepancy in the number of treatment sessions among theMWM and Cyriax group should be overcome to see the exactimprovement in outcome measures with similar number oftreatment sessions.

Quantification of the force was not done while administeringthe MWM and the amount of force was purely guided by thecomfort level of the patient. Therefore future studies shouldconsider the recommended force levels while administering thetechnique to eliminate the individual force differences.

ConclusionMWM and Cyriax, both were effective in reducing pain and

improving grip strength after the treatment sessions. But benefitsof MWM in tennis elbow patients as compared with Cyriax infollow up period are substantial, therefore proving MWM to bethe better treatment strategy than Cyriax.

References1. Muztagh J. Tennis Elbow. Aust Fam Physician 1988; 17:

90-5.2. Piniapaki T, Tarvainen T. Progressive strengthening and

stretching exercises and ultrasound for chronic lateralepicondylitis. Physiotherapy 1996; 82: 522-30.

3. Vasselien O. Low level laser versus traditionalphysiotherapy in the treatment of tennis elbow.Physiotherapy 1992; 78: 329-34.

4. L Jung BO, Friden J. Substance P and Calcitonin generelated peptide expression at the extensors carpi radialisbrevis muscle origin. J Ortho Res 1999; 17: 554-9.

5. Fedarzyk JM. Tennis elbow: blending basic science withclinical practice. J Hand Ther 2006; 19: 146-53.

6. Zeisig E. Extensor origin vascularity related to pain inpatients with tennis elbow. Knee Surg Sports TraumatolArthrosc 2006; 14: 659-63.

7. Vicenzino B, Wright A. Effects of a novel manipulativephysiotherapy technique on tennis elbow: A single case-study. J Manual Therapy 1995; 1: 30-35.

8. Cyriax HJ, Cyriax JP. Cyriax’s illustrated manual oforthopaedic medicine-Oxford; Butterworth-Heinmann,1983.

9. Kerson M, Atkins E. Orthopaedic medicine: A practicalapproach. Oxford; Butterworth-Heinmann, 1998.

10. Cyriax HJ, Cyriax JP. Cyriax illustrated manual oforthopaedic medicine. Oxford: Butterworth- Heinemann,1983.

11. Miller J. Orthopaedic Discussion Review, May/June 2000.Miller J.

12. Jan D Tom J, Joy C. Validation of the Patient Rated TennisElbow Evaluation Questionnaire. Journal of Hand therapy2007; 20: 3-11.

13. Smidt N, Assendelft WJ. Interobserver reproducibility of theassessment of severity of complaints, grip strength andpressure pain threshold in patients with lateral epicondylitis.Archives of Phy Med Rehab 2002; 83: 1145-1150.

4. Binder A, Hodge G. Is therapeutic ultrasound effective intreating soft tissue lesions? Br Med Journal 1985; 290: 512-15.

14. Amelia Williamson and Barbara Hoggart. Pain: a review ofthree commonly used pain rating scales. J of clinical nursing2004, 1365-2702.

15. Kesson M, Atkins E. Orthopaedic Medicine: a practicalapproach, Oxford: Butterworth-Heinmann, 1998.

16. Selvier T, Wilson J. Methods utilised in treating lateralepicondylitis. Physical Therapy Review 2000; 5; 117-27.

17. Chamberlain G. Cyriax’s friction massage: a review. JOrthop Sports Ther 1982; 4: 16-22.

18. De Bruijn R. Deep transverse friction: its analgesic effect.Int J Sports Manual 1984; 5: 35-6.

19. Gregory M, Deanc M, Mars M. Ultrastructural changes inuntraumatised rabbit skeletal muscle treated with deeptransverse friction. Physiotherapy 2003; 89: 408-16.

20. Goats GC. The scientific basis of an ancient art. Part 2,Physiology and therapeutic effects. J Sports Med 1994; 28:151-6.

21. Kaada B, Torsteinbo O. Increase of plasma beta endorphinsin connective tissue massage. Gen Pharmacol 1989; 20:487-9.

22. Walker H. Deep transverse friction in ligament healing. JOrthop Sports Phys Ther 1984; 6: 89-94.

23. Kushner S, Reid D. Manipulation in the treatment of tenniselbow. J Orthopaedics Sports Physical Ther 1986; 7: 264-72.

24. Binder A, Hodge G. Is therapeutic Ultrasound effective intreating soft tissue lesions? Br med J 1985; 290: 512-14.

25. Excelby Linda. Mobilisations with movement; a personalview, physiotherapy, 1995; 81(12): 724-729.

26. Mulligan R.B. Manual Therapy “NAGS”, “Snags”, and “:MWM’s”. Plane View Press Wellington 1999.

27. Miller J. Case study: Mulligan concept management of“Tennis elbow” Orthopaedic Discussion Review, May/June2000. Miller J. Orthopaedic Division Review. May/June2000.

28. Paungmali A, Vicenzino B. Hypoalgesic andSympathoexcitatory effects of Mobilisations with Movementfor lateral epicondyalgia. Physical Therapy 83; 374-83.

29. Mc Lean S, Reed and Vicenzino B (2002): A pilot study ofthe manual force levels required to produce manipulationinduced hypoalgesia. Clinical Biomechanics 17: 304-308.

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Use of electrical stimulator to detect neurosensory changes - acase reportPrachur Kumar*, C.S Ram**, Suhas S. Godhi****M.D.S, Senior Lecturer, Department of Oral and Maxillofacial Surgery, K.M.Shah Dental College & Hospital, Vadodara, **M.S.P.T,Director, Department of Physiotherapy, I.T.S, Ghaziabad, ***M.D.S, Professor, I.T.S C.D.S.R., Ghaziabad

AbstractThe zygomatic bone provides prominence to the cheek

which leads to its increased chances of fracture and theinfraorbital nerve is often involved in the trauma to the zygomaticcomplex resulting in the sensory disturbance of the areainnervated by it. The aim of the study was to evaluate thepersistent sensory disturbances of the infraorbital nerve afterrecovery from isolated zygomatic complex fracture. The patientswas evaluated for sensory disturbances in infraorbital nerve byperforming two tests that included Pin prick test and Electricaldetection threshold test. The results suggested thatneurosensory disturbance in infraorbital nerve was present inthe patients with zygomatic complex fracture. At one month post-operatively some sensory deficit was present on the affectedside. After six months the patient showed near to normalimprovement comparable to normal side.

KeywordsNeurosensory , Electrical Stimulator, Electrical detection

threshold

IntroductionPain, temperature, touch, pressure, and proprioception

(sense of body position) are transmitted centrally from the peri-oral structures via the inferior alveolar, lingual, infraorbital andmental nerves. Each of these sensations is carried out bydifferent types of sensory receptors and nerve fibers, eachshowing different susceptibility to injury and recovery. After aninjury, each of these sensory modalities must be tested and theirrecovery must be monitored. Maxillofacial neurosensorydeficiencies may be caused by various surgical procedures suchas third molar surgery, trauma, osteotomies, preprostheticprocedures, excision of large tumors or cysts, surgery oftemporomandibular joint.1

The sensory disturbances of the infraorbital nerve arefrequently present in zygomatic complex fractures.2 The nervecan be damaged by a secondary mechanism through a blunt,crush type of injury or by a bony compression of the nerve at thefracture site as it leaves the infraorbital foramen.3

Case reportA female patient 35 yrs of age reported to Department of

Oral and maxillofacial surgery with a chief complaint of swellingon her face on the right side along with numbness and wasunable to open her mouth. Patient had a road traffic accidentwhich occurred while she was traveling on a bike along with herhusband and had a fall from the bike .She had a fall which causedher face to hit the ground on the right side. Her medical historywas unremarkable. Tenderness was present at the right side atthe infraorbital rim .On examination a definite step was presentat the infraorbital rim along with pain and swelling on the affectedside. Paresthesia was present on the right side (lower eye lid,lateral side of the nose, upper lip and cheek). Radiographicexamination revealed zygomatic complex fracture right side. Toevaluate the neurosensory defecit Electical detection thresholdtest along with Pin prick test was performed. We performedelectrical detection threshold test at all the four sites (lower eyelid, lateral side of the nose, upper lip and cheek) (Fig.1).Continuous trains of Interrupted Galvanic stimuli were deliveredthrough a pen electrode (active) from an electrical stimulatordevice (Vectrostim) (Fig.2). Passive electrode was placed behindthe neck. Stimulus frequency was 100 Hz. Polarity of theelectrodes was randomized. Stimulating current was increasedat a fixed rate until the subject indicated detection. The detectionthreshold value at each location was noted. Results wereexpressed in ratios between the injured side and the controlside. Pin prick test was performed with the help 0.2-mm diameterblunted acupuncture needle (Fig.3) which was pushed againstthe patients skin until the needle slightly bends (the skin will bedimpled but not penetrated)(Fig. 4). The graded sensation ofpatient was recorded in 100 mm visual analogue scale. Resultswere recorded as the difference in the VAS values between thecontrol and injured sides.

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Electrical detection thresholdFig 1: Lateral side of nose

Material usedFig. 2: Electrical stimulator device (Vectro Stim®) used forelectrical detection threshold.

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For the treatment of the fracture zygoma was done byperforming Open reduction with internal fixation using 2 mmstainless steel plate along with screws.

Patient was again evaluated again with both these testsafter one month and showed hyposthesia on the affected side.On evaluation of the patient after 6 months the patient showednear to normal sensation on the affected side when comparedwith the unaffected side.

DiscussionThe infraorbital nerve is often involved in trauma to the

zygomatic complex at the site of the infraorbital fissure,infraorbital canal, or foramen. The neurological symptoms arisefrom the fact that the fracture line runs through or in theimmediate vicinity of the infraorbital canal and foramen, affectingthe infraorbital nerve.4 This results in sensory disturbancesincluding all kinds of dysaesthesia and neuralgic pain skin ofthe lower eyelid, cheek, lateral side of the nose, and upper lipand to the labial mucosa, gingival and teeth.3

Previous studies have shown that the frequency ofpersistent sensory disturbance was independent of the methodof reduction and fixation. However, a little more favorable resultswere obtained in those cases in which infraorbital nerve wasexplored and relieved at the infraorbital foramen. Some wereable to prevent persisting morbidity of the infraorbital nerveregardless of the treatment procedures.

In the present study the recovery of the infraorbital nervefunction was evaluated with two different procedures whichincluded electrical detection threshold and pin prick method.Patient was treated by open reduction and miniplate fixationand almost complete recovery of infraorbital nerve was observedafter 6 months.

However it is extremely difficult to compare across studiesthat have employed diverse methodologies to assess nervefunction. Two-point discrimination, pressure thresholds , pinpricktest , gross assessment with sharp and blunt instruments andthermography, and gross temperature assessments have allbeen adapted to the study of nerve recovery followingtrauma.5,6,7,8,9..

Physiological studies have confirmed the Lewis theory,stating that when a nerve is compressed, the fibers are affecteddifferently: the bigger the fiber, the more likely to be affected bytrauma. Fibers are therefore affected in the order of their size.10

Electrical detection threshold and Pin Prick are relativelyless used in the assessment of nerve recovery. The advantageof multimodal testing is the ability to differentiate between largelymechanosensitive neurons (Aâ fibers) by employing electricalstimuli and Pin prick for selectively activated nociceptors (Aäand C fibers).9 Electrical threshold and pinprick responses areuseful tools.

Most cases of Infraorbital nerve dysfunction followingzygomatic fractures will recover by 6 months. The incidence ofresidual sensory dysfunction varies with the testing modality.

Fig 4: Photograph of Pinprick test being performed on the cheek

ConclusionNerve recovery can be accurately tested using electrical

detection threshold method.

Legends

Fig. 3: 0.2-mm diameter blunted acupuncture needle used forpin prick test

Pinprick test findings as VAS score after 1 monthSite Control side Affected sideLower eye lid 2 3Lateral side of nose 2 3Upper lip 3 5Cheek 2 4

Findings of Electrical threshold detectionAfter one month

Site Control side Affected sideLower eye lid 4 amp 5 ampLateral side of nose 3 amp 3 ampUpper lip 4 amp 3 ampCheek 3 amp 4 amp

Pre operative pinprick test findings as VAS scoreSite Control side Affected sideLower eye lid 2 1Lateral side of nose 2 4Upper lip 2 3Cheek 2 6

PreoperativeElectrical threshold detection test findingsSite Control side Affected sideLower eye lid 5 amp 5 ampLateral side of nose 3 amp 4 ampUpper lip 3 amp 3 ampCheek 3amp 6amp

After six monthFindings of Electrical threshold detection

Site Control side Affected sideLower eye lid 4 amp 4 ampLateral side of nose 3 amp 3 ampUpper lip 3 amp 2 ampCheek 4 amp 4 amp

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Relationship between depression and duration from the onset ofinjury in traumatic spinal cord injured patientsRenu Singh*, Ruby Aikat***Research Student, ISIC Institute of Health and Rehabilitation Sciences, Vasant Kunj, New Delhi, **MOT (Neurology), Lecturer,ISIC Institute of Health and Rehabilitation Sciences, Vasant Kunj, New Delhi

Background and purposeResearch finding regarding relationship between

depression and duration from the onset of injury in traumaticspinal cord injured patients.

Study designCorrelational survey design.

Subjects96 subjects were recruited from Indian Spinal Injuries

Center, Vasant Kunj, New Delhi.

MethodPurposive sampling of 96 SCI subjects was done according

to inclusion criteria and exclusion criteria. Written informedconsent had been taken from the subjects, in English orHindi languages. The quadriplegia patients, who could notsign the consent form, thumb-impression had taken. Aftertaking the in formed consent, the subjects were divided into3 groups depending upon the duration of SCI, i.e. 0-1month (group-1), >1-6 months (group-2), and >6-12 months(group-3) post injury. In each group there were bothquadriplegic, and paraplegic patients. Depression wasassessed by CES-D scale.

ResultsWeak correlation between CES-D and duration from

onset of injury was found for the total sample, r-value0.039. The comparison of CES-D among the three groupswas taken. The mean value of group-3 was higher than themean value of other two groups. Also, the f-value was 0.67but was not significant at level 0.05. Comparison of CES-D scores with the level of injury i.e. quadriplegics andparaplegics for the total sample was done. Paired t-valuewas 5.57** which was highly significant at p < 0.01 level.Comparing on the basis of age groups (20-35 years and36-50 years age-ranges), the younger age group had highermean value than the older group.

ConclusionThe level of depression was found to be higher in

group-3, that is >6-12 months from injury, as compared tothe other two groups 0-1 month, >1-6 month.

Depression was found to be highly significant inquadriplegics in all groups (0-1 month, >1-6 months, >6-12months) as compared to the paraplegics .

Also, the results showed that the depression was morein younger age group (i.e. 20-35 years) as compared to theolder age group 36-50 years.

Spinal cord injury is defined as damage or trauma tothe spinal cord that in turn results in a loss or impairedfunction resulting in reduced mobility or feeling. 1

It is a low incidence, high cost disability requiring

tremendous changes in an individual’s life-style. The effectsof SCI have an impact not only on the lives of the clientand family but also on society as a whole. Clients need awell-coordinated, specialized rehabilitation program consistingof a team of physicians and health care professionals toprovide the tool necessary to depression and hopelessness,an indirect indicator of suicide risk in the SCI population.

According to a study done by Y. Kishi. The mooddisorders appear to be related to the heterogeneousetiological factors, including previous psychiatric history andseverity of impairment in activities of daily living. It couldalso be seen that starting three months after SCI, abouthalf of the depressions resolved. Nonrecovery fromdepression may be related to lack of adequate socialsupport. 3

But the depressive disorders developed within a monthof the injury as well as post injury depressive disorderswere more common in patients with complete spinal cordlesions and were divided equally between paraplegics andquadriplegics. 4

Depression is a condition that causes feeling of sadnessand hopelessness. It may be short term or long term. Itaffects the person’s health, interpersonal relations, work,and ability to enjoy life. Depending upon its severity, mostpeople, when properly assisted, will experience significantimprovement within a few weeks and complete improvementwithin 6 to 12 months. Improvements in the symptoms ofdepression quickly lead to improvement in other areas,including personal relations, motivation, health and qualityof life. 5

The CES-D scale is one of the most common screeningtests for helping an individual to determine his or herdepression quotient. The quick self-test measures depressivefeelings and behaviours during the past week. 6, 7

The CES-D scale is designed to measure depressivesymptoms in the general population. The 20-item self-administered scale measures the major components ofdepressive symptomatology, including depressive mood,feeling of guilt and worthlessness, psychomotor retardation,loss of appetite and sleep disturbances. 8

From the Medical Record Department (MRD) of ISICHospital by the permission of Medical Superintendent (MS).Written informed consent had been taken from the subjects,in English or Hindi languages. The Quadriplegia patients,who could not sign the consent form, thumb-impressionhad been taken. After taking the in formed consent, thesubjects were divided into 3 groups depending upon theduration of SCI, i.e. 0-1 month (group-1), >1-6 months(group-2), and >6-12 months (group-3) post injury. In eachgroup there were both quadriplegia, and paraplegia. TheDemographic details had been taken. Then the Depressionwas assessed by CES-D scale.CES-D with duration

There is weak correlation between CES-D and durationfrom onset of injury for considering all for the wholesample (Table-1). r-value 0.039, p-value 0.01.

develop a satisfying and productive post injury life-style. 1

In the light of these disabilities, the mental state ofpatients also has been considered and many researchers

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have documented the elevated levels of depression andsuicide in the spinal cord injured populations, with themajority of suicide attempts occurring within 12 months ofinjury onset. Various social supports have been linked withthe depression and suicidal intent, and it’s mandatory todetermine the impact of the quality and quantity of thesocial support on levels of

MethodsA purposive sample of 96 SCI subjects took part in thestudy those were being assessed at the RehabilitationDepartment of ISIC, Vasant Kunj, New Delhi.VariablesIndependent variable - Duration from onset of SCI. Level of injury. Age range.Dependent variables - CES-D scale.Inclusion criteria1. Traumatic SCI.2. Age group - 20-50 years.3. Both males and females.4. Duration of SCI up to 12 months from onset of SCI.Exclusion criteria1. Any other higher mental function disorder.Withdrawal criteria1. Frustration and irritability on the part of the patients.2. Subject wishes to withdraw his participation any time

during the course of the study.Instrumentation1. Centre for epidemiologic studies depression scale ( CES-D scale ) in English.2. Centre for epidemiologic studies depression scale ( CES-D scale ) in Hindi.

ProcedureTranslation of CES-D scale in to Hindi: After taking

permission from the author, the developer of quick self-testmeasures depressive feelings and behaviours during thepast week. 6, 7

The CES-D scale is designed to measure depressivesymptoms in the general population. The 20-item self-administered scale measures the major components ofdepressive symptomatology, including depressive mood,feeling of guilt and worthlessness, psychomotor retardation,loss of appetite and sleep disturbances. 8

From the Medical Record Department (MRD) of ISICHospital by the permission of Medical Superintendent (MS).Written informed consent had been taken from the subjects,in English or Hindi languages. The Quadriplegia patients,who could not sign the consent form, thumb-impressionhad been taken. After taking the in formed consent, thesubjects were divided into 3 groups depending upon theduration of SCI, i.e. 0-1 month (group-1), >1-6 months(group-2), and >6-12 months (group-3) post injury. In eachgroup there were both quadriplegia, and paraplegia. The

Demographic details had been taken. Then theDepression was assessed by CES-D scale.

Data analysis

The data was managed on an Excel spreadsheet andwas analyzed using SPSS software. Statistical tests usedwere t-test, DUNCAN’S Mean Test and Pearson correlationcoefficient to analyse the data.

CES-D with durationThere is weak correlation between CES-D and duration

from onset of injury for considering all for the wholesample (Table-1). r-value 0.039, p-value 0.01.

CES-D scale, for getting the CES-D scale translatedinto Hindi, the translation procedure was done by the BackTranslation Method. 9 Then the Hindi version was piloted on

Table 2: Comparison of CES-D among those group (Gp-1 duration < 1 month, Gp-2 duration, 1-6 months, Gp-3 duration 6-12 months) DUNCAN’S Mean Test.Variables GP-1 (N=30) GP-2 (N=33) GP-3(N=33) G1 V/S G2 G1 V/S G3 G2 V/S G3 F-Value

Mean SD +_ Mean SD +_ Mean SD +_CES-D 19.27 7.96 18.21 8.50 20.64 9.03 - - - 0.67

Not significant at p < 0.05 level.

Table 1: Correlation of duration with CES-D in the wholesample i.e. (N=96).

DURATION CESDDURATION Pearson Correlation 1 .039

Sig. (2-tailed) .708N 96 96

CESD Pearson Correlation .039 1Sig. (2-tailed) .708N 96 96

Significant at level 0.01.

10 SCI Hindi speaking patients.Sample selection procedure

Purposive sampling of 96 SCI subjects was doneaccording to inclusion criteria and exclusion criteria. Out ofthe total 96 patients, 90 patients had been taken from ISICRehabilitation Center. Also, the addresses of the dischargedSCI patients who fulfilled the inclusion criteria had beentaken The comparison of CES-D among the three groupswas taken through the DUNCAN’S Mean Test and therespective means and standard deviation for each groupsare as ( Table-2). Out of these three set of datas, the meanvalue of group-3 is higher than the mean value of othertwo groups. Also, the f-value is 0.67 which was not significantat level 0.05.CES-D with level

Comparison of CES-D scores with the level of injuryi.e. quadriplegics and paraplegics. In the whole sample,comparing the CES-D between quadriplegics and paraplegics(Table-3), the quadriplegics had a higher mean value.Paired t-value was 5.57** which was highly significant atp < 0.01 level.

Comparison of CES-D between diagnosis-1(quadriplegia) and diagnosis-2 (paraplegia) of group-1 (Table-4). By this, it is quite obvious to see that diagnosis-1 hashigher mean value than diagnosis-2. Also, paired t-value is2.25* is significant at p < 0.05 level

In the similar manner, the comparison of CES-Dbetween diagnosis-1 and diagnosis-2 of group-2 (Table-5),out of which, diagnosis-1 has higher mean value. Paired t-value is 4.22** which is highly significant at p < 0.01 level.

In similar ways, the comparison of CES-D betweendiagnosis-1 and diagnosis-2 of group-3. It is also seen thatdiagnosis-1 has higher mean value (Table-6). Paired t-valueis 3.24** which is again highly significant at p < 0.01 level.

CES-D with age rangeNow comparing on the basis of age groups (20-

35 years and 36-50 years age-ranges) (Table-7). Thegroup-1 has higher mean value than group-2 and the t-value is 0.06 which is not significant.

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DiscussionCES-D with duration

In the present study, the duration was correlated withthe CES-D. A weak correlation between

CES-D and duration from injury, for 96 subjects, wasfound ( Table 1 ). The possible reason could be the variousfactors that affect the level of depression. Some factorstend to increase and some level to decrease the level ofdepression. For example, according to A. Beedie 2 and Y.Kishi, 3 soon after injury the depression is usually more, aspatient receives increase as there is some impressiondepression might become less as patient may becomehopeful of improvement gradually as patient realise thatimprovement has reached a plateau and he is still notindependent in all his activity of daily living and otherelements he is likely to get depressed again. This could beone of the reason why a high correlation has not beenfound in my sample of subjects.

Also when the CES-D scale was compared among allthe three groups i.e. 0-1 month (group-1), >1-6 months(group-2), >6-12 months (group-3) (Table 6 ), the result wasnot significant. The possible reason could be that, assupported by the past studies, depression is a symptomwhich is seen in most of the SCI patients, irrespective oftheir duration from the injury. 2,3,4

CES-D with level of injuryNow, when comparing the levels of depression according

to the level of injury i.e. diagnosis-1 (Quadriplegic) and

diagnosis-2 (Paraplegic) (Table 3), the depression wasfound to be more in the quadriplegics and results werehighly significant. Possible reason could be that the level ofdisability and dependence on others for activities of dailyliving is much more in quadriplegics as compared toparaplegics (Table 3), contributing to higher degrees offeelings of sadness and depression. 10

CES-D with age rangeWhen comparison of level of depression was donein the 2 age range i.e. 20-35 years and 36-50 years

(Table 7), the results showed that depression was more inyounger age group i.e. 20-35 years as compared to 36-50years. Possible reason could be that the younger agegroup usually had people who had not settled in their livesyet: during this age people have aspiration and unfulfilledambitions in life. As a consequence of SCI, that getsshattered, leading to a high degree of depression ascompared, to age group 36-50 years.

Significance of the studyThe result of this study show that when we plan the

occupational therapy program for a SCI patients we needto keep in mind the duration from injury and correspondinglythe likely level of depression in the patients.

Also, since the study shows that quadriplegics sufferfrom depression more than paraplegics. This aspect alsohas to be kept in mind when giving therapy to suchpatients.

Also, while dealing with SCI patients belonging toyounger age group, we need to emphasise more uponcounselling and managing the levels of

depression, as compared to when dealing with theolder age group.

ConclusionConclusion of this study is that the level of depression

was found to be higher in group-3, that is >6-12 monthsfrom injury, as compared to Depression was found to behighly significant in quadriplegics subjects in all groups (0-1 month, >1-6 months, >6-12 months) as compared to theparaplegics subjects.

Also, the results showed that the depression was morein younger age group (i.e. 20-35 years) as compared to the36-50 years age group.

LimitationsThe relationship of depression was found out with only

one variable that is duration from injury. Relationship withother variables such as age etc was not out.

Future recommendationsA large sample can be taken such that gender based

comparison can be performed.

AcknowledgementsAppreciation is expressed to Ms. Ruby Aikat, M.O.Th.,

Lecture of Occupational Therapy (Neurology), ISIC Institute ofHealth and Rehabilitation Sciences, for her unwaveringencouragement, valuable advice and expertise. More wordsdo not suffice to express my feeling and gratitude to allSpinal Cord Injury Patients, without whose participation thestudy would have not been completed.

References

Table 5: Comparison of CES-D between diagnosis-1 anddiagnosis-2 of group 2 (1-6 months).

Diagnosis N Mean SD +_ T-ValueDiag-1 17 23.11 8.52 4.22**Diag-2 16 13.00 4.50

**Significant at p < 0.01 level.

Table 4: Comparison of CES-D between diagnosis-1(quadriplegia) and diagnosis-2 (paraplegia) of group 1 (< 1month).

Diagnosis N Mean SD +_ T-ValueDiag-1 15 22.33 7.33 2.25*Diag-2 15 16.20 7.56

*Significant at p < 0.05 level.

Table 3: Comparison of CES-D between diagnosis-1(quadriplegia) and diagnosis-2 (paraplegia) whole samplei.e. (N=96).

Diagnosis N Mean SD +_ T-ValueDiag-1 48 23.58 8.50 5.57**Diag-2 48 15.16 6.68

Table : 7 Comparison of CES-D between 20-35 years and36-50 years.Variables Gp-1 (N=57) Gp-2 (N=39) t-value

Mean Std Mean Std 0.06Dev ± Dev ±

CES-D 19.52 8.81 19.41 8.29Not significant at p d” 0.05 level.

Table 6: Comparison of CES-D between diagnosis-1 anddiagnosis-2 of group 3 (6-12 months).

Diagnosis N Mean SD +_ T-ValueDiag-1 16 25.25 8.41 3.24**Diag-2 17 16.29 7.43

**Significant at p < 0.01 level.

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1) Darcy A. Umphered. Traumatic spinal cord injury: MyrticeB. Atrice, Sarah A. Morrison, Shari L. Mc Dowell, BetsyShandalov, editors.Neurological RehabilitationMissouri:Mosby Publisher, 2001; p. 477-530.

2) Beedie and P. Kennedy. Quality of social supportpredicts hopelessness and depression post spinal cordinjury. Journal of clinical the other two groups 0-1 month,>1-6 month. psychology in medical settings.2004,9(3):227-234.

3) Y Kishi, RG Robinson and AW Forrester. Prospectivelongitudinal study of depression following spinal cordinjury. J Neuropsychiatry clin neurosci.1994,6:237-244.

4) Fullerton D T, Harvey R F, Klein M H, Howell T. spinalcord injuries. Arch gen psychiatry. 1981,38(12):1369-71.

5) Bryan J. Kemp. The national spinal cord injury association’sSpinal cord. org, 1998. Available from: http://users.erols.com/nscia/newsroom/ scilife/depression.html

6) CES-D scale scoring. [cited 2009 Jan 16], Available from:h t tp : / /www.ho lze ren t . com/pages / fo rms /w/ces -

depr%20scale.doccounsellingresource.com/quizzes/cesd/index.html

7) L. S. Radloff and B. Z. Locke. CES-D scale reliability andvalidity. [cited 2009 Jan 16], Available from: http://saka i . ohso .edu /access / con ten t / use r / b rodym/N574A%20spring08/ appendix/CESDepre.doc

8) Locke, B. Z., and Putnam, P. Center for epidemiologicstudies depression scale. [cited 2008 April 23], Availablefrom: www.friendsnrc.org/download/outcomeresources/toolkit/annot/cesd.pdf

9) Ali Montazeri, Amir Mahmood Harirchi, MohammadShariati, Gholamreza Garmaroudi, Mehdi Ebadi andAbolfazl Fateh. The 12-item general health questionnaire:translation and validation study of the iranian version. Healthand quality of life outcomes. 2003.

10) Joannis N, Nestoros MD, Louise A, Demers-DesrostersMD. and Lucy A., Dalicandro RN., levels of anxiety anddepression in spinal cord-injured patients.Psychosomatics. 1982,23:823-830.

Renu singh / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1

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Efficacy of Mulligan Concept (NAGs) on Pain at available endrange in Cervical Spine: A Randomised Controlled TrialKumar D1, Sandhu J S1, Broota A2,1Guru Nanak Dev University, Amritsar, 2University of Delhi, Delhi.

Abstract

PurposeThe aim of the study is to evaluate the effects of NAGs on

pain at available end range in cervical spine pain and stiffness.

MethodEthical approval was taken from Guru Nanak Dev University.

It is a repeated measure design, with double blind controlledtrials. VAS score in available end rage and the range of motionwere the dependent measures.

Participants100 patients, attending OPD, suffering from mechanical

neck pain, meeting the predefined criteria were included in thesample. The sampling was incidental; subjects were randomlyassigned to 3 experimental and 1 control group. All groupsreceived hot packs for 12 minutes along with set of activeexercises from day 1 to day 12. In experimental group 1, 2, and3, NAGs as mobilisation technique was added at different pointsof study. All patients were assessed before and after thetreatment on day 1, 2, 6, 7, 12 and 42 as follow up.

AnalysisSimple analysis of covariance (ANCOVA) with post-hoc t-

test with adjusted means and graphical presentations.

ResultsA significant improvement in ROM and decrease in pain at

available end ranges was noticed in all experimental groupsimmediately after NAGs and was maintained on 42nd Day. Group1 showed better recovery than group 2 and 3.

ConclusionsThe results indicate that the NAGs is a useful manual

therapy technique for achieving faster result as measured interms of ROM and pain at available end ranges.

KeywordsNAGs, Pain, Range of motion and Cervical Spine.

IntroductionNeck pain is one of the commonest musculoskeletal

disorders more common in women and its prevalence graduallyincreases with age1,2,. They also stated that certain cervicalmovements like turning and bending result in unbearable pain,crunching sounds and a feel of neck stiffness. Along with neck

pain, other disabling features of neck disorders are decrease inrange of motion3,4 and altered position sense5. Côté6 reportedthat in comparison to low back pain, neck pain has been poorlyresearched. In a population-based study by Evans7, in Canadaand Finland, 70% of adults had suffered from neck pain at somestage of their life. They also concluded that 5-10% of suchpopulation complained of severe disability and around 14%developed chronic pain. Whereas, in a 3 months epidemiologicalstudy it was reported that 31% of the population suffered fromneck pain in the U.S.8 Though little is known about its aetiologyand its related disability, workplace physical exposures likesedentary work position, repetitive work, precision work,awkward work postures, physical work environment, andcomputer workstation setup and psychosocial exposures likequantitative job demands and social support at work are therisk factors for neck pain in workers 9,10. Neck pain has amultifactorial aetiology and its development is dependent onthe presence of more than one risk factor9. Disability associatedwith neck pain varies from less to highly severe and its incidencein the general population is very common 11 and results in aconsiderable economic burden12, 13. MaCaulay14 reported thatneck pain has personal (pain and stiffness), social (disability)and health system costs. It has been estimated that pain andstiffness is responsible for over 500 million dollars in lost wageseach year, and people with pain and stiffness lose an averageof two and one-half work days each month7,15. Hence, personalsufferings and lost work productivity have been some of thereasons that require effective management of this condition.

A large number of conservative treatment options arereported in the literature for treating mechanical neck pain. Therehas been a mixed response available regarding their efficacy.Therapies involving manual therapy and exercise were foundto be more effective than alternative strategies for patients withneck pain16. Increasing inclination towards manual therapy wasseen in a U.S. survey in which 54% of total patients soughttreatment from manual therapist17. Mulligan’s approach isfrequently used in clinical practice for reducing pain andimproving functional abilities of neck pain sufferers18. Passiveoscillatory movements called natural apophyseal glides (NAGs)and sustained glides with active movements are the mainstayof Mulligan’s spinal treatment concept19. NAGs arepredominantly useful in restoring painful loss of active cervicalmotion20. Further, NAGs are much less likely to provoke latentpain than other spinal techniques.

The literature on the efficacy of Mulligan techniques isscanty and descriptive case report publications 20,21 generallydominate whatever researches are available. Exelby22 presenteda paper on application of mulligan concept on spinal conditionsin which she reported the clinical examples to illustrate theconcept’s application to the spine, how it has evolved and beenintegrated into constantly changing physiotherapy practice.

Personal sufferings and lost work productivity have beensome of the reasons that require effective management ofcervical spine pain. The limited evidence of the effectiveness ofMulligan techniques in the cervical spine, lack of literature on itsefficacy in improving the cervical spine problems andrecuperating the patient’s daily activities encouraged the authorto further explore the problem. The objective of the presentresearch, therefore, is to provide an integrated source ofevidence-based information, which can be used to bridge the

Kumar D. / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No.1

Address for correspondence:Deepak Kumar179, Basement, Jagriti EnclaveKarkardooma, Delhi-110092, IndiaTel: +919810265641; deepakcapri@hotmail.com

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gap between research and best practice.

Aims and objectives• To evaluate the efficacy of Mulligan concept in improving

ROM in lower cervical pain and stiffness.• To evaluate the efficacy of Mulligan concept in decreasing

pain at available end ranges in lower cervical pain andstiffness.

• To establish a scientific evidence to use Mulligan Conceptfor the benefit of the patient.

MethodologyDouble blind, randomized, controlled clinical trials with 4

different treatments. It is a single factor analysis of covariance(ANCOVA) design23. A total of 100 subjects were assignedrandomly to the 4 groups, 3 experimental and 1 control, on thebasis of predefined inclusion and exclusion criteria.

Inclusion Criteria• Both male and female subjects of 30 years and above.• Patients with either local spinal pain or joint stiffness or

combination of both between C3-C7 with no radiating painin the upper limbs.

• Neck pain that was located at least partly in the area definedby Merskey24, i.e. anywhere within the region betweensuperior tip of 3rd cervical spinous process and an imaginaryline drawn through the tip of the 1st thoracic spinous processand laterally by sagittal planes tangential to the lateralborder of neck.

• The pain was of perceptible intensity to the individual topermit a clinically demonstrable effect.

• Only subjects who gave informed consent in writing wereincluded.

Exclusion Criteria• Subjects were excluded if found to have any of the following

disease or had them in last 6 months: Cancer, Tuberculosis,Osteoporosis, aortic aneurysm, Neurological deficit due toProlapsed inter vertebral disc, Vertebrobasilar insufficiency,local infection of cervical spine, lymphadenopathy, recenttrauma to cervical spine, cervical myelopathy, upper motorneuron disorder, metabolic bone / joint disorder, hypermobility, on anticoagulant therapy, on steroids, onchemotherapy, on radiotherapy, and psychologicaldisorders like depression, mania or any other majorpsychosomatic problem. All these conditions arecontraindicated to any manual therapy.

• If they had undergone neck surgery in the previous twelvemonths.Four groups (1, 2, 3, and 4) were formed through random

assignment. Further, the 4 treatments were assigned randomlyto the groups. Patients were assessed on day 1, 2, 6,7,12, and42 (as follow-up) and both pre- and post-treatment data wererecorded. Range of motion (ROM) of cervical spine and painintensity in all six cervical ranges, at available end range wasrecorded. In present research, dual inclinometer technique wasused for measuring cervical spine ROM as American MedicalAssociation25,26 has accepted the inclinometer as “a feasible andpotentially accurate method of measuring spine mobility” figure:1(a), (b), (c), and (d) demonstrate the placement of inclinometerto record various ranges. VAS is the standard tool for rating thepain either by patient himself or by the health care workers,thus, used as a tool for measuring pain levels. The patientswere asked to track the pain along a straight line by circling thenumber that best describes the question being asked. As a

Kumar D. / Indian Journal of Physiotherapy and Occupational Therapy. Jan.-March, 2011, Vol. 5, No. 1

Fig. 1: Position of the bubble inclinometers measuringA: Flexion

D: Rotation.

B: Extension

C: Side flexion

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treatment, all 4 groups received hot pack for 12 minutes alongwith a set of active range of motion exercises and isometricstrengthening exercises for the cervical spine. NAGs areoscillatory accessory movements in anteriocranial direction,gliding one spinal facet upon facet beneath it, and are performedpassively on a patient21. Wilson20 mentioned that NAGs arecarried out in mid to end range and are used to treat movementproblems originating from C2-T3. Applied centrally or unilaterallywith the cervical spine in neutral or positioned in the direction ofmovement limitation. Direction of the glide is upwards andforwards, towards the patient’s eyes. Patient was seatedcomfortably on a chair before the treatment to be delivered asshown in figure 2. Group 1 (experimental 1) received Mulligan’sMobilization in forms of NAGs from day 1 to day 12. Group 2(experimental 2) also received Mulligan’s Mobilization in formof NAGs but only from day 1 to day 6. From seventh day onwardsthis group was treated with sham intervention. Group 3(experimental 3) did not receive any form of NAGs from day 1 today 6 and only a placebo was given. On 7th day onwards NAGswas added to this group and continued till day 12. Group 4(control) did not receive any form of NAGs on any day and onlythe placebo was continued from day 1 to day 12. Frequency ofthe glide was 1-2/sec and duration was 30 sec. in each set andthere were 3 sets in a session. Total treatment was for 12 days.Patient was asked to do home exercises in the form of activeexercises and isometrics strengthening exercises. Patients wereregularly re-assessed on day 1 [post treatment, observation 2(O2)], day 2 [post treatment, observation 4 (O4)], day 6 [posttreatment, observation 6 (O6)], day 7 [post treatment, observation8 (O8)], day12 [post treatment, observation 12 (O12)], and day42 [follow up, observation 13 (O13)], and the data were recorded.Observation 14 (O14) is the average of the above mentioned sixpost treatment and follow-up observations (O2 to O13).

ResultWhen studying the VAS scores at available end ranges of

all ranges of motion, it is observed that value of F (between O1and O14) of different groups associated with ANCOVA are highlysignificant. The values of VAS (Flexion) and VAS (Extension)are found to be [F (3, 95) = 5.45; p < .01] and [F (3, 95) =6.83; p< .01], respectively. This indicates that there is a highly significantdifference between the groups treated with NAGs and shamintervention. All the experimental groups showed better

improvement in terms of VAS in side flexion and a highlysignificant difference is seen. The value of F (between O1 andO14) of different groups associated with ANCOVA, of VAS in sideflexion to left and to right are found to be [F (3,95) =4.02; p <.01] and [F (3,95) =5.33; p < .01], respectively. While studyingthe collected data of VAS in rotations, a significant difference isobserved between the group treated with NAGs and grouptreated with sham intervention. The value of F associated withANCOVA in VAS in rotation to left is [F (3, 95) =6.59; p < .01]while the value of F in VAS in rotation to right is [F (3,95) =6.15;p < .01]. Figure 3 shows the adjusted means of VAS at availableend ranges in all ranges of cervical spine.

Fig. 2: NAGs. Position of the patient & therapist’s handplacement.

Fig. 3: Adjusted means of VAS in all available end ranges inthe cervical spine, O1 (pre-Treatment) and O14 (Average of sixpost- treatments) of different groups

In post-hoc comparison of both VAS in flexion and VAS inextension (showing average of six observation between O2 toO13) and the multiple comparisons among the means (t), it wasobserved that the overall recovery between 1 vs. 4, 2 vs. 3, 2vs. 4 is highly significant (p < .01) and 1 vs. 3 is significant at(p<.05). This indicates that overall recovery of the group 1receiving NAGs is significantly better than group 3 which startedreceiving NAGs from 7th day onwards and group 4 receivingplacebo throughout, similarly group 2 is overall significantly betterthan group 3 and group 4.

While studying the Range of motion it is observed that thereis a significant difference between the groups treated with NAGsand sham intervention. The value of F (between O1 and O14) ofdifferent groups associated with ANCOVA of range of motion inflexion and extension is found to be highly significant. The valueof F in ROM (Flexion) and ROM (Extension) is [F (3, 95) =4.50;p < .01] and [F (3, 95) =15.41; p < .01], respectively. ROM inside flexion to left also showed similar results. The difference

Fig. 4: Adjusted means of all range of motions in the cervicalspine, O1 (pre-Treatment) and O14 (Average of six post-treatments) of different groups.

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between the groups was found to be highly significant as thevalue of F associated with ANCOVA in ROM in left side flexionwas [F (3,95) =6.16; p < .01]. However, the value of F associatedwith ANCOVA in ROM in side flexion to right is not significant atthe conventional .05 level of confidence, but it is found to besignificant at .1 level of confidence [F (3,95) = 1.57; p < .1].

ROM in rotation to left and to right showed highly significantdifferences. The value F associated with ANCOVA in ROM (Lt.Side rotation) and ROM (Rt. Side rotation) is [F (3,95) =8.51; p< .01] and [F (3,95) =6.30; p < .01], respectively. The significantdifference in ROM in all cervical ranges is evident from figure 4.

DiscussionIt was found that NAGs is effective in improving the range

as well as decreasing the level of pain at newly achieved endrange. Post treatment observation revealed that ROM increasesafter NAGs and VAS score at new range is also lower than VASscore at pre-treatment range. After treating with NAGs, cervicalranges are better and less painful. Decline in VAS scores canbe due to neurophysiological effect of NAGs. Excitation ofmechanoreceptors inside joint capsule initiates the stimulationof higher centres, which in turn inhibits incoming nociceptiveinformation. This spinal gate control mechanism eradicatedpain27. Stimulation of other centres such as dorsal periaqueductalgrey matter (DPAG) region produces a profound and selectiveanalgesia28, and it has been implicated that spinal mobilizationtherapy may exert its initial effects by activating this region.

VAS scores at available end ranges are reduced, whichcan be explained by the positional fault theory18, mechanicalneck pain is usually associated with zygapophyseal joint mal-tracking and failure of the posterior column joints to glide properlymay result in an altered instantaneous axis of rotation andincreased anterior column stress29,30,31. Mulligan19 statedphysiology of NAGs can be explained as appropriate accessorymovement correcting the mechanical block within a joint andmake the joint return to it physiological position. The accessorymovement takes the joint through what would be the normalphysiological movement of the joint. The pre-injury joint trackingis re-established reasserting the ‘joint memory’ or priorconditioning of the healthy joint. These techniques are uniquebecause they consist of the application of accessory glide to ajoint, after which the patient performs a previously painfulmovement of that joint19. Reduction in pain seen may alsopossibly be attributed to the fact that the accessory glidecomponent of cervical NAGs could ameliorate pain by eitherseparating the facet surfaces or releasing the entrappedmeniscoid, or by allowing the entrapped meniscoid to return toits intra articular position, or perhaps by stretching adhesions. Itmay be this intimate relationship that can best explain why NAGs,which would appear to principally affect apophyseal joint function,are often dramatically effective32. Significant improvement inROM may be attributed to the mechanical effect of NAGs.Mechanical effects could involve a permanent or temporarychange in length of connective tissues structure such as jointcapsule of the zygapophyseal joints, ligaments and muscle.Threlkeld33 suggests that the forces used in mobilization are notgreat enough to result in micro failure of tissues and more likelyto cause temporary length changes due to creep which isreversible over time. Motion involves a combination of vertebraltilt and translations at the zygapophyseal joints 34,35. Vascular,fat-filled synovial folds project between articular surface asmeniscoid inclusion, and are prone to bruising or rupture ininjuries forming joint hemarthroses36. After passive inter-vertebralaccessory movements the frequency of entrapment of synovialfolds readily decreases. After NAGs with no soft-tissueentrapment, better physiological translation at facet joint andincreased range of motion pain is less in the patients. Rotationsare coupled with lateral bending further enhancing the chancesof lateral root compression through osteophytes. NAGs

decreases the chances of lateral root compression as stated byMulligan19 (1999) technique restores the normal movementoption to the joint, which may have both mechanical andneurological components. Whereas, Wilson20 summarized thatthe core of Mulligan’s work in symptom free joint mobilizationadded to muscular activity. Better plane of movement and addedmuscular activity increase the range of motion and decreasethe pain at available end range.

ConclusionThe results of this study highlight the effectiveness of NAGs

in improving Range of motion and decreasing pain at availableend range simultaneously in the patients suffering from cervicalpain and stiffness. NAGs is effective in improving the range aswell as decreasing the level of pain at newly achieved end range.Group 1 and group 2 treated with NAGs show better and quickerrecovery than group 3 and control group. Better physiologicalmovements have led to decline in pain at available end ranges,thus making the movement smoother and easier. This will serveas evidence in establishing effectiveness of employing thetechnique as a treatment of cervical pain and stiffness.

LimitationsWith a sample size of 100 subjects, the number of elderly

participant being less in the sample, it may not be possible togeneralize the results of the study to larger population. Further,the study was conducted at one place and with local population;replicating the study with different populations could obviate thisdeficiency. Besides treating cervical pain with NAGs, heatingmodality and exercises were also introduced to take care ofethical issues involved. Employing VAS score as a dependentvariable for measuring pain was a limitation to an extent, as it isa subjective way of assessment. This being the first investigationto study the efficacy of NAGs in treating cervical pain andstiffness, the outcome of results has not been substantiated andsupported by other studies.

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