ijpot july sept 2008

Number 3 July - Sept. 2008

Contentswww.ijpot.com

July - Sept. 2008

01 High voltage pulsed galvanic stimulation: effect of treatment durations on healing of chronic pressure ulcers Emad T.Ahmad

06 Role of latissimus dorsi in chronic mechanical low back pain due to thoraco-lumbar dysfunction

Dongre Alpana, Sharma Sanjeev

09 Effect of graded incremental mobilization on exercise tolerance following lung resection surgery T Sivakumar, G Arun Maiya

13 Dietary supplementation for reduction of muscle soreness during physical therapy: Case report Dennis R. Sparkman

17 Pilot study with Myolymphokinetic activities in the treatment of lymphedema after breast cancer Maria de Fátima Guerreiro Godoy, José Maria Pereira de Godoy, Domingo Marcolino Braile

20 Asurveyofinjuriesinfieldhockeyplayersinrelationtoplayingsurface Kawaldeep Kaur, Vikram Singh Yadav, Jaspal Singh Sandhu

24 Demographic characteristics of individuals with paraplegia in India- A survey Nalina Gupta, John Solomon M, Kavitha Raja

29 Chest physiotherapy in post extubation atelectasis in neonates - A case study Narasimman S, Varadaraj Shenoy K, Natraj R, Anita Maria Andrade

30 The effectiveness of self snags over conventional physiotherapy management in chronic neck pain among computer professionals Shilpi Chhabra, Deepti Chhabra, Jatinder Sachdeva, Amit Chaudhary

35 Effect of positive expiratory pressure technique over forced expiratory technique on bronchial hygiene in patients with moderate chronic bronchitis Smibi Skaria, Arul Joseph Arun, Jasobanta Sethi

42 BalanceDeficitsandRecoveryTimelineafterDifferentFatigueProtocols Pallavi Khanna, Gagan Kapoor, Kalpana Zutshi

Volume 2, Number 3

Indian Journal of Physiotherapy and Occupational Therapy. July - Sept. 2008, Vol. 2, No. 3 I

INDIANJOURNALOFPHYSIOTHERAPYANDOCCUPATIONALTHERAPY

Editor Dr. Archna Sharma

Head, Dept. of Physiotherapy, G.M. Modi Hospital, Saket, New Delhi - 110 017E-mail : [email protected]

Executive EditorDr. R.K. Sharma, AIIMS, New Delhi

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

“Indian journal of physiotherapy and occupational therapy” An essential indexed peer reviewed journal for 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 tretment techniques; learning about and assimilating new methodologies developing in related professions; and communicating information about new practic settings. The journal serves as a valuable tool for helping therapists deal effectively with the challenges of the field. It emphasizes articles and reports that are directly relevant to practice. The journal is now covered by INDEX COPERNICUS, POLAND. The journal is indexed with many international databases.The journal is registered with Registrar on Newspapers for India vide registration DELENG/2007/20988

Website : www.ijpot.comEditor

Dr. Archna Sharma Head, Dept. of Physiotherapy

G.M. Modi Hospital, SaketNew Delhi - 110 017

Printed, published and owned by Dr. Archna Sharma

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©All right reserved. The views and opinione expressed are of the authors and not of the Indian journal of physiotherapy and occupational therapy. The Indian journal of physiotherapy and occupational therapy does not guarantee directly or indirectly the quality or efficacy of any product or service featured in the advertisement in the journal, which are purely commercial.

National Editorial Advisory BoardProf. U. Singh, New DelhiDr. Dayananda Kiran, IndoreDr. J.K. Maheshwari, New DelhiDr. Nivedita Kashyap, New DelhiDr. Renu Sharma, New DelhiDr. S.L. Yadav, New DelhiDr. Veena Krishnananda, MumbaiDr. Anjani Manchanda, New DelhiDr. M.K. Verma, New DelhiDr. J.B. Sharma, New DelhiDr. G. Arun Maiya, ManipalProf. Jasobanta Sethi, BangaloreProf. Shovan Saha, ManipalProf. Narasimman S., MangaloreProf. Kamal N. Arya, New Delhi

International Editorial Advisory BoardDr. Amita Salwan, USA

Dr. Smiti, CanadaDr. T.A. Hun, USA

Heidrun Becker, GermanyRosi Haarer Becker, Germany,

Prof. Dra. Maria de Fatima Guerreiro Godoy, Brazil

II Indian Journal of Physiotherapy and Occupational Therapy. July - Sept. 2008, Vol. 2, No. 3

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High voltage pulsed galvanic stimulation: Effect of treatmentdurations on healing of chronic pressure ulcersEmad T.AhmadChairman, Physical Therapy Department, Health Sciences College for Males, Taif, Saudi Arabia

AbstractThe purpose of the current study was to determine theoptimal treatment duration of high voltage pulsed galvaniccurrent (HVPC) in treating Chronic pressure ulcer. Sixtyvolunteers suffering from chronic pressure ulcer wereparticipated in this study for a treatment period of five weeks.They were divided randomly and equally into four groups(3 treatment groups and one control group). Patients in thetreatment group ( G1, G2, and G3) received HVPC for 45,60, and 120 minutes for 7days /week respectively. Whilepatients in the control group received shame HVPC (45minutes , 7days/week).wound surface area(WSA) wereused to measure the outcomes before starting the studyand after 3rd and 5th weeks post-treatment. It was foundthat, there was a significant reduction in WSA in G2 (60minutes) and G3 (120 minutes) when compared with G1(45minutes) and control group (shame HVPC). On the otherhand , there was no significant difference between G2(60minutes) and G3(120 minutes).It could be concluded thatthe application of HVPC for 60-120 minutes, 7days/weekis the optimal duration in enhancing chronic dermal ulcerhealing.

IntroductionA healing wound is an extremely complex and dynamictissue process. Scientific enquiry into the many facts ofwound healing is far from complete and consequently theknowledge base is continually being enriched by input, asmuch from the clinician at the bed side, as the researcher’sbench9.

Pressure ulcer is defined as “a maceration of skin and /ordeeper tissues due to unrelieved pressure, shear force(s),and /or frictional force(s)2.Development of pressure ulceris a problem that threatens the activities of every person.There are many precipitating factors for ulcer formation;intrinsic factors include sensory, autonomic, and motorimpairment; obesity; mal nourishment; and diabetes.Extrinsic factors include unrelieved pressure; friction, directtrauma, and inadequate skin hygiene10.

Conservative (non-surgical ) management of establishedpressure sores involves control of the causal factors, suchas: removal of pressure, avoidance of skin maceration,correction of nutritional deficiencies, removal of necrotictissue, control of infection, and encouragement of soft tissuerepair(11). A plethora of methods for accelerating granulationand re-epithelialization of chronic wound exist in medicalpractice5

The role of electrotherapeutic intervention is not new withinthe realms of physiotherapy; there is in fact a long historyof electrical, electromagnetic and electrophysicalapplications that have been employed to relieve painpromote tissue repair and assist in the restoration offunction12.

It was reported that a 12 hours period of tourniquet –inducedischemia prevents the gangrene noted in the leg of controldogs15. Also it was found that a maximum effect on DNAand protein synthesis in cultured human fibroblasts usingHVPC intensity of 50 to 75 V, stimulated frequency of100PPs, and a negative electrode polarity. Maximalbactericidal effects were found using high voltage pulsedcurrent (HVPC) with an intensity of 250V at the cathode fora treatment period of two hours1.

However, it was found that a 30 minutes application of HVPCproduced no bactericidal effect at any intensity and it washypothesized that a treatment time greater than 30 minutesmay be required to produce a bactericidal effect in vitrowith HVPC6. On the other hand, it was found that one hourapplication of HVPC produced a significant increase in thehealing rate of pelvic ulcer in patients with spinal cord injury5.Moreover it was found that application of HVPC for 45minutes, three times per week for four week produced asignificant increase in the healing rate of chronic leg ulcers7.

This study aimed to compare the effect of different treatmenttimes of HVPC on chronic dermal ulcer healing.

Material and methodsPatients population

Sixty patients with 60 wounds at four investigating sitesparticipated in the study .Subjects with indolent pressureulcers grade (II) according to Yarkony-Kirk classification14

were randomly assigned into three treatment groups andone control group.

Treatment Groups: (15 wounds for each group)

Group I: Received HVPC for 45 minutes for seven days /week.Group II: Received HVPC for 60 minutes for seven days /week.Group III: Received HVPC for 120 minutes for seven days/week.

Emad T.Ahmad/Indian Journal of Physiotherapy and Occupational Therapy. July - Sept. 2008, Vol. 2, No. 3

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Control group: (15 wounds)They received same HVPC for 45 minutes for seven days /week in addition to conventional wound therapy (wetdressing, and whirlpool therapy four to five times per week).

All wounds were debrided before admission to the study,wounds were between four and ten cm2 in size. A table (1)provides general description of the study population eithertreatment groups or the control group. The subjects in thisstudy had stage II chronic pressure ulcers. Their agesranged from 30 to 50 years. There were no sex restrictionsfor participants in the study. The patients were participatedin the study for five weeks, because we believed that samemeasurable effect on healing would occur in that amountof time. Patients were excluded from the study if they hadcardiac pacemaker, peripheral vascular diseases, disposingthem to thrombosis, or active osteomyelitis or if they werepregnant or receiving long-term radiation therapy, steroidtherapy, or chemotherapy. Following the initial evaluationto determine whether the wound and the patients met theselection criteria, each patient signed an informed consentform.

EquipmentA small portable high voltage monophasic twin pulsedgenerator was used in this study. The unit parameters wereset accurately at a frequency of 120 Hz, an interphaseinterval of 50 µsec, and a voltage just below that capableof producing a visible muscle contraction (100-175V).

Procedure of the studyHVPC Treatment protocol (Treatment phase)

Patients in the treatment groups received 45, 60, and 120minutes of HVPC applied to the ulcer site once daily, sevendays per week. A piece of heavy –duty aluminum foil, slightlywet and larger than ulcer perimeter, was attached withalligator clip to negative lead of the HVPC unit. The foilelectrode was placed over the ulcer on top of saline soakedgauze. A sand bag or elastic wrap was used if needed tohold the wound electrode in place. The dispersive electrodewas strapped over the patients’ medial thigh, with wet gauzeplaced between the electrode and the patients’ skin. Theactive electrode was of negative polarity for the first threedays of HVPC application, while the dispersive electrodewas of positive polarity. After these three days period, thepositive polarity was now at the active electrode and thenegative polarity was the dispersive electrode. The positivepolarity was maintained at the active electrode until thewound healed or a plateau in healing was noted, if such aplateau was reached the protocol of negative polarity atthe wound site for three days period was restarted.

Control Group (Treatment phase)

Patients in the control group had electrodes applied in thesame manner as patients in the treatment groups, but thevoltage was maintained at zero.

Wound Healing Assessment phase

The measurement of wound surface area (WSA) wasconducted by tracing of wound perimeter according Klothand Feedar8. The WSA measurement was conducted bythe following steps:

A sterilized transparency film was placed over the ulcer.The ulcer perimeter was traced by using the film tippedtransparency marker. Each ulcer was traced three times toestablish measurement reliability. After tracing thetransparency film face which faced the ulcer was cleanedby a piece of cotton and alcohol. The carbon paper wasplaced over the metric graph paper one mm2. The tracedtransparency film was placed over the carbon paper with awhite paper in between, and transcribed the tracing ontothe metric graph paper. The number of square millimeterson the metric graph within the wound tracing was countedto determine the WSA. The mean of the three trials wascalculated and considered as WSA. The WSAmeasurements were taken at zero(Pre), 3rd (Post I) and 5th

(Post II) week.

Data analysis. A paired t Test was conducted to compareboth wound area initially and after 3rd and 5th weeks oftreatment. Unpaired t test was conducted to comparetreatment groups (GI,GII,GIII) with control group.

ResultsI-Results of treatment group

A-Results of the Group I(HVPC for 45 minutes)

The mean value and standard deviation of WSA (Cm2) inthis group before application of the treatment(Pre) was7.12±1.63 Cm2, while the mean values of WSA afterapplication of HVPC for 45 minutes measured after 3rd (PostI)and 5th weeks (Post II) were, (6.4±1.53 and 5.1±1.73 Cm2)respectively . There was a significant decrease in the WSAmeasured after 3rd (Post I) and 5th weeks (Post II) postapplication of HVPC for 45 minutes compared to initialmeasurement (before application of the treatment),(P<0.001) as shown in table (2) ,and fig(1).

B- Results of the Group II (HVPC for 60 minutes)

The mean value and standard deviation of WSA (Cm2) inthis group before application of the treatment was 7.12±1.62Cm2 ,while the mean values of WSA after application of


Table 1: General characteristics of patients.

Groups SexM/F Age(years)Mean ±S.D. Wound duration (months)Mean ±S.D.Group I(45 minutes) 6/9 38.4±6.82 4.41±0.9

Group II(60 minutes) 7/8 38.47±1.68 4.4±0.9

Group III(120 minutes) 8/7 39.4±1.74 4.41±0.9

Control group 9/6 39.4±1.69 4.48±0.9

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HVPC for 60 minutes measured after 3rd (Post I)and 5th

weeks (Post II) were 3.46±0.82 and 0.6±0.35 Cm2,respectively . There was a significant decrease in the WSAmeasured after 3rd(Post I) and 5th weeks(Post II) postapplication of HVPC for 60 minutes compared to the initialmeasurement,(P<0.001), as in shown in table (3) ,and fig(2).

C- Results of the Group III (HVPC for 120 minutes)

The mean value and standard deviation of WSA (Cm2) inthis group before application of the treatment was7.14±1.57Cm2while the mean values of WSA after application ofHVPC for 120 minutes measured after 3rd (Post I) and 5th

weeks (Post II) were 3.68±0.79 and 0.64±0.61 Cm2,respectively. There was a significant decrease in the WSAmeasured after 3rd (Post I)and 5th weeks (Post II) weekspost application of HVPC for 120 minutes compared to theinitial measurement (P<0.001) , as shown in table (4) ,andfig(3).

II-Results of the Control Group

The mean value WSA (Cm2) in the control group beforeapplication of the treatment was 7.21±1.54 Cm2, while themean values of WSA after application of sham HVPC for45 minutes, seven days per week, and conventional woundtherapy (wet dressing, whirlpool therapy for four to five times

Fig. 1: The mean values of WSA in the group I (HVPC for 45 minutes) at,zero, (Pre), 3rd(Post I) and 5th week(Post II).

Fig. 2: The mean values of WSA in the group II (HVPC for 60 minutes) atzero, (Pre) 3rd(Post I) and 5th week(Post II).


Table 2: The WSA in the group I (HVPC for 45 minutes) at, zero, (Pre), 3rd(Post I) and 5th week(Post II).

WSA( Cm2) Group 1 (45 minutes)

Zero 3rd week Zero 5th week 3rd week 5th weekPre Post I Pre Post II Post I Post II

Mean 7.12 6.4 7.12 5.1 6.4 5.1

S.D.± 1.63 1.53 1.63 1.73 1.53 1.73

S.E. 0.42 0.39 0.42 0.44 0.39 0.44

t-value 9.66 14.56 12.72

P-value <0.0001 <0.0001 <0.0001

Table 4: The WSA in the group III (HVPC for 120 minutes) zero, (Pre) 3rd(Post I) and 5th week(Post II).

WSA( Cm2) Group III (120 minutes)


Mean 7.14 3.68 7.14 0.64 3.68 0.64

S.D.± 1.57 0.79 1.57 0.61 0.79 0.61

S.E. 0.4 0.2 0.4 0.15 0.2 0.15

t-value 16 22.78 29.2

P-value <0.0001 <0.0001 <0.0001

Table 3: The WSA in the group II (HVPC for 60 minutes) at , zero, (Pre) 3rd(Post I) and 5th week(Post II).

WSA( Cm2) Group II (60 minutes)


Mean 7.12 3.46 7.12 0.6 3.46 0.6

S.D.± 1.62 0.82 1.62 0.35 0.82 0.35

S.E. 0.42 0.21 0.42 0.09 0.21 0.09

t-value 13.97 17.13 17.32

P-value <0.001 <0.0001 <0.001

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per week) measured after 3rd (Post I) and 5th weeks were 6.65±1.47 and 5.39±1.79 Cm2, respectively. There was asignificant reduction in the WSA measured after 3rd (PostI)and 5th weeks post application of sham HVPC comparedto the initial measurement (P<0.001), as shown in table(5), and fig(4).

III- Comparison and analysis of the mean value of WSAfor treatment groups and control group beforeapplication of the treatment (zero week) and after 3rd ,and 5th week) post treatment.

A-Before application of treatment (Zero weeks)

There were no significant differences in WSA among controlgroup and treatment groups (GI, GII, and GIII) (P>0.05).

B-After 3rd week post treatment

During this period of measurement, there was a significantreduction in WSA in the 3 treatment groups when comparedwith control group (P< 0.001). On the other hand , therewas a significant reduction in WSA in GII compared to GI,(P<0.001). There was a significant reduction in WSA in GIIIcompared to GI (P<0.001). There was a significant reductionin WSA in GII compared to GIII, (P<0.001).

C-After 5th week post treatment

During this period of measurement, there was a significantreduction in WSA in the 3 treatment groups when comparedwith control group (P< 0.001). On the other hand , therewas a significant reduction in WSA in GII compared to GI,(P<0.001). There was a significant reduction in WSA in GIII, compared to GI, (P<0.001). On the other hand therewas no significant reduction in WSA in GIII compared toGII (P>0.05).

DiscussionThis study was designed to compare different HVPCapplication times on acceleration of pressure ulcer healing.No significant differences existed between the treatmentgroups and the control group which would be expected toaffect treatment outcome.

Since the all treatment groups received identical ulcermanagement except for duration of application, anydifferences in healing between the three treatment groupsmay be attributed to the duration of application of HVPC.

It was found that after the 3rd week of HVPC applicationthere was significant reduction in WSA measured after 60minutes of application more than that reported after 120minutes of application. On the other hand at the 5th weekpost HVPC, there was no significant difference in WSAmeasured after 60 and 120 minutes of application.

The results of this study are agree with that of other studiesshowing that application of HVPC for 60 minutes enhancethe rate and extent of healing of chronic wounds.

A similar findings was reported by Kloth and Feedar8, who stated that the HVPC treatment time which satisfactorilyenhanced tissue healing did not exceed 60 minutes perday for five to seven days a week. This treatment time is incontrast to the 20 to 45 hours of electrical stimulationtreatment per week reported in other studies.

The treatment time between three to seven hours per weekreported by Kloth and Feedar8, and seven hours per weekreported in this study may be beneficial.

It was no surprising to us to find that there was a significantreduction in WSA in control group measured after 3rd and5th weeks, because each of these wounds received anintensive amount of additional care, including maintenance

Table 5: The WSA in the control group at, zero, (Pre), 3rd(Post I) and 5th week(Post II).

WSA( Cm2) Group III (120 minutes)


Mean 7.21 6.65 7.21 5.39 6.65 5.39

S.D.± 1.54 1.47 1.54 1.79 1.47 1.79

S.E. 0.39 0.38 0.39 0.46 0.38 0.46

t-value 16.7 15.69 10.28

P-value <0.001 <0.001 <0.001

Fig. 3: The mean values of WSA in the group III (HVPC for 120 minutes) atzero, (Pre) 3rd(Post I) and 5th week(Post II).

Fig. 4: The mean values of WSA in the control group at, zero, (Pre), 3rd

(Post I) and 5th week(Post II).


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of moist wound microenvironment as part of the shamtreatment.

There is a growing evidence that exogenous electricalcurrents can augment the healing process of dermal ulcer,perhaps by mimicking the body’s own bioelectrical signals.A convincing evidence exists that electrically augmentedhealing of delayed ulcer is best facilitated by HVPCstimulation for 60 minutes for seven days per week.Additional studies are needed to identify the mechanisminvolved in the promotion of wound healing with HVPC andto determine the stimulus variables that most effectivelyaccelerate tissue repair.

It is well established that all cells are electrically active, notjust those of the excitable tissue. The cell membrane has amembrane potential which averages 70mv, and thiselectrical cell membrane activity is critical to normal cellfunctions. The level of electrical activity of the cellmembrane influences the general activity of the cell. If themembrane is electrically quiescent, the cell down regulates,and its functional capacity diminishes. Conversely, withincreased levels of electrical activity, up-regulation occursand the general cell activity levels increase3.

By influencing the activity levels of the cell membrane, it ispossible to adjust the excitement level in the cell. This canbe achieved with a variety of exogenous energy sources13.

Results from our study and previous studies led us tosuggest that wound closure is enhanced with HVPC, if theselected duration of application is appropriate. This studyconfirms the efficacy of HVPC, as given for wound healingvia epithelial closure. These results suggest that the use ofHVPC in dosage and manner used in this study is a safeand effective way to treat stage II chronic dermal ulcer.

The WSA significantly decreases after HVPC for 3rd and 5th

weeks .However there was no significant differencebetween application of HVPC for 60 and 120 minutes.

It could be concluded that the application of HVPC for 60-120 minutes, 7days/week is the optimal duration inenhancing chronic dermal ulcer healing.

References1. Bourguignon GJ and Baurguignon LYW : “Electrical

Stimulation of Protein and DNA Synthesis in Human

Fibroblasts” FASEBJ. 1987; 1:398-402.2. Crebshow RP, and Vistnes LN : “A decade of Pressure

Sore Research 1977-1987” J Rehabil Res Dev 1989;26: 63-74.

3. Charman RA: “ Bioelectricity and ElectrotherapyToward a New Paradigm: Part 1, The Electrical Cell”Physiotherapy 1990; 76: 503-508.

4. Delrsay JA, and Mikulic MA:” Pressure Ulcer: Whatto do if Preventive Management Fails” PostgraduateMed 1985;77:209-220.

5. Griffin JW, Tooms R, Mendius RA, Clifft ,R, VanderZwaag, and Zeky : “ Efficacy of High Voltage PulsedCurrent for healing of Pressure Ulcer in Patients withSpinal Cord Injury” Phys Ther 1991;71: 433-444.

6. Guffey JS and Asmussen MD:”In Vitro BactericidalEffects of High Voltage Pulsed Current Versus DirectCurrent Against Staphylococcus Aureus” ClinicalElectrophysiology 1989;1:5-9.

7. Houghton PE, Kincaid CB, Lovell M, Campbell KE,Keast DH, Woodbury MG, and Harris KA: “ Effect ofElectrical Stimulation on Chronic Leg Ulcer Size andAppearance” Phys Ther 2003; 83:17-28.

8. Kloth LC, and Feedar JA, “Acceleration of WoundHealing with High Voltage Monophasic PulsedCurrent” Phys Ther 1988;68;503-508.

9. Kumar S, Wong PF, Leaper DJ: “ What Is Knew inWound Healing?” Turk J Med Sci 2004; 34: 147-160.

10. Nussbaum EL, Biemann I, Mustard B :” Comparisonof Ultrasound/ Ultraviolet-C and Laser for Treatmentof Pressure Ulcer in Patients with Spinal Cord Injury“ Phys Ther 1994;74:812-825.

11. Skylar CG: “Pressure Ulcer Management in theNeurologically Impaired Patient” J Neurosci Nurs1985; 17:30 -36.

12. Watson T: “Current Concepts in Electrotherapy”Haemophilia 2002; 8:413-418.

13. Watson T: “The Role of Electrotherapy inContemporary Physiotherapy Practice” Man Ther2000; 5:132-141.

14. Yarkony GM., Kirk PM., Carlson C., Roth EJ., LovellL., Heineman A., King R., Lee MY., and Betts HB. : “Classification Of Pressure Ulcer” Archives OfDermatology 1990; 126(9): 1218-1219.

15. Young HG : “Electrical Impulse Therapy Aids WoundHealing” Modern Veterinary Practice 1966;47:60-62.


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Role of latissimus dorsi in chronic mechanical low back pain dueto thoraco-lumbar dysfunctionDongre Alpana1, Sharma Sanjeev2

1Professor, 2Assistant professor, Ravi Nair Physiotherapy College, DMIMS Sawangi Wardha India [email protected]

Study Design: Randomized controlled single blindedclinical trial.

Objective: To identify prevalence of thoraco-lumbardysfunction (TLD) and analyze the role of latissimus dorsiin it.

Summary of background data: 30% of chronic mechanicalback pains are reported to be due to TLD. The thoraco-lumbar muscles control the dynamic and postural stabilityof the lower spine. Though core stabilization exercises arewidely recommended for low back pain, but no reports areavailable for exercises specific to thoraco-lumbardysfunction.

Methods: 30 subjects in age group of 25 to 40 years withnon traumatic, chronic mechanical low back pain wereidentified for study and randomly divided into two groups.Group-A (n=15): only core stabilization exercises andGroup-B (n=15): latissimus dorsi strengthening and corestabilization exercises. Primary outcome measure was painintensity (VAS score). Secondary outcome measures weregeneral health (SF-36) and back pain disability (Aberdeenback pain disability score). Outcome measurement scoreswere compared using unpaired student t-test.

Results: 42 % of all subjects had back pain of TLD origin.88% of TLD subjects had latissimus dorsi strength < 4. Highlysignificant improvement in general health (p <0.0001), andsignificant improvement in disability score (p= 0.0017) wasobserved in the Group-B subjects. Re-assessment after 3and 6-months reflected better scores in Group-B subjects.Conclusion: Identification of TLD as a cause of low backpain is recommended in all non-traumatic, chronic,mechanical low back pains. Strengthening of latissimusdorsi relieves thoraco-lumbar related back pain.

Key words: low back pain, thoraco-lumbar dysfunction,latissimus dorsi strengthening, dorso-lumbar fascia.

Key points: 42% of non-traumatic chronic low back painsare due to thoraco-lumbar dysfunctions. Contractions oflatissimus dorsi with lumbar stabilizers act towards thoraco-lumbar stabil ization. It leads to early pain relief,improvement in general health and reduction of back paindisability.

IntroductionBack pain is a primary reason to seek medical advice.Considering 80% of people suffering with back pain, wecan say it is a universal epidemic requiring attention.Sources of back pain are numerous, usually sought in aslesions of disc or facet joints at L4-L5 and L5-S1 levels1.

Robert Maigne described thoraco-lumbar dysfunction (TLD)as pain originating in thoraco-lumbar region, but reportedby patients in either the low back or upper buttocks. Thesepains are mostly chronic in nature and constitute 30% ofall low back pains2,18.

Thoraco-lumbar fascia is used for load transfer3. Thesuperficial lamina gets tensed by contraction of variousmuscles, such as the latissimus dorsi, gluteus maximusand erector muscle3.

Many rehabilitation techniques for LBP are proposed.Several researchers have used different stabilizing exercise,strengthening the muscles of the trunk and backemphasizing the correct timing and co-contraction4-8. Theiraims are short time pain decrease, muscular strengthening,and increased hip and lumbar spine mobility, increasedlumbar and pelvic proprioceptive sensibility9.

Core strengthening has become a major trend inrehabilitation. It is in essence a description of the muscularcontrol required around the lumbar spine to maintainfunctional stability10.

The core contraction alone is logically presumed ineffectivein producing required forces for the stabilization of thoraco-lumbar junction. The extensive and thick attachments tothe superior part of thoraco-lumbar fascia have a definiterole to play in the stability of this junction. In our opinion,circumstances where thoraco-lumbar dysfunction is foundto be the cause of low back pain, concentric strengtheningof latissimus dorsi with core stabilization exercises willproduce the required tensile forces at the thoraco-lumbarregion and contribute towards its functional stability.

The patients we cater in our physiotherapy clinic are fromrural area, where compliance to institution based treatmentby patients is poor. We wanted to design a home-basedself performed exercise program that can be reviewedperiodically.

The study was designed to a) identify the cases of low backpain with TLD, b) ascertain whether lumbo-pelvicstabilization exercises are alone effective in low back painwith TLD and c) analyze the association between latissimusdorsi and low back pain due to TLD.

Material and methodsThe study was approved by the college ethical committee.All subjects were informed of procedures and an informedconsent was obtained. Subjects who reported tophysiotherapy clinic with complaint of low back pain wereclinically assessed for signs of TLD. Patients with TLD were

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identified by the:1) positive ‘iliac crest point’ test, 2) positiveskin roll test, 3)localized tenderness over spinous processat the thoraco-lumbar junction (T11 to L2), and 4)tenderness over involved apophyseal joint at the thoraco-lumbar junction11. Subjects with positive signs of TLD wereincluded in the study. Those with associated lumbarradiculopathy, sacroilliac joint dysfunction or history oftrauma or surgery to lumbar spine were excluded.Radiculopathy was clinically assessed by Lassegue’s test.Sacroilliac joint dysfunction was confirmed by striding tests.Latissimus dorsi muscle strength was tested using manualmuscle testing as described by Kendall and colleagues12.All subjects identified for the study were also evaluatedusing back pain disability score (Aberdeen low back paindisability score) intensity of pain (visual analogue score)and general health score (SF-36), 100 subjects in the agegroup of 25 to 40 years with low back pain were assessedfor clinical signs of TLD. 18 (18%) subjects tested positivefor lumbar radiculopathy, and 10 (10%) subjects hadsacroilliac joint dysfunction (2 subjects had associated signsof lumbar radiculopathy). Following the exclusion criteria,72 (72%) subjects were then evaluated for TLD of which30 (42%) tested positive.

These 30 subjects included 12 (40%) females and 18 (60%)males. They were randomly assigned to two groups. Group-A received only core muscle stabilization exercises insupine and quadruped positions. Group-B receivedlatissimus dorsi muscle strengthening exercises usingtheraband along with core muscle contractions. Subjectswith muscle spasm were given moist heat therapy beforeexercises.

To ensure that the subjects do not go wrong with therequired muscle contractions, they were instructed to attendhospital based treatment 1-week. Later, they continued theexercises at home for 1-month. SF-36, Aberdeen low backpain disability score and VAS score were then re-evaluated.Follow-up assessment was done at a 3-month and 6-monthinterval using all the three outcome measures.

ResultsMean age of Group-A subjects was 33.73± 12.6 and ofGroup-B was 34.4 ± 7.058. . All subjects (100%) presentedwith complaints of pain in anterior and lateral part of thigh.56.6% (n=30) complained of pain in upper glutei and 86.6%(n=30) reported lower lumbar pain. Only 46.6 % of allsubjects reported with pain in thoraco-lumbar region (Figure1). Latissimus dorsi muscle strength was found to be < 4 in88% (n=30) subjects (Figure 2).

The different outcome measures were analyzed usingunpaired student’s t-test. Following the 1-month exercises,highly significant improvement in general health (t= 3.4695,p<0.0001), very significant reduction in back pain relateddisability (t=5.1999, p=0.0017) and significant reduction inpain (t=2.1767, p=0.0381) was observed in subjects whoreceived latissimus dorsi strengthening along with corestabilization exercises (Table 1).

Follow-up assessment at 3-month interval was witnessedwith no change in the scores of either SF-36, Back paindisability or VAS. After 6-month interval, the average SF-

36 scores alone increased by 5% but individuals reportedbetter social and family relations and less frequency ofpains.

DiscussionThoraco-lumbar dysfunction as a cause of back pain in 42%of subjects with low back pain is suggestive of the need toregularly check its presence in all cases of low back pains.The patients may have radiological evidence of lumbarpathology. Also the thoraco-lumbar junction may / may nothave radiological signs of involvement, but the importanceof clinical assessment of the thoraco-lumbar junction cannotbe under-estimated. Posterior layer of thoraco-lumbarfascia has two laminae. The superficial lamina is formedby the aponeurosis of latissimus dorsi13. Tensiletransmission across the thoraco-lumbar fascia (TLF) servesas an important element for back stability14. The thoraco-lumbar muscles control the dynamic and postural stabilityof the lower spine13. Both superficial and deep laminae ofthe posterior layer are more extensive superiorly.Contractions of latissimus dorsi produce a superior andlaterally directed tension on the superior aspect of thoraco-lumbar fascia. This is likely to have implications on thestability of thoraco-lumbar junction. The thickness of thesuperior attachments is also variable15. Functional instabilityis defined as a relative increased range of the neutral zone16.Active stability can be achieved through muscular co-contraction, akin to tightening the guys of a tent to unloadthe center pole16.

In one of the research studies, lumbo-pelvic stabilizationexercises were found to be non-effective in abdominal orback muscle activity and pain or functional disability

Fig. 1: Graph showing the distribution of pain in 30 subjects with thoraco-lumbar dysfunction (TLD).

Fig. 2: Percentage of 30 subjects with thoraco-lumbar dysfunction and MMTgrades of their latissimus dorsi muscle.


8

indices17. We feel that the subjects with latissimus dorsimuscle weakness in the presence of thoraco-lumbardysfunction will not respond positively to lumbo-pelvicstabilization exercises alone. The core stabilization exerciseincrease tension in the thoraco-lumbar fascia, more in itsinferior part. If the subjects have latissimus dorsi muscleweakness, then there will be slackness in the superiorportion of the fascia. This slackness is adjusted by thoracickyphosis and instability at the thoraco-lumbar junction. Thisconcept also seems to be the basis of resolving thesacroilliac pain by fixation of thoraco-lumbar junction usingjoint manipulations18.

The posterior rami of the T-12 and L-1 nerve roots innervatethe superior gluteal regions and the inferior subcutaneoustissues. The anterior rami innervate the inferior abdomenand groin. A lateral cutaneous branch innervates thetrochanteric region. Our observation of 100% subjectsreporting with anterior/lateral thigh pain can be explainedwell with this. Concentric contractions of the latissimus dorsiand core stabilization exercises together will reduce thecompression forces over the facet joints of T10 to L1 levels.This will reduce the irritation to the posterior, anterior andlateral primary rami of the T12 and L1 nerve roots.

The importance of examining the thoraco-lumbar junctioneven in the presence of clinically evident lumbar pathologycannot be under-estimated. Core stabilization exercisesalone are ineffective in cases where low back pain isassociated with thoraco-lumbar dysfunction. Concentricstrengthening of latissimus dorsi and core stabilizationexercises together are very effective in relief of back pain.Also, it produces an improvement of general health,improved social and family relations. The effects werelasting even after 6-months of supervised care.

References1. Schwarzer A et al. The relative contribution of the disc

and zygapophyseal joint in chronic low back pain.Spine 1994; 19:801-06.

2. Maigne R. (1980). Low Back Pain of thoracolumbarOrigin. Arch. Phys. Med. Rehabil.,61;389-95

3. Vleeming A, Pool-Goudzwaard AL, Stoeckart R,et al.The posterior layer of the thoraco-lumbar fascia, itsfunction in load transfer from spine to legs. Spine1995; 20(7):753-58.

4. Hides JA, CA Richardson and GA Jull. Multifidusmuscle recovery is not automatic after resolution of

acute, first-episode low back pain. Spine 1996; 21(23):2763-69.

5. O’Sullivan PB, et al. Evaluation of specific stabilizingexercise in the treatment of chronic low back painwith radiologic diagnosis of spondylolysis orspondylolisthesis. Spine 1997; 22(24): 2959-67.

6. O’Sullivan PB. Lumbar segmental ‘instability’: clinicalpresentation and specific stabilizing exercisemanagement. Man Ther 2000; 5(1): 2-12.

7. O’Sullivan PB, L Twomey and GT Allison’.Alteredabdominal muscle recruitment in patients with chronicback pain following a specific exercise intervention. JOrthop Sports Phys Ther 1998. 27(2):114-24.

8. Poivaudeaus, Lefevre-Colau MM, Mayoux-BenhamouMA, Revel M. Which rehabilitation for which back pain.Rev Prat 2000 Oct 15;50(16):1779-83.

9. Hides JA, GA and CA Richardson, Long-term effectsof specific stabilizing exercises for first-episode lowback pain. Spine 2001; 26(11): E243-48.

10. Akuthota V, Nadler Sf. Core strengthening. Arch PhysMed Rehabil 2004 March; 85(3 suppl):586-92.

11. Maigne R. Diagnosis and treatment of pain of vertebralorigin. A manual medicine approach. Baltimore:Williams & Wilkins, 1996:411-17.

12. Kendall FP, Kendall-McCreary E, Provance P.Muscles: Testing and Function, 4th ed. LippincottWilliams & Williams, 1993.

13. Bogduk N, Macintosh JE. The applied anatomy of thethoracolumbar fascia. Spine 1984 Mar;9(2):164-70.

14. Barker P J, Briggs C A, Bogeski G 2004 Tensiletransmission across the lumbar fascia in unembalmedcadavers: effects of tension to various muscularattachments. Spine 29(2): 129-138.

15. Barker PJ, Briggs CA. Attachments of the posteriorlayer of lumbar fascia. Spine 1999 Sep 1;24(17):1757-64.

16. Brukner and Khan. Core stability. In: 3ed. Clinicalsports medicine. Mcgraw-Hill Australia: 2006: 158-159.

17. Arokoski JP, Valta T, Kankaanpaa M, Airaksinen O.Activation of lumbar paraspinal and abdominalmuscles during therapeutic exercises in chronic lowback pain patients. Arch Phys Med Rehabil 2004 May;85(5):823-32.

18. Joseph Kurnik. Thoracolumbar junction responsiblefor 40% of low back pain. Dynamic Chiropractic, Dec15, 2000; 18(26). Available at: website http://www.chiroweb.com/archives/18/26/14.4html .Accessed July 14, 2007.

Table 1: Unpaired t-test analysis of the improvement of the different parameters between two groups


% of change in SF-36 scores % of change in Aberdeen back pain Difference in VAS score

related disability scoreGroup-A Group-B Group-A Group-B Group-A Group-B

Mean and 42.5 ± 72.62 ± 65.52 ± 90.151 ± 56.16 ± 65.18 ±

SD 19.005 27.74 16.43 8.156 9.69 11.90

t-value 3.4695 5.1999 2.2737

Df 28 28 28

p-value <0.0001 =0.0017 =0.0309

Highly significant Very significant Significant

9

Effect of graded incremental mobilization on exercise tolerancefollowing lung resection surgeryT Sivakumar1, G Arun Maiya2

1Assistant Professor, 2Head and Associate Professor, Dept of Physiotherapy, Manipal College of Allied Health Sciences,Manipal University, Manipal

in the first three weeks post operatively and showssubsequent improvement.1,2 The resection of the pulmonaryparenchyma, thoracic incision and diaphragmatic inhibitionwere quoted as the factors causing the reduced ventilatorydysfunction.1,2,3 The exercise tolerance following pulmonaryresection also follows the same pattern of ventilatorydysfunction i.e., greater reduction in the early postoperativeperiod and subsequent improvement during fourth weekfollowing the surgery.4,5,6 As reported in many studies,exercise tolerance following lung resection, is reduced andthe major contributing factor for this ventilatory dysfunctionfollowing the surgery. As the ventilatory dysfunctionimproves the exercise tolerance shows improvement.4,5,6

In patients with low aerobic reserve, the surgery and itsaccompanying multiple co-morbidities impose a major loadon the remaining lung. There is a need for effectivemanagement to optimize the oxygenation according to theincreased demand and to prevent complications followingsurgery in these patients. Incremental exercises above thethreshold intensities can be a stimulus and lead to betteroptimization of oxygenation, and thereby improve exercisetolerance during the postoperative period. The objective ofthis study was (i) to evaluate the changes in exercisetolerance following lung resection with six minute walk testand (ii) to evaluate the influence of graded incrementalmobilization exercises on exercise tolerance duringpostoperative period following lung resection.

MethodologyEighteen patients who were electively posted for pulmonaryresection were selected for the study. Informed consentwas taken from the patients. All patients were randomlyassigned into two groups control group and experimentalgroup. All patients were evaluated preoperatively andpreoperative physiotherapy was given to both the groups.The experimental group patients were given instructionsregarding the graded incremental mobilization. Followingsurgery physiotherapy treatment started in the day ofsurgery. Patients in both groups were treated according toroutine postoperative physiotherapy protocol. Patients inexperimental group received graded incrementalmobilization exercises from postoperative day two onwards.In this, every session the patient’s mobilization wasincremented by 150% of the prior session. For example,every session the patient was asked cover 150% of thedistance covered in the previous session. Following thedischarge, experimental group patients were givenmaintenance program.

AbtractObjective: To evaluate the effect of graded earlymobilization on exercise tolerance during post operativeperiod following lung resection surgeries

Design: Controlled experimental trial; Descriptive study.

Subjects: Patient who underwent elective lung resectionsurgery were selected and randomly assigned in to twogroups control group and experimental group using blockrandomization.

Procedure: All patients were evaluated preoperatively forpulmonary function measures and six minute walk distance(6MWD) with spirometry and six minute walk testrespectively. Patients in both groups underwentconventional postoperative physiotherapy protocol.Experimental group patients received graded incrementalmobilization exercises in addition. The mobilizationexercises were incremented by 150% for every session.Pulmonary function measures and 6MWD were measuredon tenth postoperative day and at the end of fourthpostoperative week.

Results: Within group comparison of the variables wasdone with paired ‘t’ test and between group comparisonswith independent ‘t’ test. FEV1, MVV and 6MWD werereduced on tenth postoperative day and showed a recoveryby fourth week in both groups. However in experimentalgroup the decrease on tenth day was less, and significantly(p = 0.00) improved during fourth week postoperativelywhen compared to control group.

Conclusion: Graded incremental mobilization enhancesthe recovery of lung function and exercise tolerance in thepost operative period following lung resection surgeries.

Keywords: Graded incremental mobilization, exercisetolerance, six minute walk test, six minute walk distance,lung resection.

IntroductionLung resection is the common surgical procedure in variousadvanced pulmonary pathologies like, pulmonarytuberculosis, lung abscesses, and bronchiectasis. Lungresection may lead to various levels of circulatory andventilatory dysfunctions. Ventilatory dysfunction is greatest

Corresponding Author:T SivakumarAssistant Professor, Dept of Physiotherapy, MCOAHS, Manipal UniversityManipal, Karnataka – 576104, INDIA

T Sivakumar et al/Indian Journal of Physiotherapy and Occupational Therapy. July - Sept. 2008, Vol. 2, No. 3

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All patients performed pulmonary function test(PFT) andsix minute walk test(6MWT) preoperatively(preop), tenthpostoperative day(Post op I) and at the end of fourthpostoperative week (Post op II). PFT was performedaccording to American thoracic society guidelines. 6MWTtest was performed according to American thoracic societyguidelines statement.7 The parameters considered for thestatistical analysis were FEV1, Maximum VoluntaryVentilation (MVV) and Six minute walk test distance(6MWD).

Statistical analysisWithin group comparison of preoperative and post operativemeasures of control and experimental group was doneusing Wilcoxon signed rank test. And to evaluate the effectof graded incremental mobilization exercises, comparisonchanges between the control and experimental group wasdone using Mann Whitney U test. The level of significancewas set at p d” 0.05.

ResultsOut of eighteen patients underwent elective lung resectionsurgery; fifteen patients were taken up for the study. Amongthe three excluded, one expired during acute post operativeperiod as perioperative complication and the other two hadco morbid diseases which would affect their exerciseperformance in 6MWT. The characteristic features of thepatients who participated in this study are summarized inthe table 1.

Though pneumonectomy and lobectomy lead to variouslevels of pulmonary dysfunction, they were considered

together. This might have lead to variability in the outcomemeasures, however having equal no of pneumonectomyand lobectomy patients in either group would have reducedthe confounding due wide range of dysfunction (table 1).

The preoperative and postoperative PFT and 6MWDmeasures of control group and experimental group aresummarized in the table 2 and table 3 respectively. Fromthe data collected from control group, it is evident that thereis a decrease in the early postoperative period (post op I)from preoperative period (pre op) and recoverysubsequently by one month postoperative period (post opII) of FEV1, MVV and 6MWD. The decrease during post opI from preop values is statistically significant (table 2); butthe subsequent improvement during post op II was notsignificant (table 2).

The analysis of data from the study group, it was foundthat changes in the FEV1, MVV and 6MWD following surgerywere similar to that of control group. The decrease duringthe post op I from preop (table 3), and the improvementduring post op II was found to be statistically significant(table 3). The change in 6MWD in the experimental groupduring fourth postoperative week is 57m which is more thanthreshold for clinical significance7 which is not evident incontrol group. On comparison between the experimentalgroup and control group, there was statistically significantdifference in the recovery during fourth postoperative week.The differences in the pulmonary function measures andsix minute walk distance between the control andexperimental groups are illustrated in the figure 1 – 3. Theresults indicate that there was better improvement inpulmonary function and 6MWD in experimental group thancontrol group but which is also clinically significantaccording to ATS statement guidelines.7

Table 3: Pulmonary function and 6MWD (mean ± SD) of control group


Parameters Pre op p* Post op I p# Post op IIFEV1(l) 1.75±0.54 0.01 1.26±0.41* 0.00 1.55±0.35*

MVV (l/min) 62.3±21.0 0.01 49.4±17.1* 0.00 61.5±12.9*

6MWD (m) 495±104.9 0.00 406±102.6* 0.00 463±107.5

* p value of difference of Post op I against Pre op

# p value of difference of Post op II against Post op I

Table 2: Pulmonary function and 6MWD (mean ± SD) of control group

Parameters Pre op p* Post op I p# Post op IIFEV1(l) 1.76±0.49 0.04 1.32±0.38* 0.75 1.36±0.38

MVV (l/min) 69.2±17.2 0.01 52.5±15.9* 0.77 53.5±12.7

6MWD (m) 352±144.9 0.04 281±103.0* 0.34 292±95.5

* p value of difference of Post op I against Pre op

# p value of difference of Post op II against Post op I

Table 1: Characteristics of patients in control group and experimental group

Demographics Control Group n = 8 Experimental Group n = 7Age (yrs) 39.8±7.8 39.8±7.0

Gender 5 males & 4 males &

3 females 3 females

Operative Pneumonectomy = 2 Pneumonectomy = 2

procedure Lobectomy = 6 Lobectomy = 5

11

DiscussionThe posterolateral thoracotomy and lung resection imposesevere injury to chest wall and lung in the early postoperative period. These leads to decrease pulmonaryfunction and thereby exercise capacity.1,2,3,4,5 Recovery inpulmonary function is evidenced from third post operativeweek. Exercise capacity follows the pulmonary function inthe trend of recovery.4,5 The routine physiotherapy protocollacks exercises of training threshold to enhance therecovery of exercise capacity during the early postoperativeperiod. Therefore in our study we included gradedincremental exercise to enhance recovery of exercisetolerance in the early post operative. The graded incrementis based on the patient’s performance and on everysuccessive session the patient effort was increased by150%.

6MWT is one of the popular and common used exercisetolerance test used worldwide health care set up. Thereliability and validity of 6MWT were established, and foundto be good, making it a reliable research tool in assessingexercise tolerance. We have considered 6MWT to measureexercise tolerance in lung resection patients in thepostoperative period for its feasibility and reproducibility.

In this study, the pulmonary function test variable i.e., FEV1,and MVV which predicts exercise tolerance, were found tobe reduced in the early postoperative period(post op I).This also confirms the findings in the earlier studies byMiyoshi et al4 and Nezu et al6. The exercise tolerance interms of 6MWD of control group was reduced in the earlypostoperative period during 10th postoperative day.Following this initial drop the exercise tolerance has

increased when measured at fourth week post operatively.This is in keeping with the results of the previous study byMiyoshi et al.4 Miyoshi et al in their study have concludedthat ventilation was the major restricting factor for theexercise tolerance in the acute post operative period. Butit may be primitive to conclude that ventilation is restrictingfactor for exercise tolerance, as this needs a directmeasurement of ventilatory reserve by analysis of expiredgases. Moreover hemodynamic variables indicates thatcirculation along with ventilation were also responsible forreduced exercise tolerance in the postoperative period.

The improvement in experimental group in the late postoperative period nearly reached the preoperative status.The FEV1 and MVV which had a fall of 70% in the earlypostoperative period were improved to 90% by one monthagainst 80% in the control group population. Similarchanges were accounted in MVV also. These resultssuggest that the recovery pattern in experimental can beattributed to vigorous early mobilization protocol.

The exercise tolerance, 6MWD that had fallen to 60% inthe early postoperative period had almost reached thepreoperative status in the late postoperative period. Theimprovement in 6MWD from the acute postoperative periodtill the one month was 57m in experimental group against12m in control group. This mean increase in 6MWD exceedsthe 54m threshold for clinical significance as reported inATS guidelines statement for 6MWT.7,8

These inter group difference, which was clinically andstatistically significant, could be due to absence ordesensitization of symptoms and enhanced recovery ofpulmonary function. These changes in the experimentalgroup can be attributed to graded incremental mobilizationexercises. From the observation of patients in both thegroups, it was found that two patients in control group hadpostoperative pulmonary complications, and none of thepatients in the experimental group had any postoperativecomplications.

ConclusionFrom this study we conclude that following lung resectionsurgery,

1. Exercise tolerance is reduced in the early postoperativeperiod and recovers subsequently improves by fourthweek postoperatively as evidenced by 6MWT

Graph 1: Changes in Forced expiratory volume in 1s (FEV1) between groups Graph 2: Changes in Maximum Voluntary Ventilation (MVV) between groups

Graph 3: Changes in distance (6MWD) covered in 6MWT between groups


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2. Graded incremental mobilization exercises lead toenhanced recovery of exercise tolerance in the postoperative period.

Recommendations for further research are to consider moreobjective measures to evaluate the limiting factors forexercise tolerance and their recovery pattern following lungresection surgeries.

References1. Gorlin R, Knowles JH, Storey CF. Effects of

thoracotomy on the pulmonary function. J Thorac Surg1957; 34: 242-49

2. Hazerligg SR et al. The effect of muscle sparing versusstandard posterolateral thoracotomy on pulmonaryfunction. J Thorac Cardiovasc Surg 1991; 101: 394-401

3. Maeda et al. Diaphragm function after pulmonaryresection. Am Rev Respir Dis 198; 137: 678-81

4. Miyoshi et al. Exercise capacity of thoracotomypatients in the early postoperative period. Chest 2000;118: 384-90

5. Nugent et al. Effect of thoracotomy patients and lungresection on exercise capacity in patients with lungcancer. Thorax 1999; 54(4): 334-38

6. Nezu et al. Recovery and limitation of exercisecapacity after lung resection. Chest 1998; 113(6):1511-16

7. ATS statement: Guidelines for the six minute walktest(6MWT). Am J Respir Crit Care Med 2002; 166: 111-7

8. Redelmeier, D. A., A. M. Bayoumi, R S Goldstein andG H Guyatt. Interpretation small differences infunctional status: the six minute walk test (6MWT) inchronic lung disease patients. Am J Respir Crit CareMed 1996; 155: 1278-82


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Dietary supplementation for reduction of muscle soreness duringphysical therapy: Case reportDennis R. SparkmanSouthwest Immunology, Inc. Ennis, TX 75119 USA

Corresponding Author:Dennis R. Sparkman, Ph.D.Southwest Immunology, Inc.P.O. Box 8262, Ennis, TX [email protected]

AbstractObjective: The current literature offers ample evidence tosupport the use of amino acid therapy to prevent musclesoreness following overuse and to help maintain and restoremuscle tissue following prolonged periods of inactivity. Thepurpose of this case report is to demonstrate that acarbohydrate-amino acid supplement can safely be usedduring physical therapy to prevent muscle soreness.

Methods: A 74-year old female underwent elective hipreplacement surgery followed by a week of rehabilitativephysical therapy. The patient elected to use a carbohydrate-amino acid supplement as a means to prevent musclesoreness following physical therapy and consented toobservation.

Results: During the course of physical therapy the patientreported no muscle soreness on the days following therapywhile using the carbohydrate-amino acid supplement. Theone occasion where the supplement was not used followingphysical therapy, noticeable discomfort due to musclesoreness was reported.

Conclusions: This case report supports the use ofcarbohydrate-amino acid supplementation to preventmuscle soreness while restoring lean muscle and strengthfollowing physical therapy, even though definite conclusionscannot be drawn from a single case report design. Currentliterature in conjunction with this case report supports theneed for properly designed studies to further investigatethe therapeutic benefits of a carbohydrate-amino acidsupplement as an adjunct to physical therapy andrehabilitation.

Key Words: Dietary Supplements, Physical TherapyModalities, Inflammation, Muscles, and Amino Acids.

IntroductionFollowing any unaccustomed or prolonged use of themuscles that leads to overuse will inevitably result in musclesoreness. This muscle soreness is referred to as delayedonset muscle soreness or DOMS.1,2 Because DOMS is nota direct manifestation of the resulting disruption of thecontractile component of the muscle tissue and muscle

membranes, the soreness is not felt immediately. DOMSis a symptom of the damage that occurs when solublemuscle proteins leak into the extra cellular space resultingin local inflammation and the muscle swelling that ensues.Peak levels of DOMS have been shown to coincide withpeak levels of edema.3, 4 For this reason, the sorenessbegins to develop gradually following exercise and can lastfor several days. Although this muscle soreness is mostoften associated with athletic training, it can affect anyone,especially persons undergoing physical therapy. BecauseDOMS can have a negative impact on muscle function andreduce one’s ability to perform physical activities, it cancurtail further physical activities for days. For the patientrequiring physical therapy following surgery or an injury,the muscles can be weakened and/or atrophied fromphysical inactivity. Such a scenario makes the patient anideal candidate for experiencing DOMS during physicaltherapy, even though physical therapists strive to managetherapy intensity to maintain a balance between strengthgains and muscle soreness. For this reason, finding aneffective intervention to prevent or reduce DOMS whilehelping to rebuild atrophied muscles would facilitate apatient’s physical therapy and recovery.

The role of oral supplementation of amino acids in theprevention of DOMS is a field of interest for nutritionalscience that has a direct and practical application in thefield of sports medicine. Oral supplementation with 77 mg/kg branched chain amino acids (BCAA) before exercisehas been reported to suppress endogenous muscle proteinbreakdown.5 This finding was corroborated in another studywhereby giving 100 mg/kg of BCAA before, during and afterexercise showed a protein sparing effect on muscleproteins.6 Supplementation with 12-g/day BCAA for 2 weeksplus 20 g before and after exercise reduced serum creatinephosphokinase (CPK) for several days following exercise.7

A recent study that investigated administering 5 g BCAAbefore exercise noted a reduction on DOMS for severaldays following exercise.8 Previous studies have shown thatadministering 40 g EAA after exercise results in a changefrom net protein degradation to net protein synthesis.9

Carbohydrate-amino acid mixtures have also recently beenshown to help reduce muscle soreness. When a liquidcarbohydrate beverage was consumed 10-minutes beforeand immediately after exercise, it resulted in a morefavorable anabolic response, although it did not alter thecatabolic response.10 When a solution of 8% carbohydrate+ 2% protein was consumed immediately following exercise,there was a perceived reduction in soreness amongathletes.11 Administration of a 6% carbohydrate solutioncontaining 6 g EAA during weight resistance exercise

Dennis R. Sparkman/Indian Journal of Physiotherapy and Occupational Therapy. July - Sept. 2008, Vol. 2, No. 3

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suppressed cortisol release, stimulated insulin release andreduced myofibrillar protein degradation12,13 and increasedthe anabolic response.14

Mixtures of amino acids have also been reported to reduceDOMS. Mixes of amino acids have been shown to reduceserum CPK activity following exercise.15,16 When an aminoacid mixture containing 60% essential amino acids wasgiven at a total daily dose of 7.2 g twice daily on the day ofexercise and for 4 days following exercise, there was astatistically significant reduction in both serum CPK levelsand DOMS in the days following exercise.17

A recent study has described the use of beta-hydroxy-beta-methylbutyrte (HMB) in the prevention of DOMS. In thisstudy administration of 3g HMB/0.3g KIC for 14 days priorto a single bout of eccentric resistance training determinedthat CPK and DOMS were significantly reduced after 14days supplementation with HMB/KIC compared tocontrols.18 One previous study looked at the effects of shortterm HMB supplementation on eccentric resistance trainingfound that six days supplementation with 40 mg/kg HMBdid not reduce DOMS after a single bout of exercise.19

This case report examines the role for using a carbohydrate-amino acid supplement containing HMB in the preventionof muscle soreness during post-operative physical therapy.

Patient and methodsThe patient was a 74-year old Caucasian female who hadundergone elective left hip replacement. She was 5 feet 8inches tall, weighed 175 lbs.

The patient had become progressively immobile over aperiod of approximately 2-years due to the degenerativeleft hip. At the time of surgery, the patient was barely ableto walk across the room without having to stop to sit andrest. Because a great deal of her time was sedimentary,she had become weak and lost muscle strength.

The patient requested to be provided with a sample of apatent-pending carbohydrate-amino acid dietarysupplement that was designed to prevent or significantlyreduce muscle soreness following muscle overuse. Herintention was to use the product during her physical therapyto aid in reducing muscle soreness and to help regainmuscle strength. Her request was granted and in returnpermission was obtained from the patient to observe andinterview her during the physical therapy.

The patient used a pre-production sample of acarbohydrate-amino acid dietary supplement. A singleserving of the supplement contained 44 g of a proprietaryblend which consisted of sucrose, maltodextrin, calciumbeta-hydroxy-beta-methylbutyrate, L-leucine, L-phenylalanine, L-lysine, L-threonine, L-valine, L-histidine,L-isoleucine, L-methionine). Among the eight essentialamino acids, 40% was made up of the branched chainamino acids. The recommended serving of approximately50 g was mixed with 500 ml of water and consumedimmediately following physical therapy.

ResultsFollowing a successful hip replacement and recovery, the

patient was moved from the hospital on the fifth day to alocal rehabilitation center in the Southwest United States.On the seventh post-operative day, physical therapy wasstarted and consisted of hip abductions, hip extensions,knee raises, knee flexions, ankle pumps, bed supportedknee bends and straight leg raises. As therapy progressed,rubber bands were added to add resistance to the exer-cise routine.

Immediately following each physical therapy session, thepatient consumed one dose of the carbohydrate-amino acidsupplement. Each day prior to physical therapy the patientwas asked to rate the level of muscle soreness in her legsfrom the previous day’s therapy using a visual analog scale(VAS) of 1 to 10 with one being no soreness and ten beingthe most severe soreness. Following six of her daily physi-cal therapy sessions, the patient reported no muscle pain,as indicated with a VAS soreness value of 1, when the car-bohydrate-amino acid supplement had been used immedi-ately post-therapy the preceding day. Other hip replace-ment patients in her therapy group were interviewed to de-termine if they were experiencing muscle soreness in con-junction with the physical therapy regimen. The other pa-tients who were not using any type of supplementation re-ported that they did experience muscle soreness and dis-comfort, especially in their thighs. Although physical therapysessions are not typically conducted on the weekends, herassigned physical therapist was on weekend duty and gavethe patients an unscheduled session of physical therapy.Following this session, the patient did not have the carbo-hydrate-amino acid supplement, which was routinely pre-pared and brought in daily by a family member. In this oneinstance where the patient did not receive post-therapynutritional supplementation, she did report a noticeableamount of discomfort from muscle soreness the followingday and reported a VAS soreness value of 4. The patientcommented that her thighs were sore and felt some tight-ness in her muscles. This VAS soreness value when notusing the supplement was a noticeable increase over pre-vious values when the supplement was used and the de-gree of muscle soreness noted is a reasonable value forwhat one would expect for the level of muscle exertionemployed during physical therapy. No further soreness wasnoted on subsequent therapy sessions when the supple-ment was used.

DiscussionThe present case report observes that a post-surgicalpatient who used a carbohydrate-amino acid supplementcontaining HMB immediately following each therapy sessionperceived no muscle soreness. The support for herperception of having no muscle soreness while using thesupplement is bolstered by her experiencing musclesoreness on the one occasion when the supplement wasnot used following physical therapy.

Although the patient chose to use the carbohydrate-aminoacid supplement to prevent muscle soreness duringphysical therapy, there are several other potential benefitsthat may have assisted in her post-surgical recovery.Previous studies have shown that when essential aminoacids are consumed along with a high glycemic


15

carbohydrate following exercise, there is a greater gain inmuscle protein synthesis over that induced by exercise ornutritional supplementation alone.20 This increase in muscleprotein synthesis in conjunction with physical therapy wouldlead to muscle hypertrophy and aid the patient in regainingstrength and rebuilding atrophied muscles. As many elderlypatients may also suffer from some degree of malnutrition,an anabolic nutritional supplement may also provide basicnutritional benefits.

Manninen21 has described the optimal recovery drink ascomposed of high glycemic carbohydrates, proteinhyrdrolysate and supplemental L-leucine. The purpose ofthese ingredients is to provide carbohydrate/protein toinduce an optimum insulin response, provide proteinhydrolysate as a source of amino acids for protein synthesisand L-leucine as an insulintrophic amino acid. The presentcomposition provides a high glycemic mix of simple andcomplex carbohydrates to make the drink isotonic so itempties quickly out of the stomach and is absorbed rapidly.It preferably utilizes free-form essential amino acids as theycan be absorbed rapidly and because the non-essentialamino acids can be made by the body and are not ratelimited in protein synthesis.9 The essential amino acidsserve as a protein source to potentiate the induction ofinsulin. Furthermore, the essential amino acids containsL-lysine, one the most potent insulinotrophic amino acids,in addition to L-leucine and L-phenyalanine, which aresomewhat less potent and L-methionine and L-valine whichare moderately potent. L-leucine’s effect on muscle isthough to be due largely to it being metabolized intoketoisocaproate, which is metabolized into HMB andultimately the end product HMG-CoA, which supportsmuscle membrane repair through increased intramuscularcholesterol synthesis. Therefore, the downstreammetabolite HMB is included in this composition to bypassother metabolic pathways and promote greater conversioninto HMG-CoA. For these reasons, this composition offersseveral advantages over Manninen’s proposed optimalrecovery drink.

A recent study investigated the benefits of using an anabolicnutritional supplement on malnourished rats that wererecovering from a bone fracture. Those rats receiving ananabolic supplement consisting of 30% protein withconditionally essential amino acids showed greaterimprovements in bone mineralization, body mass andmuscle mass than those receiving protein alone.22 Essentialamino acid supplementation has been shown to have asimilar effect on muscle and bone in osteoporotic rats.23

Therefore, nutritional supplementation of orthopedicpatients with anabolic supplements may augmentmusculoskeletal recovery following corrective surgery forbone fractures and other orthopedic procedures.

Injuries or disease that require long periods of immobilityduring recuperation can have a deleterious effect onmuscles. The muscles enter a catabolic state and othertissues, such as the immune system and injured tissue,use the amino acids released from the degradation ofmuscle. This results in muscle atrophy and physicalweakness. Once healed, the patient must be rehabilitatedthrough physical therapy to regain muscle mass andstrength. Previous studies have demonstrated that essentialamino acid-carbohydrate supplements can help prevent and

reverse the catabolic effects of prolonged inactivity and theresulting loss of muscle protein.24-26

A study on muscle recovery following six weeks of non-weight bearing inactivity demonstrated that after 12 weeksof physical therapy, muscle function had improvedsignificantly, but was still less than weight bearing inactivenormal controls.27 This study also documented that therapypatients often do experience muscle soreness duringphysical therapy; and demonstrated a positive correlationbetween the degree of DOMS and the resulting progressin muscle recovery and strength. This study showed thatthe patients who experienced the most muscle sorenessduring the study were the ones who showed the greatestimprovement in muscle strength at the end of the study.The reasoning for this was that those who worked thehardest and experienced the most DOMS gained the mostbenefit from therapy. Patients who did not experience asignificant degree of DOMS had the least muscle strengthat the end of the study. These latter patients may haveintentionally performed their physical therapy at a lowerintensity to avoid the discomfort of muscle soreness.

Based on published studies and the observed results inthis case report, it is fair to speculate that orthopedicpatients, as well as other ambulatory patients, could benefitfrom an amino acid-carbohydrate supplement that was ableto provide both anabolic properties and prevent musclesoreness during physical therapy. Such post surgicalsupplementation should allow both the bone andsurrounding muscle tissue to experience improved post-operative healing. Additionally, supplementation should alsoallow the therapist to increase the intensity of the therapywithout limiting subsequent activities due to DOMS. Thiswould allow the patient to perform better during physicaltherapy due to lack of muscle soreness resulting fromreloading muscles, and atrophied muscles should respondto the exercise by showing increased hypertrophy and gainsin strength.

Further studies need be carried out using the presentcarbohydrate-amino acid supplement to determine if boneand tissue repair can be improved following surgery. Also,if patients can undergo more intense physical therapywithout the undesirable discomfort from DOMS, they willbe able to recoup more muscle strength at a faster rateduring rehabilitation. Such nutritional therapy would be verybeneficial to patients with injuries as it could help maintainmuscle mass during convalesce and enhancemusculoskeletal repair. This could enable the patient to bein better physical condition upon entering rehabilitation andperform both qualitatively and quantitatively better whenundergoing physical therapy.

Additionally, as the population grows older and life spansincrease, orthopedic injuries will increase proportionately.Any adjunct nutritional therapy that results in a moresuccessful outcome following surgery and faster return tonormal activities would be of enormous benefit to both thehealthcare system and patients.

AcknowledgementsThe amino acid – carbohydrate supplement was providedby Southwest Immunology, Inc., P.O. Box 8262, Ennis, TX75119.


16

References1. Connolly DAJ, Sayers SP, McHugh MP. Treatment

and prevention of delayed onset muscle soreness. JStrength Cond Res 2003; 17:197-208.

2. Cheung K, Hume PA, Maxwell L. Delayed onsetmuscle soreness. Treatment strategies andperformance factors. Sports Med 2003; 33: 45-164.

3. Crenshaw AG, Thornell LE, Friden J. Intramuscularpressure, torque and swelling for the exercise-inducedsore vastus lateralis muscle. Acta Physiol Scand1994; 152: 265-277.

4. Evans GFF, Haller RG, Wyrick PS, et al. Submaximaldelayed-onset muscle soreness: correlations betweenMRI imaging findings and clinical measures.Radiology 1998; 208: 815-820.

5. MacLean DA, Graham TE, Saltin B. Branched-chainamino acids augment ammonia metabolism whileattenuating protein breakdown during exercise. AmJ Physiol 1994; 267: E1010-E1022.

6. Blomstrand E, Saltin B. BCAA intake affects proteinmetabolism in muscle after but not during exercise inhumans. Am J Physiol Endocrinol Metab 2001; 281:E365-E374.

7. Coombs JS, McNaughton LR. Effects of branched-chain amino acid supplementation on serum creatinekinase and lactate dehydrogenase after prolongedexercise. J Sports Med Phys Fitness 2000; 40: 240-246.

8. Shimomura Y, Yamamoto Y, Bajotto G, et al.Nutraceutical effects of branched-chain amino acidson skeletal muscle. J Nutr 2006;136: 529S-532S.

9. Tipton KD, Gurkin BE, Matin S, Wolfe RR.Nonessential amino acids are not necessary tostimulated net muscle protein synthesis in healthyvolunteers. J Nutr Biochem 1999; 10: 89-95.

10. Thyfault JP, Carper MJ, Richmond SR, Hulver MW,Potteiger JA. Effects of liquid carbohydrate ingestionon markers of anabolism following high-intensityresistance exercise. J Strength Cond Res 2004;18:174-179.

11. Millard-Stafford M, Warren GL, Thomas LM, Doyle JA,Snow T, Hitchcock K. Recovery from run training:efficacy of a carbohydrate-protein beverage. Int JSport Nutr Exerc Metab 2005;15: 610-624.

12. Bird SP, Tarpenning KM, Marino FE. Liquidcarbohydrate/essential amino acid ingestion duringa short-term bout of resistance exercise suppressesmyofibrillar protein degradation. Metabolism 2006a;55: 570-577.

13. Bird SP, Tarpenning KM, Marino FE. Effects of liquidcarbohydrate/essential amino acid ingestion on acutehormonal response during a single bout of resistanceexercise in untrained men. Nutrition 2006b; 22: 367-375.

14. Bird SP, Tarpenning KM, Marino FE. Independent andcombined effects of liquid carbohydrate/essentialamino acid ingestion on hormonal and muscular

adaptations following resistance training in untrainedmen. Eur J Appl Physiol. 2006c; 97: 225-238.

15. Ohtani M, Maruyama K, Suzuki S, Sugita M, KobayshiK. Changes in hematological parameters of athletesafter receiving daily dose of a mixture of 12 aminoacids for one month during the middle- and long-distance running training. Biosci Biotechnol Biochem2001; 65: 348-355.

16. Kraemer WJ, Ratamess JS, Volek JS, et al. The effectof amino acid supplementation on hormonalresponses to resistance training overreaching.Metabolism 2006;55: 282-291.

17. Nosaka K, Sacco P, Mawatari K. Effects of aminoacid supplementation on muscle soreness anddamage. Int J Sport Nutr Exer Metab 2006;16: 620-635.

18. Van Someren KA, Edwards AJ, Howatson G.Supplementation with â-hydroxy-â-methylbutyrate(HMB) and a-ketoisocaproic acid (KIC) reduces signsand symptoms of exercise-induced muscle damagein man. Int J Sport Nutr Exer Metab 2005;15: 413-424.

19. Paddon-Jones D, Keech A, Jenkins, D. Short-termbeta-hydroxy-beta-methylbutyrate supplementationdoes not reduce symptoms of eccentric muscledamage. Int J Sport Nutr Exerc Metab 2001; 11: 442-450.

20. Rasmussen BB, Tipton KD, Miller SL, et al. An oralessential amino acid-carbohydrate supplementenhances muscle protein anabolism after resistanceexercise. J Appl Physiol 2000;88: 386-392.

21. Manninen AH. Hyperinsulinaemia, hyperami-noacidaemia and post-exercise muscle anabolism:the search for the optimal recovery drink. Br J SportsMed 2006; 40: 900-905.

22. Hughes MS, Kazmier P, Burd TA, et al. Enhancedfracture and soft-tissue healing by means of anabolicdietary supplementation. J Bone Joint Surg 2006; 88A:2386-2394.

23. Ammann P, Bonjour JP, Rizzoli R. Essential aminoacid supplements increase muscle weight, bone massand bone strength in adult osteoporotic rats. JMusculoskelet Neuronal Interact 2000: 1: 43-44.

24. Paddon-Jones D, Sheffield-Moore M, Urban RJ, etal. Essential amino acid and carbohydratesupplementation ameliorates muscle protein loss inhumans during 28 days bedrest. J Clin EndocrinolMetab 2004; 89: 4351-4358.

25. Paddon-Jones D, Wolf RR, Ferrando AA. Amino acidsupplementation for reversing bed rest and steroidmyopathies. J Nutr 2005; 135: 1809S-1812S.

26. Paddon-Jones D, Sheffield-Moore M, Urban RJ, etal. The catabolic effects of prolonged inactivity andacute hypercortisolemia are offset by dietarysupplementation. J Clin Endocrinol Metab 2005; 90:1453-1459.

27. MacIntyre DL, Eng JJ, Allen TJ. Recovery of lowerlimb function following 6 weeks of non-weight bearing.Acta Astronautica 2005; 56: 792-800.


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Pilot study with myolymphokinetic activities in the treatment oflymphedema after breast cancerMaria de Fátima Guerreiro Godoy1, José Maria Pereira de Godoy2, Domingo Marcolino Braile3

1Occupational Therapist, Teacher of post graduation Lato-Sensu course in Rehabilitation of Lymphedema of the MedicalSchool in São José do Rio Preto (FAMERP) 2Livre Docente of the Cardiology and Cardiovascular Surgery Department ofthe Medical School in São José do Rio Preto (FAMERP), Professor of the Graduation and post graduation courses ofFAMERP and CNPq researcher 3Livre Docente of the Cardiology and Cardiovascular Surgery Department of the MedicalSchool in São José do Rio Preto (FAMERP); Coordinator of the post graduation Stricto Sensu course of FAMERP.

Corresponding Author:José Maria Pereira de GodoyRua Floriano Peixoto, 2950São José do Rio Preto-SP, Zipe code: 15020-010E-mail: [email protected]

AbstractBackground: Lymphedema is one of the maincomplications seen after breast cancer treatment. Clinicaltreatment of lymphedema has been recommended as themain approach over the last few years in which anassociation of therapies is suggested and recently, severalforms of treatment.

Purpose: The objective of the current study was to evaluatethe reduction in edema associated with myolymphokineticexercises using a non-elastic contention sleeve (‘gorgurão’)in patients suffering from lymphedema of the upper limbs.

Method: Twelve female patients, who were being treatedfor lymphedema of the arms, were selected to continuetheir myolymphokinetic activities using non-elasticcontention sleeves daily during a period of 30 days. Theirages ranged between 32 and 76 years with a mean of 52,6years. They were assessed using displacement of waterbefore and after the 30-day treatment program. Statisticalanalysis was achieved using the paired student t-test withan alpha error of 5% considered acceptable.

Results: Analysis demonstrated a statistically significantdifference between the volumetric evaluations before andafter the treatment period (p-value = 0.001). Conclusion:In conclusion, myolymphokinetic activities associated witha ‘gorgurão’ sleeve as a contention mechanism cancontribute in reducing the size of arms in the treatment oflymphedema.

Key words: Myolymphokinetic, activities, lymphedema,treatment, upper limbs.

IntroductionLymphedema is one of the main complications seen afterbreast cancer treatment and consists of an abnormalaccumulation of fluids and substances in the tissuesresulting from a failure of the lymph drainage systemassociated with insufficiency of the extracellular proteolysisof proteins in the cellular interstice and of the mobilizationof macromolecules such as for example hyaluronic acid1.

Clinical treatment of lymphedema has been recommendedas the main approach over the last few years in which an

association of therapies is suggested2-5. The mostcommonly used association was first described by Földiand includes lymph drainage, bandaging and a dailyhygiene routine which became known as the complexphysical therapy6. More recently, several forms of treatmenthave been suggested however there is no consensus whenused in isolation. There have been no studies publishedevaluation the effect of exercising or performing manualactivities, although it is well known that excessive strenuousactivities increase edema.

The aim of this study was to evaluate volumetric reductionof the upper limbs by associating myolymphokineticactivities with the use of a non-elastic contention sleevemade of gorgurão (a cotton-polyester material).

MethodTwelve female patients with lymphedema of the upper limband being treated in the Godoy Clinic were randomlyselected for this study. All patients had been submitted toradical mastectomy with axilary dissections and after aradiotherapy and chemotherapy regimen. The patientsremained without normal treatment sessions duringDecember 2006. Their normal treatment included twoweekly sessions of manual lymph drainage using the Godoytechnique5,7,8, myolymphokinetic exercises using facilitatingdevices developed by Godoy9 and myolymphokineticactivities10, that is, occupational activities and personalhygiene routines. The patients were requestd not to useexcessive force or lift heavy objects with guidance on howthey should be performed. To repeat one specific movementover a long period of time and to avoid incorrect whenperforming the movement avoiding joint injuries togetherwith the use of daily non-elastic contention (gorgurãosleeve).

The ages of the women varied from 32 to 76 years old witha mean age of 52.6 years old. The patients were advisedto maintain the myolymphokinetic activities and contentionduring the period of their vacation. Volumetric displacementof water was performed in the consultation immediatelybefore the vacation and on their return to the normaltreatment program 30 days later. Volumetric displacementof water was achieved using a glass container with 35 cmin width and 65 cm in height. The displacement of watervolume was measured on a calibrated digital scales. Theactivities common to all the women were washing up,cooking in small and medium-sized pans, brushing the floorusing the affected limb, brushing the teeth, brushing thehair, washing clothes (small pieces) without scrubbing,

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ironing clothes (small and light pieces) during the morning,making the bed, hanging clothes on the washing line (smallpieces) at shoulder height evaluated for each patient andwatering the garden. The study received the approval ofthe Local Ethics Research Committee and participantssigned written consent forms. For statistical analysis thepaired student t-test using the PAD program was utilizedwith an alpha error of 5% considered acceptable (p-value< 0.05).

ResultsThe volumetric evaluations, before and after thirty days offollow up, are illustrated in Table 1. The paired t-testidentified statistically significant differences (p-value <0.001) for the volumetric evaluations before and after thethirty day study period with the women usingmyolymphokinetic activities and personal hygiene routine.

DiscussionThe current study evaluated the volumetric reduction inpatients with lymphedema of the upper limbs associatingmyolymphokinetic activities with a gorgugão non-elasticcontention sleeve and showed that this association is analternative treatment giving greater independence to thesepatients, by maintaining the volumetric size of the limb. Thepatients were already being treated and constantlypresenting with reductions in the size of the affected limband the 30-day vacation did not aggravate the edema; infact there was a continued volume loss in most participants.

It is important to stress that these activities were evaluatedand each patient received guidance in their transformationinto myolymphokinetic activities. The day-to-day activitiescommon to all the patients were identified and a specificanalysis of these activities was made considering the typesof movements, the groups of muscles involved, the extentof the movement, the necessary muscle force, the intensityof performing the movement and posture. These activitieswere adapted to modify the posture so as not to harm thejoints, the intensity was moderated, there was a control ofrepeated movements and the use of excessive force wasavoided so that, associated with contention, a workingpressure favoring lymph drainage was generated, as wellas movements favoring motor activities which frequentlysuffer with lymphedema. The routine evaluations usingvolume plethysmography is another important factor as it

shows, by means of measurement, the results of treatment,serving as motivation for patients.

Daily tasks, as a form of treatment for lymphedema, arealso an alternative for better compliance to the proposedtreatment. This new perspective contemplates a series ofimportant aspects in the treatment of post-breast cancerlymphedema, as for example, returning patients to theiroccupations from which, in the majority of cases, they weregiven sick leave.

The study evaluates experiences in the daily lives of womenaffected by lymphedema after breast cancer surgerydemonstrating changes in the practical and psychosocialorder. The most common themes related to changes werethe attitudes of people in their setting in respect to theirproblem, the appearance of lymphedema, understandingabout a chronic disease, the treatment, the emotionaldifficulties to understand and accept the problem, and thedifficulties to perform day-to-day activities11-13.

It is also important to stress that, even when there is aconsiderable reduction of the lymphedema of the limb, it isnecessary to continue with specific precautions. Theseinclude the daily use of contention, specific activities andexercises that favor lymph drainage in order to maintainthe improvements in size as lymphedema is a chronicdisease. With the patients of this study, there was areduction in volume with five of them and for the sixth theaffected arm was a size similar to the healthy arm. Guidanceby a specialist and involvement of the family from the startof treatment with facts about the disease and its treatmentincluding the association of myolymphokinetic activities athome contribute to the good results.

These preliminary results suggest that normal occupationalactivities can be associated with contention in thetreatment14, thereby constituting myolymphokineticactivities. Patients who use this form of treatment for longperiods have confirmed the benefits of this approach.

ConclusionMyolymphokinetic activities associated with a contentionsleeve made from gorgurão cause volumetric reductionsin the treatment of lymphedema of the upper limb.

References1. Godoy JMP. Fisiopatologia do Sistema Linfático. In

Godoy JMP, Belczack CEQ, Godoy MFG. ReabilitaçãoLinfovenosa. Rio de Janeiro: DiLivros, 2005. p.37.

2. Foldi M, Foldi E. Therapy of lymphedema. Med Welt.1980 May 23;31(21):801-6.

3. Casley-Smith JR, Boris M, Weindorf S, Lasinski B.Treatment for lymphedema of the arm—the Casley-Smith method: a noninvasive method producescontinued reduction. Cancer. 1998 Dec 15;83(12Suppl American):2843-60.

4. Ciucci1 JL, Marcovecchio LD. MétodoTransdiciplinario. In Ciucci JL. Linfedema del MiembroSuperior. Buenos Aires: Nayarit, 2004. p.79-100.

5. Godoy JMF, Godoy MFG, Batigalia F. PreliminaryEvaluation Of A New, More Simplified Physiotherapy


Table 1: Volumetric evaluations, before and after thirty days using.

Patient # Initial Evaluation (grams) After 30 days (grams)1 2038 19612 2128 20403 1980 19074 1363 12605 1902 18206 2303 22167 1826 17858 2465 23269 3129 305010 2213 217111 3167 310012 1325 1335

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Technique For Lymphatic Drainage. Lymphology2002; 35: 91-93.

6. Foldi M, Foldi E, Kubik S. Textbook of Lymphology.Munchen: Elsevier, 2003. p. 517-9.

7. Godoy JMP, Torres CAA. Self-Drainage LymphaticTechnique. Angiology 2001;52(8): 573-4.

8. Godoy JMP, Braile DM, Godoy MFG. A Thirty-monthFollow-up of the Use of a New Technique for LymphDrainage in Six Patients. European Journal VascularEndovascular Surgery 2002, 3: 91-3.

9. Godoy JMP, Godoy MFG, Destito EC. Directives forthe creation and adaptation of myolymphokineticexercises in the treatment of lymphovenous diseases.Abstracts Book XIX International Congress ofLymphology, Freiburg, 2003. p 63

10. Godoy MFG. Atividades de Vida Diária no Tratamentodo Linfedema. Lymphology 2002/03; 35(Suppl 2):213-5.

11. Johansson K, Holmstrom H, Nilsson I, Ingvar C,Albertsson M, Ekdahl C. Ekdahl C. Breast cancerpatients’ experiences of lymphoedema. ScandinavianJournal of Caring Sciences 2003 Mar; 17(1):35-42.

12. Karki A, Simonsen R, Malkia E, Selfe J.Impairments, activity limitations and participationrestrictions 6 and 12 months after breast canceroperation. Journal Rehabilitation Medicine 2005May; 37(3):180-8.

13. Godoy MFG, Godoy JMP, Braile DM. Tratamento doLinfedema de Membros. Exercícios e AtividadesLinfomiocinéticas. Rio de Janeiro:DiLivros 2005.130p.

14. Godoy JMP, Godoy MFG. Assessment of inelasticsleeves in patients with upper limb of lymphoedema.Indian Journal of Physiotherapy and OccupationalTherapy 2007; 1(4):3-5.


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A survey of injuries in field hockey players in relation to playingsurfaceKawaldeep Kaur, Vikram Singh Yadav, Jaspal Singh SandhuDepartment of Sports Medicine and Physiotherapy, Guru Nanak Dev University, Amritsar (Punjab) India - 143 001

AbstractIntroduction

Field hockey is one of the most popular team sport in theworld and is thought to be the forerunners of all stick andball games. Injuries in hockey are numerous and can beserious. Despite the sports apparent popularity, the dataon injury rates among field hockey players are limited. Mostof the research on field hockey was completed over 6 yearsago, but the game has undergone significant changes sincethat time.

AimTo examine the injuries in field hockey players in relationto playing surfaces.

Material and methodologyDistrict, state, university, national, international hockeyplayers (N=407) completed the survey questionnaire. Theyreported personal characteristics (age, height, weight), fieldhockey information (level, years of experiences, surface),injury history (type, site, cause, severity), and back paininformation.

ResultsIn overall injuries, 64.87% injuries occurred in training onnatural grass and 35.13% injuries occurred while trainingon artificial turf.

ConclusionThere is increase in number of injuries in grass as comparedto artificial turf.

Key words: Hockey, playing surfaces, injuries, artificial turf.

IntroductionSome form of ball and club game is as old as man itself.The man has always been fond of playing with round objectsand there has always been great fascination in hitting roundobjects with a stick. Hockey is an ancient game thought tobe the forerunners of all ‘stick and ball’ games. The moderngame of the hockey is played in 132 countries around theworld and is second in popularity to soccer as a team sport.

Hockey is an outdoor game played by two opposing teamsof 11 players, whose sticks were carved at the spiking endto hit a small, hard ball into their opponent’s goal. It issometimes called field hockey to distinguish it from thesimilar game played on ice.

Injuries are a part of sport. There has been gradual changein the pattern of sporting injuries. Some years ago mostinjuries were acute, traumatic such as fracture, dislocation,ligament sprains and muscle tears. While these injuriesare still common, injuries such as tendonitis, stress fractureand compartment syndrome appears to be increasing infrequency. This is undoubtedly due to the increased loadplaced upon musculoskeltal structure by the increasedtraining demands of modern day sports.

Despite the sport’s apparent popularity, the data on injuryrates among field hockey players are limited. The majorityof the injuries reported are minor ankle sprains andcontusions. More serious injuries such as torn kneeligaments, concussions and eye trauma leading toblindness, have also been noted.1,2,3

Because these studies tend to focus on elite level athletes,it has been difficult to generalize their results to the fieldhockey community as a whole. Some authors suggest thatincreased skill, conditioning and a smooth playing surfacedecreases the risk of injury2,3,5,6 whereas others indicatedthat elite players not only have an increased ‘exposure time’but they may be prepared to take more risks.1,13

Hockey players are exposed to various injuries duringrunning, turning, twisting and stretching activities. It wasreported that the majority of injuries in elite players are tothe lower limb and to the back.7,8,9

A major factor in the etiology of lower limb injuries can bethe playing surfaces. Playing on harder surface is widelybelieved to increase the incidence of lower limb overuseinjuries.

Material and methodologyAim of the study was to examine the injuries in field hockeyplayers in relation to playing surface. The sample of thestudy confined to group of 407 hockey players who belongto district, state, university, national and international levels.They reported personal characteristics (age, height, weight),field hockey information (levels years of experience,surface), injury history (type, site, cause, severity) througha survey questionnaire. Each player signed a consent formbefore filling out the questionnaire.

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Surveyed players had a average age of 18.4 (+7.21) andan average experience of 5.12(+3.75). Of the total surveyedplayers 74.45% were males and 25.55% were female. Outof 407 surveyed players, there were 21.61% district level,19.4% state, 48.41% national, 3.19% university, 7.3%international players. All the players reported that they haveencountered with atleast one injury during field hockeygame or practice.

The present study demonstrated ankle sprain (28.05%) ongrass and (26.17%) on turf, shin pain (18.20%) on grassand (13.08%) on turf, hamstring strain (11.99%) on grassand (13.61%) on turf, achillies tendonitis (7.00%) on grassand (5.75%) on turf, knee ligament (7.28%) on grass and(6.28%) on turf, in relation to playing surface in the lowerlimb. Among these injuries, in the present study we have

consider 3 main injuries i.e. ankle sprain, shin pain andhamstring strain as they occurred in greater percentagecompared to other injuries.

In the present study upper limb shows contusion (58.53%)on grass and (47.61%) on turf, finger and hand fracture(26.82%) on grass and (38.09%) turf, shoulder injuries(7.34%) on grass and (9.52%) on turf, elbow injuries(7.31%) on grass and (4.78%) on turf in relation to playingsurface.

Injuries resulted in head and face are abrasion (73.09%)on grass and (62.5%) on turf, ocular trauma (15.38%) ongrass and (37.5%) on turf, dental trauma (7.69%) on grass,concussion ( 3.84%) on grass in relation to playing surface.

In the back the present study shows back dysfunction(90.80%) on grass and (84.14%) on turf, acute back pain(8.55%) on grass and (14.28%) turf, Sacroiliac joint pain(0.65%) on grass and (1.58%) on turf in relation to playingsurface.

According to the overall injuries reported 64.87% injuriesoccurred in playing/practicing on with natural grass and35.13% occurred while playing/practicing on artificial turf.In the lower limb 47.79% injuries were reported from grassas compare to 19.54% in turf, whereas 4.19% of upper limbinjuries occurred in grass and 2.14% occurred in turf. Inhead and neck 2.69% injuries occurred in grass as compareto 1.63% injuries in turf and 15.58% of back injuries werereported in grass as compared to 6.44% injuries in turf.

S.No. Specific injuries

1. Contusion upper limb 58.53% 47.61%

2. Finger and hand fracture 26.82% 38.09%

3. Shoulder injuries 7.34% 9.52%

4. Elbow injuries 7.31% 4.78%

Graph 1: Common injuries of lower limb in relation to playing surface.

Graph 2 : Common injuries of upper limb occurring on different playingsurfaces.


Table 2 : Common injuries of upper limb in occurring on different playingsurfaces.

Playing Surface

Grass Turf

(Supraspinatous tendonitis)

Table 1: Distribution of lower limb injuries in relation to playing surface.

S.No. Specific injury

1. Ankle sprain 28.05% 26.17%

2. Shin pain 18.20% 13.08%

3. Hamstring strain 11.99 13.61%

4. Achilles tendonitis 7.00% 5.75%

5. Knee ligament 7.28% 6.28%

6. Quadriceps strain 6.40% 4.71%

7. Groin strain 6.21% 10.47%

8. Patellar tendonitis 6.20% 8.90%

9. Patellofemoral pain syndrome 4.00% 3.14%

10. Gastronemius strain 3.64% 4.71%

11. Foot contusion 1.00% 1.57%

12. Mensci tear 1.00% 1.57%

Playing Surface

Grass Artificial turf

Table 3: Specific injuries of head and face occurring on different playingsurfaces.

S.No. Specific injuries Grass Turf1. Abrasions 73.09% 62.5%

2. Occular trauma 15.38% 37.5%

3. Dental trauma 7.69% -

4. Concussion 3.84% -

Table 4 : Specific injuries of back occurring on different playing surfaces.

S.No. Specific injuries Grass Turf1. Back dysfunction 90.80% 84.14%

2. Acute back pain (Muscle strain) 8.55% 14.28%

3. Sacroiliac joint pain 0.65% 1.58%

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DiscussionThe present study shows an increase in the number ofinjuries in grass compared to artificial turf. In Indian setting,natural grass surface is not fully maintained in terms ofquality and texture. The surface is not smooth and groundbeneath the grass is irregular further leading to the bouncingeffect of the ball which predisposes the players to injury.Also, the grass surface is slippery and less frictional forcesare there leading to the instability of the lower limb duringactivities like running. Increased skill, conditioning andsmooth playing surfaces decrease the risk of injury.2,3,5,6

Jamison et al.7 in 1989 reported more injuries in turf (18%)compared to that of grass (12%) which is not consistentwith the findings of the present study. This may be due todifference in time spend by a player on both the playingsurfaces as compared to that of foreign playing situations.In India a player spends most his time playing on grassdue to the decrease in number and availability of the artificialsurfaces.

Lower limb is the most frequent site of injury (67.33%) onboth the surfaces that were taken into account and anklesprain was the most common injury reported on grass(28.05%) as compared to synthetic turf (26.17%). The highincidence of this injury can be attributed to the irregularityand ruggedness of the grass surface. Sudden twisting andturning movements which are the requirements of the gamealong with the interference of stick and ball on the playingsurfaces (grass) which is usually uneven, leads to inversionand plantar flexion, resulting in ankle sprains. In additionto this, improper protective devices and foot wear may alsocause this injury. In the present study it was observed thatincidence of shin pain was higher on grass surface(18.20%). This can be attributed to the impropermaintenance of the play grounds, as the surfaces was veryhard and irregular. Usually athletes suffer from shin painbecause of being overweight, overtraining, tight calfmuscles, compartment syndrome and improper playingsurfaces. Tight calf muscles, which commonly occur as aresult of hard training, will restrict dorsiflexion, increase thetendency for excessive pronation and lead to shin pain.Incidence of hamstring was high on turf (13.61%). Injury

to the hamstring muscle can be devastating to the athletebecause these injuries heal slowly and have a tendency torecur.4 Synthetic turf produces more resistance to the lowerlimb while playing than on natural grass. The impact of thesurfaces get heightened if there is dysfunction of thehamstring muscles. Inappropriate rehabilitation andrepetitive trauma to the muscle may cause a devastatingeffect on the muscle and reoccurrence of injury.

Upper limb injuries occur due to the contact of stick or ballwhich comes with greater speed. Finger and hand fractureoccur more on the turf (38.09%) as the ball move with higherspeed on turf in comparison to grass field. Hence multiplyingthe impact and leading to fractures and injuries. Improvedstick construction allows players to hit the ball with greatervelocity and different techniques for stopping the ball onartificial turf may have led to an increased risk of upperlimb injury.10 Recent surveys of collegiate and high schoolfield hockey indicate that 14.0% to 15.8% of the total injuriesare to the upper limb and most of these are wrist and fingerfractures.11,12

In the present study the percentage of head and faceinjuries (4.32%) on both the surfaces was relatively lessbut it can be catastrophic is nature compare to the otherinjuries. The vigorous use of hockey stick for handling theball increases the potential risk of injury. Abrasions mostcommonly occur on the grass because the surface isirregular, uneven and when the player falls or dive forstopping, defending and hitting the ball then the injuryoccurs. Ocular trauma more on turf because of stick andball contact which comes with high velocity.

In the present study incidence of back dysfunction on grassis very high (90.80%). Sudden twisting movements whichresult from irregular surface of the grass, conveysunbalancing forces to the spine resulting in pain anddysfunction. The incidence of acute back pain (musclestrain) (14.28) is higher on artificial turf, the back takes theimmediate brunt of the impact caused by hard surfaces ofthe turf resulting in acute back pain, which usually subsideswhich rest.


Graph 3: Specific injuries of head and face occurring on different playingsurfaces.

Graph 4: Specific injuries of back occurring on different playing surfaces.

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ConclusionTraining in natural grass demonstrated more injuries(64.87%) as compare to artificial turf (35.13%). There isdifference in playing situation in India and other countrieswhich lead to difference in injury pattern regarding playingsurface.

SuggestionsThe present study includes general population of male andfemale players, similar other works may be considered tounderstand the gender specific injury patterns. Furtherexamination of the injury in relation to playing positions andplaying situations that lead to injury should be considered.

References1. Bolhuis, JH., Leurs, JM and Flogel, GE : Dental and

facial injuries in international field hockey. BritishJournal of Sports Medicine, 21(4): 174-177 (1987).

2. Fox, N : Risks in field hockey. In: Sports fitness andsports injuries. T. Reilly (Ed.) Boston: Faber andFaber, pp. 112-117 (1981).

3. Rose, CP : Injuries in women’s field hockey: a fouryear study. The Physician and Sports Medicine, 9(3):97-100 (1981).

4. James, AC : Hamstring injuries proposed etiological

factors, prevention and treatment. Sports Medicine,2: 21-33 (1985).

5. Spedding, I : Is there a risk of injury in modern hockey?Sports Coach (Perth, Australia), 10(1) : 3-4 (1986).

6. Moore, S: Field hockey, In: catastrophic injuries insports. Avoidance strategies. 2nd Ed., Adams, SH.,Adrian, MJ., Bayless, MA (Eds.), Indianpolis, In:Benchmark. Pres Inc, 67-77 (1987).

7. Jamison, S., Lee, C : The incidence of female injurieson grass and synthetic playing surfaces. AustralianJournal of Science and Medicine in Sport (Canberra,Australia), 21(2): 15-17 (1989).

8. Frake, M., Dalgleish, M: Injuries in women’s fieldhockey. Part one. Sport Health (Canberra, Australia),12(1): 41-42 (1994a).

9. Frake, M., Dalgleish, M: Injuries in women’s fieldhockey. Part two on tour. Sport Health (Canberra,Australia), 12(3): 44-46 (1994b).

10. Karen, Murtaugh : Injury patterns among female fieldhockey players. Med. Sci. Sports Exerc, 33(2): 201-207 (2001).

11. National Collegiate Athletic Association (N.C.A.A).Injury surveillance system reports: Field Hockey,Overland Park, KS, 199 (1998-99).

12. Powell, JW., Barber-Fors, KD : Injury patterns inselected high school sports: a review of the 1995-1997 seasons. J. Athl. Training, 34: 277-284 (1999).

13. Jones, NP : One year of severe eye injuries in sport.Eye, 2(pt. 5): 484-7 (1988).


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Demographic characteristics of individuals with paraplegia inIndia- A surveyNalina Gupta1, John Solomon M2, Kavitha Raja3

1Department of Physiotherapy, Sardar Bhagwan Singh Post- graduate Institute of Biomedical Sciences and Research,Dehradun; 2,3 Department of Physiotherapy, Manipal College of Allied Health Sciences (MCOAHS), Manipal, Karnataka,India.

Corresponding Author:Nalina Gupta, LecturerDepartment of Physiotherapy, Sardar Bhagwan Singh Post- graduateInstitute of Biomedical Sciences and Research, DehradunTel no. +91 9719832566, +91 9719018650, +91 9719217737Email: [email protected]

AbstractStudy Design: A postal survey from August 2004 to May2006.

Objective: To ascertain the demographic characteristicsof individuals with paraplegia in India.

Settings: India

Methods: The questionnaire was mailed to the identifiedindividuals (n=600) whose addresses were obtained fromthe medical records section of our hospital and by contactingnon-government organizations (NGOs), working forindividuals with paraplegia in various cities. Thedemographic characteristics studied were age, gender,education, etiology, level of lesion, duration since injury andemployment after injury.

Results: The return rate was 46% (276/600). Falls fromheight was the leading cause (25%), followed by road trafficaccidents (17.4%). Fifty-three subjects (19.2% each) werein the age group of 18-<25 and 40-<50 years age group.Majority of the subjects were men (233/276), had secondaryeducational level (148/276) and had the lesion at the lumbarlevel (60.1%).

Conclusions: Fall from a height is still the leading causefor spinal cord insult in India. Traumatic lesions are commonin men and non-traumatic in women. Lumbar level is thecommonest level of lesion in these individuals. Survival rateand the employment after injury are still towards the lowerside.

Sponsorship: This study was funded in part by “IndianAssociation of Physiotherapists”.

Key words: Demographics, etiology, age at injury, gender,level of lesion, spinal cord injury.

IntroductionIn India, approximately fifteen lac people live with spinalcord injury. Every year, ten thousand new cases add to thisgroup of individuals. Majority of them (82%) are males inthe age group of 16-30 years. However, this is only anestimate as there is no reliable national database.1

Chacko, Joseph, Mohanty and Jacob in 1986 evaluatedthe problems encountered in a general hospital situated inrural India. They found that male to female ratio was 13.5:1,60.5% of cases with neurological deficits were in the 3rd

and 4th decade of life and the causes for spinal injury werefalling from trees (55.2%), road traffic accidents (12.8%),weights falling on patients (18.4%) and other causes(13.6%). The infrequent occurrence of road traffic accidentswas most likely due to the rural bias of the patients.2

An epidemiologic study done in Harayana, by Roop Singh,have reported male to female ratio of 2.96:1 and theaverage age at injury of 35.4 years. Fall from height wasthe most common cause of trauma (44.5%), followed bymotor vehicle accidents (34.7%). Most common level ofinjury was first lumbar vertebra among individuals withparaplegia.3 A hospital based study done by Agrawal P,Upadhaya P and Raja K have also reported ratio of men towomen who sustained spinal injuries being 3.6:1.Themaximum number of patients was in the age range of 20-39 years . Mechanisms of injury recorded were fall fromheight (58.9%), fall of weight (7.2%), Motor Vehicle Accident(21.3%) and non-traumatic causes (12.6%).4

From casual observation, it appears that the demographictrend that Chacko etal had seen in their study is still thesame even after 20 years. The author had highlighted thenecessity for appropriate preventive measures and also hadre-emphasized the shortcomings of treatment in generalhospitals.2 So, it is intuitive to assume that the rescue andretrieval systems for these patients are still inadequate inIndia and the knowledge regarding precautions to be takenwhen transporting the patient is also lacking. Globally, theetiology responsible for the maximum number of SCI is roadtraffic accidents (RTA).

There is a lack of team approach to these individuals invarious centers all over India. There are some Non-Government Organizations (NGO’s), workings for theseindividuals. But there is still a lack of team approach to thecommunity from the various hospitals to give awarenessprogramme regarding spinal cord injury, its prevention andtreatment. There is also a lack of regular follow-ups.5

But all these aspects cannot be generalized. Although thereare studies going on in different parts of India, they areeither regional or hospital based. There are no reportedstatistics covering the whole country.

Thus, this study was an attempt to ascertain thedemographic characteristics of individuals with paraplegiain the entire country, which may pave the way for betterprimary care all over India. The demographic characteristics

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studied were age, gender, education, etiology, level of injury,duration since injury and employment after injury.

MethodStudy designPostal survey.

SubjectsIndividuals with paraplegia of any cause, either gender withevidence of complete cord lesion who were 18 years orolder were selected. Subjects included were communitydwelling as well as institutionalized individuals.

Study period1 August 2004 to 31 May 2006.

ProcedurePart I: Development of questionnaire and validationWe developed a questionnaire in English, which wasconstructed at the language level of third-grade education.The questionnaire was evaluated for face validity by fivephysiotherapists. Each of the physiotherapists had aminimum of 5 years working experience with SCI includingcommunity-based work with this population. Thesuggestions put forth by the evaluators were incorporatedand the revised questionnaire was pilottested on 10 SCIindividuals for comprehensibility. Changes suggested wereincorporated and this version was again pilot-tested on fivepatients who had not participated in the first pilot testing.The final version was translated into Indian languages bymeans of parallel back translation ensuring that thelanguage level was maintained at the third grade level inall languages. The final versions of the questionnaireconsisted of three sections. The first section includeddemographic and disease characteristics,namely age,gender, education, occupation, level of lesion, durationsince injury and ambulation status. The expected responsesto this section were open ended except ambulation status,which was dichotomous (walking/not walking). The secondsection consisted of questions regarding occurrence ofmorbidities, namely respiratory dysfunction, continuous useof catheter, pressure sores, postural hypotension, pain,spasticity, and fractures. The third section consisted ofdetails of employment following the SCI. The responses tothis section were open-ended.

Part II: Administration of questionnaireOwing to the absence of a national database on SCI,addresses of potential subjects were collected fromhospitals, organizations and associations dedicated to theSCI population.Addresses of individuals living in 20 of 28 states in Indiawere collected. The questionnaire in English and therelevant regional language was mailed to the identifiedindividuals (n=600). The mail packet included a coveringletter in English and the regional language, clearly outliningthe purpose of the questionnaire, the subject’s option toparticipate or not, and the expected return date; thequestionnaire itself with instructions for completion and areply paid self-addressed envelope. One reminder was senta week after the expected date of reply had passed. Thosesubjects who did not respond to the reminder were notcontacted again.

Data analysis

Demographic data even those that were ordinal in naturewere pooled into categories for ease of analysis.However,owing to the lack of substantial number of subjects, allgroups were not of equal intervals. The demographic datawere analysed using descriptive statistics. Associations ofdemographic characteristics was carried out using lambdacoefficient of association for categorical data.

ResultsReturn rateOf the 600 individuals, 276 responded to the mailedquestionnaire, with a return rate of 46%.

DemographicsDemographic details are mentioned in table 1.Age: Of the 276 participants, 53 (19.2%) were in the agegroup of 18-<25 years, 53 (19.2%) in 40-<50 years, 49(17.8%) in 25-<30 years, 41 (14.9%) in 35-<40 years, 38(13.8%) in 30-<35 years, 30 (10.9%) in 50-<60 years andone each (0.4%) in 70-<80 and more than 80 years.Gender: 233 subjects were men and 43 were women.

Education: 148 subjects (53.6%) belonged to secondaryeducation category, 40 (14.5%) subjects had highersecondary education, 23 (8.3%) subjects were illiterate, 22(8%) subjects were graduates, 19 (6.9%) subjects wereprofessionals, 19 subjects (6.9%) had primary educationand 5 (1.8%) subjects were post-graduates. Relationshipbetween age, gender and education is as shown in table 2.

Level of lesion: 166 subjects (60.1%) had the lesion at thelumbar level, 39 subjects (14.1%) at the upper thoracic level,31 subjects (11.2%) at the lower thoracic level and 40subjects (14.5%) did not mention about the level.

Etiology: Falls from height was the leading cause for spinalcord insult (25%), followed by road traffic accidents (17.4%),non-traumatic insult (8.3%), fall of an object (6.5%), gunshot injuries (4.3%) and sports related cause of an insult(0.7%). Thirty-eight percent individuals did not mention thecause for injury. The etiology is shown in figure I. We foundan association of etiology with age at injury and gender,which is as shown in figures 2 and 3.

Duration since injury: The duration since injury wasarbitrarily divided into 11 categories, ranging from 1-<6months to more than 25 years. Of the 276 participants, mostof the subjects (57, 20.7%) were 1-<6 months post injuryand the least (6, 2.2%) were in 15-<20 years post injuryperiod.

Employment: 162 subjects (59%) were non-employed and114 subjects (41%) were employed.

DiscussionFor the sake of clarity, we will discuss each of thedemographic characteristics separately.

AgeMajority of the SCI victims in the present study were in theage group of 18-<25 years and 40-<50 years. We found anassociation of age at injury with etiology, as depicted infigure 2. Fall from a height was the commonest cause forthe spinal cord insult in all the age groups, especially till40-<50 years. Road traffic accident was the leading cause


26

in construction, head load working etc. These causes aremodifiable with increase in awareness and safety guards.

EducationMajority of the SCI victims had secondary educationfollowed by subjects with higher secondary education. Thegroup of patients with lower education is often blue-collarworkers and is most likely to be engaged in the high-riskoccupations.

Level of lesionThe most common level of lesion in individuals withparaplegia is lumbar (60.1%). This is similar to the findingsof Roop Singh, where he found the first lumbar vertebrabeing the most common level of lesion.3

EtiologyAs shown in figure 1, falls from height were the leadingcause of spinal cord insult followed by road traffic accidents.Our findings are similar to those shown by Chacko, Joseph,Mohanty and Jacob in 19862 , by Roop Singh in 20053 andby Agrawal P etal in 20064, where fall from trees was thecommonest cause for spinal cord injury in India followedby road traffic accidents. Thus, we can say that theappropriate preventive measures which Chacko et al hadstressed upon in 1986 are still lacking in our country. Thisnecessitates the need to create an awareness regardingthe causes for spinal cord insult in the community and toimpart knowledge regarding transportation of SCI victim.We assume that attention towards these individuals in the


Table 1: Demographic characteristics (n=276)Demographics (%)

1. AGE (IN YRS)18-<25 19.225-<30 17.830-<35 13.835-<40 14.940-<50 19.250-<60 10.960-<70 3.570-<80 0.4>80 0.4

2.GENDERMen 84Women 16

3.EDUCATIONNo education 8.3Primary 6.9Secondary 53.6Higher secondary 14.5Graduation 8Post-graduation 1.8Professional 6.9

Fig. 1: Etiology of spinal cord insultDemographics (%)

4.ETIOLOGYFall from a height 32Fall of an object 7Road traffic accident 22.5Sports related 1Gun shot injury 4.5Non-traumatic 11.5

5.LEVEL OF LESIONUpper thoracic (T1-T6) 14.1Lower thoracic (T7-T9) 11.2Lumbar (T10 and below) 60.1

6.Duration since injury1-<6 months 20.76-<12 months 14.91-<2 years 15.22-<3 years 10.53-<4 years 6.54-<5 years 6.25-<10 years 10.510-<15 years 4.315-<20 years 2.220-<25 years 4.3>25 years 3.6

in 18-<25 years age group. This is in contradiction towestern data where motor vehicle accidents are thecommonest cause for injury and falls were the leading causeof injury after the age 45.6 In the present study, falls werethe leading cause even before the age 45. This can beexplained, as the majority of the patients in the study weremanual workers and compared to western countries, inIndia, falls from heights still rank first under the etiologycategory. These findings have a notable part to play inincreasing awareness. The population most at risk is alsothat which is contributing the most to the society. Hence,the social impact of these preventable causes of SCI is acause for concern.

GenderThe most common cause for the insult to spinal cord injuryin males was traumatic and in females, it was non-traumatic.This finding is in agreement with those of McKinley, Seeland Hardman, in their five years prospective study in 1999.They had reported that the individuals with non-traumaticspinal cord injury were significantly females.7 Fall of objecton the head was another common cause in both thegenders. This can be attributed to unsafe working conditions

S.No. Age groups Gender Education(in years) Men Women 0 1 2 3 4 5 6

1. 18-<25 45 08 04 00 22 16 07 00 04

2. 25-<30 41 08 03 01 25 09 08 00 03

3. 30-<35 32 06 01 03 23 04 03 01 03

4. 35-<40 34 07 01 05 25 05 02 01 02

5. 40-<50 45 08 05 06 34 04 02 00 02

6. 50-<60 24 06 07 00 16 02 00 01 04

7. 60-<70 10 00 02 03 03 00 00 02 00

8. 70-<80 01 00 00 00 00 00 00 00 01

9. >80 01 00 00 01 00 00 00 00 00

Note: Education categories: 0- no education, 1- primary education, 2- secondary education, 3- higher secondary education, 4- graduation, 5- post graduation and 6- professional

Table 2: Description of frequencies of age, gender and education (n=276)

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community is still inadequate. Thirty eight percent subjectsdid not mention the etiology, this could be due to the non-comprehensibility of the question or the insult was non-traumatic in nature.

Duration since injuryThe least group in our study was the one in 15-<20 yearspost injury period. We had some individuals in 20-<25 yearsand more than 25 years post injury period. But the majoritywas in 1-<6 months. It might be due to the fact that in India,the survival rate is still low. Decreased survival rate couldbe due to lack of acute and rehabilitation services, lack ofpre-discharge home visits, development of secondarymorbidities at home, lack of regular follow-ups, socio-cultural variations, unfavorable family atmosphere andpsychological impact of the injury.

EmploymentIn the present study, one hundred and fourteen subjectswere employed. Majority of these subjects were eithergetting pensions or were working in sheltered workshops.Individuals living in the community were either havingtelephone booths, fruit shops or were taking care of theirfamily business. Some of the individuals were professionalstoo. But one hundred and sixty eight patients wereunemployed. Unemployment can be due to their level oflesion, as individuals with lesion at upper thoracic level weremore likely to be unemployed. Lack of specialized centersand NGOs in most of the areas, lack of knowledge regardingthe job opportunities and lack of initiative on the part ofmedical or paramedical personnel, can be some of thereasons for their unemployment. Another factor may bereluctance on the part of family to allow the disabledindividual to seek employment.

ConclusionFall from height is still the leading cause for spinal cordinsult in India. Road traffic accident is the commonest causein the younger age group i.e. 18-<25 years. Traumaticlesions are common in men and non-traumatic lesions arecommon in women. Lumbar level is the commonest levelof lesion in individuals with paraplegia. Though there is anadvent of new technologies and rehabilitation facilities,

Fig. 2: Association of age with etiology

Note: Age at injury categories (in years): 1-18-<25, 2-25-<30, 3-30-<40, 4-40-<50, 5-50-<60, 6-60-<70 and 7-70-<80.

Fig. 3: Association of etiology with gender

survival rate and the employment after injury are still low.

Limitations of the studyThe comprehensibility of the questionnaire is one of thelimitations as many subjects did not mention about theetiology and level of lesion. The return rate of thequestionnaire was not uniform from different parts of thecountry. Hence the sample may not be representative ofthe country.

ImplicationsThe results of this study suggest the following:

• It is essential to increase the awareness regardingthe usage of safe-guards at construction-sites andother high risk jobs.

• It is essential to create an awareness regarding safetransportation of SCI victim.

• Emphasis is to be given for better rehabilitation allover India.

• Emphasis is to be for formation of multidisciplinarycommunity rehabilitation teams.

• It is essential to have regular life long follow-ups forthese patients.

• Vocational rehabilitation should be given importance

References1. Awareness and Prevention.

[http://www.isiconline.org/aware.htm.]2. Chacko V, Joseph B, Mohanty S.P, Jacob T.

Management of spinal cord injury in a general hospitalin rural India. Paraplegia 1986; 330-335.

3. Singh R, Sharma SC, Mittal R, Sharma A. TraumaticSCI in Haryana: An epidemiologic study. IndianJournal of Community Medicine 2005; vol.XXVIII, No.4.

4. Agrawal P, Upadhaya P, Raja K. A DemographicProfile of Traumatic and Non-Traumatic Spinal InjuryCases: A hospital based study from India. Spinal cord2007; 597-602.

5. Chhabra HS. Life after SCI in India- Results of asurvey of 53 centres. [http://www.iscos.org.uk/abstract13.html.]

6. Spinal cord injury information network.[http://www.spinalcord.org.]

7. Mckinley WO, Seel RT, Hardman JT. Non-traumaticspinal cord injury: incidence, epidemiology and functionaloutcome. Arch Phys Med Rehabil 1999; 80: 619-623.


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Chest physiotherapy in post extubation atelectasis in neonates -A case studyNarasimman S1, Varadaraj Shenoy K2, Natraj R3, Anita Maria Andrade4

1Asst. Professor, Dept of Physiotherapy, 2Professor, HOD, Dept of Pediatrics, 3Resident, Dept. of Pediatrics, 4Post GraduateStudent, Dept of Physiotherapy, Father Muller Medical College, Mangalore

AbstractChest physiotherapy is often used to correct post extubationatelectasis in the neonatal intensive care units. This casestudy explains the efficacy of carefully administered chestphysiotherapy in a 2 day old neonate, who developed postextubation right upper lobe collapse followed by pneumonia.Chest physiotherapy was administered every three hoursfollowed by gentle oral and nasal suction. Chest X rayrevealed full expansion of the lung after a day of chestphysio physiotherapy.

Key Words: Chest Physiotherapy, Atelectasis,postextubatin, Neonates

IntroductionLiterature states that about 10 to 50% of the neonatesdevelop atelectasis after extubation1. The risk of pulmonarycomplications is more in neonates due to immaturity of therespiratory system. Chest physiotherapy is often used incritically ill neonates in the neonatal intensive care unit.The aim of chest physiotherapy in the newborn is to increasethe clearance of lung secretions and maintain the lungexpansion2, 3. This case study describes the efficacy of chestphysiotherapy in correcting post extubation atelectasis.

History A male child 2 days of age born to a primi mother by LSCSwas admitted in the NICU with a history of respiratorydistress. The Baby had cried immediately after birth. Apgarscore was not known since the child was not born in ourhospital. Immediate chest X-ray suggested pneumonia andthe sepsis workup were positive. Since the baby was notmaintaining saturation , he was intubated and connectedto the mechanical ventilator on P-CMV mode withrespiratory rate 35 breath per minute and FiO2 60%. Onday four the baby was weaned from the mechanicalventilator after normalization of the ABG report and clinicalimprovement. Baby was then extubated. The postextubation X ray revealed right upper lobe collapse andthe baby was referred for physiotherapy. Antibiotics werecontinued thorough out the course.

Physiotherapy AssessmentOn observation, baby was receiving 8 liters of Oxygenthrough hood. SpO2 was 92% with respiratory rate 40 perminute.On auscultation, absence of air entry in the right upper zone

was noticed. ABG report showed reduced Oxygenation(PaO2 86 mmHg)

Chest PhysiotherapyPrior to chest physiotherapy base line heart rate, respiratoryrate, and oxygen saturation was noted during every session.The baby was held in up right and right lateral position.Gentle percussion using the face mask was given alongwith vibrations with minimal compressive pressure. TheBaby’s head was supported by the therapist’s free handduring the physiotherapy session. Gentle oral and nasalsuction was done after 20 minutes of chest physiotherapy.Every hourly the position of the baby was changed. Samephysiotherapy was continued every three hourly during theday time. Gentle upper intercostal stretching was added.All the details of the treatment were documented. Repeatchest X ray was done on the next day which showedexpansion of the right lower lobe.

DiscussionThe aim of chest physiotherapy in this baby was to reexpand the atelectatic lung and to improve the lungexpansion. Prior to each session of physiotherapy the vitalparameters were noted and were observed during the entirecourse of physiotherapy to ensure that there were noadverse effects. A Cochrane systematic review by 4 FlenadyV. J, and coauthor revealed only 4 randomized controlledtrails. They concluded that there was insuffient data to

Chest X ray shows Right upper Lobe Collapse

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comment on the effects of chest physiotherapy in postextubation atelectasis. They added that active chestphysiotherapy reduces the rate of post extubationatelectasis. In this case utmost care was taken in order toavoid complications and chest physiotherapy was given onlyafter consultation with the resident pediatrician. The protocolgiven by Department of Neonatal Medicine, Royal PrinceAlfred Hospital 5 also suggests that careful administrationof chest physiotherapy could be useful in preventing andcorrecting post extubation atelectasis. Some studiesrevealed that chest physiotherapy improved oxygenation,and reduced airway resistance. These studies were onlyobservational.6, 7

ConclusionThough there is limited evidence for the efficacy of chestphysiotherapy in correcting post extubation atelectasis,

Chest physiotherapy could be considered as an adjunct inthe management of post extubation atelectasis. In view ofcost effectiveness, careful administration of chestphysiotherapy could be effective in correcting postextubation atelectasis.

References1. Finner NN, Moriartey RR, Boyd J, Philips HJ, Stewart

AR, Ulan O. “Post extubation atelectasis: aretrospective review and a prospective controlledstudy”. J Pediatric 1979;94:110-3

2. Krause MF, Hoehn T “Efficiency and risk of chestphysiotherapy in newborn – review of literature” KlinPaediatr 1999 Jan – Feb ; 211(1): 11-7 ( Abstract)

3. Colin Wallis, Ammani Prasad “Who needs chestphysiotherapy? Moving from anecdote to evidence”Arch Dis Child 1999; 80: 393 – 397

4. Flenady VJ, Gray PH “Chest physiotherapy forpreventing morbidity in being extubated frommechanical ventilation”. The Cochrane Database ofsystematic Reviews 2002, Issue CD 000283:10.1002/14651858.CD000283.

5. Department of Neonatal Medicine Protocol Book,Royal Prince Alfred hospital, Chest Physiotherapy.http. // www. cs.nsw.gov.au

6. Tudehope D, Bagley C. “Techniques of Physiotherapyin intubated babies with the respiratory syndrome”.Aust. Paediatr. J 1980; 16: 226 – 228

7. Dall’ Alba P, Burns Y. “The relationship betweenarterial blood gases and removal of airway secretionsin neonates”. Physiotherapy theory and practice1990:10: 107- 116

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The effectiveness of self snags over conventional physiotherapymanagement in chronic neck pain among computerprofessionalsShilpi Chhabra, Deepti Chhabra, Jatinder Sachdeva, Amit ChaudharyDepartment of Therapies and Health Sciences, Faridabad Institute of Technology, Faridabad, Haryana

AbstractObjective: To prove the effectiveness of self SNAGS overconventional Physiotherapy management in chronic neckpain among Computer Professionals.

Methods: A structured questionnaire was used to obtaininformation from 38 Computer users, using for at least 4-5hours per day from various Software Companies. Theincidence of neck pain, range of motion and disability inthe experiment group (receiving self SNAGS along withconventional management) was compared with theincidence in the treatment group (only conventionalmanagement) over a period of one month. Subjectsreported symptoms in a weekly diary. Participants with neckpain for more than 3 months were considered symptomatic.

Results: Though, pain scores showed significantimprovement with p=0.03 while cervical rotation of right sideshowed significant improvement at p= 0.04 during followup period in experimental group statistically, there was notmuch significant difference in the incidence of disability andneck range of motion between two groups. Clinically, theresults depicted that experimental group was superior totreatment group.

Conclusion: This study depicted that group receiving selfSNAGS showed better carry over effect during treatmentphase and more during follow up phase as compared togroup receiving conventional physiotherapy alone. Hence,self SNAGS can be incorporated as a treatment tool forchronic neck pain patients. Further studies may require withsubjects as general population with chronic neck pain oras a rationale for adapting the specific interventionaccording to the repeated assessment findings.

IntroductionThe use of the computer is improving the quality of healthcare systems as well as the efficiency of the workers onone hand but on the other hand, as one uses computersfor many hours continuously, he or she may notice increas-ing aches and pains in some parts of the body, usually,musculoskeletal in nature.

Pain in the neck has become one of the leading problemsnowadays. Neck flexion, forward head posture, scapularretraction, forward stoop posture are some of the faultypostural alignment, resulting in neck pain due to increasedcervical muscle activity to support head in forward positionand results in increase in fatigue.

Neck pain may lasts for few days and considered as acuteneck pain and may result from facet syndrome or muscularrheumatism. But if it persists for a longer time i.e more than3 months, it becomes chronic and presents a greaterproblem. It may also result in restricted movements of neck.Pain in the neck arises from musculoskeletal impairmentand physical therapies such as manipulative therapy,therapeutic exercise, electrophysiological agents havetraditionally been the treatments of choice. But concretedata is not available regarding the efficacy of modernmanual techniques over conventional physiotherapy.Hence, the present study involves the comparison for theefficacy of modern manual therapy (Mulligan’s self SNAGS)over conventional therapy for chronic neck pain in computerprofessionals.

Mulligan’s concept of mobilization with movements(MWMs), first used in cervical spine, carry the acronym,SNAGS, stands for sustained natural apophyseal glides,used to improve function, restriction or pain in flexion,extension, rotation, side flexion of cervical spine. Selftreatment using SNAGS with a small hand towel can alsobe beneficial.

Mulligan proposed that when an increased in pain freerange of movement occurs with a SNAG, also influencesthe entire spinal functional unit. Clinically, SNAG on a painfulmobile level may not always achieve a full pain freemovement whereas restricting the movement of a painfulmobile segment or gliding a nearby stiff segment doesachieve the desired result.

It was hypothesized that self SNAGS in conjunction withconventional physiotherapy management would be morebeneficial in alleviating pain and improving neck functionthan conventional physiotherapy management aloneamong Computer professionals. If proved effective, SNAGScan be then incorporated as specific treatment tool forpatients with chronic neck pain.

It is clear from the literature available, that though neckpain is a common complaint among computer professionalsand the computer technology is advancing at a faster pace,little is done in preventing the ailments that are associatedwith its use. There is lack of evidence based studies in thisarea. Therefore, due to an almost complete lack of empiricalevidence supporting the clinical use of self SNAGS forchronic neck pain, this study is being conducted.

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MethodsA convenience sample of subjects was solicited fromvarious Software Companies. Inclusion criteria included anyperson (20- 50 years) using Computer for at least 4-5 hoursper day, complaining of neck pain for the last three months.Exclusion criteria included pregnant women, persons withrheumatoid arthritis, ankylosing spondylitis, tumors,vertebro basilar insufficiency symptoms, fracture ordislocation, recent undergone surgery or any acuteinflammatory problem.

Materials: Universal Goniometer, Visual analog scale, neckdisability index, hot packs and hand towel.

ProcemdureParticipants were recruited from Software Companies(n=38, age range= 20-50 years, mean age= 35 years, maleor female) and asked to fill questionnaire form aboutmusculoskeletal symptoms and intensity or severity of painexperienced. Subjects were then allocated into two groups,Group A, where subjects were taught carefully self SNAGSfor extension, rotation and lateral flexion of cervical spinewith the help of hand towel along with hot packs and advisedon correct posture during work hours. Subjects in Group Bwere just asked to take hot packs for 15-20 minutes at nightand postural advice given.

For cervical extension

• Towel is held on the cervical spine and the selvage onone side is hooked under the spinous process.

• The patient grips each end of the towel and pulls upalong the treatment plane as he or she extends theneck.

• Extension overpressure must be applied at the endrange by patient or by someone in the patient’shousehold and sustained until neck returns to neutralposition.

• Repeat it 6-10 times and can be repeated every twohours.

• If there is pain experienced by the patient whileperforming SNAGS, stop the treatment immediatelyand try other levels until they get it right.

For cervical rotation

• The selvage on one side of the towel is hooked underthe spinous process.

• For right rotation, grasp the left side of the towel withright hand and the right side of the towel with the lefthand.

• The left arm (beneath) is hooked on the back of thechair to stabilize the arm. The right hand now pulls thetowel up in the direction of facet joint or towards thedirection of eyeball and patient rotates his/ her headto the right.

• Overpressure is then applied at the end range andsustained for few seconds until neck returns to neutralposition.

• Repeated 6-10 times, every 2 hours.

For lateral flexion• Similar done as cervical rotation, only difference is while

towel is being pulled, patient side flexes the neck andthen overpressure applied at the end range.

• Repeated 6-10 times, every 2 hours.

Postural advice has been given to subjects to preventbad posture. Participants were advised to:- Keep the spine upright while sitting on chair during

work hours.- Keep the shoulders straight and retracted.- Take frequent breaks between work hours.

Outcome Measures- Pain and Range of motion wererecorded on day 0, day 16 and day 31 whereasdisability scores were recorded on day 0 and day31.

ResultsA total of 38 subjects were identified as potential participantsfor this study and were allocated to the experimental andtreatment groups. The mean age of the respondents was40.8 years, with 53% females and 47% males. Therespondents had a mean of 9 years of experience with anaverage of 7 hours spent on computer per day.

The data obtained was tabulated and statistically analyzedusing SPSS 14.0 package. Due to nature of outcomemeasures i.e pain, disability and neck range of motion,parametric statistical tests, independent t sample test andpaired t test were used.

Subjects showed marked reduction in pain intensity whencompared to baseline value. The improvement isalmostwhereas disability scores were recorded on day 0and day 31.

Independent t sample test was used for between groupanalyses while paired t test was used for within group analy-sis for all the outcome measures. Significant level was de-fined at p< 0.05 and the 95% confidence interval.

Graph 1: Line Diagram showing comparison between groups for pain scores.


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Though, pain scores showed significant improvement withp= 0.03 while cervical rotation of right side showed signifi-cant improvement at p= 0.04 during follow up period inexperimental group statistically, there was not much sig-nificant difference in the incidence of disability and neckrange of motion between two groups. Clinically, the resultsdepicted that experimental group was superior to treatmentgroup.

similar in both the groups but experimental group is moresuperior to treatment group in treatment as well as followup phase.

DiscussionThe proposed study suggests that the technique of selfSNAGS can be incorporated as a treatment tool for Com-puter professionals during their work hours, along with theapplication of hot packs as well as postural advice. It re-sulted in an overall improvement in pain, functional out-come and range of motion for neck extension, lateral flex-ion and rotation, as tested. The significant improvementwas seen clinically for all the outcome measures, as re-ported by subjects receiving self SNAGS. Early recoveryfrom pain with lesser number of sessions of self SNAGSand improvement in neck range of motion was reported bythe subjects in experimental group. It is clearly seen fromthe graphs that consistent and significant improvement had

occurred during the treatment phase as well as follow upphase of the intervention. This improvement possibly maybe attributed to the fact that the accessory glide compo-nent of a cervical SNAG could ameliorate any of these prob-lems either by separating the facet surfaces and releasingthe entrapped meniscoid, or by allowing the entrappedmeniscoid to return to its intra articular position, or per-haps by stretching adhesions.19

Statistically, there was no significant improvement fordisability scores and range of motion for extension andlateral flexion. Though reduction of pain and increase inrange of motion for rotation were statistically significant too.This may be due to poor patient compliance towards homeprogram or because of certain abnormal work posturesduring work hours.

This study attempted to identify a specific subgroup ofindividuals, specifically computer professionals with chronicneck pain using this diagnostic focus and to determine theefficacy of self SNAGS over conventional physiotherapymanagement alone.

Mulligan (1994 a) has put forward a theory which couldhelp to explain the need for ipsilateral physiological rotationduring application of a cervical SNAG. He suggested thatthe superior facet of the implicated functional spinal unitipsilateral to the side of the pain may be jammedposteroinferiorly in an extension or ‘closed down’ position,

Graph 2: Graph showing comparison between groups for NDI scores Graph 3: Graph showing comparison between groups for ROM extension

Graph 4: Graph showing comparison between groups for ROM left lateralflexion

Graph 5: Graph showing comparison between groups for ROM rightlateral flexion


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hence, ipsilateral rotation could cause pain due to excessive‘closing down’ of the zygapophyseal joint. Application ofaccessory glide component of cervical SNAG may thereforereposition the superior facet superioanteriorly allowing agreater range of pain free ipsilateral rotation.

The interventions in the current study, in comparison, werea more realistic representation of a pragmatic approach ofthe management of chronic neck pain. Both interventionshad components of a home program and posture correctionin addition to the intervention under study and it isacknowledged that this common component may accountfor some of the improvement in both the groups. Thesubjects chosen for this study fulfilled the symptomaticcriteria for chronic neck pain.

The cause of the subject’s signs and symptoms waspostulated to be musculoskeletal because of the behaviorof pain and reduced range of motion of cervical spinewithout radiation of pain and neurological deficit. The riskfor neck pain was significant higher for women than men.This agrees with earlier studies.

Due to almost complete lack of empirical evidencesupporting the clinical use of cervical SNAGS, a discussionon the functional spinal unit biomechanics and the articulartissues of the mid lower cervical spine is worthwhile.19

Cervical SNAGS are said to have immediate effect (Mulligan1999), it seems likely that their underlying mechanism iseither purely mechanical, reflexogenic (Herzog et al 1999)or a combination of the two, and does not primarily involvechemical processes or natural resolution(Wall, 1992).Mulligan states that cervical SNAGS are specific in theirefforts to a single functional spinal unit, potentially excludingmechanisms such as the placebo effect(Wall,1992), the‘laying on of hands’ (Zusman 1986) and therapist charisma(Hartman, 1985).

It is unlikely that osseous pathology would undergoimmediate and prolonged improvement followingmobilization, thus implicating soft tissue structures suchas meniscoid inclusions, the zygapophyseal joint capsulesand intervertebral disk as most likely articular sources forany manually reversible pain.

As self SNAGS and the intervention which we provided tothe groups were self practiced by the subjects at home orduring their work hours. Supervision for them was not being

done everyday. This may have been acted as a confounder.Also, it was not possible to control the use of analgesicsdue to the ethical consideration. This may also acted as aconfounder.

The results of this study are in agreement with the findingsthat cervical self SNAGS along with the application of hotpacks and postural advice can be incorporated as atreatment tool for chronic neck pain.

Due to relatively small sample size, it was not possible toinfer patient characteristics corresponding with treatmentoutcome. Future research is essential for the subjects withchronic neck pain as general population along with largesample size and to further optimize clinical practice. Also,further studies may require more regular assessment duringthe intervention period to determine the timeframe ofimprovement and to investigate the outlining of elementsof the technique and the rationale for adapting the specificintervention according to the repeated assessment findings.

ConclusionIt was found that group receiving self SNAGS showed bettercarry over effect during treatment phase and more duringfollow up phase as compared to group receivingconventional physiotherapy management alone. Thus, thefindings of this study suggests that self SNAGS as atreatment technique can be incorporated for chronic neckpain and is more effective than conventional physiotherapymanagement alone.

References1. Naveen Thacker.Computer Ergonomics. In: Tanmay

R Amladi. Computer For Doctors. Jaypee 2003.2. Rufus A, Adedoyin et al. Musculoskeletal pain

associated with the use of computer systems inNigeria. The Internet J of Pain, symptom control andpalliative care. 2004; Vol 3: No.2.

3. Eugene Kay. Neck pain and the office workers;Ergosense Issue 19.In Minneapolis.

4. Julia Hush M, Chris Maher G, Kathryn Refshauge M.Risk factors for neck pain in office workers: aprospective study. BMC Musculoskeletal Disorders2006 Oct 25; 7: 81.

Graph 6: Graph showing comparison between groups for ROM left rotation Graph 7: Graph showing comparison between groups for ROM right rota-tion


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5. Hagberg M. ABC of work related disorders: Neck andarm disorder. BMJ 1996 Aug 17; 313: 419-22.

6. www.Ergonomics/ Optimum neutral posture- ergotron;Sep 2002.

7. Aker P D, Gross A R, Goldsmith H, Peloso P.Conservative management in mechanical neck pain:systemic overview and meta analysis. BMJ 1996; 313:1291-96.

8. Ariens G.M et al. Are neck flexion, neck rotation andsitting at work risk factors for neck pain? Results ofprospective cohort study. Occup. Environ Med.2001;58: 200-7.

9. Gerr F et al. A randomized controlled trial of posturalinterventions for prevention of musculoskeletalsymptoms among computer users. Occup. Environ.Med 2005 Jul; 62 (7): 478- 87.

10. Cagnie B et al. Individual and work related risk factorsfor neck pain among office workers: a cross sectionalstudy. Eur Spine J.2006 Dec 8.

11. Steill JG et al. The Canadian C spine rule forradiography in alert and stable trauma patients. J ofAm. Med. Assoc. 2001 Oct 17; 286 (15): 1841-48.

12. Evidenced Based management of acutemusculoskeletal pain. Australian faculty ofMusculoskeletal medicine.

13. Cynthia Norkin C. Joint structure and function, acomprehensive analysis; 3rd ed.; India: F.A Davis:Jaypee 2001.

14. James W.Devocht, DC, PhD, Biomech. Tech 613, Fallwinter 2006, Module 3: Functional anatomy of cervicalspine (Herzog Chap 3).

15. Erik E Swartz, R T Floyd, Mike Cendoma. Cervicalspine functional anatomy and the biomechanics ofinjury due to compressive loading. J Athl Train. 2005Jul- Sep; 40(3); 155-161.

16. Sebastian Deepak. Principles of manual therapy: Amanual therapy approach to musculoskeletaldysfunction. 2nd ed.New Delhi: Jaypee publishers2007.

17. Karen Jacobs. Ergonomics for Therapists. 2nd ed.Butterworth Heinmann 1996.

18. Brandt L.P et al. Neck and shoulder symptoms anddisorders among Danish computer workers. Scand JWork Environ Health. 2004 Oct; 30(5): 399-409.

19. Hearn A, Rivett D A. Cervical SNAGS: abiomechanical analysis: Man Ther 2002: 7(2): 71-9.

20. Exelby L. The Mulligan Concept: Its application in themanagement of spinal conditions. Man Ther 2002:7(2); 64-70.

21. Mulligan Brian R. Manual Therapy ‘NAGs’, ‘SNAGS’,‘MWMS’ etc. 5th ed: Wellington: Plane View ServicesLtd.

22. Jack Miller. The Mulligan Concept; The next step inthe evolution of manual therapy.Orthopaedic divisionreview: May/Jun 1999.


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Effect of positive expiratory pressure technique over forcedexpiratory technique on bronchial hygiene in patients withmoderate chronic bronchitisSmibi Skaria1, Arul Joseph Arun2, Jasobanta Sethi3

1M.P.T (cardiothoracic) student, 2Associate Professor, 3Professor & Principal, Goutham College of Physiotherapy, Bangalore.

AbstractBackground and objectives: An understanding of thebasis of findings reported in the studies of positive expiratorypressure technique assist physical therapists in planningand modifying mucus clearance program of their clients.This study was intended to ascertain the effectiveness ofpositive expiratory pressure technique over forcedexpiratory pressure technique in improving bronchialhygiene in moderate chronic bronchitis patients.

Methods30 chronic bronchitis patients were divided into two groups(Group A and Group B) in a randomized controlled trail studycomparing positive expiratory pressure technique usingFlutter device over forced expiratory pressuretechnique.(each of 2 sessions per day for 15 minutes for5 days weekly for totally 2 weeks.) Improvement in bronchialhygiene was assessed using peak expiratory flow meter,pulse oxy meter and modified Borg’s scale.

ResultsAt the end of 2nd week of intervention, significant improve-ment in bronchial hygiene was found with independent‘t’test at p< 0.05 in Group A when compared with Group B.There were significant changes in peak expiratory flow rate(with peak expiratory flow meter), O2 saturation (with pulseoxy meter) and dyspnea level (with modified Borg’s scale)in Group A than Group B.

ConclusionPositive expiratory pressure technique using flutter deviceeliminates mucus from the bronchial airway and thusimproves bronchial hygiene in moderate chronic bronchitispatients. This study will be helpful for the physiotherapiststo incorporate flutter device for improving bronchial hygienein their patient care.

Key words: Moderate Chronic Bronchitis, positiveexpiratory pressure technique, Flutter device, forced

expiratory pressure technique, Autogenic drainage,Bronchial hygiene.

IntroductionDiseases of respiratory system are the major causes ofillness affecting a greater part of population worldwide.1

Chronic obstructive pulmonary disease (COPD) is theinternationally preferred term encompassing chronicbronchitis, emphysema and asthma.2 Chronic obstructivepulmonary disease (COPD) is the most common chronicpulmonary disorder afflicting 10 to 15% of adults over theage of 45, COPD is a disorder characterized by thepresence of airflow obstruction that is generally progressive,accompanied by airway hyper reactivity and may be partiallyreversible.3A review of population studies from India,estimated that total number of COPD patients aged 40 yearsand above in 1996 were 8.15 million males and 4.21 millionsfemales.4

Chronic Bronchitis is one of the common COPD disorderand is defined as chronic cough and expectoration whichpersists for at least 3 months period for at least 2consecutive years. The cause of chronic bronchitis is relatedto long term irritation of the tracheobronchial tree.2 The mostcommon cause of irritation is cigarette smoking. Othercauses are air pollution, bronchial infections andoccupational diseases.5

Conventional methods like chest physical therapy, Activecycle of breathing technique, Airway clearance techniqueslike postural drainage, percussion, vibration, shaking andforced expiratory techniques are used for mucus clearancein chronic bronchitis patients.6 Recent methods like positiveexpiratory technique using flutter device and Autogenicdrainage are also used for improving bronchial hygiene inchronic obstructive pulmonary disease patients.2

A form of PEP in combination with high frequency oscillationis available in a device (Flutter Device) developed inSwitzerland, by Patrick Althaus, a Swiss physiotherapistwho added a steel ball vibrating inside a cone to the PEPdevice which quickly gained popularity worldwide.7 TheFlutter device is a handheld device that interrupts theexpiratory flow and decreases the collapsibility of theairways. The functional principle of flutter device is basedon oscillative positive expiratory pressure which is designedto improve the patients’ abilities to eliminate the excessivemucus from their airways independently. It also promotescorrect breathing patterns with effective distribution ofventilation which improves gaseous exchange.8

Corresponding Author:Smibi SkariaMPT (Cardiothoracic) student, Gautham College of Physiotherapy#173,187 Main road, Kamalanagar, Bangalore.Mobile No.9916159070, Email: [email protected]

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In contrast to flutter therapy bronchial secretion duringautogenic drainage are mobilized not only by high frequencyoscillation, pressure changes and the air flow changes butby a special calm breathing technique.8 Autogenic Drainagewas introduced by Chevaillier in Belgium in 1967 for thetreatment of chronic obstructive pulmonary diseasepatients.9 Autogenic Drainage uses diaphragmatic breathingto mobilize secretions by varying expiratory airflow. Itconsists of three phases; Firstly, breathing at low-lungvolumes to “unstuck” the peripheral secretions andsecondly, breathing at low to mid lung volume to collect themucus in the middle airways. Finally, breathing at mid tohigh lung volumes to evacuate the mucus from the centralairways.10

All detectable rheologic differences in the sputum collectedat the end of every autogenic drainage and flutterphysiotherapy section may be caused by high frequencyoscillation and pressure and air flow changes produced bythe flutter device.8 Many studies have been conducted toshow the individual effect of positive expiratory pressuretechnique and autogenic drainage to improve the bronchialhygiene in moderate chronic bronchitis patients. Hence thisstudy aims to analyze the effectiveness of both the treatmenttechniques and prove the better effectiveness by comparingpositive expiratory pressure technique and autogenicdrainage in improving the bronchial hygiene in moderatechronic bronchitis patients.

Study designThis study was an experimental design involving thecomparative analysis of the two groups treated with positiveexpiratory pressure technique and Autogenic drainagerespectively and assessed by dependant variables namelyOxygen saturation (SaO2), Peak Expiratory Flow Rate(PEFR) & Rate of Perceived Exertion (RPE).

The Selection Criteria was as follows:

Inclusion criteria• Clinically diagnosed moderate chronic bronchitis

patients.• Moderate Chronic bronchitis patients with dyspnoea

grading above 3 (10-point modified Borg’s scale)• Both males and females.• Age group between 40-60 years.

Exclusion criteria• Clinically diagnosed mild & severe chronic bronchitis

patients.• Age group below 40 and above 60 years.• Associated unstable cardiovascular diseases & any

other neurological deficits.• Chronic bronchitis patients who has undergone recent

thoracic and abdominal surgeries.• Any other associated restrictive lung diseases.

Measurements tools

The following were the measurement tools used for thestudy.• Pulse Oxymeter (Oxygen saturation level ,SaO2)• Peak expiratory flow meter (Peak expiratory flow rate,

PEFR)

• 10-point Modified Borg’s Scale (Rate of perceivedexertion, RPE).

Procedure30 subjects clinically diagnosed as moderate chronicbronchitis were selected according to inclusion andexclusion criteria and divided randomly into twoexperimental groups, as Group A and Group B, consistingof 15 subjects each. A brief explanation about the treatmentsession was explained to all the subjects.

The treatment duration for both the groups was given aslisted below:Duration per session : 15 -20 minutes / sessionNo. of sessions per day : Twice a dayNo. of days per week : 5 DaysDuration of the study : 2 weeks

The pre- post test values of O2 saturation, peak expiratoryflow rate and Rate of perceived exertion were noted beforethe test and at the end of 2nd week of treatment. Group Awas treated with positive expiratory pressure techniqueusing flutter device and Group B received AutogenicDrainage.

Group A: (Positive expiratory pressure tech-nique)The subjects were asked to seat in a comfortable positionleaning forward with elbows supported on a table and neckslightly extended in order to open up the airway. The flutterdevice was held horizontally and tilted slightly upwards inorder to get maximal oscillatory effect and was placed inthe mouth. Inspiration was done through the nose. A slowbreath in, only slightly deeper than normal with a breathhold of 3-5 seconds followed by breath out through the flutterdevice at a slightly faster rate than normal. After 4-8 ofthese breaths, a deep breath with a ‘hold’ at full inspirationwas followed by a forced expiration through the flutterdevice. This precipitated expectoration and was followedby a pause for breathing control, and then according to thesubjects’ preference a cough or huff was done.14

The full effects of the vibrations induced by the flutter maybe received by changing the angle of the device. Movementof the flutter upward increases the pressure and frequencywhile movement of the device downward results in lowerpressure and frequency. While doing the procedure thepatient must keep the cheeks flat and use the abdominalmuscles effective exhalation. The vibration of the chest maybe palpated by the patient to provide feedback as to theoptimal angle of the device. A flutter session consists of 10to 15 breaths followed by huffing, with session lasting about15 to 20 minutes. To avoid dizziness due to hyperventilation, a patient should refrain from forced exhalation.It may be necessary to pause every 5 to 10 exhalationsbefore resuming the session. 15

The flutter device should be cleaned regularly with hot andsoapy water. In the hospital the equipment should besterilized according to infection control recommendations14.


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Group B: (Autogenic Drainage)The patients were seated up straight in a chair with backsupport. The upper air ways were cleared of secretions byhuffing or blowing the nose. The therapist was seated tothe side and slightly behind the patient, close enough tohear the patient’s breathing. One hand was placed to feelthe work of abdominal muscles and the other hand placedon the upper chest.14 In all phases, the inhalation was doneslowly through the nose, using diaphragm; two to threebreath holds allowing collateral ventilation to get air behindthe secretions. Exhalation was done through the mouth.The vibration of mucus is felt with hand placed on upperchest. The frequency of vibrations revealed their locations.High frequencies reveal secretions located in small airways.Low frequencies mean that secretions were moved to largerairways.9

1. The Unsticking Phase: Inspiration was followed by adeep expiration in to the expiratory reserve volume. Itwas done by contracting the abdominal muscles. Thislow lung volume breathing continued until the mucuswas loosened and started to move in to the largerairways.9

2. The Collecting Phase: The tidal volume breathing wasthen changed gradually from expiratory reserve volumetowards the inspiratory reserve volume range so thatthe lungs were expanded more with each inspiration.The patient increased both inspiration and expirationto move a greater volume of air. This low to middlelung volume breathing continued until the sound ofmucus decreased, signaling its movement in to thecentral airways to be evacuated.9

3. The Evacuating Phase: In this Phase, the patientincreased inspiration in to the inspiratory reservevolume range. This middle to high lung volumebreathing continued until the secretions were in thetrachea and ready to be expectorated. The collectedmucus was evacuated by a stronger expiration or ahigh volume huff.9

The duration of each phase of autogenic drainagedepended on the location of the secretions. The durationof a session depended on the amount and viscosity of thesecretions.14

The post test values of Oxygen saturation, Peak expiratoryflow rate and Rate of perceived exertion according tomodified Borg’s Scale were noted at the end of secondweek of treatment. Then the pre & post test values wereconsidered for data analysis to infer the results.

Data analysisThe statistical tool used in this analysis was independent‘t’test. The difference of values between pretest and post testwere found. It was done for the values taken before and atthe end of two weeks respectively. The mean differencesof Oxygen Saturation, Peak Expiratory Flow Rate and Rateof Perceived Exertion of Group A were compared with GroupB and the actual pattern of variation in all the categorieswas observed.With the acquired‘t’ value from the pretest and post test,the accurate level of significance was analyzed and

interpreted. An alpha level of P<0.05 was the level ofsignificance for the test.A dependent‘t’ test was performed to analyze the efficacyof treatment within the groups.

Results & interpretationThirty patients with Moderate Chronic Bronchitis with amean age of 50.23years were selected for the study. Themean, variance and standard deviation values of the agegroups according to the distribution of the sex are shownin Table-1.1 & 1.2

Descriptive statisticsThe following tables & graphs illustrates the mean, variance& SD values of the different parameters individually, therebyshowing the improvement within the group by the respectivetraining procedures.

InterpretationThe above table shows the value of t = 2.4076 for meanimprovement in the values of Peak Expiratory Flow Rate(PEFR) at p<0.05 As the t’ value was greater than the tablevalue (1.701) it was concluded that Positive ExpiratoryPressure Technique had a more significant effect thanAutogenic Drainage in improving the Bronchial Hygiene ofpatients with Moderate Chronic Bronchitis.InterpretationThe above table shows the value for mean improvement for allthe parameters such as Oxygen Saturation (SaO2), Peak Expiratory

Table 1.1: Mean, Variance & Standard Deviation values of age group inGroup A

GENDER N MEAN VARIANCE SDMales 10 50.9 52.54 7.24

Females 5 49.2 16.7 4.08

Total 15 50.33 39.24 6.26

Table 1.2: Mean, Variance & Standard Deviation values of age group inGroup B

GENDER N MEAN VARIANCE SDMales 10 50.7 58.9 7.67

Females 5 49 29.5 5.43

Total 15 50.13 46.98 6.85

Table 3.1: Mean, Variance & SD values of pre & post tests for Oxygensaturation (SaO2) of Group A

Test Mean Variance Standard DeviationPre Test 90.47 5.69 2.38Post Test 92.73 4.92 2.21

Table 3.2: Mean, Variance & SD values of pre & post tests for Oxygensaturation (SaO2) of Group B



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Flow Rate (PEFR) and Rate of Perceived Exertion (RPE) assessedusing the Modified 10-point Borg’s Scale. All the parameters showa greater improvement with Positive Expiratory Pressure Techniquedone using Flutter Device than Autogenic Drainage in improvingthe Bronchial Hygiene of patients with Moderate Chronic Bronchitis.

Interpretation of statistical resultsThis study was done with 30 moderate chronic bronchitissubjects allotted into two experimental groups namelyGroup A and Group B consisting of 15 each, to know theeffectiveness of Positive Expiratory Pressure Techniqueusing Flutter Device over Autogenic Drainage in improvingthe Bronchial Hygiene of patients with Moderate ChronicBronchitis.

The parameters used were Oxygen Saturation (SaO2), PeakExpiratory Flow Rate (PEFR) and Rate of PerceivedExertion (RPE) assessed using the Modified 10-point Borg’sScale. It was taken before the treatment and at the end ofsecond week post treatment. The data were analysed usingdependent ‘t’ test to find the significance of the interventionsused within the groups and then an independent ‘t’ testwas used for the above mentioned parameter to find thesignificance between the groups. The dependent ‘t’ testshowed significance for both the groups stating both theexperimental Groups were improving the bronchial hygienewith their respective treatments done.

The results were found to be significant with independent‘t’ test at p<0.05 with the calculated ‘t’ values as 3.8473,2.4076 & 2.0371 for Oxygen Saturation (SaO2), Peak

Expiratory Flow Rate (PEFR) and Rate of PerceivedExertion (RPE) respectively and being more than the tablevalues. This stated that there is better effectiveness whenPositive Expiratory Pressure Technique was given usingFlutter Device than Autogenic Drainage in improving theBronchial Hygiene of patients with Moderate ChronicBronchitis.

DiscussionThe chief objective of the study was to compare the efficacyof Positive expiratory pressure technique and Autogenicdrainage. The study undertaken included patients who hadmoderate chronic bronchitis; hence this study can’t begeneralized to whole of the population who are sufferingfrom chronic bronchitis. Although many treatment methodsare currently in vogue in order to deal these kinds of patientswe are in emergent need of applying the correct techniquewhich suits the patient’s need. The growing demand formeeting various problems associated with pulmonarycomplications are indeed worth considering.

The study was detailed and tailored to find the efficacy ofwhich mode of treatment was better in the two groups using

Table 3.4: Mean, Variance & SD values of pre & post tests for PEFR ofGroup B

Test Mean Variance Standard DeviationPre Test 223.33 1738 41.69Post Test 343.33 3523 59.36

Table 3.5: Mean, Variance & SD values of pre & post tests for Rate ofperceived exertion (RPE) of Group A


Table 3.6: Mean, Variance & SD values of pre & post tests for rate ofperceived exertion (RPE) of Group B


Table 6: Mean improvement in all the parameters between Group A & Group B

Parameters Group A Group B

Oxygen Saturation 2.26 1.33PEFR 179.33 120RPE 1.83 1.4

Fig. 5:

Fig. 6:


Table 3.3: Mean, Variance & SD values of pre & post tests for PEFR ofGroup A

Test Mean Variance Standard DeviationPre Test 217.33 3221 56.75Post Test 396.67 8738 93.47

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Fig. 7: Fig. 8:

Fig. 9: Fig. 10:

Fig. 11: Fig. 12:

Fig. 13: Fig. 14:


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three different evaluating tools such as Oxygen saturationlevel, Peak expiratory flow rate and the Rate of perceivedexertion. The analysis of variance between treatments ofboth the Groups using all the parameters exhibitedsignificant improvement for Positive expiratory pressuretechnique than Autogenic drainage.

The results of this study show that Flutter therapy resultedin a significant reduction in sputum viscoelasticity and thusimproves mucus clearance. This is in accordance with thestudy by Konstan et al, who found a large increase inexpectorated sputum volume with Flutter therapy comparedwith cough or conventional chest physiotherapy.7 Fluttertherapy improved cough clearance by keeping the airwaysopen during lightly forced expiration, through the addedpositive airway pressure produced during expiration. Theshear rates during such a cough maneuver, with theconsequent flow and pressure changes, have to be highenough to move bronchial secretions, but not so high thatairways collapse occurs.8

The results of this study is in accordance with AndreasPfleger et al (1992) who suggested that airway clearancetechniques are used to aid in mucus clearance in a varietyof diseases such as COPD and new techniques like Positiveexpiratory pressure technique & autogenic drainage canbe used to rely heavily on basic airway clearance.17 AlsoBellone A et al (2000) who compared the effectiveness ofoscillating positive expiratory pressure using flutter devicewith postural drainage and ELTGOL (expiration with theglottis open in the lateral posture) on oxygen saturation andsputum production; concluded that flutter techniques wasmore effective in prolonging secretion removal in chronicbronchitis.18

The results of the study also has got strong evidences fromthe study done by Eaton T et al (2007) who had suggestedthat flutter device was well accepted and tolerated airwayclearance device and the patient’s preference was morefor flutter device compared to active cycle of breathing andpostural drainage.19

The statistical analysis done above correlated that the grouptaken for the study; both Group A treated by Positiveexpiratory pressure technique or Group B treated byAutogenic drainage, showed significance in improving thebronchial hygiene of moderate chronic bronchitis patients.It also showed that Group A had higher significance whencompared to the Group B treated by Autogenic drainage.Based on this data, we accept the Experimental Hypothesis.

In Contrast Van Hengstum M et al (1988), Olseni L et al(1994) had done separate studies on obstructive pulmonarydisease patients using forced expiratory techniquecombined with either postural drainage or positive expiratorypressure breathing and concluded that mucus clearancewas more effective with postural drainage and forcedexpiratory technique than positive expiratory pressure andforced expiratory technique.20, 21

Whereas this study implies that both Positive expiratorypressure technique & autogenic drainage can be used inthe chest physiotherapy intervention of chronic bronchitispatients but the Positive expiratory pressure technique ismore efficient than the former and it is also better to go for

this advanced bronchial hygiene technique when there isa high risk of complications arising in chronic bronchitispatients.

ConclusionThis study can be concluded stating that Positive expiratorypressure technique is more effective when compared toautogenic drainage in improving the bronchial hygiene andthe health status of moderate chronic bronchitis patients.In case of other types of chronic bronchitis who tend to fallunder the low risk group of pulmonary complications; boththe techniques are equally preferred. This study will behelpful for the physiotherapists to incorporate flutter devicefor improving bronchial hygiene in their patient care.

References1. Barbara. A. Webber; Physiotherapy for respiratory &

cardiac problems; 3rd edition 2001:113-123.2. Elizabeth Dean, Cardio pulmonary function in health

and disease.3rd edition, 1996.3. Ellen A. Hillegass, H Steven Sadowsky; Essentials of

cardiopulmonary physiotherapy; W.B. SaundersPublications; 1993: 12-15.

4. Murray C J L, Lopez A D; The global burden ofdisease: a comprehensive assessment of mortality $disability from disease, injuries $risk factors in 1990$ projected to 2020; Harvard University press,Cambridge; 1996.

5. U S Surgeon General (1984), The HealthConsequences of Smoking; chronic obstructive LungDisease. Pub No.84-50205, Washington, D C:USDepartment of Health and Human Resources

6. Jennifer A Pryor, S Ammani Prasad; Physiotherapyfor respiratory and cardiac problems adults andpaediatrics; Churchill Livingstone Publication; 3rd

Edition; 2001: 485 - 486 .7. Konstan M W, Stern R C, Doershuk C F. Efficacy of

the flutter device for airway mucus clearance inpatients with cystic fibrosis Pediatrics May 1994; 124:689-693.

8. E M App, R Kieselmann, D Reinhardt, H Linder Mann,B Dasgupta,M King and P Brand; Sputum Rheologychanges in cystic fibrsis lung disease following twodifferent types of physiotherapy: flutter Vs autogenicdrainage; Chest 1998;114;171-177.

9. Chevailler,J (1992). Airway clearance Techniques,course presented at sixth Annual North AmericanCystic Fibrosis conference, Dallas.

10. David A Autogenic drainage: the German Approach.In: Proyor J A, ed Respiratory care, Edinbuergh:Churchhill Livingstone, 1991; 65-78.

11. Darbee J C, Kanga J F, Ohtake P J; Physiologicevidence for high frequency chest wall oscillation andpositive expiratory pressure breathing in hospitalizedsubjects with cystic fibrosis; Phys Ther.2005; 85(12):1278-89

12. Inal-Ince D,Savci S,Coplu L,Arikan H;Functionalcapacity in severe chronic obstructive pulmonarydisease;Saudi med J ,2005 Jan ; 26(1);84-9.


41

13. Savci,Sama ;Ince,Denizinal ms;Arikan,Hulya; Acomparison of autogenic drainage and the activecycle of breathing techniques in patients with chronicobstructive pulmonary disease;Jan/Feb 2000, Journalof cardiopulmonary rehab 20(1):37-43.

14. Anne Mejia Downs, Cardio pulmonary function inhealth and disease.3rd edition, 1996.

15. Althaus, P. (1993). Oscillating PEP. In BronchialHypersecretion: Current Chest Physiotherapy inCystic Fibrosis (CF), Published by InternationalCommittee for CF (IPC/CF).

16. Kothari CR: Research methodology, methods &techniques; New Age International publishers; 2nd

edition, 2004:233-76.17. Andreas Pfleger, Barbara Theissl, Bratrica

oberwaldner and Maximilian S Zach; SelfAdministered chest physiotherapy in cystic fibrosis:A Comparative study of High-pressure PEP andAutogenic Drainage; Lung (1992) 170:323-330

18. Bellone A, Lascoli R, Raschi S, Guzzi L, Adone R;Chest physical therapy in patients with acuteexacerbation of chronic bronchitis: effectiveness ofthree methods; Arch Phys Med Rehabil, 2000 May;81(5): 558-60.

19. Eaton T,Young P,Zeng I,Kolbe J;A randomizedevaluation of the acute efficacy, acceptability andtolerability of flutter and active cycle of breathing withand without postural drainage in non-cystic fibrosisbronchiectasis;Chron Respir Dis.2007;4(1);23-3.

20. Van Hengstum M et al;1988;3(1)- Study on obstructivepulmonary disease patients using forced expiratorytechnique combined with either postural drainage orpositive expiratory pressure breathing.

21. Olseni L, Midgren B, Hornblad Y,Wollmer P;Respirmed.1994 July;88(6);435-Chest physiotherapy inchronic obstructive pulmonary disease:Forcedexpiratory technique combined with either posturaldrainage or positive expiratory pressure breathing.


42 Pallavi Khanna et al/Indian Journal of Physiotherapy and Occupational Therapy. July - Sept. 2008, Vol. 2, No. 3

Balance deficits and recovery timeline after different fatigueprotocolsPallavi Khanna1 Gagan Kapoor2 Kalpana Zutshi3

1Post Graduate Physical Therapy Student (Sports Medicine), Jamia Hamdard 2Senior Sports Physiotherapist 3PhysicalTherapy Lecturer (Sports Medicine), Jamia Hamdard.

Background and purposeBalance is affected after fatigue protocol consisting ofaerobic and anaerobic exercises and balance recoverswithin 20 minutes. The purpose of this study is to evaluatewhat is the effect of various fatigue protocols i.e. aerobic,anaerobic and mixed fatigue protocol on balance andrecovery time line for balance.

Method30 active, normal subjects participated in the study. Eachsubject performed aerobic, anaerobic and mixed fatigueprotocol on different days. Balance was assessed bybalance error scoring system (BESS) for three stances,double leg, single leg and tandem on two surfaces, firmand foam.

Each trial lasted 20 seconds. Using the Borg scale ratingof perceived exertion (RPE) was also measured for level ofphysical exertion. Pretest balance reading was taken thenthe subject performed the specific fatigue protocol and thenbalance was assessed immediately after the protocol(Posttest 1), 5 minutes after the protocol (Posttest 2), 10minutes (Posttest 3), 15 minutes (Posttest 4) and 20minutes (Posttest 5) after the protocol.

Data analysisThe General Linear Model Repeated Measures Analysis ofVariance (ANOVA) was used to examine the conditionsseparately for balance and perceived exertion. BonferroniPost hoc analysis was done if there was significantdifference. One-way ANOVA was used to compare balanceand exertion scores between conditions. Post hoc analysisfor between conditions was done for comparison. Thesignificance level set for this study was p<0.05.

ResultsThe results show that balance is affected after differentfatigue protocols as evident in BESS posttest reading 1which is increased after fatigue in all the protocols andbalance recovers in 15 minutes after aerobic fatigueprotocol, 10 minutes after anaerobic fatigue protocol and20 minutes after mixed fatigue protocol. Similarly rating ofCorresponding Author:Pallavi KhannaM.P.Th (Sports Medicine), M.I.A.P44E, Reading Road, Edison, New Jersey- 08817. U.S.A,Ph: 001-732-666-5181, E-mail: [email protected]

perceived exertion score is also increased after fatigue andrecovers the same way as balance.

Discussion and conclusionAerobic, anaerobic and mixed fatigue protocols all hadeffect on balance and balance recovers from theseprotocols within 20 minutes of rest. This information canbe applied to the athletic population where the coachescan design a training program in such a way that fatiguedoes not interfere with performance ability and does notincrease the chances of injuries.

KeywordsBalance, fatigue, aerobic protocol, anaerobic protocol,mixed protocol, recovery.

IntroductionBalance is a complex task that requires intact informationfrom somatosensory, visual and vestibular system and anintact central nervous system to maintain upright stance1,3.

Balance can be defined as ability of body to maintainequilibrium and orientation within the base of support7,17,18,21.

First stimuli from visual, vestibular and somatosensorysources are required to contribute information about thebody's position in space. The three sub components of thebalance mechanism collect peripheral information tomaintain balance. Afferent information collected by thesesystems is transferred to the central nervous system, wherediffering anatomical regions of the brain integrate the signalsand produce a motor output. The basal ganglia receive thefirst inputs and begin a motor response based on the currentposition of limbs. The signal is integrated with the plannedactions of the motor cortex in the cerebellum, where motorimpulses are coordinated. A final efferent signal is generatedand transmitted through the brainstem to alpha motorneurons. These nerves innervate the skeletal muscles thatmaintain posture and balance24.

Thus coordinated responses to stimuli must be transmittedto the appropriate muscles to produce correctivemovements in certain joints to balance a standing position.Proper balancing movements of separate body segmentsare essential in maintaining upright stance, firstly to stabilizethe body segments and secondly to enable the necessarydynamic changes of the body3.

Since the human body is never stable a control system isrequired to stabilize the body. Here comes the concept of

43Pallavi Khanna et al/Indian Journal of Physiotherapy and Occupational Therapy. July - Sept. 2008, Vol. 2, No. 3

postural control that helps to keep the body close toequilibrium point3. The postural control system involves thecomplex organization of many senses that are related bycentral nervous system to many muscles that act onmultilinked musculoskeletal system4.

Balance is a static as well as dynamic process. Thusbalance / postural control can be static or dynamicdepending upon whether the base is static or dynamic5.Postural control helps to keep the body's center of gravitywithin borders of base of support. Overall goal of balancecontrol system is stability and function.

In normal circumstances minimal or no active musclecontraction is required to maintain equilibrium. An externaldisturbance of the body brings into play anticipatory posturalreflexes even before the COG shifts. If however thesevarious anticipatory responses are insufficient then acollection of righting reflexes are brought into play to protectbalance. Such postural reactions are triggered by muscular,vestibular or visual cues about body imbalance. Finally ifanticipatory postural responses and righting reflexes areinsufficient to prevent falling, the normal subjects willengage in a series of protective reflexes to prevent damagewhen falling for example the arms are thrown out to cushionthe landing24.

Reactive control occurs in response to external forces(threats, perturbations) displacing the center of gravity ormovements of base of support6.

Proactive control (anticipatory) occurs in anticipation ofinternally generated destabilizing forces imposed on body'sown movements6.

An individual's prior experiences allow the various elementsof postural control system to be pretuned or readied forupcoming movements. Postural stability is needed in mostactivities of daily l iving and major contribution toperformance in sports such as golf, gymnastics, shooting,basketball, and soccer7.

Balance movements involve a number of joints such aship, knee, ankle and coordinated movement along kineticchain. In event of balance disruption body must be able todetermine what strategy to utilize in order to maintainbalance.

A variety of methods have been developed to assesspostural stability both subjectively and objectively includingRomberg Test, Functional Reach Test, Get Up and Go Test,Chattecx Balance system22 and more recently Balance errorscoring System (BESS)1,2. BESS is a clinical field test thatwas developed to provide health care professionals withan inexpensive and objective way to assess posturalstability outside laboratory1,2,8. BESS measures posturalstability through a clinical assessment battery and is scoredby counting the number of errors the subject commits duringthe test.

Advantages of BESS are that it is less expensive than forceplatform system and requires less training for effectiveadministration. It is a valid and reliable method as has beenproven already.

Factors that impact postural stability include muscularweakness, proprioceptive and range of motion deficits.

Fatigue also affects balance. If inaccurate information isprovided by any of the three sensory systems because oflocal fatigue and central nervous system is disturbedthrough central fatigue and compensation is inadequatebalance is disturbed1,2.

Thus Postural stability decreases after isolated musclefatigue and whole body fatigue (central fatigue). Any formof exercise results in fatigue that is caused by combinationof physiologic processes that occur at both central andperipheral levels.

Nardone et al17 noted significant increases in sway path inboth eyes closed and eyes open condition, and increasesin sway area in eyes closed condition after 25 minutesexhausting treadmill run.

Johnston et al 30 found that fatigue affects ability of anindividual to maintain balance on an unstable platformdevice and fatigued individuals are at increased risk ofinjury.

Lepers et al18 studied the influence of prolonged exerciseon postural control as assessed by dynamic posturography.He found that the ability to maintain balance underconflicting sensory conditions was decreased immediatelyafter 25 km run.

Ludin et al32 examined the effects of plantarflexor anddorsiflexor fatigue on postural control. The fatigue protocolresulted in significant increase in mediolateral postural swayamplitude and increase in anteroposterior postural sway.

Numerous variables including postural stability, maximumvoluntary contraction force, and reaction time have beenstudied in conjunction with fatigue protocols to understandhow fatigue affects body balance and ability of body tofunction or perform. These studies have measured posturalstability using expensive computerized equipments. Now ithas been proven that BESS is a clinical field test that canbe used to assess balance1,2,8.

Fatigue (central and peripheral) is a complex interaction ofphysiological, chemical, sensory and psychologicalfeedback9. The factors that contribute to fatigue fromvoluntary activity are numerous and interact in a complexmultifactorial phenomenon.

The lack of singular factor inducing fatigue points tomultitude of mechanisms that protect muscles. Thesefactors decrease the muscle force that occurs duringexercise.

The decrease in muscle force leads to decrease in workingcapacity and represents an internal perturbation to motorsystem. It can therefore produce impairment in motorcoordination and possible postural control.

It is known that small differences in postural sway or bodybalance because of fatigue or physical exercise might haveimportant effects on outcomes of performance9.

Fatigue is one of the most important factors that limitssustained exercise in sports. Fatigue is often associatedwith increased clumsiness10. Immediate effect of fatigue isreduction in ability to apply muscle force. Reduced abilitycan impair efficiency of muscle, skill and performance11.

44

Improved performance is related to reduction or delay inonset of fatigue. Studies have shown relationship betweenperformance under fatigue and increased incidence ofinjury16.

Rating of Perceived exertion can be used to detect andinterpret sensations arising from body during physicalexercise. The evaluation of physical effort during exerciseis based on two factors: local factor related to feeling ofstrain in the exercising muscle and/ or joints and centralfactor related primarily to sensations or feelings fromcardiopulmonary system23. 15 Point Borg scale has beenrecommended for investigations of perceived exertion andfor predictions of exercise intensities26.

The concept of specificity can be extended to fatigue, thatis, specific exercises lead to specific mechanisms of fatigue.Thus the effect depends upon the type of exercise andintensity and duration of work12.

High intensity short duration exercises are associated withrapid recovery from fatigue whereas long duration exerciseshave prolonged recovery time from fatigue. So it can besaid that different duration, intensity and exertion levels ofexercise leads to difference in recovery time for balancedeficit.

It has been shown that balance recovers within 20 minutesafter fatigue protocol that consisted of both anaerobic andaerobic exercises for 20 minutes duration1,2. But it has notbeen studied yet what effects specific fatigue protocols suchas aerobic, anaerobic have on balance and if balance isaffected after how much time it is regained. This informationcan be useful when applied to the athletic population wherethe coaches can design a training program in such a waythat fatigue does not interfere with performance ability anddoes not increase the chances of injuries.

The purpose of this study is to evaluate what is the effectof various fatigue protocols i.e. aerobic, anaerobic andmixed fatigue protocol on balance and recovery time linefor balance.

Method30 active normal subjects participated in the study. Eachsubject participated in each of the three groups of conditions(Condition A, Condition An, Condition M). The names ofthe group denote type of fatigue protocol (A - Aerobic, An -Anaerobic, M - Mixed) they are subjected to.Condition A - aerobic fatigue protocol till exhaustion.Condition An - anaerobic fatigue protocol till exhaustion.Condition M - mixed anaerobic and aerobic fatigue protocolfor 20 minutes.

Inclusion criteria1. Active normal individuals not undergoing any kind of

physical training.2. Age group: 20-25 year3. Male subjects.

Exclusion criteria1. Any visual, balance or vestibular disorder 2. Head injury

within last 6 months3. Musculoskeletal lower extremity injury within last 6

months4. Cardiovascular or pulmonary dysfunction.

Method of selectionSubjects were selected based on the inclusion andexclusion criteria. All the subjects were made aware of thepurpose and procedure of the study. A signed informedconsent was obtained from the prospective candidatesbefore their participation

Each subject was asked to participate in all the three fatigueconditions (Condition A, Condition An, Condition M).

Design of the studyDesign of the study is experimental, same subject designwith pre test posttest design where each subject participatesin all three fatigue conditions.

Instrumentation and tools for data collectionTreadmill in which speed and grade can be varied, Digitalstopwatch for noting the time during balance assessment,12-inch step and Medium density foam block. (46 x 46 x 13cm).

Independent variablesMixed Fatigue Protocol

7-station exertion protocol designed by Wilkins et al1 wasused. Station 1 was a 5 minute jog at the subject's selfselected pace. Station 2 was sprint up and down thebasketball court for 3 minutes. Station 3 was 2 minutes ofpush-ups. Station 4 was 2 minutes of sit-ups. Station 5 was3 minutes of 12-inch step-ups. Station 6 was another 3minutes of sprints. Station 7 was 2 minute run during whichsubjects were instructed to maintain the fastest pace theycould for entire 2 minutes. All subjects were given verbalfeedback in an attempt to maintain high level of exertionthroughout the entire exertion protocol.

Aerobic Fatigue ProtocolThe standard Bruce protocol was used20. The athlete ranon a treadmill to exhaustion. At timed stages during thetest the speed (km/hr) and grade of slope (%) of thetreadmill were increased as detailed.

The treadmill was set up with the Stage 1 speed (2.74 km/hr) and grade of slope (10%) and the athlete commencedthe test. At the appropriate times during the test the speedand slope of the treadmill were adjusted. So after 3 minutesinto the test the speed was adjusted to 4.02 km/hr and theslope to 12%, after 6 minutes into the test the speed wasadjusted to 5.47 km/hr and the slope to 14%, and so on.

Pallavi Khanna et al/Indian Journal of Physiotherapy and Occupational Therapy. July - Sept. 2008, Vol. 2, No. 3

45

The test continued until the patient got exhausted, that ishe was not able to continue further.

Anaerobic fatigue protocolThe athlete undertook a warm-up on the treadmill for 5minutes at self-selected moderate pace29. A few shortpractice starts getting onto the treadmill at the test speedwere also performed. Then the treadmill was set at 8.0miles/hr (13 km/hr) speed and incline of 20%. Then theathlete started running unsupported. The test continued untilexhaustion, meaning the athlete was not able to maintainthe speed required and was not able to continue further.

Dependent variablesBalance assessment

Balance Error Scoring System (BESS) was used to assessbalance under 3 testing stances (double leg, single leg,and tandem) on 2 surfaces, firm and foam.1, 2 In the doubleleg stance the participants stood with their feet together. Inthe single leg stance, participants stood on the nondominant leg (dominance determined by which leg theywould prefer to kick a ball), with the contra lateral legpositioned in approximately 30 degree of hip flexion and90 degree of knee flexion and foot held approximately 6inches off the ground. In the tandem stance, participantsstood with the dominant foot in heel toe fashion. Eachstance was performed on firm surface and medium densityfoam block. The firm surface was the floor of the gym.

One 20 second trial of each test condition was performedand the order of BESS testing was counterbalanced acrossconditions for each subject so that the effects of fatiguewould not be greater for one condition than another. Thesame order of testing was used for each subject pretestand posttests. Before testing all subjects were given apractice session for each condition to familiarize them withthe actual test. The subjects were asked to keep their eyesclosed and their hands on the iliac crest while maintainingthe appropriate stance. The subjects were instructed that ifany time they fell out of position, they were to return to thetest position as quickly as possible, keeping their eyes openuntil they regained balance. As the subjects performed each20-second trial, number of errors the subject made wererecorded. During the testing the scorer stood 8 to 10 ft awayfrom the subject so that the subjects eyes, hand and feetcould all be observed.

One BESS error was scored if the subject engaged in anyof the following:• Lifting the hands off the iliac crest• Opening the eyes• Stepping, stumbling or falling out of position• Moving the hip into more than 30 degree of flexion or

abduction• Lifting the forefoot or heel• Remaining out of test position for more than 5 seconds

Rating of Perceived ExertionBorg 15 point scale was used to measure each subjectsRating of Perceived Exertion (RPE) 19 in an attempt toquantify the amount of exertion displayed by each subject.The rating scale was in full view of the subject during theentire test. For all subjects RPE scores were monitoredimmediately before the intervention and then after theintervention according to different posttests. Validity andreliability of this scale has been proved through variousstudies.

Before noting the RPE scores the subjects were familiarizedwith the scale. They were told how to use the scale andwhat each number in the scale denotes. It was only afterthe subjects understand the proper use of the scale andhow to rate their perceived exertion that the scale was used.Borg’s 15-point scale can be described as6 no exertion at all7 very, very light89 very light1011 fairly light1213 somewhat hard (feels tired but can continue)1415 hard (heavy)1617 very hard (very strenuous)1819 very, very hard (cannot continue further)20 maximum exertion

ProcedureThe subjects were selected according to the inclusioncriteria. Each subject was explained about the purpose andsignificance of the study and only those who gave voluntaryconsent participated in this study.

All subjects were familiarized with the equipments, methodsand different scales used in the study. They were giveninstructions about what they were supposed to do in eachprotocol and test and when to terminate the protocol.

Each subject participated in all three test group protocols.There was two days rest interval between each test protocol.Randomization of protocols was done.

All subjects performed one practice session with BESS andfamiliarized themselves with RPE scores. They were then

Stage Time (min) Speed (km/hr) Slope1 0 2.74 10%2 3 4.02 12%3 6 5.47 14%4 9 6.76 16%5 12 8.05 18%6 15 8.85 20%7 18 9.65 22%8 21 10.46 24%9 24 11.26 26%

10 27 12.07 28%


46

asked to self stretch as needed before testing to preventinjuries during balance testing and exertion protocol.

They were then tested for balance using Balance ErrorScoring System (BESS) and perceived exertion notedthrough Borg’s 15-point scale of Rating of PerceivedExertion (RPE).

The subjects in each of the test group were tested oncebefore the exertion protocol (Pretest) and then the specificfatigue protocol was given depending upon the group inwhich they are on that particular day. The Condition A groupperformed Aerobic exercise protocol, Condition An groupperformed Anaerobic exercise protocol while Condition Mgroup performed Mixed exertion Protocol.

The subjects in the aerobic and anaerobic test group weremonitored for their exertion level and told to continue thetest until they feel exhausted and cannot continue furtherand felt that their RPE score is around 19. At that time theystopped the test.

After completion of test protocol each test group was testedimmediately for balance and perceived exertion (Posttest1). Then again after 5, 10, 15 and 20 minutes each testgroup was tested for balance and perceived exertion(Posttest 2, 3, 4, 5).

All the subjects were tested three times on three differentdays and average of the readings was taken.

Data was collected in the gym and basketball court, undersimilar conditions for each of the subjects by the sameinvestigator.

Data analysisUsing SPSS 11.5 software the General Linear ModelRepeated Measures Analysis of Variance (ANOVA) wasused to examine all the conditions together. Bonferroni Posthoc analysis was done for time if there was significantdifference. The General Linear Model of repeated measuresANOVA was used to examine all the conditions separatelyfor balance and perceived exertion. Bonferroni Post hocanalysis was done if there was significant difference.

One-way ANOVA was used to compare balance andexertion scores between conditions. Post hoc analysis forbetween conditions was done for comparison.The significance level set for this study was p<0.05.

Results(Table 1.1,1.2,1.3,1.4)Analysis of BESS scores for all the conditions taken togetherrevealed significant time (F = 5620.06, p< 0.05), condition(F= 26.790, p<0.05) and time x condition effect (F=176.615,p<0.05).

Post hoc analysis of time for all conditions taken togetherrevealed significant differences between pretest andposttest (p<0.05)

Analysis of RPE scores for all the conditions taken togetherrevealed significant time (F= 16341.34, p<0.05), condition(F=445.18, p<0.05) and time x condition effect (F=337.29,p<0.05)

Post hoc analysis of time for all conditions taken togetherrevealed significant differences between pretest andposttest (p<0.05)

Since the analysis for all the conditions taken togetherrevealed differences for time and conditions the conditionswere examined separately.

Condition AAnalysis of BESS score within the condition revealedsignificant differences (F=1846.75, p<0.05).

Post hoc analysis of BESS score across pretest anddifferent posttests revealed significant differences betweenpretest and posttest 1,2,3,4,5 (p<0.05), posttest 1 andposttest 2,3,4,5 (p<0.05), posttest 2 and posttest 3, 45(p<0.05), posttest 3 and posttest 4, 5(p<0.05), posttest 4and posttest 5 (p<0.05)

Analysis of RPE score within the condition revealedsignificant differences (F=6454.197, p<0.05).

Post hoc analysis of RPE score across pretest and differentposttests revealed significant differences between pretestand posttest 1,2,3,5 (p<0.05), posttest 1 and posttest 2,3,4,5(p<0.05), posttest 2 and posttest 3, 4 5(p<0.05), posttest 3and posttest 4, 5(p<0.05), posttest 4 and posttest5 (p<0.05).

Table 1.2: Condition A- Total BESS and RPE scores (Mean ± S.D), Figure 1.1, 1.4

Pretest Posttest 1 Posttest 2 Posttest 3 Posttest 4 Posttest 5

BESS 16.31 ± 1.44 27.07 ± 0.97 23.84 ± 0.99 20.07 ± 0.99 15.81 ± 1.36 15.44 ± 1.39

RPE 6.34 ± 0.37 18.12 ± 0.39 14.31 ± 0.37 10.20 ± 0.41 6.34 ± 0.32 6.18 ± 0.15

Table 1.3: Condition An- Total BESS and RPE scores (Mean ± S.D), Figure 1.2, 1.5


BESS 16.36 ± 1.41 30.08 ± 0.99 23.02 ± 1.54 15.93 ± 1.34 15.72 ± 1.32 15.31 ± 1.32

RPE 6.66 ± 0.32 18.39 ± 0.46 12.87 ± 0.86 6.50 ± 0.20 6.36 ± 0.32 6.24 ± 0.25

Table 1.4: Condition M- Total BESS and RPE scores (Mean ± S.D), Figure 1.3, 1.6


BESS 16.38 ± 1.37 28.69 ± 1.13 25.23 ± 0.99 22.52 ± 0.99 19.26 ± 0.84 15.75 ± 1.33

RPE 6.49 ± 0.37 18.09 ± 0.25 14.81 ± 0.23 11.76 ± 0.51 9.22 ± 0.34 6.29 ± 0.31

Table 1.1: Subject Characteristics

Age (Mean ± S.D), years 22.27 ± 1.79

Height (Mean ± S.D), cm 172.07 ± 7.45

Weight (Mean ± S.D), kg 69.23 ± 7.27

Body Mass Index (Mean ± S.D), kg/m2 23.3 ± 0.95


47

There was insignificant difference between pretest andposttest 4 (p>0.05)

Condition AnAnalysis of BESS score across time within the conditionrevealed significant differences (F=2157.50, p<0.05).

Post hoc analysis of BESS score across pretest anddifferent posttests revealed significant differences betweenpretest and posttest 1,2,3,4,5 (p<0.05), posttest 1 andposttest 2,3,4,5 (p<0.05), posttest 2 and posttest 3, 45(p<0.05), posttest 3 and posttest 4, 5(p<0.05), posttest 4and posttest 5 (p<0.05)


Post hoc analysis of RPE score across pretest and differentposttests revealed significant differences between pretestand posttest 1, 2,3,4,5 (p<0.05), posttest 1 and posttest2,3,4,5 (p<0.05), posttest 2 and posttest 3, 4 5(p<0.05),posttest 3 and posttest 4, 5(p<0.05), posttest 4 and posttest5 (p<0.05).

Condition MAnalysis of BESS score within the condition revealedsignificant differences (F=1922.15, p<0.05).

Post hoc analysis of BESS score across pretest anddifferent posttests revealed significant differences betweenpretest and posttest 1,2,3,4,5 (p<0.05), posttest 1 andposttest 2,3,4,5 (p<0.05), posttest 2 and posttest 3, 45(p<0.05), posttest 3 and posttest 4,5(p<0.05), posttest 4and posttest5 (p<0.05)


Post hoc analysis of RPE score across pretest and differentposttests revealed significant differences between pretestand posttest 1, 2,3,45 (p<0.05), posttest 1 and posttest2,3,4,5 (p<0.05), posttest 2 and posttest 3, 4 5(p<0.05),posttest 3 and posttest 4, 5(p<0.05), posttest 4 and posttest5 (p<0.05).

Between ConditionsOne way ANOVA was used to compare the balance errorscoring system score and rating of perceived exertion scorefor between conditions, aerobic, anaerobic and mixed. Posthoc analysis was also done for between conditioncomparisons, aerobic with anaerobic protocol, aerobic withmixed protocol and anaerobic with mixed protocol.

It revealed that the three conditions had effect on balanceand rating of perceived exertion that was according to thecondition performed and that the recovery time was differentfor three conditions.

DiscussionOverall findings demonstrate a decrease in balance andpostural stability possibly as a result of fatigue from three

different fatigue protocols as measured by total BalanceError Scoring System (BESS) scores and an increase inexertion level as measured by Rating of Perceived Exertion.

A decrease in postural stability after fatigue has been foundin previous studies using both central1,2,7,18,31 and localmeans of fatigue2,30 and different measures of posturalstability.

Different sports have different metabolic demands and thus,athletes experience different levels of exertion. We useddifferent fatigue protocols, aerobic, anaerobic and mixedprotocol of aerobic and anaerobic exercises. The aerobic,anaerobic fatigue protocols were designed in such a waythat athlete would stop exercising when he felt exhaustedand fatigue was thus induced and the mixed protocol wasthe same as used by Wilkins et al 2 in his study.

The protocols chosen were those that would replicate thefatigue athletes experience during the course of gameorpractice and fatigue leads to decreased motor control soit is reasonable to hypothesize that fatiguing exercise willhave an effect on postural control.

Although fatigue effect on balance has been studied usingforce platform systems or sensory organization tests andother computerized equipments, only few studies have usedBESS performance to study the influence of fatigue protocolon balance1,2.

Wilkins et al 2 studied effect of fatigue protocol consistingof sprinting, jogging, step ups, and found that fatigue groupscored more errors than control groups on posttest thanon pretest. They measured balance by balance error scoringsystem (BESS). They said that factors that could potentiallycause a decrease in balance performance after fatiguecould focus on both central and local means of fatigue.Because balance depends upon central nervous systemsand three sensory systems, alteration in CNS ability due tofatigue will affect one’s ability to maintain balance.

Nardone et al17 assessed body sway variables bydynamometric platform in both eyes open and eyes closedcondition following 25 minutes of treadmill run. There wassignificant increase in body sway path in both eyes openand eyes closed condition. They said that exercise of thisduration caused failure of energy metabolism. AlsoRomberg Quotient was increased in eyes closed condition.They said that change in sensory inflow or possibly alteredcentral processing of proprioceptive input occurred due todecreased spindle discharge.

Lepers et al18 investigated perturbations of equilibrium afterprolonged exercise run by dynamic posturography andsensory organization test. The results showed that abilityto maintain postural stability during conflicting sensoryconditions decreased after exercise. Decrease in effectorsystem efficiency due to muscle fatigue because ofmetabolic accumulation and changes in proprioceptiveinformation led to impaired postural regulation.

Johnston et al30 studied effect of lower extremity isokineticmuscle fatigue on motor control performance. Theyassessed balance on instrumented balance system.Findings revealed that fatigue significantly decreases theability to balance on balancing device since there was no


48

visual feedback to augment proprioception. Also fatiguinga muscle inhibits the joint’s neuromuscular feedbacksystem. Motor control depends upon afferent sensory andproprioceptive mechanisms such as Golgi, spindle and jointreceptors. Fatigue caused muscle spindle desensitization.This led to decreased efferent muscle response and poorability to maintain balance.

Not all researchers of fatigue and postural stability havedemonstrated a decrease in balance after exercise.

Contrary to our results Derave et al 7 found no change incenter of pressure velocity measured by posturography after2 hour cycling protocol indicating that exercise bout did notelicit decrease in postural stability. They however showeda significant exercise-hydration status interaction. Posttestsresults demonstrated higher COP velocities when subjectswere not given fluid replacements during exertion protocol.It should be noted that posttest took 20-30 minutes afterend of 2-hour cycle bout, thereby allowing recovery timebefore posttest.

Thus the factors that could potentially cause a decrease inbalance after fatigue focus on both peripheral and centralmeans of fatigue.

Localized muscle fatigue is influenced by decrease inmetabolic substrates available for muscle contraction suchas adenosine triphosphate, creatine phosphate andglycogen, as well as increase in metabolites including lacticacid in muscle, resulting in inability to maintain desiredmuscular force output. Contraction mechanism andneuromuscular junction impairments constitute peripheralfatigue14,39,76.

Limitation in energy supply has been always the classicalhypothesis for muscle fatigue. This is supplemented byfindings that coincide with specific intramuscular metabolicchanges such as depletion of glycogen with prolongedexercise and depletion of PCr with high intensity exercise.40 Also reduced sarcoplasmic reticulum calcium release andimpaired excitation contraction coupling have beenimplicated60

CNS fatigue is a form of fatigue associated with specificalterations in CNS function that cannot be accounted forby peripheral dysfunction within the muscle itself. CNS hasa profound effect in mediating fatigue since changes inmotivational level have profound effect on performance andthe first indication that fatigue may be imminent is increasedperception of effort.

Inhibition of motor units, decreased firing rate, dischargerate of afferents such as Ia from muscle spindle 77, Ib fromGolgi tendon organ and small diameter afferents areaffected because of fatigue. This constitutes the Centralcomponent of fatigue35.

Sahlin et al 65 demonstrated that during intense periodsactivity when anaerobic energy system is being taxed thereis increase in muscle lactate concentration and muscleacidosis that caused fatigue and this high lactate and lowpH impaired muscle performance.

Bangsbo et al 42 showed that the development of fatigueduring high intensity leg exercise is related to accumulation

of potassium in muscle interstitium as shown by musclebiopsy taken from active leg muscle. It is elevated to around12mmol/l in intense short-term exercise less than 3 minutesthat is high enough to depolarize the muscle membranepotential and reduce the force development41. Also musclepH was lowered.

Fatiguing effects of declining pH during exercise includesallosteric inhibition of rate limiting enzyme phospho-fructokinase, glycogen phosphorylase, decrease releaseof calcium from sarcoplasmic reticulum hindering theexcitation contraction coupling process, and reduction innumber and force of muscle cross bridge activation11,43,64,75.

In efforts lasting less than 30 seconds it is decline in ATPproduction and increase in ADP concentration, caused bydepletion of phosphocreatine and fall in rate of glycolyisthat causes fatigue44,45,68. In exercise lasting 1-3 minuteshydrogen accumulation predominates71,72.

All this constitutes the peripheral mechanisms of fatigue.Thus it can be said that during anaerobic exercise theperipheral fatigue mechanisms were activated as a resultof accumulation and depletion of various metabolites andimpairment of contractile mechanism that leads tofatigue73,66.

Earlier it was thought that during prolonged aerobic exercisefatigue was associated with mechanisms that result indysfunction of the contractile process. More recently CNSmechanisms have been implicated in the fatigue process13.

Reduction in CNS drive to the muscle may be mediated byafferent feedback from muscle or reduction on corticospinalimpulses reaching the motoneurones. Changes in afferentfeedback from muscle may be result of changes in musclemetabolites during exercise. A reduction in corticospinalimpulses reaching motoneurones could be result ofalterations in neurotransmitter function in brain13.

In fatigue, changes in enkephalinergic, dopaminergic andserotonergic systems occur. These control vigilance, pain,motivation and tolerance while other neuroendocrinechanges alter availability of substrates for muscle activation.Manipulation of these factors alter centrally mediatedcomponent of fatigue.

Nybo et al46 examined the neurohumoral alterations duringprolonged exercise. They showed that serotonin levels inbrain increase after aerobic exercise when plasmaconcentration of free tryptophan (TRP) also increased. Thiscaused fatigue because of its role in arousal, sleepinessand mood.

There is change in stretch sensitivity of muscle spindle andtendon organ afferents during muscle fatigue. Musclespindle discharge decreases during fatigue asdemonstrated by Macfield et al79. Kniffki et al63, Kaufmanet al 67, 81 in their experiments showed that the discharge ofsmall diameter (group III and IV) muscle afferents increasein accordance to temperature, chemical, mechanicalenvironment caused by fatigue. Following fatigue mostgroup II non spindle afferents and group IIImechanosensitive afferents have increased discharge ratesincreased sensitivity to stretch and reduced response tocontractions and force47.


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Pedersen et al 48 showed that sensory informationtransmitted by ensembles of primary muscle spindle (MSA)after muscle fatigue of medial gastrocnemius muscleinduced by isometric contractions was reduced becauseof changes in gamma motoneurones activity that is affectedby group III and IV afferents80. Primary MSA’s havesignificant role in balance and proprioception anddecreased capacity to discriminate after fatigue hasimportant implications on position and balance.

Fatigue in exercise lasting greater than 15 minutes is alsoassociated with glycogen depletion. Mc Conell et al 50

examined the influence of carbohydrate availability onmuscle metabolism during prolonged exercise. Musclebiopsies obtained immediately after exercise showed thatingestion of carbohydrate increases performance. Thus theyconcluded that fatigue during prolonged exercise isassociated with muscle glycogen depletion orhypoglycemia. It is suggested that decrease in carbohydrateavailability results in inability to resynthesize ATP at ratethat matches ATP degradation which causes fatigue. Alsocarbohydrate ingestion improves endurance performancein subjects via alterations in central nervous systemfunction.

Thus mainly CNS as well as some component of peripheralmechanisms influence fatigue during aerobic exercise.

During exercise which involve both the aerobic as well asanaerobic systems such as the mixed fatigue protocol usedin our study it can be said that both the central andperipheral mechanisms of fatigue were involved.

Thus its can be said that fatigue can result from combinationof peripheral and central factors and fatigue caused by theseresulted in impaired balance ability.

During exercise somatosensory inputs are stimulated.Under normal circumstance individual is more reliant onsomatosensation than on visual inputs in correcting bodysway. Alteration in somatosensory information leads tobalance loss. There is decreased proprioception, increasedjoint laxity and a delay in muscle response after fatiguingexercise. The activity of joint receptors, muscle spindlesand Golgi tendon organs may be reduced by fatigue,resulting in proprioceptive deficiency in muscle receptorsand loss of muscular reflexes responsible for joint stability.Since this afferent information is important for themaintenance of postural control this may lead to decreasedmuscle response and poorer ability to maintain balance.51

Moreover muscle fatigue causes accumulation anddepletion of metabolites and muscle damage. A decreasein effector system efficiency because of muscle fatigue andchanges in proprioceptive information and their integrationcould probably impair postural control18.

Thus, if inaccurate information is provided by any of the 3sensory systems because of local fatigue and if the centralnervous system is suppressed through central fatigue,balance is disturbed1,78.

Another finding was that although balance was affected,post tests Balance Error Scoring system scores graduallydecreased with time. This was because as the effect offatigue weaned off balance deficit started to recover. In

aerobic fatigue protocol it was seen that balance stared torecover in 15 minutes and had recovered by 20 minutes,10 minutes in anaerobic protocol and 20 minutes in mixedfatigue protocol.

These findings agree with previous studies that placedbalance recovery at approximately 20 minutes1,17,31.

Also recovery from fatigue is very important before furtherexercises can be continued otherwise fatigue effects willlead to decreased performance and increased incidenceof injuries. Recovery of muscle function is dependent onintensity, and duration of exercise as well as time allowedfor recovery.

Hebestreit et al 52 showed that after 30 seconds WingateAnaerobic test recovery occurred in 2 minutes in boys and10 minutes in adults. This was because fatigue was causedby peripheral factors, which recovered earlier, and alsobecause of differences in recovery pattern between boysand adults.

Study by Ozturk et al 54 showed that after Wingate Anaerobictest recovery period must be atleast 10 minutes and lactateaccumulates more depending on intensity of exercise.Lower lactate after a given exercise bout may facilitate fasterrecovery55,56. Reduction in lactate during recovery isbecause it is distributed to sites of metabolism such asliver, heart, and inactive muscle or taken up by mild tomoderate active skeletal muscle20.

Boska et al 58 demonstrated recovery of phosphocreatineand inorganic phosphate in first 2 minutes and gradualrecovery in next few minutes. Signorile et al 57 showed thatfollowing exhaustive exercise ATP stores are approximatedto be 90 – 95% repleted in 3 minutes because thephosphocreatine stores have been repleted.

Baker et al 59 demonstrated that most of the anterior tibialismuscle force is recovered within 15 minutes after longduration fatigue protocol and after short duration fatigueprotocol recovery occurred in 5 minutes. They said thatduring short duration activities metabolic processes comeinto play and this causes early recovery whereas duringlong duration it is the non-metabolic factors that delay therecovery. Susco et al1 showed that balance recovered within20 minutes after mixed fatigue protocol because both thecentral and peripheral fatigue mechanisms were involvedin fatigue process and central fatigue mechanisms requiremuch more time for recovery as compared to peripheral.From these studies it seems reasonable that balancerecovery should occur within 20 minutes.

Studies of the process of recovery from fatigue have hadvaried results, particularly because researchers have useddifferent methods and fatigue protocols as well as differentvariables to measure fatigue effects. The fatigue protocoltargeting only the peripheral mechanisms has more rapidrecovery to baseline values as compared to central. Thedifferences in fatigue protocol and the type of fatigue shouldbe considered when attempting to compare fatigue effectsand the recovery process36.

The results of our study demonstrated that RPE readingsalso increased as compared to pretest after all the threefatiguing protocol. Changes in RPE Scores demonstrate


50

that the subjects were fatigued to a level representative ofworking at > 80% HRmax or VO2 max, and this fatigue elicitedpostural instability during the test.

Borg RPE scale is used in an attempt to quantify the amountof fatigue. It gives values of perceived feelings in relationto exertion level. Because perceived exertion and VO2 maxare highly correlated, the RPE scale may be used as asubstitute to determine exercise intensity2.

Perceived exertion is the single best indicator of degree ofphysical strain. The overall perceived exertion ratingintegrates various information, including the many signalselicited from the peripheral working muscles and joints, fromthe cardiovascular and respiratory functions and fromcentral nervous system. All these signals, perceptions andexperiences are integrated into perceived exertion26.

Using the 15-point Borg RPE scale, Seliga et al 2 showedperceived exertion scores increased significantly with anincrease in workload. The RPE values ranged from 9 to 10during a light workload to 11 to 12 during a moderateworkload to 14 to 16 during a heavy workload. They alsonoted that sway values were higher after exercise at higherworkloads.

Other investigators have correlated RPE with percentageof maximum heart rate reserve, or percentage of VO2 maxduring various exercise tasks2,28. In a group of physicallyactive males, RPE was measured during a treadmillexercise, cycle exercise, and simulated ski exercise at 70%,80%, and 90% VO2 max. The RPE values ranged from 13to 14.2 at 70% VO2 max across the exercise modes to 15.4to 16 at 80% and 18 to 18.2 at 90%2.

Thus, during our protocol subjects were working at a levelgreater than 70% VO2max, and the decrease in BESSperformance noted during the posttests was a result of theirfatigue.

The RPE values noted in the studies previously done areall similar to RPE values in our study so we can say thatsubjects were fatigued and this fatigue caused balanceimpairment.

Another finding was that RPE readings in all protocolsreturned to baseline level within 20 minutes indicating thatthe subjects had recovered from fatigue. RPE values startedreturning to baseline in 15 minutes in aerobic protocol, 10minutes in anaerobic protocol and 20 minutes in mixedfatigue protocol.

When comparing the three different fatigue protocols forBESS scores and rating of perceived exertion scores itshowed that there was insignificant difference for the pretestreadings which meant that the subjects pretest reading wassimilar in all the three conditions. But posttest revealedsignificant differences, which meant that fatigue protocolshad effect on balance and each protocol caused balancedeficit in accordance with the protocol used. It also revealedthat the recovery was also different for all the conditions.

We attempted to quantify levels of fatigue by using the RPEscale, a clinical measurement tool that can easily beadministered on the sidelines of athletic events. Yet variousfactors can influence RPE scores, including level of fitness,psychological state, and environmental conditions2.

Thus it could be said that aerobic, anaerobic and mixedfatigue protocols all had effect on balance and balancerecovered from these protocols within 20 minutes.

Relevance to clinical practiceEven minute changes in posture have shown to determinethe outcome of performance and accuracy tasks such asrifle shooting33. Decreased postural control because offatigue affects performance. It is suggested that individualsare at higher risk of injury after fatigue30.

It is seen that a tennis match may be lost simply becauseof fatigue and loss of concentration at the end of set.25

Studies have shown relation between performance underfatigue and increased incidence of injury16.

With the trend of injuries possibly occurring during the laterhalf of games and practices, perhaps more can be done toprepare these athletes for central and local fatigue. If wecan better train the athlete to operate in a fatiguedenvironment, or limit the amount of fatigue an athlete isexperiencing as a result of improved conditioning, thenperhaps injuries may not be as correlated with the amountof fatigue that they are experiencing.

Although it is not realistic to expect a coach to stop practiceor decrease practice times because someone isexperiencing fatigue that may lead to injury, this topic needsattention. To be realistic, most coaches could rearrangehow practices are conducted. For example, a coach who ishaving three-hour basketball practices could schedule themore difficult and higher risk activities in the first half ofpractice and leave the lower risk activities for the last hourwhen the athletes will be feeling the effects of fatigue.

Often balance assessment is done immediately afterconcussion injury apart from other neuropsychological teststo assess postural stability1,2. In most cases athlete hasjust come off the field and is fatigued. If balance testing isdone at this time when the effects of concussion are cloudedby effects of fatigue an athlete might score significantlygreater number of errors due to combined effects of injuryand fatigue and an accurate record of postural stability willnot be recorded. Based on our findings it can be said thatclinicians should wait for atleast 15 minutes after aerobicexercises ceases, 10 minutes after anaerobic exerciseceases and 20 minutes after mixed exercise ceases to allowathlete to return to resting baseline state and yieldconsistent measures.

Future research

More research in general needs to be conducted lookingat activity related or functional fatigue and how it affectsbalance.

In the future use something besides the rating of perceivedexertion to guarantee fatigue in the participants. Adynamometer could be used to measure local fatigue aboutthe ankle, knee, and hip. A VO

2max test coupled with this

could ensure proper cardiovascular endurance as well. Inaddition, blood samples can be taken and muscle biopsiescan be done or invasive techniques can be used to detect


51

blood lactate and other fatigue metabolites such as ATPlevel, phosphocreatine level.

Using an actual practice or competition instead of a fatiguingprotocol may help demonstrate exactly what fatigue anathlete may experience during competition in their sport.However, this type of protocol would be difficult tostandardize.

Since some studies say that recovery from fatigue after

prolonged exercise takes longer time40, 60, 61 futureresearches can assess the recovery patterns after 1 hour,2 hours and even 24 hours time interval so that exact timeof recovery can be ascertained.

Since in this study only male patients were taken the resultscan only be generalized to male population. So futureresearch can focus on taking female subjects as well andalso comparing the balance deficits in both the sexes.

Fig. 1.1 Fig. 1.2

Fig. 1.3 Fig. 1.4

Fig. 1.5 Fig. 1.6


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ConclusionsFrom the results it can thus be concluded that differentfatigue protocols, aerobic, anaerobic and mixed have effecton balance and balance is impaired as evident in increasedposttest readings. Balance recovers within 20 minutes afterall the fatigue protocols.

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

An essential journal for all Physiotherapists & Occupational therapists provides professionals with a forum in which to discuss today’s challenges-identifying the philosophical and conceptural foundations of the practice; sharing innovative evaluation and treatment techniques; learning about and assimilating new methodologies developing in related professions; and communicating information about new practice settings. The journal serves as a valuable tool for helping therapists deal effectively with the challenges of the field. It emphasizes articles adn reports that are directly relevant to practice. The journal is internationally indexed and is also covered by Index Copernicus (Poland).

Note for SubscribersAdvance payment required by Cheque / Draft in the name of “Indian Journal of Physiotherapy and Occupational Therapy” payable at New DelhiConcellation not allowed except for duplicate payment.Claim must be made within six months from issue date.A free copy can be forwarded on request.

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Indian Journal of Physiotherapy and Occupational Therapy407, Hawa Singh Block, Asiad Village, New Delhi - 110 049 (India)

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