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Rajiv Gandhi University of Health Science
Bangalore, Karnataka.
ANNEXURE-II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1. Name of the Candidate
and Address
PRIYANKA GANESH PATIL
A/403, Shiv-Shakti appt, Sangitawadi,
Shivmandir road, Dombivli (E) 401201.
2. Name of the Institution
and Address
K.T.G. COLLEGE OF PHYSIOTHERAPY
Hegganahalli cross, Vishwaneedam Post,
Sunkadakatte via Magai Road.
Bangalore- 560 091
3. Course of study and subject MASTER OF PHYSIOTHERAPY
(Musculoskeletal Disorders and Sports
Physiotherapy)
4. Date of admission to course 7th April 2012
5. TITLE OF THE TOPIC:
A COMPARATIVE STUDY ON MUSCLE ENERGY TECHNIQUE AND
POSITIONAL RELEASE THERAPY IN ACUTE LOW BACK ACHE
6. Brief resume of the intended work:
6.1 Need for the study :
Low back pain is the largest cause of sick leave and half of the population will have
experienced a significant incident of low back pain by age of 30. In India its incidence has been
reported to be 23.09%. They are classically stratified into acute, sub acute and chronic, with
respective cut-offs of <6 weeks, 6–12 weeks and >12 weeks. Acute low back pain is usually the
result of various causes, such as postural abnormalities, muscle dysfunction (imbalances,
shortening or weakening of muscle), overuse, instability, and articular dysfunction in the lower
back, injury or accident, most often road vehicle accidents. 85-90% of all episodes of low back
pain are non specific in nature.1 This is the most common type of back pain. About 19 in 20 cases
of acute (sudden onset) low back pain are classed as non-specific. This is the type of back pain
that most people will have at some point in their life. It is called non-specific because it is usually
not clear what is actually causing the pain. In other words, there is no specific problem or disease
that can be identified as to the cause of the pain. The severity of the pain can vary from mild to
severe.2
The treatment of patients with back pain can be extremely interesting and rewarding.
However, some patients with low back pain can be difficult to treat and care of these patients is
quite often challenging. People who report LBP often have reduced spinal motion. When motion
is limited, spinal extension is more restricted than flexion. Reduced spinal extension can be result
of pain or stiffness and can be classified as being either general (total spine) or segmental (one
vertebral level). The function and co-ordination of the muscles that stabilize the lumbar
spine, especially the back extensor muscles are often impaired in patients with low back pain.
Sorensen found that good endurance of back extensor muscles in men appeared to protect them
from low back pain. Erector spinae strain and fatigue is one of the causes of back pain. In general,
positional release therapy and muscle energy techniques are the forms of manual therapy that are
used in an effort to reduce pain and improve range of motion.1
Muscle Energy Technique is a direct technique originally developed by Fred Mitchel, Sr.,
DO. The purpose of this technique is to treat joint hypomobility (stiffness) and restore proper
biomechanical and physiological function to the joint. Different patient positions are utilized to
engage the restriction before asking the patient to perform an isometric contraction to pull the
restricted segment into a new motion barrier. The isometric contraction is performed in a precisely
controlled direction against a precisely controlled counterforce by the therapist. The result is
improved spinal mobility without the need for passive manipulation. Muscle Energy Technique is
effective for mobilizing restricted joints, relaxing hypertonic and spastic muscles as well as
facilitating neuromuscular reorganization. It is an appropriate technique for patients whose
symptoms are aggravated by certain postures or bodily positions.2 Greenman defined muscle
energy technique as a manual medical treatment procedure controlled direction, at varying levels
of intensity against a distinctly executed counter force applied by the operator. The goal is to
increase joint mobilization and lengthen contracted muscles.1 Each treatment session begins and
ends with a screening technique to assess the outcome of the manual techniques. This can be
rewarding for the patient as the experience changes in mobility with concomitant reduction in
pain.3
Positional Release Therapy is a manual technique that restores a muscle to its normal
resting tone. Assessment of trigger points allows identification of hypertonic muscles that are
creating somatic dysfunction. The tender point is used as a guide and the position of comfort is
maintained.1 These efferent impulses were attempting to protect the tissue from being over
stretched. By interrupting this pathway, the patient’s muscle is allowed to relax and assume a
normal resting tone. The process is completed by slowly and passively returning the patient to an
anatomical neutral position without firing of the muscle spindle.4 This position of minimal
discomfort is usually a position where the muscle is at its shortest length. The position is held for
90 seconds and the joint is slowly and passively returned to the neutral position. This prolonged
shortening of the muscle causes shortening of both the intrafusal (muscle spindle) and extrafusal
fibers. These changes in turn result in a significant increase in function range of motion and a
decrease in pain.1 Patients are placed in positions that approximate the origin and insertion of the
hypertonic muscle. In doing so the muscle spindle activation is inhibited thereby decreasing the
amount of afferent impulses to the brain. This leads to less efferent impulses to the same muscle.
The patient is then instructed in appropriate.5
Even though both muscle energy technique and positional release therapy are beneficial
for management of acute low back pain, optimal treatment intervention is not agreed upon till
date. Hence, further research is necessary to find the most effective treatment option in the
management of patients with acute low back pain. Therefore the purpose of the study is to
compare the effectiveness of Muscle energy technique and Positional release therapy for reduction
of pain and improving functional ability in subjects with acute low back pain.
Research Question:
Which form of manual therapy is more effective in improving functional ability and reducing pain
in subjects with acute low back pain – Muscle Energy Technique or Positional Release Therapy?
Hypothesis:
Null hypothesis:
There will be no significant difference between Muscle Energy Technique and Positional Release
Therapy in improving functional ability and reducing pain in subjects with acute low back pain.
Alternate hypothesis:
There will be significant difference between Muscle Energy Technique and Position Release
Therapy in improving functional ability and reducing pain in subjects with acute low back pain.
6.2 Review of Literature:
P Naik Prashant, A Heggannavar et. al. (2010): studied the effects of MET and PRE on low
back pain and concluded that both were helpful in improving lumbar mobility and decreasing pain
in non specific low back pain.1
Wilson E, Payton O, Donegan-Shoaf L, Deck K et. al. (2003):studied effects of MET on non
specific low back pain in a perspective pilot clinical trial on 20 subjects over a 4 week period and
found that MET combined with supervised motor control and resistance exercises may be
superior to neuromuscular re-education and resistance training for decreasing disability and
improving function in patients with acute low back pain2
Nogelle M Selkow, Terry L Grindstaff, Kevin M Cross, Kelli Pugh, Jay Hertel, Susan Saliba
K et. al. (2003): studied effects of MET in non specific lumbopelvic pain in a randomized control
trial. The main finding of this study was that the MET group demonstrated a decrease in VAS
worst pain. This technique can be accomplished without causing further pain or harm to the
patient.3
Wong, Christopher Kevin, Schauer, Carrie e.t. al (2004): studied effect of Positional Therapy
on pain and strength in hip musculature on 50 volunteers. They have concluded in their study that
positional release therapy definitely reduces pain which indeed improves strength.4
Kerry J.D’Ambrogio, George B. Roth e.t. al (1997): suggested Positional release therapy also
known as ‘’counter strain’’ is a helpful tool for Assessment & Treatment of Musculoskeletal
Dysfunction. Although positional release was invented as a structural technique, physiologically it
can be seen as a way of resetting proprioceptors, primarily at tendon-osseous junctions.5
S Stander- Acta Derm Venerol . et. al. (2012): studied validity and reliability of Visual
Analogue Scale in comparison to Numerical Rating Scale and Verbal Rating Scale. They
concluded that VAS is more sensitive and reliable tool than NRS and VRS for pain assessment.6
Boonstra, Anne M. Reneman, Michiel F. , Posthumus, Jitze B. , Stewart, Roy E. , Schiphorst
Preuper, Henrica R. et. al. (2008):conducted a study to determine the reliability and concurrent
validity of a visual analogue scale (VAS) for disability as a single-item instrument measuring
disability in chronic pain patients. 52 patients in the reliability study, 344 patients in the validity
study were selected. They concluded that the reliability of the VAS for disability is moderate to
good.7
Julie M Fritz and James J Irrgang et. al. (2008): did a comparative study on reliability of
Modified Oswestry Low Back Pain Disability Questionnaire and the Quebec Back Pain Disability
Scale on 60 subjects over a 4-week period and found that results for the modified OSW were
superior than for the QUE. The modified OSW was more responsive than the QUE as assessed by
GRI and in correlations between change scores and the global rating of change.8
H Breivik, S. M. Allen et. al. (2008): studied importance of validity and reliability of pain
assessment. They concluded that any assessment of pain must take into account other factors, such
as cognitive impairments or dementia and assessment tools validated in the specific patient group
being studied. 9
6.3 Objectives:
To compare the effects of Muscle energy technique and Positional release therapy in Acute Low
Back Ache on pain and disability.
7. Material and Methods
7.1 Study design:
Comparative Study design with two groups- Group A(HMP+MET) and Group B(HMP+PRT)
7.2 Methodology:
Study subject :
Subjects with non specific low back pain for less than 3weeks.
Sample size:
Study will be done on 30 subjects (15 in Group A and 15 in Group B)
Study setting and source of data
Study will be conducted in K.T.G. Hospital, Bangalore and other Rehabilitation Centres.
Sampling method
Simple random sampling method.
Study duration:
2weeks study : daily sessions
Sample selection:
Inclusion Criteria:
Both male and females.1
Age group between 20 to 65 years.1
Non specific low back pain.1
Symptoms less than 3 weeks.1
Subjects who willing to participate.1
Low back pain without radiation to buttock, thigh or leg.1
Exclusion Criteria:
History of spinal surgery.1
Motor weakness .1
Spinal fractures or tumors.1
Lumbar radiculopathy.1
Altered sensation such as paraesthesia, numbness,hyperaesthesia, anesthesia.1
Altered deep tendon reflexes.1
Subjects receiving muscle relaxants.1
Material used:
Couch with pillow.
Assessment Performa
Measuring Tape
Pen and paper
7.3 Method of data collection:
Ethical Clearance-
As the study includes human subjects ethical clearance is obtained from ethical community
of K.T.G college of Physiotherapy.
Subjects who meet the inclusion criteria will be assigned to two groups based on simple
random sampling.
Group A : Hot moist pack and Muscle energy technique
Group B : Hot moist pack and Position release therapy
Pre interventions measurements such as pain using VAS, ROM and functional ability using
MODQ will be measured.
Group A – In this group, subjects will be given Hot moist pack and Muscle energy technique.
Patients first will receive hot moist pack. The study participant was made to lie prone on the
couch comfortably. Hot moist pack was kept on the participant’s lumbar region for a period
of
10 minutes.1
Muscle energy technique - After receiving hot moist pack therapy for 10 minutes, muscle energy
technique for erecter spinae was performed on the participant for 10 hold with 20 seconds
relaxation for 9 times i.e. total of 270 seconds in following way:
The participant sits with back to therapist on treatment couch, legs hanging over side and
hands
clasped behind the neck. The therapist places knee on the couch close to the participant, at
the
side towards which side bending and rotation will be introduced. The therapist passes a hand
in
front of participant’s axilla on the side to which the participant is to be rotated, across the
front
of participant’s neck, to rest on the shoulder opposite. The participant is drawn into flexion,
side bending and rotation over the therapist’s knee. The therapist’s free hand monitors the
area
of tightness and ensures that the various forces localize at the point of maximum
contraction/tension. When the participant has been taken to a comfortable limit of flexion, is
asked to look towards the direction from which rotation has been made, whilst holding the
breath for 7 to 10 seconds, or to do this while also introducing a very slight degree of effort
towards rotating back to upright position, against firm resistance from the therapist. The
patient
is then asked to release the breath, completely relax and to look towards the direction in which
side bending/ rotation is being introduced (i.e. towards the resistance barrier). The therapist
waits
for the participant’s second full exhalation and then takes the participant further in all the
direction of restriction, towards new barrier, not through it.1.2.3
Group B – In this group, subjects will be given Hot moist pack and Position release therapy.
Patients first will receive hot moist pack. The study participant was made to lie prone on the
couch comfortably. Hot moist pack was kept on the participant’s lumbar region for a period
of
10 minutes.
Position release therapy- After receiving hot moist pack therapy for 10 minutes, positional release
therapy for erecter spinae for 90 seconds with 3 repetitions i.e. total of 270 seconds was given in
following way. The participant is prone with trunk laterally flexed towards the tender side. The
therapist stands on the side of the tender point. The therapist places his or her knee on the table
and rests the participants affected leg on the therapist’s thigh. The participant’s hip is extended
and adducted and slight rotation is used to fine tune.1,4,5
VAS score and lumbar range of motion (extension) were measured pre and immediately post
intervention. All the participants will receive the selected treatment daily over a period of 2
weeks. After 8 days of intervention, post treatment outcome measures will be recorded.
Subjects
will be reevaluated. As pain using VAS , lumbar extension ROM by Schobers method and
functional ability using MODQ will be measured.
The measured date will be used for analysis.
Outcome measures:
Visual analogue Scale (VAS) for pain. (Annexure-1)6,7,9
Modified Oswestry Disability Questionnaire for functional ability.(Annexure-2)8
Statistical test:
Statistical analysis will be performed by using SPSS software for window (version 16) and
p-value will be set as 0.05.
Statistical measures such as unpaired‘t’ tests and paired‘t’ tests were used to analyze the
data. The results were concluded to be statistically significant with p< 0.05.
Paired‘t’ tests were used to compare the differences of scores on day 1 and day 8th within
a single group. Unpaired‘t’ tests were used to compare differences between the two groups,
MET group and the PRT group.
Repeated measures ANOVA as a parametric Fredmans ANOVA as a non parametric will
be used to analyse the variables within the group.
7.4 Ethical Clearance:-
As this study involves human subjects, the ethical clearance has been obtained from the
ethical Committee of K.T.G college of Physiotherapy, Bangalore as per the ethical guidelines for
Bio-medical research on human subjects, 2000 ICMR, New Delhi. Also a written consent will be
taken from each subject who participates in the study.
8. List of References:
1. Capt. Eric Wilson, Otto Payton, Lisa Donegan-Shoaf,Katherine Dec: Muscle energy
technique in patients with low back pain: A pilot clinical trial JOSPT.2003:33(9):502-
5102. Sharma SC, Singh R, Sharma AK, Mittal R: Incidence of low back pain in work age
adults in rural North India. Medical journal of India.2003:57:4: 145-147
2. Jouhua A. Cleland et al: The use of lumbar spine manipulation technique by physical
therapists in patients who satisfy clinical prediction rule: a case series. JOSPT.2006:36:4
3. George E. Ehrlich: Bulletin of the World Health Organization; Special Theme –Bone and
Joint Decade 2000 –2010; 2003; 81:671-676
4. White AH, Anderson R. "The challenge of conservative care." In: White AH, Anderson R.
Conservative Care of Low Back Pain. Baltimore: Williams & Wilkins,1991:427-434.
5. McGregor A, Anderson L, Gedroyc W. the assessment of intersegmental motion and
pelvic tilt oarsmen.Med Sci Sports Exerc. 2002;34:1143-1149
6. Burton Ak, Battie MC, Gibbions L, et al. Lumbar disc degeneration and saggital
flexibility. J Spinal Disorder.1996;9:418-424.
7. Latimer J, Lee M, Adams R, Moran CM. An investigation of relationship low back pain
and lumbar postero-anterior stiffness. J Manipulative Physical Ther.1996; 19: 587-591
8. Troup JD, Foreman TK, Baxter CE, Brown D. 1987 Volvo award in clinical sciences: the
perception of back pain and role of psychophysical tests of lifting capacity. Spine. 1987;
12:645-657
9. 10. Melllin G. Decreased joint and spinal mobility associated with low back pain in young
adults. J Spinal Disord. 1990; 3:238-243
10. Pearcy M, Portek I, Shepherd J. the effect of low back ache on lumbar spine movements
measured by three dimensional X-ray analysis. Spine. 1985; 10:150-153
11. Julie Moreland, Elspeth Fiinoh et al: Interater reliability of Six tests of Trunk Muscle
Function and Endurance.J OrthoSportsPhys Ther.1997;26(4):200-208.
12. Jorgensen K, Nicolaisen et al: Trunk Extensor Endurance Determination and Relation
to Low Back Trouble. J Orthop Sports Phys Ther 1987; 30: 259-267.
13. Kerry J.D’Ambrogio, George B. Roth.Positional release therapy Assessment &Treatment
of Musculoskeletal Dysfunction. Mosby publication: Philadelphia:1997:2025
14. DiGiovanna EL, Martinke DJ, Dowling DJ. Introduction to osteopathic medicine. An
Osteopathic Approach to Diagnosis and Treatment. Philadelphia: JB Lippincott;1991:1-31.
Naik Prashant P. / Indian Journal of Physiotherapy and Occupational Therapy. April - June
2010, Vol. 4, No. 2 35
15. Heilig D. The 1984 Thomas L. Northup memorial address: osteopathic manipulative care
in preventive medicine. J Am Osteopath Assoc. 1986;86:645651.
16. Leon Chaitow, Judith Walker Delany. Clinical application of neuromuscular techniques.
Vol 2.London: Elsevier Health Science. 2000
17. Leon Chaitow, Ed Wilson, Dylan Morrissey, John M. McPartland. Positional Release
Techniques. 2 Edi. London: Elsevier Health Sciences, 2002
18. Korr IM: The neural basis of the osteopathic lesion JAOA 1947; 47:191-198
19. John V. Basmajian, Rich Nyberg: Rational Manual Therapies. Manipulation, Spinal
Motion, and Soft Tissue Mobilization: Williams & Wilkins : University of Michigan:1993:
301-313
20. http://www.centerimt.com/ejournal/articles/ej00037.htm
21. Sjolie, Astrid N, Ljunggren et al: The Significance of High Lumbar Mobility and Low
Lumbar Strength for Current and Future Low Back Pain In Adolescents. Spine.
2001;26(23):2629-2636
22. Fritz and Irrgang: A Comparison of a Modified Oswestry Low Back Pain Disability
23. Questionnaire and the Quebec Back Pain Disability Scale.
PhysicalTherapy.2001;81(2):7767
9. Signature of Candidate
10. Remarks of the Guide
11. Name and Designation of
11.1 Guide :
11.2 Signature
11.3 Co-Guide :
11.4 Signature
11.5Head of Department :
11.6 Signature
12. 12.1Remarks of the Chairman & Principal
12.2Signature
ANNEXURE -1
CONSENT FORM
I MISS. PRIYANKA GANESH PATIL have explained to..... (Subject name).... the purpose of the research,
the procedures required, and the possible risks and benefits to the best of my ability.
......................................... ...............................................
Investigator Signature Date
College: K.T.G. COLLEGE OF PHYSIOTHERAPYPlace: Bangalore
CONSENT TO PARTICIPATE IN THE STUDY
Purpose of Research
I .........................have been informed that this study will be for COMPARISON OF MUSCLE ENERGY
TECHNIQUE AND POSITIONAL RELEASE THERAPY IN SUBJECTS WITH ACUTE LOW BACK
PAIN. Both approaches /techniques are acceptable Physiotherapy intervention for this problem. This study
will help physiotherapy better understand the use of Physiotherapy services in management of Acute Low
Back Pain with comparative study of Muscle Energy Technique and Position Release
Procedure
I understand that I will be assigned by lot to receive exercise therapy. I will be expected to attend
Physiotherapy treatment sessions two to three times in a week in addition to doing exercises at home.
I am aware that in addition to ordinary care received, I will be examined and asked a series of questions by a
research Physiotherapist. The Physiotherapist examination consists of measuring Visual analog scale (VAS)
for Pain and Modified Oswestry Disability Questionnaire for functional ability. I have been asked to
undergo these tests at the beginning of the study, and after the study.
Risk and Discomforts
I understand that I may experience some pain or discomfort during the examination or during my treatment.
This is mainly the result of my condition, and the procedures of this study are not expected to exaggerate
these feelings which are associated with the usual course of treatment.
Benefits
I understand that my participation in the study will have no direct benefit to me other than potential benefit
of the treatment which is planned to reduce my pain and increase my hand function. The major potential
benefit is to find out which treatment program is more effective.
Confidentiality
I understand that the information produced by this study will became part of my research record and will be
subject to the confidentiality and privacy regulation, but will be stored in the investigator’s research file.
If the data are used for publication in the literature or for the teaching purpose, no names will be used, and
other identifiers, such as photographs and audio or videotapes, will be used with my special written
permission.
Refusal or Withdrawal of Participation
I understand that my participation is voluntary and that I may refuse to participate or may withdraw consent
and discontinue participation in the study at any time without prejudice to my present or future care at the
Hospital. I also understand that Miss. Priyanka Ganesh Patil may terminate my participation in this study at
any time after She explained the reasons for doing so.
I confirmed that Miss. Priyanka Ganesh Patil has explained to me the purpose of the research, the study
procedures that I will undergo, and the possible risks and discomforts as well as benefits that I may
experience. Alternatives to my participation in the study have also been discussed. I have read and I
understand this consent form. Therefore, I agree to give my consent to participate as a subject in this
research project.
............................................... ..........................................
Participant Signature Date
.............................................. ..........................................
Witness to Signature Date
ANNEXURE -2
Visual Analog Scale (VAS):
VAS is presented as 10cm line.
No pain at one end and worst imaginable pain at other end
Patient is asked to mark a 100mm line to indicate pain intensity
ANNEXURE -3
Patient's Name__________________________________________________ Number_____________Date_____________________
Modified Oswestry Disability QuestionnaireThis questionnaire has been designed to give the doctor information as to how your back pain has affected your ability to manage in everyday life. Please answer every section and mark in each section only ONE box which applies to you. We realize you may consider that two of the statements in any one section relate to you, but please just mark the box which MOST CLOSELY describes your problem
Section 1 - Pain Intensity
I can tolerate the pain without having to use painkillers
The pain is bad but I can manage without taking painkillers.
Painkillers give complete relief from pain.
Painkillers give moderate relief from pain.
Painkillers give very little relief from pain.
Painkillers have no effect on the pain and I do not use them.
Section 2 - Personal Care (Washing, Dressing, etc.)
I can look after myself normally without causing extra pain.
I can look after myself normally but it causes extra pain.
It is painful to look after myself and I am slow and careful.
I need some help but manage most of my personal care.
I need help every day in most aspects of self care.
I do not get dressed, I wash with difficulty and stay in bed.
Section 3 – Lifting
I can lift heavy weights without extra pain
I can lift heavy weights but it gives extra pain.
Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently
positioned, for example on the table
Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are
conveniently positioned
I can lift very light weights
I cannot lift or carry anything at all.
Section 4 - Walking
Pain does not prevent me from walking any distance
Pain prevents me from walking more than one mile
Pain prevents me from walking more than one half mile
Pain prevents me from walking more than one quarter mile
I can only walk using a stick or crutches
I am in bed most of the time and have to crawl to toilet
Section 5 – Sitting
I can sit in chair as long as I like
I can only sit in my fav chair as long as I like
Pain prevents me from sitting more than one hour
Pain prevents me from sitting more than 30 minutes
Pain prevents me from sitting more than 10 minutes
Pain prevents me from sitting almost all the time.
Section 6 – Standing
I can stand as long as I want without extra pain .
I can stand as long as I want but it gives extra pain
Pain prevents me from standing more than 30 minutes
Pain prevents me from standing more than 10 minutes
Pain prevents me from standing at all
Section 7 – Sleeping
Pain does not prevent me from sleeping well
I can sleep well only by using tablets
Even when I take tablets I have less than 6 hrs sleep
Even when I take tablets I have less than 4 hrs sleep
Even when I take tablets I have less than 2 hrs sleep
Pain prevents me from sleeping at all
Section 8 – Social Life
My social life is normal and gives me no extra pain
My social life is normal but increases the degree of pain
Pain has no significant effect on my social life apart from limiting my more energetic interests
e.gdancing
Pain has restricted my social life and I do not go out as often
Pain has restricted my social life to my home
I have no social life because of pain
Section 9 – Travelling
I can travel anywhere without extra pain
I can travel anywhere but it gives me extra pain
Pain is bad but I manage journeys over 2 hours
Pain is bad but I manage journeys less than 1 hour
Pain restricts me to short necessary journeys under 30 minutes
Pain prevents me from travelling except to doctor or hospital
Section 10 – Changing degree of pain
My pain is rapidly getting better
My pain fluctuates but overall it is definitely getting better
My pain seems to be getting better improvement is slow at the present
My pain is neither getting better nor worse
My pain is gradually worsening
Scoring: Questions are scored on a vertical scale of 0-5. Total scores and multiply by 2. Divide by
number of sections answered multiplied by 10. A score of 22% or more is considered significant activities
of daily living disability. (Score___ x 2) / (____Sections x 10) = _____________ % ADL
Comments : ____________________________________________________