scientific research journal of india _srji_ vol- 2, issue- 3, year- 2013

Scientific Research Journal of India (Multidisciplinary, Peer Reviewed, Open Access, Journal of science)

ISSN: 2277-1700 Vol: 2, Issue: 3, Year: 2013

Editor in Chief

Dr. Krishna N. Sharma (PT)

Editors

Dr. Popiha Bordoloi

Dr. Kuki Bordoloi

Dr. Sudeep Kale

Dr. Waqar Naqvi

Junior Editor

Mrityunjay Sharma

Office Dr. L. Sharma Campus, Muhammadabad Gohna, Mau, U.P., India. Pin- 276403

Website http://srji.drkrishna.co.in

URL Forwarded to http://sites.google.com/site/scientificrji

Email [email protected]

Contact +91-9320699167

Declaration: The contents of the articles and the views expressed therein are the sole responsibility of the authors, and the

editorial board will not be held responsible for the same.

Copyright © 2013 Scientific Research Journal of India

All rights reserved.

CONTENTS

Title Author/s Department Page

Editorial Dr. Krishna N. Sharma i

Effect of core stabilization

training on endurance of trunk

extensor and functional capacity

in subjects with mechanical low

back pain

Ranjeet Kumar, Dr.

Prosenjit Patra Physiotherapy 1

Effect of trunk muscles

stabilization exercises and general

exercises on disability in recurrent

non specific low back ache

Kumar Amit, Gupta

Manish, Kumar Satish,

Katyal Taruna

Physiotherapy 9

Study of respiratory capacity and

core muscle strength in Indian

classical singers

Shweta S. Devare Phadke,

Sukhada Prabhu, Sujata

Yardi

Physiotherapy 18

Aerobic capacity, body mass

index and fat fold measurements

of healthy athletes in Dehradun –

A cross sectional study

Sharma Chetan, Dr. Dar

Shahid Mohd. Physiotherapy 24

Effects of bimanual functional

practice training on functional

performance of upper extremity in

chronic stroke

Dr Jasmine Anandabai,

Dr Manish Gupta Physiotherapy 30

A comparison study on physical

impairments and functional

limitations of patients: 1 year after

total knee arthroplasty versus

control subjects

Amit Murli Patel Physiotherapy 40

Respiratory physiotherapy in

triple vessel disease with post

coronary artery bypass grafting

surgery (CABG)

Shanmuga Raju P,

Renkha Rao, Rajendhra

Kumar J, SuryaNaryana

Reddy V

Physiotherapy 55

ISSN: 2277-1700 ● Website: http://srji.drkrishna.co.in ● URL Forwarded to: http://sites.google.com/site/scientificrji

iv

Occupational therapy marketing

indian prospective Koushik Sau Occupational Therapy 59

Annotated bibliography of studies

w.r.t statistical methods Neha Dewan Physiotherapy 67

i

EDITORIAL

Dear Readers! I am very pleased to present this issue of the Scientific Research Journal of India (SRJI).

With this issue. This issue of the multidisciplinary and open access Journal of science contains total 8 papers

in Physiotherapy, and 1 paper in Occupational Therapy. I hope you’ll find these papers informative.

Here I would like to bring one more thing to your notice that new and permanent URL is

http://SRJI.DrKrishna.co.in and it will be directed to http://sites.google.com/site/scientificrji .

Do drop a mail to us ([email protected]) if you have any comment and suggestion.

Happy Reading.

Regards,

Dr. Krishna N. Sharma

Editor in Chief

1

EFFECT OF CORE STABILIZATION TRAINING ON ENDURANCE OF

TRUNK EXTENSOR AND FUNCTIONAL CAPACITY IN SUBJECTS WITH

MECHANICAL LOW BACK PAIN

Ranjeet Kumar, MPT (Musculoskeletal Disorder)*, Dr. Prosenjit Patra, MPT

(Cardiopulmonary)**

ABSTRACT

STUDY OBJECTIVES: To determine the effect of Core stabilization training on trunk extensor endurance

and functional capacity in subjects with mechanical low back pain. DESIGN: Experimental study.

SETTING: All the Subjects were taken from Dolphin (PG) Institute Of Biomedical and Natural Science,

Dehradun and the community in and community in and around Dehradun. SUBJECTS: A total of 30 subjects

(M: 14, F: 16) were recruited for the study on the basis of inclusion and exclusion criteria after signing the

informed consent form. METHODS: A total of 30 subjects (M: 14, F: 16) were recruited for the study on the

basis of inclusion and exclusion criteria after signing the informed consent form. The subjects were then

divided into two groups, (Group A= Core Stabilization and Endurance Training & Group B= Endurance

Training). All the subjects were asked to perform 5 min warm-up exercise before the intervention. The total

duration of the protocol was 6 weeks and frequency of exercise performed is 3 times per weeks. OUTCOME

MEASURE: Trunk Extensor Endurance Test was measured using Prone Double Straight-Leg Raise Test, &

Functional Capacity was assessed using Modified Oswestry Disability Index. RESULTS: The result of the

study demonstrates that both the Groups showed significant improvement when comparison is made within

the groups with p=0.001 for both trunk extensor endurance test and functional capacity. However, Group A

shows significant improvement between the groups post intervention p=0.023 & p=.000 respectively.


2

CONCLUSION: From the present study it can be concluded that core stabilization training is effective in

increasing trunk extensor endurance and functional capacity in subjects with mechanical low back pain.

KEY WORDS: Core stabilization training, Endurance training, Trunk extensor endurance, Mechanical low

back pain, Trunk Extensor Endurance

INTRODUCTION

Low back pain is one of the most common

and costly musculo-skeletal pain syndromes,

affecting up to 80% of people at some point during

their lifetime. The re-occurrence rate of low back

pain is high and these disorders often develop into

a chronic fluctuating problem with intermittent

flares.6

Caring for chronic low back pain, is one of

the most difficult and unrewarding problems in

clinical medicine, as no approach to diagnose or

any form of treatment, has been shown to be

clearly definitive or effective. One possible

explanation for the inability to identify effective

treatment protocols is the lack of success in

defining groups of patients who are most likely to

respond to a specific treatment approach.6 For most

patients with acute low back pain, the etiology is

thought to be a mechanical cause involving the

spine and surrounding structures.12 A wide range

of terms is used for non-specific mechanical

causes, including low back strain/sprain, facet joint

syndrome, sacroiliac syndrome, segmental

dysfunction, somatic dysfunction, ligamentous

strain and myofascial strain.3

Biomechanics may be altered due to low

back pain or injury to the spine, producing

weakness and loss of muscle control, which leads

to further injury because the joints are not

appropriately supported again, this may result in

over-compensation by the pelvis or lower

extremities, which will increase the predisposition

to chronic injuries.5

The core has been described as a box with

the abdominals in the front, paraspinal and gluteals

in the back, the diaphragm as the roof and the

pelvic floor and hip girdle musculature as the

bottom. Therefore, the core serves as a muscular

corset that works as a unit to stabilize the body and

spine.1

Panjabi (1992) describe the spinal

stabilization system is conceptualized as consisting

of three subsystems; passive muscular skeletal

subsystem, which includes vertebra facet

orientation, intervertebral disc, spinal ligament and

joint capsules, as well as the passive mechanical

properties of the muscles. The active muscular

skeletal subsystem consists of muscles and tendons

that surround the spinal column. The neural and

feedback subsystem consists of various force and

motion transducers located in ligaments, tendons,

muscles and neural control centers. These passive,

active and neural control subsystems - although

conceptually separate - are functionally

independent. The passive subsystem does not

provide any significant stability to the spine in the

vicinity of the neutral position. It is towards the

ends of the ranges of motion that the ligaments

develop reactive forces that resist spinal motion.

The active subsystem is the means through which

the spinal stabilization system generates forces and

provides the required stability to the spine. The

Scientific Research Journal of India ● Volume: 2, Issue: 3, Year: 2013

3

magnitude of the force generated in each muscle is

measured by the force transducers (signal

producing devices) located in the tendons of the

muscles.15

Therefore, this aspect of the tendons may

be part of the neural control subsystem. Within the

neutral zone of motion, (that part of the range of

physiological intervertebral motion, measured

from the normal position, within which the spinal

motion is produced with a minimal internal

resistance - it is the region of high flexibility

around the mid-zone of motion) the restraints and

control for bending, rotating and shear force are

largely provided by the muscles that surround and

act on the spinal segment. The neural subsystem

receives information from the various transducers,

determines specific requirements for spinal

stability and causes the active subsystem to

achieve the stability goal.16

Well-developed core stability allows for

improved force output, increased neuromuscular

efficiency and a decrease in the incidence of

overuse injuries.9 The normal function of the

stabilization system is to provide sufficient

stability to the spine to match instantaneous

varying stability demands made by changes in

spinal posture, static and dynamic load.15 Hicks et

al, suggest that core stability system has a role in

ensuring spinal stability and according to van

Dillin et al. (2001), a decrease in spinal stability

places stress and excessive load on the spinal

joints and tissues, which eventually results in low

back pain.19

Control of back pain and prevention of its

occurrence can be assisted by enhancing muscle

control of the spinal segment through core stability

exercises. Therefore, exercise programs, which are

based on active rehabilitation, can reduce low back

pain intensity, alleviate functional disability and

improve core stability and back extension strength,

mobility and endurance.17

According to Chok et al. (1999), poor

endurance of the trunk muscles may induce strain

on the passive structures of the lumbar spine,

eventually leading to low back pain. Evidence

suggests that muscle endurance is lower for people

with low back pain than for individuals without

low back pain. Due to endurance being less in

trunk muscles, fatigue can affect the ability of

people with low back pain to respond to the

demands of an unexpected load. Fatigue, after

repetitive loading, also leads to loss of control and

precision, which may predispose an individual to

developing low back pain. Therefore, trunk muscle

endurance training has been recommended to

elevate fatigue threshold and improve

performance, thus, reducing disability of the

lumbar spine.4

Endurance training of back extensor

muscles, including the multifidus, has long been

recognized as a crucial preventative of recurrent

low back pain. The function and coordination of

the muscles that stabilize the lumbar spine,

especially the lumbar extensor muscles, are often

impaired in patients with low back pain.13

The role of trunk stabilizers is to retain the

musculature; to control, coordinate and optimize

function. Trunk fatigue, which occurs during

intense training or matches, produces a loss in

synchrony between upper and lower extremities,

which may cause a reduction in muscle strength.

This may in turn prevent a proper transfer of force

resulting in inappropriate compensation by the

body while performing a particular function.5

Dynamic trunk stability training includes

building muscle strength, endurance and using


4

neuromuscular control to maintain dynamic trunk

stability.10

METHODOLOGY

An experimental study was conducted on 30

subjects (14 male and 16 female) who were

recruited from Dolphin (PG) Institute of

Biomedical and Natural Science and the

community in and around Dehradun based on the

inclusion and exclusion criteria and they were

divided into two groups after informed consent

was obtained. Group A (Core Stabilization and

Endurance Training) & Group B (Endurance

Training). Pre intervention measurement of Trunk

Extensor Endurance Test was measured using

Prone Double Straight2-Leg Raise Test, &

Functional Capacity was assessed using Modified

Oswestry Disability Index8. For both the groups 5

min of warm exercise was given before the

intervention. The total duration of protocol was 6

weeks and frequency of exercise was 3 times per

week.

Protocol for Group A: All subjects in this

group received Core stabilization training and

Endurance training on a Swiss ball.

1. Lunge

○ Sets-2

○ Repetition-8

○ Rest-1minute

2. Supine lateral roll.

○ Sets-2

○ Repetition-8

○ Rest-1minute

3. Abdominal crunch

o Sets-2

o Repetition-8

o Rest-1minute

4. Supine Russian twist

o Sets-2

o Repetition-8

o Rest-1minute

Protocol for Group B: All subjects in this group

received Endurance training on a Swiss ball.

1. Bilateral shoulder lifts

○ Sets-6

○ Repeatation-5

○ Rest-1 minute

○ Holding-20sec


5

2. Contra-lateral arm and leg lifts

o Sets-2

o Repeatation-8

o Rest-1 minute

o Holding-20sec

3. Bilateral shoulder lifts with hands

behind the head

o Sets-2

o Repeatation-8

o Rest-1 minute

o Holding-20sec

4. Bilateral shoulder lifts with arms in

full elevation

o Sets-2

o Repeatation-8

o Rest-1 minute

o Holding-20sec

DATA ANALYSIS

Data was analysed using statistical package of

social sciences SPSS software (version 14.0). Pair

t-test was used for data analysis within the group

A and group B for Extensor muscle endurance test

and Modified Oswestry Low Back Pain Disability

Index. Independent t-test was used for data

analysis between the group A and group B for

Modified Oswestry Low Back Pain Disability

Index. The p value was set at (<0.05).

RESULTS

Data was analysed for 30 participants: 15

in each Group A & Group B.

Table1.1: Comparison of mean value for age

between group A and B

Table 1.2: Comparison of Pre and Post EET score

for group A and group B

Table1.3: Comparison of Pre and Post MODI

score for group A and group B


6

Table 1.4: Comparison of Pre and Post EET score

between group A and group B

Table 1.5: Comparison of Pre and Post MODI

score between group A and group B

Results of the study showed that there is

improvement in trunk extensor endurance and

functional capacity after the intervention in both

the groups. This improvement in pressure

threshold was found to be statistically significant.

Group A (Trunk Extensor Endurance & Core

Stabilization) showed more improvement when

compared to Group A and this was found to be

statistically significant with p=0.023 & p=.000

respectively.

DISCUSSION

The present study investigated the effect

of core stabilization training on endurance of trunk

extensor and functional capacity in subjects with

mechanical low back pain. Endurance of Trunk

extensor and functional capacity was measured 2

times: pre-intervention and post-intervention

through prone double straight leg raise test and

Modified Oswestry Low Back Pain Disability

Index respectively. Subjects were divided into two

groups as Group A and Group B. Group A was

given Core stabilization training and Endurance

training on a Swiss ball and Group B was given

Endurance training on a Swiss ball. Both groups

received training three times a week for six weeks.

The changes observed in this study were

noteworthy. Within group comparison showed

significant changes with improvement in isometric

hold time and functional capacity in both groups A

and B. In between groups, statistically significance

difference was found in isometric hold time and

functional capacity.

According to Moffroid, Progression of

loading through postural changes produces

increases in endurance time of the back extensors,

as measured by the Sorensen Test. These postural

progressions increase the load moment on the

spine and thereby stress the erector spinae

muscles, multifidus and others.14

In addition adoptive changes occur in

skeletal muscle during endurance training ie,

slower rate of glycogenolysis, slower rate of

lactate production during submaximal exercise

occurs due to raise in the lactate threshold both in

absolute and relatives terms ie, o2 uptake(VO2)at

LT and vo2 max at LT, increased mitochondrial

enzyme activity and increase capillary density.7

Therefore, it is reasonable to expect

increased endurance of trunk extensor muscle in

group B subjects who only underwent endurance

training.

Core stabilization training has a theoretical

basis in treatment and prevention of various

musculoskeletal conditions.

Core stabilization training is hypothesized

to increase muscle activation by increasing motor

unit recruitment, rate and synchronization of

firing11


7

Richardson found that individual with low

back pain exhibits delayed activation of the

transversus abdominis muscle when compared

with normal individual. Low back pain patient

have an impaired ability to consciously contract

transversus abdominis and this is an important

component of abdominal stability training.17

Performance of exercises on unstable

surfaces like Swiss ball has been shown to increase

the activity of the rectus abdominis. It also causes

changes in muscle activity and force output and

may be another way of potentially altering

neuromuscular recruitment pattern17

Spinal instability occurs generally as a

result of delayed recruitment of core muscle/local

muscle like transversus abdominus, multifidus and

core stabilization training address these core

muscle, thereby increase spinal stability.17

Study by Kimitake Satoand Monique

Mokha has shown that core stabilization training

let to an increase in 5000meter run time

performance. The proposed mechanism was that

subjects who underwent core stabilization were

conscious of using their core muscle to stabilize

their running form. A similar mechanism may

exist in our study where by subjects who

underwent core stabilization training were able to

stabilize their form better during performance of

prone double leg raise test, thereby resulting in

longer hold times than subjects who only

underwent endurance training.18

So over all core stabilization training

increases muscle activation (transversus

abdominus, lumbar multifidus), alters

neuromuscular control and also increases spinal

stability, leading to decreased pain which may

have led to the increased isometric hold time and

functional capacity in group A subjects as

compared to subjects in group B.

Limitation of the study are sample size

was limited and no blinding was done during the

study. So the further recommendation for future

studies need to be done with broader dimensions,

EMG could be used to quantify the activation of

core muscle and it can also be used to track global

muscle activation during core stability testing.

Bio-mechanical marker can be measured.

CONCLUSION

From the present study it can be concluded that

core stabilization training is effective in increasing

trunk extensor endurance and functional capacity

in subjects with mechanical low back pain.

REFERENCES

1. Akuthota V. and Nadler, S.F. Core Strengthening. Physical Medicine and Rehabilitation. 2004; 85(1):

86-92.

2. Arab A M, SalawatiMahyar, Mohhammad E. Sensitivity, specificity and predictive value of the

clinical trunk muscle endurance tests in low back pain. Clinical Rehabilitation. 2007;21:640-647

3. Atlas, S.J. and Deyo, R.A. Evaluating and Managing Acute Low Back Pain in the Primary Care

Setting. Journal of General Internal Medicine. 2001; 16(2): 120-131.

4. Chok, B., Raymond. L., Latimer, J. and SeangBeng, T. Endurance Training of the Trunk Extensor

Muscles in People With Sub Acute Low Back Pain. Physical Therapy. 1999; 79(11):1032-1042.


8

5. Cholewicki, J. and McGills, S.M. Lumbar Posterior Ligament Involvement During Extremely Heavy

Lifts Estimated from Fluroscopeic Measurement. Journal of Biomechanics. 1992; 25:17-28. 8)

6. Dankaerts, W., O’Sullivian, P.B., Straker, L.M, Burnett, A.F. and Skouen, J.S. The Inter- Examiner

Reliability of a Classification Method for non- Specific Chronic Low Back Patients with Motor

Control Impairment. Manual Therapy.2005; 2:1-12.

7. Edward F, Coyle H, Martin, Susan A, Bloomfield, Oliver H, Lowry, John O, Holloszy. Effects of

detraining on response to submaximal exercises. J.Appl. Physiol.1985 59(3): 853-859

8. Fritz JM, Irrgang JJ. A Comparison of a Modified Oswestry Disability Questionnaire and the Quebec

Back Pain Disability Scale. Phys Ther 2001; 81:776-788.

9. Hedrick, A. Training the Trunk for Improved Athletic Performance. Strength and Conditioning

Journal. 2000; 22(3), 50-61.

10. Hubley-Kozey, C.L. and Vezina, M.J. Muscle Activation During Exercise to Improve Trunk Stability

in Men With Low Back Pain. Journal of Physical Medicine and Rehabilitation. 2002; 83(8): 1100-

1108

11. Kisner C, Colby LA. Therapeutic Exercise Foundations and Techniques. 5th ed.Philadelphia: F.A

Davis Company; 2007.

12. Krismer, M. and van Tulder, M. Low Back Pain (non-specific). Journal of Biomechanics. 2007;

21(1): 79-91.

13. Liebenson, C. Spinal Stabilization Training: The Therapeutic Alternative to Weight Training. The

Journal of Body Work and Movement Therapies. 1997; 1 (2): 87-90

14. Moffroid MT, Haugh LD, Haig AJ, et al. Endurance training of trunk extensor muscles. Phys Ther.

1993; 73:10 –17.

15. Panjabi, M.M. The stabilizing system of the spine, Part 1: Neutral zone and instability hypothesis.

Journal of Spinal Disorder. 1992; 5(4) 383 – 389.

16. Panjabi, M.M. The stabilizing system of the spine, Part 2: Neutral zone and instability hypothesis.

Journal of Spinal Disorders. 1992; 5(4): 390 – 397.

17. Richardson C.A. and Jull G.A. Muscle control-pain control. What exercise would you

prescribe?.Manual Therapy. 1995; 1: 2-10.

18. Sato K, Mokha M Does core strength training influence Running kinetics, lower-extremity stability,

And 5000-m performance in runners? Journal of Strength and Conditioning Research. 2009;

23(1):133-140

19. VanDillin, L.R., Sahrmann, S.A., Norton, B.J., Coldwall, C.A., Flemming, D., McDonell, M.K. and

Bloom, N.J. Effect of Active Limb Movements on Symptoms in Patients with Low Back Pain. Journal

of Orthopaedic and Sports Physical Therapy. 2001; 31 (8): 402-4144.

20. http://www.exercise-ball-exercises.com/list-free-exercise-ball-exercises.htm

CORRESPONDENCE

** Asst. Prof. Dolphin (PG) Institute, Dehradun (UK)

* Student Researcher, Dolphin (PG) Institute, Dehradun (UK)

9

EFFECT OF TRUNK MUSCLES STABILIZATION EXERCISES AND

GENERAL EXERCISES ON DISABILITY IN RECURRENT NON SP ECIFIC

LOW BACK ACHE

Kumar Amit*, Gupta Manish, Kumar Satish**, Katyal T aruna***

ABSTRACT

OBJECTIVE: To study the Effect Of Trunk Muscles Stabilization Exercises And General Exercises On

Disability In Recurrent Non Specific Low Back Ache. DESIGN: Pre-test and Post test control group design.

SETTING: Inpatient and rehabilitation hospital. PARTICIPANTS: A total number of 80 patients with

recurrent non specific low back pain are allocated randomly into 1 of 2 groups; control group received

general exercise only (n=40) and experimental group received specific stabilization (n=40)

INTERVENTION Both groups received 6 weeks exercise intervention with 30-40 min per session, thrice per

week and written advice. Main Outcome Measures: A Rolland Morris low back disability questionnaire were

used to measure disability. Outcomes were measured before and after intervention. RESULTS: The

calculated t-values for the RMDQ showed a significant variation at p=0.00. It showed that there is fulfilled

improvement in post test RMDQ values when compared to pretest ODQ values in both the groups. The mean

improvements between the two groups of low back pain patients were tested for significance using student t-

test. The calculated t-values for the RMDQ scale was significant at p=0.011. This shows that mean

improvement in the group II that received core strengthening is higher when compared to the group I that

received conventional exercise program. CONCLUSION: This study concludes that specific stabilization

exercise is beneficial in reducing disability and improved function in chronic non specific low back pain.


10

KEYWORDS: Exercise, Low Back Pain, Stabilization, muscle, pain, disability

INTRODUCTION

Technological and organizational changes in

the industrial countries during last few decades

have markedly increased the number of jobs

performed in Monotonous and constrained

postures. Low back pain is one of the most

Common musculoskeletal health problem in the

industrialized countries affecting about 80% to

90% of the population at sometime during their

lives. Out of these 30% develop chronic low back

pain. Chronic low back disability appears to be

increasing faster than any other form of

incapacity1. Deep trunk muscles eg, transversus

abdominis and multifidus responsible for

maintaining the stability of the spine2. So

strengthening of these muscle and their restoration

should be effective in the management of

persistent LBP.Therapeutic workouts for

superficial and the deep muscles seem to be

effective in the treatment of CLBP3. Trunk

muscles exercises activate the abdominal and

paraspinal muscles as a whole and at a relatively

high contraction level4. There are many

randomized controlled trials RCTS on the

usefulness of classic trunk exercises5, 6, increasing

attention recently has been paid to the preferential

retraining of the local stabilizing muscles of the

spine7, 8. No randomized control trial has done that

stabilization training is beneficial in a sample of

patients with sub acute or chronic nonspecific low

back pain using pain and disability as outcome.

Two relevent randomized control trial have been

conducted in specific subgroup of patients with

low back pain7, 8. But, in these trial, the specific

effect of the trunk stabilization exercise regiment

was not compare to general back and abdominal

exercise. A more recent study that compared

stabilization exercise against 2 other general back

extensor exercise regiments in patients with

nonspecific chronic low back pain demonstrated

positive results for multifidus muscle

crosssectional area increase in favor of one of the

general exercise approach9. A study found that a

General exercise program can be improved in

reducing disability in short term than specific

stabilization and general exercises in subjects with

recurrent nonspecific low back pain10 Though

conventional back care exercises and stabilization

exercises are proved to be effective in chronic

mechanical low back pain patients, no literature

comparing the effectiveness on each other were

found which necessitated the present study to

compare the outcome of conventional and

stabilization exercises in in chronic non specific

low back pain.

METHODOLOGY

A total number of 80 subjects, with

nonspecific low back pain, were recruited from the

physiotherapy department of Sir Ganga Ram

Hospital, New Delhi, India. All the subjects to the

physical department were referred from orthopedic

outpatient after proper detailed assessment by an

orthopaedician. A total 150 subjects and

performed 120 subjects clinical evaluation by their

physician including radiograph images. 40 subjects

are dropped out and therefore sample consisted of

80 subjects with nonspecific CLBP.

Inclusion criteria were:

1. Patients who had a history of recurrent

LBP (repeated episodes of pain in past


11

year collectively lasting less than 6

months),

2. Patients who have nonspecific nature of

pain

3. Patients who are willing to participate in

the exercise program and willing to travel

independently to the hospital from the

home10

4. Mean age of subject is 30-50yr

5. Both gender are included.

Exclusion criteria were:

1. Patients with previous spinal surgery

2. Patients who have signs and symptoms of

gross spinal instability radiological

diagnosis of spondylolysis or

spondylolisthesis

3. Patients who had red flags suggesting

serious spinal pathology11.

4. Patients with cardio –pulmonary diseases

5. Patients with tumor, infection and fracture

6. Patients with rheumatic and inflammatory

condition

7. Patients with disc disease

8. Lumbar strain or sprain

9. Lumbar canal stenosis

10. Bowel and bladder dysfunction

The patients were not aware of the theoretical

basis of each of the exercise regimes but they were

briefed the study objective. All the subjects were

interviewed and examined by a clinical

physiotherapist of Sir Ganga Ram Hospital who

was unaware of their group. By using random

sampling method, the subjects with non specific

low back pain were assigned to 1 of 2 treatment

groups. Group–I received general low back

exercise only flexion and extension exercise and

group-II received specific trunk muscle

stabilization exercise . Functional disability were

assessed by the Rolland morris disability

questionnaires, were considered most appropriate

and yield reliable and valid data. Suitable patients

were asked to complete a number of

questionnaires of the Rolland Morris low back

pain disability questionnaire that were repeated

immediately and after 6 weeks. Interventions were

conducted over 6 weeks duration and each class

duration of 30-40 min for thrice per week for both

groups. Common components of the 2 programs

included Short wave diathermy given for 15

minutes to relieve pain.For Group-l, Simple classic

exercises for extensor Paraspinals and flexor

abdominals muscle groups were administrated

appendix. If subjects were able to progress each

week to a new level, on graded exposure exercise

principle, otherwise they remained at the same

exercise level.The exercises were repeated at

home, for a maximum of half an hour 3 times per

weeks, from the beginning of the program. For

Group-II, exercises were instructed as previous

recommendation appendix. The first session was

given individually for subjects assigned to this

group and lasted 30-45 minute. Initially exercises

with low intensityfor local stabilizing muscles was

initially administered with no movements

isometric and in minimally loading positions. The

holding time and the number of contractions were

increased progressively in these positions up to 10

contractions repetitions x 10 sec duration each 1st

and 2nd week. To ensure correct activation of the

transverse abdominis muscle was to observe a

slight drawing in maneuvers of the lower part of

the anterior abdominal wall below the umbilical

level consistent with the action of this muscle.


12

Various tactile and pressure cues and auditory cues

were given to the patient to enhance the

contractions and to get maximum corrective

position and outcomes. Too much effort of initial

contraction of muscles was discouraged.

Integration with dynamic function through

incorporation of the stabilizing muscles’ co-

contraction into light function tasks was advised

next 4-6 weeks as soon as the specific pattern of

co-activation was achieved in the minimally

loading position and the subjects could

comfortable performed 10 contraction repetition x

10 sec duration each. A senior clinical physical

therapist assessed the outcome measures of this

study. All subjects received an information booklet

providing the latest scientific facts on low back

pain management at the beginning of the program.

RESULTS

The outcome of the data was analyzed, using

bar-graphical representation, mean, standard

deviation of the pre test and post test values of the

two groups individually. Comparison of mean

within the group was done and the difference of

mean, standard deviation between the group is also

done. Calculation was done according to M.S

excel soft ware.

The mean improvements between the two

groups of low back pain patients were tested for

significance using student t- test. The calculated t-

values for the RMDQ showed a significant

variation at p=0.00. It showed that there is fulfilled

improvement in post test RMDQ values when

compared to pretest RMDQ values in both the

groups., but the mean improvement in the group II

that received core strengthening is higher when

compared to the group I that received conventional

exercise program. The mean improvements

between the two groups of low back pain patients

were tested for significance using student t- test.

The calculated t-values for the RMDQ scale was

significant at p=0.011.

Table No 1: Comparison of disability (Rolland

Morris) within Control group.

The disability in the control group has

decreased post intervention, as in shown by their

means, Further analysis on the scores revealed

that these changes are statistically highly

significant in the control group (t=9.79, p=0.00)

Graph No 1: Comparison of disability ((Rolland

Morris) within control group.

Table No 2: Comparison of disability ((Rolland

Morris) within Experimental group.


13

The disability in the experimental group has

decreased post intervention, as in shown by their

means, Further analysis on the scores revealed

that these changes are statistically highly

significant in the control group (t=6.79, p=0.00)

Graph No 2: Comparison of disability within

experimental group.

Table No 3: Experimental Vs control group-

Disability (post pre difference)

The disability in the experimental & control

group has decreased post intervention, as in shown

by their means, though the change in the

experimental group was much higher than in the

control group. Further analysis on the scores

revealed that these changes are statistically

significant. (t=2.73, p=0.011)

Graph No 3: Experimental Vs control group-

Disability (post pre difference)

Interpretation:

The table-1and 2 showed that there is highly

significance difference between pre and post test

values of VAS within the groups. The calculated t-

values for the RMDQ showed a significant

variation at p=0.00. It showed that there is fulfilled

improvement in post test RMDQ values when

compared to pretest RMDQ values in both the

groups

The table-3 showed that there is highly

significance difference between pre and post test

values of RMDQ between the two groups.The

calculated p value showed a significance of

difference in improvement at p=0.011, which

indicates that experimental group has higher gains

in improvement in RMDQ scale than control

group.

DISCUSSION

Our findings suggest that stabilization

exercises reduce subject’s pain more effectively

immediately after the end of treatment protocol

over general exercise protocol with statistical

significant. The results of this study support the

initial hypothesis that specific exercise training of

the "stability" muscles of the trunk is effective in


14

reducing pain in patients with chronically

symptomatic low back pain. Analysis of the pain

revealed that there is a difference in improvements

between both the groups. This treatment approach

was more effective than other conservative

treatment approaches which mainly involved

conventional exercise programs. This is in support

of Punjabi’s hypothesis that the stability of the

lumbar spine is dependent not solely on the basic

morphology of the spine, but also the correct

functioning of the neuromuscular system.

Therefore, if the basic morphology of the lumbar

spine is compromised, as in the case with

symptomatic CLBP, the neuromuscular system

may be trained to compensate, to provide dynamic

stability to the spine during the demands of daily

living.Consistent with these findings, McGill

reported that lumbar stability is maintained in vivo

by increasing the activity (stiffness) of the lumbar

segmental muscles, and highlighted the importance

of motor control to coordinate muscle recruitment

between large trunk muscles and small intrinsic

muscles during functional activities, to ensure

stability is maintained.

The trunk muscle stabilization exercise group

exercised the TrA and LM muscle14. In individual

with low back pain, the TrA has decreased

anticipatory capacity, meaning that it has reduced

segmental protective function15. Rodacki et al,

suggested that abdominal exercises are associated

with low back pain improvement, since during

abdominal contraction the pressure on the

intervertebral disks was decreased as a

consequence of the increased intra abdominal

pressure. However, no improvement on TrA

capacity were observed16. From methodological

point of view the frequency and duration of the

study were deemed appropriate to produce

demonstrable benefits, based on previous studies

of similar or less exercise duration5,17,15,18. Increase

in doses of exercise, increase in benefit of

exercise15. However, the stabilizing function of

trunk musculature is especially important around

the neutral posture, where the spine exhibits the

least stiffness. Increased neutral zone, a region of

low stiffness around the neutral spine had been

suggested first by Punjabi19. Richardson suggested

that the simultaneous isometric contraction

exercise for the local deep muscle TrA and LM is

most beneficial for re-educating the stabilizing

muscle and can incoporated with dynamic

functional exercise. In addition, both disuse and

reflex inhibition are likely to affect the slow twitch

or tonic holding contraction at a low level would

be most effective in retraining the stability

function of these muscle20. The other advantages

of core stability strengthening program is that, they

apart from improving core strength and stability

also improved flexibility, posture, ease of

movement, heightened body awareness, balance

and coordination. Hence, it showed more

significant in early phase of treatment than the

later phase. In non specific low back pain patients

the neutral zone muscles gets more affected than

the other muscles of back. Hence, early

rehabilitation of these muscles produced good

results within short time.

CONCLUSION

Both the exercise groups showed statistical

significance but stabilization exercise exercise

group showed more significant over general

exercise group in reducing disability in nonspecific

low back pain. Specific stabilization exercise

improves TrA and LM muscle activation capacity.

So specific stabilization exercise was superior in


15

reducing disability than general exercise group.

Limitation of the study were no intermediate

and long-term follow up examination.

Biopsychosocial factors were not observed in this

study.

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1. A randomized clinical trial of three active therapies for chronic low back pains, Spine, 24(23),

2435-48 (1999)

2. Luciana G. Macedo, Christopher G. Maher, Jane Latimer and James H. McAuley, Motor

Control Exercise for Persistent, Nonspecific Low Back pain: A Systematic Review, Physical

Therapy, 89, 9-25 (2009)

3. Franca F.R., Burke T.N., Hanada E.S. and Marques AP: Segmental Stabilization and muscular

Strengthening in chronic low back pain – a comparative study, Clinics, 65(10), 1013-

1017(2010)

4. Stuart M McGill, Low Back Exercises, Evidence for Improving Exercise Regimens, Physical

Therapy, volume 78, 754-764 (1998)

5. Hansen F.R. and Bendix T., et al: Intensive, dynamic backmuscle exercises, conventional

physiotherapy, or placebocontrol treatment of low-back pain. A randomized, observer-blind

trial, Spine, 18, 98-108 (1993)

6. Rich S.V. and Norvell N.K., et al: Lumbar strengthening in chronic low back pain patients.

Physiologic and psychological benefits. Spine , 18(2), 232-8 (1993)

7. O’Sullivan P.B., Phyty G.D., Twomey L.T. and Allison G.T., Evaluation of specific stabilizing

exercise in the treatment of chronic low back pain with radiologic diagnosis of spondylolysis

or spondylolisthesis, Spine 22(24), 2959-67 (1997)

8. Hides J.A., Richardson C.A. and Jull G.A., Multifidus muscle recovery is not automatic after

resolution of acute, first-episode low back pain, Spine, 21(23), 2763-9 (1996)

9. Danneels L.A., Cambier D.C., Vanderstraeten G.C., Witvrouw E.E. and Bourgois J., Effect of

three different training modalities on the cross-sectional area of the lumbar multifidus muscle

in patients with chronic low back pain, Br J Sport, 35, 186-191 (2001)

10. George A. Kounmanatakis, Paul J. Watson and Trunk Muscle Stabilization Training Plus

General Exercise Versus General Exercise Only: Randomized Controlled Trial of Patients

With Recurrent Low Back Pain, Apta Physical Therapy, 85, 209-225 (2005)

11. O’Sullivan P.B., Lumbar segmental instability, clinical presentation and specific stabilizing

exercise management manual therapy, 5(2),112 (2000)

12. Fairbank J.C.T. and Pynsent P.B., Oswestry Disability Questionnaire, Spine, 25(22), 2940-2953

(2000)

13. Bayar Kilichan, Bayar Banu, Yakut Edibe, Yakut Yuvuz, Reliability and construct validity of

the Oswestry Low Back Pain Disability Questionnaire in the elderly with low back pain,

Spine 26(24), 2738-2743 (2001)


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14. Segmental stabilization and muscular strengthening in chronic low back pain a comparative

study 65(10), 1013– 1017 (2010)

15. Lindstrom I., Ohlud C. et al, Mobility, strength and fitness after a graded activity program for

patients with subacute low back pain, A randomized prospective clinical study with a

behavioural therapy approach, spine , 17(6), 641-52 (1976)

16. Rodacki CLN et al; Spinal unloading after abdominal exercise, Cli Biomech, 23, 8-14 (2008)

17. Randomised controlled trial of exercise for low back pain: clinical outcomes, costs, and ,

319(7205), 279– 283 (1999)

18. Moffett J.K. and Togerson et al, Randomised controlled trial of exercise for low back pain,

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19. Panjabi M.M., The stabilizing system of the spine.Part l.Function, Dysfunction, adaptation, and

enhancement, J Spinal Disord, 5(4), 385- 9 (1992)

20. C.A. Richardson and G.A. Jull, Muscle Control- pain control. What exercises would you

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21. Ariponnammal S., A Novel Method of Using Refractive Index as a Tool for Finding the

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17

J. Biological Sci., 1(5), 53-56 (2012)

CORRESPONDENCE

*PhD Research Scholar , Singhania University, Pacheri Bari, RajasthanIndia

**Consultant, Sir Ganga Ram Hospital, New Delhi, India

***Asst. Professor, PDM Group Of Institutions, Bahadurgarh, Haryana, India

18

STUDY OF RESPIRATORY CAPACITY AND CORE MUSCLE STREN GTH

IN INDIAN CLASSICAL SINGERS

Shweta S. Devare Phadke*, Sukhada Prabhu**, Sujata Yardi***

ABSTRACT

Classical singers are elite athletes. Their art requires total mind & body integration. Body alignment

and breathing has an effect on phonation. Proper breathing technique leads to better control over breath and

quality of tone. Core muscles supports the work of lungs and larynx to produce better tone production and

ability to sing extended phrases and sustain notes for longer.1 OBJECTIVE: To compare core muscle

strength and respiratory parameters like peak expiratory flow rate and breathe holding time between Indian

classical singers and age matched non singers. METHODOLOGY: Group 1 Indian classical singers between

age group of 15 to 30 years, practicing minimum since 1 year. Group 2 Normal healthy adults between age

group of 15 to 30 years who are not engaged in any type of singing and fitness activity. After explaining

about the aims and objectives of the study , consent taken. Height, weight, core muscle strength assessment by

Richardson and Joule's grading, breath holding time and peak expiratory flow rate with mini Wright's peak

flow meter measured. The data was analyzed using GraphPadInstat Version3.10, 32 for Windows. RESULT:

The core muscle strength and Breath holding time of classical singers is significantly more than age matched

normals. There is mean difference in PEFR of singers and age matched normals which is statistically non

significant. The study reveals that singers have good core strength and breath holding time. For quality

singing training in breathing capacity and core muscle strength will help.

KEYWORDS: core muscle strength, indian classical singer, respiratory capacity.

19

INTRODUCTION

Singing requires exceptional co-ordination,

endurance and fine motor control. Body alignment

impacts vocal techniques. Breating capacity have

effect on specialised phonation like singing. 3 The

physiological effects of proper breathing

techniques are increased lung capacity, increase in

lung volume, improved all over stamina or

endurance of respiratory muscles, and better

oxygenation of entire body.1

According to Pilates, core strength and

stability is of tremendous benefit for breathing.

The core muscle encompasses all muscles that co-

ordinate the joints of lower spine, pelvis, hip and

stabilize lower torso. Most of these muscles also

assist in respiration. The core muscles help singers

to enhance endurance of respiratory muscles and

in turn increase the breathing capacity.3 If muscles

that support the breathing mechanism are well

toned, singing will be energy efficient.2 Core

muscles works by contracting the abdominal

muscles, creating higher pressure in abdomen ,

allowing diaphragms relaxation, upward rise to be

more carefully controlled. Core muscle gives

singer a means of controlling their sound or

phonation.1 Breath holding time is a rough index

of cardiopulmonary reserve measured by length of

time that a subject can voluntarily stop breathing

after a deep inspiration. Learning to catch and time

the breath for each song is critical for a quality

performance.5

Thus, we hypothesised, the core muscle

strength and respiratory capacity measured by

peak expiratory flow rate and breath holding time

of Indian classical singers are higher than age

matched healthy adults.

METHODOLOGY

� Type of study – Cross Sectional

� Study setting – Community Indian

classical singer

� Inclusion criteria – Indian classical singers

between age group of 15 to 30 years,

practicing minimum since 1 year.

Normal healthy adults between age group

of 15 to 30 years who are not engaged in

any type of singing activity.

� Exclusion criteria – Indian classical singers

with any lung or cardiac pathology (HTN,

pregnant women, within 6 months post

delivery ).

Singers engaged in any other physical exercise

or wind instruments.

Singers less than 1 yr of training and singers

who are not undergoing appropriate training.

Normal age matched adults involved in any

type of physical fitness activity.

MATERIAL USED

� Stabilizer’s pressure biofeedback unit

� Mini Wright’s peak expiratory flow meter

� Weighing scale

� Measuring tape and stop watch


20

Procedure

1.Core muscle strength was measured by

Stabilizer’s pressure biofeedback unit, with help of

Richardson and Joule’s core muscle grading

method. This grading method was used as it is

reliable and valid method of testing core muscle

strength.18 The subject was instructed to be in

supine position with both lower limbs hip and knee

flexed. Drawing in maneuver i.e transverse

abdominis muscle activation was taught to the

subject. The inflatable bag was placed in lumbar

lordosis and pressure was raised till 40mm of Hg.

Subjects were instructed to take their umbilicus

upward and inward and maintaining this they were

graded as per following grades19-

1A- Unilateral heel slide, with other leg in hip

knee flexion resting on plinth.

1B- Unilateral heel slide with leg 5cms off the

plinth and other leg in hip knee flexion resting on

plinth.

2A- Unilateral heel slide with other leg off the

plinth in hip knee flexion.

2B- Unilateral heel slide with leg 5cm off the

plinth and leg off the plinth in hip knee flexion.

2. Peak expiratory flow rate was measured by Mini

Wright’s peak expiratory flow meter, a small

handheld device. Subject was in standing position

without any support. They were instructed to take

a deep inspiration through nose with device held in

mouth, and to blow out or expire forcefully

through mouth. 3 readings were taken, out of

which the best value was considered.17

3. Breath holding time was measured with the help

of stop watch. Subjects were in sitting position.

They were instructed to take a deep inspiration

through nose and to hold their breath as long as

possible. The normal duration was 30 seconds or

longer, diminished cardiac or pulmonary reserve

was indicated by duration of 20 seconds or less.5

RESULT

Table 1: Comparison of core muscle strength by richardson and joule’s grading

Singers Normals

Mean 2.9 1.433

Standard diviation 1.248 0.5683

'P' value <0.0001

Table 2: Comparision of breath holding time

Singers Normals

Mean 48.7 37.9


'P' value >0.01 >0.01


21

Table 3: Comparision of peak expiratory flow rate

Singers Normals

Mean 371.33 359


'P' value >0.10 >0.10

DISCUSSION

In our study, total 60 subjects participated, 30

in each group. Subjects were explained about the

study and a prior consent was taken. The age,

height (in cms), weight (in kgs), no.of training

years of the study subjects were noted. Subjects

were assessed on parameters like core muscle

strength, breath holding time, peak expiratory flow

rate (PEFR) in random order.

The data revealed that maximum no. of

singers are trained for 5-6 years. In order to

maintain homogeneous distribution these subjects

were matched based on age, height (singers- 160.4

cms, normals- 160.04 cms), and weight (singers-

61.66 kgs, normals- 60.86 kgs). The maximum no.

of study subjects assessed were females (singers-

86.6% and normals- 90%).

The statistical analysis shows that core

muscle strength of classical singers was

significantly high (P value-0.0009 ). This goes

along with our hypothesis that singers need to

build strength and flexibility throughout the torso.

The strong core muscle supports the muscles of

spine and lower ribs. which help to enhance rib

movement, resulting in improved breath capacity.

Thus core muscle strength if developed in proper

fashion helps to improve breath capacity in

singers.3 A good core encourages singer in

pushing. Pushing results when vocal cords are

squeezed together with such force that only

excessive breath pressure will allow them to

vibrate. If a singer tends to push, a stronger core

will make it possible to push a little harder.3 Core

strength and stability is of tremendous benefit for

breath co-ordination during singing. Core

strengthening exercises that strengthen the core

muscle along with abdominal muscle, back

muscle, muscle around pelvis are recommended

for singers as daily exercise program along with

their singing practice to sustain notes for longer

duration. This will also minimize work related

musculoskeletal disorders. Breath holding time of

classical singers is significantly higher than age

matched normals. Singers require a higher rate of

breath management capabilities as they need to

extend the normal breath cycle by maintaining

inspiratory position for as long as possible.3

Breathing strategies rely on ability to inhale a

substantial quantity of air and release it steadily.

This physiological mechanism of breathing is

relevant to singers as it provides energy to tone

and ability to sustain longer notes. Without

diaphragm and the muscles surrounding that

support its work, air can neither enter nor leave

from lungs. Without air expulsion the vocal cords

cannot vibrate and without vibration sound can’t

be produced.1 Cardiopulmonary fitness plays

important role in singing. It includes efficient

circulation of oxygen throughout the body and

ability to make good use of it.3 Efficient oxygen

consumption benefits singing techniques by


22

allowing singer to sustain longer phrases. Building

strong core strength leads to less work of

breathing.3

There are 2 schools of teaching about breath

management 1 -

• Supporting the breath by compressing

abdomen during phonation (i.e. on

exhalation)

• Relaxing abdominal muscle as much as

possible during inhalation and phonation,

allowing diaphragm to work on inhalation

and riding its relaxation on outgoing

breath (i.e. during phonation)

In our study as breath holding time was higher

in singers so we would like to emphasis that

inspiratory training would help singers to sustain

notes for longer.

From the study it is evident that there is no

much significant difference in PEFR of singers as

compared to age matched normals. PEFR is

person’s maximum speed of expiration. PEFR

measures airflow through bronchi and thus degree

of obstruction in the airways.6 The PEFR values

of singer are nearly same as those of normals may

be because singers have to concentrate more on

inspiratory capacity and breath holding. Relaxed

and steady expiration is recommended for singers

to sustain longer notes.

Thus cardiopulmonary fitness and core muscle

strengthening plays important role in improving

quality of singing. The study reveals that singers

require good core strengthening and breath holding

time for quality singing. Hence clinically singer

fitness programme must include core muscle

strength training and breathing exercises.

Acknowledgements

We are heartily thankful to Yashsree Sangeet

Vidyalaya,Kalva and the staff of Dept. Of

Physiotherapy, Pad.Dr.D.Y.Patil University, who

supported us from the preliminary stages of the

project.

Conflict of Interest

We, Phadke S,Prabhu S, Yardi S state that

there is no conflict of interests with other people or

organizations about our work.

Source of funding

Study was self funded.

Ethical Clearance

Study has cleared by ethical committee of

Padmashree Dr. D.Y. Patil University.

REFERENCES 1. Sing wise effective and proper breathing- An information based resource for singers. Karyn O’

Connor, 2011, page no1.

2. Sing wise effective and proper breathing- An information based resource for singers. Karyn O’

Connor, 2011, page no2.

3. Sports specific training for vocal athlete- how exercise can support your vocal techniques. Claudia

Freidlander, CPT, part 1.

4. Exercise to improve your core strength- by Mayoclinic staff. Mayo foundation for medical education

and research.


23

5. Breath holding after breathing of oxygen. F.J. klocke and H. Rahn. Journal of applied physiology,

American physiological society.

6. Peak expiratory flow rate. The Indian journal of pediatrics. Nov-Dec 1994, volume 61, issue 6, page

no. 701 .

7. An investigation of abdominal muscle recruitment for sustained phonation in 25 healthy singers. Ian

MacDonald, John S. Rubin, Ed Blake et all. Journal of voice, volume 26, issue 6, Nov 2012, page nos.

815e.9-815e.16

8. Reduced pulmonary function in wind instrument players. Omer Deniz, Sema Savci, Ergun

Tozkoparan et al. Archives of Medical Research, volume 37, issue 4, May 2006, page nos. 506-517.

9. Respiratory muscle training for singers by using respiratory muscle training device.Do Hyun Nam,

Jan Yol Lim, Chul Min Ahn et al.Yonsei Medical Journal, volume 45, issue 5, 2004, page nos.810

817

10. Study on breathing method for improving singing skills. Tae-seon-Cho Book- Green and smart

technology with sensor application, volume-338, 2012, page nos.372-377

11. Principles and practice of cardiopulmonary physical therapy (3rd edition) – Donna Frownfelter,

Elizabeth Dean.

12. Reliability of test measuring transverses abdominis muscle recruitment with a pressure biofeedback

unit. Katharnia von Garnier et al. Physiotherapy, volume 95, issue 1, March 2009, page nos. 8-14

13. Inefficient muscular stabilization of lumbar spine associated with low back pain; a motor control

evaluation of transverses abdominis muscle. Hodges PW, Richardson CA, 1996, issue 35, page nos.

783-805.

14. Tidy’s physiotherapy –by Staurt Porter. 14th edition.

CORRESPONDING AUTHOR:

*Asst. Professore, Dept. Of Physiotherapy, Pad Dr. D.Y. Patil University, 6th floor, Pad Dr. D.Y. Patil

Medical College Bldg., Sector 5, Nerul, Navi Mumbai.

**Intern, Dept. Of Physiotherapy, Pad Dr. D.Y. Patil University, 6th floor, Pad Dr. D.Y. Patil Medical

College Bldg., Sector 5, Nerul, Navi Mumbai.

***Professore & Director, Dept. Of Physiotherapy, Pad Dr. D.Y. Patil University, 6th floor, Pad Dr. D.Y.

Patil Medical College Bldg., Sector 5, Nerul, Navi Mumbai.

24

AEROBIC CAPACITY, BODY MASS INDEX AND FAT FOLD

MEASUREMENTS OF HEALTHY ATHLETES IN DEHRADUN – A CR OSS

SECTIONAL STUDY

Sharma Chetan, MPT (Sports), Dr. Dar Shahid Mohd., MPT (Orthopedic and Sports)

ABSTRACT

PURPOSE: The Aim of Present study was done to assess the Percent Body fat, Body Mass Index and VO2

Max for the athletes of Dehradun. The study would create a data for athletes in Dehradun involved in various

sporting activities which would catagorised the subject having recommended parameters of fitness.

METHODOLOGY: A survey Study with measurement of Aerobic capacity, Body Mass Index and Percent

Body Fat was done. Total of 96 subjects was included based on the inclusion and exclusion criteria.

Convenience Sampling was used for the selection of participants. Descriptive Statistics has been used for the

analysis of the data. RESULTS: A sample of 96 Athletes with Mean Age (15.634±2.54 years) had a mean

Percent Body Fat 10.537±3.51 percent, mean Body Mass Index 18.654±1.64 kg/m2 and mean VO2 Max is

41.943±6.777 ml/kg/min. CONCLUSION: There was no significant correlation found between VO2 max,

Body Mass Index and Percent Body Fat.

KEY WORDS: Aerobic capacity, Body Mass Index, VO2 Max, Percent Body Fat, 20 m Shuttle Run Test.

INTRODUCTION

Direct measurement of maximum oxygen

uptake (VO2max) is recognized as the best single

index of aerobic fitness, but the test of the direct

measurement of cardiorespiratory endurance

(VO2max) itself is difficult, exhausting and often

hazardous to perform regardless the type of

ergometer used. Since the direct testing procedure

is rather complicated on larger populations, several

indirect running and walking field tests have been


25

developed. Scientists often calculate VO2max with

indirect protocols. It has been stated that equations

for predicting VO2max indirectly using field tests

are very sensitive to populations tested on.

Therefore, before applying any indirect protocol

for prediction of VO2max, the validity of the test

should be established in a particular population.4

Body mass index (BMI) is used as a

surrogate for percent fat in classifying obesity.

However, there is no established criterion for

percent fat and health risk, and few studies have

examined the validity of Body Mass Index as a

measure of Percent fat. Body Mass Index is used

to classify athletes and young adults as obese.

Consequently, it is critical to understand the

accuracy of Body Mass Index in this populations.1

Body mass index is currently the most frequently

used and widely accepted method to classify

medical risk according to weight status. Body

Mass Index is a useful measure of adiposity in

young and middle-aged athletes.5

Body composition determined from

skinfold measurements correlates well (r = 0.70–

0.90) with body composition determined by hydro

densitometry. The principle behind this technique

is that the amount of subcutaneous fat is

proportional to the total amount of body fat. It is

assumed that close to one third of the total fat is

located subcutaneously. The exact proportion of

subcutaneous-to-total fat varies with sex, age, and

ethnicity. Therefore, regression equations used to

convert sum of skinfolds to percent body fat must

consider these variables for greatest accuracy. To

improve the accuracy of the measurement, it is

recommended that one train with a skilled

technician, use video media that demonstrate

proper technique, participate in workshops, and

increase experience in a supervised practical

environment. The accuracy of predicting percent

fat from skinfolds is approximately ± 3.5%

assuming that appropriate techniques and

equations have been used.1

METHODOLOGY

Design

This is a Cross sectional study. All the

subjects were recruited from the various sports

center from Dehradun.

Sampling

Total of 96 subjects were chosen as per the

inclusion and exclusion criteria, and informed

consent was obtained from all the subjects after the

procedure was explained to them.

Procedure:

20 Meter shuttle run test: The 20 Meter

Shuttle Run Test was administered in a sports field

using the original protocol (Leger and Lambert,

1986) but utilizing a different scoring system

developed by the Human Performance Laboratory

at The Queen's University of Belfast.7 The 20

Meter Shuttle Run test involves running between

two lines set 20 meters apart at a pace dictated by

a cassette recording emitting tones at appropriate

intervals. The test score achieved by the subject is

the number of 20 meter laps completed before the

subject either withdraws voluntarily from the test.

Scoring by aps differs from the "paliers", 6 used in

the original version of the test. The test is made up

of 23 levels where each level lasts approximately

one minute. Each level comprises of a series of

20m shuttle runs where the starting speed is 8.5

km/hr and increases by 0.5km/hr at each level. On

the tape/Compact Disc a single beep indicates the


26

end of a shuttle and 3 beeps indicates the start of

the next level.

Body Mass Index: The Body Mass Index

is used to assess weight relative to height and is

calculated by dividing body weight in kilograms

by height in meters squared (kg.m-2).1

Skinfold Measurement: Body composition

determined from skin fold measurements.

Seven Site Formula for Men (chest, mid-axillary,

triceps, subscapular, abdomen, Supra iliac, thigh).

Body density = 1.112 - 0.00043499 (sum of seven

skinfolds) + 0.00000055 (sum of seven

skinfolds)2- 0.00028826 (age) [SEE 0.008 or

~3.5% fat).1

RESULTS:

Means and standard deviations of athletes

in Dehradun, predicted VO2max by the 20-m

multi stage shuttle run test, Age, Body mass index

and Percent body fat were presented in the Table

1.

Table 1:- Mean and Standard deviation for Age,

Percent Body fat, Body Mass Index and Vo2 max

in total no. of subjects.

Figure 1: Mean with Standard deviation of Age,

Percent body fat, Body mass index and VO2 max

in total no of subjects.

Table 2: Correlation between Body Mass Index

and VO2 Max as well as Percent Body fat and Vo2

max in total no. of Subjects.

No significant variation was observed (p >

0.05) between the values of Body Mass Index and

VO2max as well as Percent Body Fat and Vo2

max. Correlation was done for comparison

between Percent Body fat and VO2 Max was found

that r = 0.058 which is not significant (p = 0.576)

and another Correlation has been done between

Body Mass Index and VO2 max was found to be r

= -0.037 which is also not significant (p = 0.721),

thus finding not significant between the respective

variables.

DISCUSSION

The Aim of Present study was done to

assess the Percent Body fat, Body Mass Index and

VO2 Max for the athletes of Dehradun. The

athletes were recruited mainly from different types

of sports those who participate in sporting

activities in different colleges and academies. A

sample of 96 Athletes with Mean Age

(15.634±2.54 years) had a mean Percent Body Fat

10.537±3.51 percent, mean Body Mass Index

18.654±1.64 kg/m2 and mean VO2 Max is

41.943±6.777 ml/kg/min. In this study Pearson

Correlation was done for comparison between

Percent Body fat and VO2 Max was found that r =


27

0.058 which is not significant (p > .05) and

another Correlation has been done between Body

Mass Index and VO2 max was found to be r = -

0.037 which is also not significant (p > .05), thus

finding not significant between the respective

variables.

In the present study it has been found that

Mean Vo2 max for 96 active athletes of age group

of 10-30 years in five different kinds of sports is

(41.943 ml/kg/min), while in a similar study was

done by S. K. VERMA et al. Department of

Human Biology, Punjabi University, Patiala who

found that the mean V02 max in 96 active athletes

age group of 17-25 years was 48.4 ± 5.1 ml/kg/min

with a highest value of 56.4 ml/kg/min and lowest

value of 44.2 ml/kg/min. Which is slightly higher

as compared to V02 max values recorded in the

present study, this probably can be due to the

greater body surface area of athletes in S.K.

Verma’s study where the age group of the subjects

was greater (17-25 years).9 Where as in the present

study the maximum sample obtained was in the

range of 10-20 years because of non-availability of

the athletes in the elder age group. As the age

increases the body surface area increases as is

already proved and the increase in the aerobic

capacity with age is also a well-established fact,4

so our values of less vo2max readings in subjects

of lesser age group than readings of other studies

is quite well understood. Hence forth we

recommend that in future the studies should make

sure that the sample possess the even distribution

of all age groups i.e.… 10-30 years.

As far as Body Mass Index of male

athletes in Dehradun is concerned, the present

study found that the mean of Body Mass Index

was 18.654±1.64 kg/m2. Percent body fat is

10.537±3.51 percentage. In support of present

study Wan Nudri WD et al. from Division of

Human Nutrition, Institute for Medical Research,

Kuala Lumpur, has found mean Body Mass Index

of athletes with age of (23.9±4.2 years) is

(22.9±3.5 kg/m2)10 the probable reason for the

difference between Body Mass Index of both study

is the age. However it was clear that the athletes

who had reduced level of Body Mass Index were

due to lean muscle mass.28 From 5 to 16 years of

age, boy’s relative muscle mass increases from

about 42–54% of body mass.2

A paper review done by American Dietetic

Association, Dietitians of Canada, and the

American College of Sports Medicine stated that

the male athletes with the lowest estimates of body

fat (less than 6%) include middle-distance and

long-distance runners and bodybuilders, whereas

male basketball players, cyclists, gymnasts,

sprinters, jumpers, triathletes, and wrestlers

average between 6% to 15% body fat. Male

athletes involved in power sports such as football,

rugby, and ice and field hockey have slightly more

variable body fat levels 6% to 19%.8 The present

study is done on population of Dehradun, India.

Although, there may be racial differences between

both the populations, it was found that level of

percent body fat had a similarity.

In this study a Correlation between percent

body fat and Vo2max also was done and study

found that the two variables are not significantly

correlated (r=.058, p > .05) . Similarly Body Mass

Index and Vo2max also were found to be

correlated non-significantly (r = -.037, p > .05).

This is in contradiction with other studies done in

the past who have found a positive correlation

between BMI and Percent body fat with VO2

max.10 The reason for non-significant correlation

in present study could be due to the non-


28

homogeneity of the sample of our study, i.e….in

present study athletes from all the games with

different Body Composition were included, which

could have given a unexpected result.

CONCLUSION:

Study is done to access VO2 max, Body mass

index and Percent body fat in a sample of 96

athletes, found out Mean VO2 max was

41.943±6.777 ml/kg/min, mean Body mass index

was 18.654±1.64 kg/m2 and mean Percent body fat

was 10.537±3.51 percent. There was no significant

correlation was found between Variables which

could have been because of non-homogenous

group.

REFERENCES:

1. Armstrong L, phd, FACSM, Balady G. J., MD, Berry M.J., phd, FACSM. ACSM's guidelines for

exercise testing and prescription. 7thed. New York. Lippincott Williams & Wilkins 2006; p. 64.

2. Armstrong N, Grant R Tomkinson GR, Ekelund Ulf. Aerobic fitness and its relationship to sport,

exercise training and habitual physical activity during youth. Br J Sports Med. 2011; 45:849–858.

doi:10.1136/850 bjsports-2011-090200.

3. Eliakim A, Burke G S, Cooper D M. Fitness, fatness, and the effect of training assessed by magnetic

resonance imaging and skinfold-thickness measurements in healthy adolescent females. Am J Cliii

Nutr. 1997; 66: 223-31.

4. Leger L, Gadoury C et al. Validity of the 20 m shuttle run test with 1 min stages to predict VO2max

in adults. Can J Sport Sci. 1989; 14(1):21-6.

5. Leitzmann MF, Moore sc, Koster a, Harris tb, Park y, et al. (2011) Waist Circumference as Compared

with Body-Mass Index in Predicting Mortality from Specific Causes. Plos One. 2011 April; 6(4):

e18582. Doi:10.1371.

6. Mechelen W.V, Hlobil H, Kemper H.C.G. Validation of two running tests as estimates of maximal

aerobic power in children. European journal of applied physiology and occupational physiology.

1986; 55 (5), 503-506, DOI: 10.1007/BF00421645.

7. Paliczka V.J, Nichols A.K, boreham C.A.G. A multi-stage shuttle runs as a predictor of running

performance and maximal oxygen uptake in adults. Brit.j.sports med. 1987; 21(4): pp. 163-165.

8. The American College of Sports Medicine, The American Dietetic Association, The Dietitians of

Canada. Nutrition and Athletic Performance. Medicine & science in sports & exercise. 2000; 0195-

9131/00/3212-2130/0.

9. Verma S. K, L. S. Sidhu, Kansal D. K. Aerobic work capacity in young sedentary men and Active

athletes in India. Brit. J. Sports Med. 1979; 13: 98-102.

10. Wan Nudri WD, Ismail MN

and Zawiak H.

Anthropometric measurements and body composition of

selected national athletes. Mal J Nutr. 1996; 2: 138-147.



29

*M.P.T. (Neurology)., F.N.R., P.G.C.D.E. Health Care Consultant, Bharathidasan Matric Hr Sec School,

Kanchipuram, Tamilnadu, India. & Consultant Physical Therapist, Star Health Care Center, Kanchipuram,

Tamilnadu, India.

**Bachelors in Physiotherapy (India), PG Dip Sci - Exercise Rehabilitation (Clinical Exercise Physiology),

University of Auckland, New Zealand.

30

EFFECTS OF BIMANUAL FUNCTIONAL PRACTICE TRAINING ON

FUNCTIONAL PERFORMANCE OF UPPER EXTREMITY IN CHRONI C

STROKE

Dr Jasmine Anandabai*, Dr Manish Gupta**

ABSTRACT

OBJECTIVE: To study the effects of bimanual functional practice training on functional performance of

upper extremity in chronic stroke. DESIGN: Pre-test and Post test design. SETTING: Inpatient and

rehabilitation hospital. PARTICIPANTS: Patients were randomized to receive bimanual functional practice

(n=15) at 3-4 months post-stroke onset. INTERVENTION: Supervised bimanual training for 50 minutes on 5

days week over 2 weeks using a standardized program. MAIN OUTCOME MEASURES: Upper extremity

outcomes were assessed by Graded Wolf-Motor Function Test (GWMFT) and Fugl-Meyer scale (F.M.S).

RESULTS: Significant differences were found within the group in mean performance time -p=0.002 and

there were significant difference found in functional ability scale (GWMFT-FAS p=0.00, similarly, there were

significant changes in Fugl-Meyer score p=0.00. CONCLUSION: This study suggests that 2 sessions of 25

minutes a day of bilateral training of functionally related tasks is effective for upper limb functional recovery

in chronic stroke patients, regardless of the initial severity of the impairment. Further more, for recovery of

functional motor performance, bimanual practices appears more beneficial. Several other studies have found

benefits of bimanual training: therefore, this approach can be accepted as an upper limb intervention in

stroke on the basis of finding of this study.

KEYWORDS: Stroke, Functional Performance, Bimanual Functional Practice Training

31

INTRODUCTION

Stroke is an acute onset of neurological

dysfunction due to an abnormality in cerebral

circulation with resultant signs and symptoms that

corresponds to involvement of focal areas of the

brain1. This can be due to ischemia (lack of blood

supply) caused by thrombosis or embolism or due

to a hemorrhage. As a result, the affected area of

the brain is unable to function, leading to inability

to move one or more limbs on one side of the

body, inability to understand or formulate speech

or inability to see one side of the visual field. In

the past, stroke was referred to as cerebrovascular

accident or CVA, but the term "stroke" is now

preferred.

The traditional definition of stroke, devised

by the World Health Organization in the 1970s, is

a "neurological deficit of cerebrovascular cause

that persists beyond 24 hours or is interrupted by

death within 24 hours". Strokes can be classified

into two major categories: ischemic and

hemorrhagic. Ischemia is due to interruption of the

blood supply, while hemorrhage is due to rupture

of a blood vessel or an abnormal vascular

structure. 80% of strokes are due to ischemia; the

remainders are due to hemorrhage. Some

hemorrhages develop inside areas of ischemia

("hemorrhagic transformation"). In an ischemic

stroke, blood supply to part of the brain is

decreased, leading to dysfunction of the brain

tissue in that area. There are four reasons why this

might happen: thrombosis (obstruction of a blood

vessel by a blood clot forming locally), embolism

(idem due to an embolus from elsewhere in the

body, see below), systemic hypo perfusion

(general decrease in blood supply, e.g. in shock)

and venous thrombosis. Stroke without an obvious

explanation is termed "cryptogenic" (of unknown

origin); this constitutes 30-40% of all ischemic

strokes.

Ischemic: Ischemic stroke occurs due to a loss

of blood supply to part of the brain, initiating the

ischemic cascade. Brain tissue ceases to function if

deprived of oxygen for more than 60 to 90 seconds

and after a few hours will suffer irreversible injury

possibly leading to death of the tissue, i.e.,

infarction.

Hemorrhagic: Hemorrhagic strokes result in

tissue injury by causing compression of tissue

from an expanding hematoma or hematomas. This

can distort and injure tissue. In addition, the

pressure may lead to a loss of blood supply to

affected tissue with resulting infarction.

Epidemiology: Stroke is a major global health

problem. It is the third most common cause of

death in world and risk factors for stroke onset are

high blood pressure, smoking, diabetes, heart

failure, carotid artery stenosis and hyperlipidemia

(SBU 1992; Gresham et al. 1995). 3

Approximately 85% of all stroke cases are

ischemic, and most ischemic strokes affect one of

the cerebral hemispheres by occlusion of the

middle cerebral artery (MCA). In the acute stage,

mechanisms such as oxygen depletion, necrosis,

brain edema, excitotoxicity and inflammatory

processes are at play. After the acute stage there is

a phase of regeneration with neuronal plasticity

and (partial) functional recovery (Dahlquist

2003).4

The effectiveness is based on

neurodevelopment techniques, repetitive unilateral

or bilateral training techniques; sensoriomotor

training or constraint induced movement therapy

has been evaluated on motor performance of the

affected arm of subjects with stroke. The

Constraint induced movement therapy concept has


32

been derived from basic research with monkeys

and consists of a family of techniques, i.e.,

constraining movements of the less affected arm

and intensively training of the more affected arm

(Taub et al. 1993; Taub et al. 1999; Morris and

Taub 2001). 4

Bilateral training activities may increase the

activity of the affected hemisphere and decrease

the activity of unaffected hemisphere providing a

balancing effect between hemispheric

cortocomotorneuron exitibility. 5

The practice of bilateral symmetrical

movements may allow the activation of the intact

hemisphere to facilitate the activation of the

damaged hemisphere leading to improve

movement control of impaired limb promoting

neural plasticity. Bimanual practice is getting both

hands to work co-operatively to hold and

manipulate an object using each hand to perform

different actions.

Thus the objective of this study is to establish

the efficacy of bimanual functional practice on

functional performance of upper extremity in

chronic stroke.

METHODOLOGY

A total of 15 subjects (12 males and 3

females), at O.P.D. of various hospitals, were

included in the study. They were given bimanual

practice intervention for 5 days a week for 2

weeks. Each treatment session will be of 1 hour.

Inclusion Criteria:

1. All Participants suffering from stoke for the

first time.

2. Onset from 3-9 months

3. Age group 40-60 yrs.

4. Most component of movement present in

affected extremity but impairment of

function relative to non-affected side (at least

100 of wrist extension and at least 100 of

active extension of each metacarpophalengeal

joint and interphalengeal joint of all digits.

5. No multiple infarctions.

6. Intact cognitive functions

7. Patients with right hand dominance with

affected left Hemispheres.

Exclusion Criteria:

1. Insufficient stamina to participate.

2. Other neurological disorders

3. Previous participation in other pharmalogical

or Physical intervention studies.

4. Any severe contractures and deformity in

upper Extremity.

5. Aphasia with inability to follow 2 step

commands.

On the first visit a complete neurological

assessment was done. Subjects found suitable for

participants in the study as per the inclusion and

exclusion criteria were requested to sign the

consent form. A detailed subjective examination

was taken regarding type, side, duration,

occurrence of stroke, handedness and motor

functions.

All the selected subjects were informed in

detail about the type and nature of the study and

asked to sign the informed consent.

After taking down the demographic data the

measurement of functional performance were

assessed by Fugl- Mayer assessment scale and

Graded Wolf Motor Function test.

Participants were trained for bimanual

activity.

Participants were encouraged to do the

bimanual practices for 25 minutes with 10 minutes


33

rest periods.

The total time period of the bimanual practice

was one hour, which was divided into two training

sessions (25*2=50 min) and one rest period of 10

minutes.

Participants were trained for following

bimanual task practices (15).

• Pouring of water from one cup to another

cup with arm held up.

• Using the telephone (one hand to hold

receiver and another to dial the number

• Rolling up a towel

• Unscrewing a jar.

• Turning the key in lock

Each participants were taught about

individually and Sitting at the chair comfortably in

front of the table.

1. To ask the patient to hold the one cup with

one hand (non-affected) which was initially filled

with water and asked to hold the cup with other

hand (affected) and both hands held up the table.

Instruct the patient to pour the water first from

non-affected hand to affected hand and then

affected hand to non-affected. This task was

performed for 5 minutes daily in two sessions.

2. To ask the patients to hold the receiver with

one hand (non-affected) and the numbers with

another hand (affected) again this task performed

alternately hold the receiver with affected hand

and dials the numbers with affected hand.

3. Initially fold the towel lengthwise and asked

the patient to roll the towel with both hands up to

the towel end.

4. Asked the patients to hold the jar with non-

affected and practiced to open the jar or move the

cup of the jar to clockwise and anticlockwise. This

task was practiced for 5 minutes in two sessions.

5. Asked the patient to hold the lock with non-

affected hand and open the lock or move the key in

the lock clockwise and anticlockwise for 5 minutes

daily in two sessions.

RESULTS

The results in table 5.4 show that MPT of

Wolf-motor Function Scale after 2 weeks of

bilateral training program was significantly less.

Similarly FAS score improved significantly after a

2 weeks training program.

Table-1 Group Analysis

The results showed that there was significant

difference in the bilateral arm training group, both

pre intervention and again after 2 weeks of

training.

DISCUSSION

The study compared the effects of bilateral

upper limb-task training on upper limb motor

functions during post stroke rehabilitation. The

result of this study showed that there was a

significant improvement in functional performance

of upper extremity on G.W.M.F.T. and Fugl-

Meyer scale in chronic stroke patients after 2

weeks of bimanual functional practice.

The result of the study showed that there was

significant difference in bimanual Pre and Post

practice group on GWMFT (Pre MPT: p=0.70 &


34

Post MPT: p=0.75 and Pre FAS: p=0.32 & Post

FAS: p=0.312) and Fugl-Meyer score. (Pre:

p=0.519 and Post: p=0.43)

Participants of bimanual practice group

showed a decrease in performance time (p=0.002)

and increase on functional ability score (p=0.00)

and showed highly significant improvement on

motor functional performance of Fugl-Meyer scale

(p=0.00).The mean time to perform 15 tasks in

GWMFT was (17.13+4.60) which decreased after

2 weeks of bimanual practice training

(15.80+5.53) and the functional ability score

(1.75+0.46) improved after training

(2.05+0.57).The result showed that 2 weeks of

bimanual training improved motor functional

performance on Fugl-Meyer scale (42.87+5.25).

The result showed that 2 weeks of bimanual

training improves motor functional performance

on Fugl-Meyer scale (44.53+6.20).

The result of the study suggested that, training

involving the practice of actions bilaterally and

simultaneously is effective in promoting recovery

of upper limb motor function in chronic stroke

patients. Of particular importance was significant

increase in participants of the bilateral training

group in functional ability of the upper limb,

demonstrating a generalization from the training of

a specific movement to general upper limb

function. Individuals receiving bilateral training

showed improvements in the time to complete the

graded wolf motor function test (GWMFT)

movement with the impaired limb 15.

In the study, participants were trained in

complex multi joint functionally relevant tasks,

whereas other bilateral training studies have

involved protocols using simple repetitive

movements with electric stimulation 48 or auditory

cueing 35, 36. Furthermore visualizing and

processing information from the non-paretic limb,

while simultaneously attempting to perform new,

progressively changing, relatively complex precise

motor goals with both arms may have provided a

dual-task challenge greater than in other studies.

The effectiveness of bilateral movement

training in promoting stroke recovery is also likely

to depend on the extent of damage sustained to

direct corticospinal pathways58. While bilateral

movements may also help recruit secondary motor

areas in both hemispheres, recovery promoted by

these areas will be less than that obtained through

direct corticospinal projections 58, 59. This can be

explained by the changes in the functional ability

of impaired limb as evidenced by GWMFT scores

and in motor performance by Fugl-Meyer score in

the patient group used in the study. Recent

research has shown that lesion location greatly

influences the pattern of motor cortex excitability

observed 60.

Intervention timing may have influenced

outcomes. The study showed significant effects of

bilateral training in chronic stroke participants,

whereas some studies showed no effects of

bilateral training in patients with acute stroke 34.

Stroke appears to alter normal transcallosal

inhibition resulting in increased intact hemisphere

excitability during hemiparetic arm movement that

may be inhibitory in nature, thus suppressing

output from the damaged hemisphere 23.

Depending on the lesion site and size, these over

activation appear transient, and more normal

contralateral activation pattern resume over time 49. Identical motor commands generated in each

hemisphere during bilateral movement may

modulate transcallosal inhibition, balancing stroke

related interhemspheric over activity and

facilitating output from the damage hemisphere as


35

well as from normally inhibited ipsilateral pathway

of the undamaged hemisphere to augment

movement of the paretic arm 50.

there is a strong neurophysiological evidence

to suggest that when the impaired and non

impaired arms are moved symmetrically, crossed

facilitatory drive from the intact hemisphere will

be produced increase excitability in homologous

motor pathways in the impaired limb 50, 51.

Additionally, cortical damage from stroke

produces hyperexcitability of the contralesional

M1 52 leading to abnormally high levels of

transcollasal inhibition (TCI) on the legend

hemisphere, thereby further impairing motor

performance of the paretic hand 53. There is recent

evidence of improved affected hand performance

in chronic stroke patients from reducing the

abnormal inhibitory drive to the ipsilesional

hemisphere 54, 55. Further more, balanced

interhemspheric interactions appear necessary for

normal voluntary movements 56 and the restitution

of the normal balance between the two

hemispheres has been linked to better recovery

following stroke 57. It has been hypothesized that

practicing by lateral symmetrical movements may

facilitate motor output from the ipsilesional

hemisphere by normalizing (TCI) influences.

Interestingly, in the subset of patients assessed

with wolf motor function test and Fugl-Meyer

scale in the study the bilateral trained patients

exhibiting the largest increase in functional ability.

In addition, bilateral training may promote

increased involvement of pathways not

investigated in the present study such as spared

corticopropriospinal pathways 50.

The chronic nature of stroke might have

allowed the plastic nature of brain to adjust to the

various levels of tasks to be performed

bimanually.Initially, just after stroke, bimanual

movement enhanced activation in the primary

motor cortex M1 of the affected hemisphere did

not differ between unimanual paretic hand and

bimanual movement 14.

The frequency and duration of the program

may not have been optimal. One may ask whether

20 25-minutes sessions devoted to the bimanual

task are sufficient to trigger brain reorganization

and to observe a change. This scheduled was based

on practical reason and although it is similar to

that used in previous study 34, 61,

The study does not suggest the training

characteristics, such as the nature of the tasks and

strength of inter limb coupling required for effects

, may influenced outcomes: therefore future work

should examined the optimal timing, dose and

training tasks that might optimize the already

known facilitatory effects of interlimb coupling.

CONCLUSION

This study suggest that 2 sessions of 25

minutes a day of bilateral training of functionally

related tasks is effective for upper limb functional

recovery in chronic stroke patients, regardless of

the initial severity of the impairment.

Furthermore, for recovery of functional motor

performance, bilateral training appears beneficial.

Several other studies have found benefits of

bimanual training: therefore, this approach can be

accepted as an upper limb intervention in stroke on

the basis of finding this study.

The study does not suggest the training

characteristics, such as the nature of the tasks and

strength of inter limb coupling required for effects,

may influenced outcomes: therefore future work

should examine the optimal timing, dose and

training tasks that might optimize the already

known facilitatory effects of interlimb coupling.


36

Thus, null-hypothesis proved.

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one? Topics in stroke rehabil, 2004; 11(4):20-30.

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*PhD Research Scholar, Singhania University

**Consultant Orthopaedics, Kapoor Medical Center


40

A COMPARISON STUDY ON PHYSICAL IMPAIRMENTS AND

FUNCTIONAL LIMITATIONS OF PATIENTS: 1 YEAR AFTER TO TAL

KNEE ARTHROPLASTY VERSUS CONTROL SUBJECTS

Amit Murli Patel*

ABSTRACT

BACK GROUND AND PURPOSE: The purpose of this study was to examine the physical impairments and functional limitations of individuals with total knee arthroplasty (TKA), as compared with individuals with no diagnosed knee disease (control subjects). Subiects. Forty-nine individuals 1 year following TKA (30 women, 19 men) and 40 age- and gender-matched control subjects (28 women, 26 men) were assessed. METHODS: Walking speed, stair climbing ability, knee torque (in newton meters), and total work performed during 15 repeated contractions were evaluated. RESULTS: Walking speeds for men with TKA were 13% and 17% slower at normal and fast speeds, respectively. Their stair climbing ability was even more compromised (51 % slower). Walking speeds for women with TKA were 17% and 18% slower at normal and fast speeds, respectively. Similarly, their stair-climbing time was more compromised (43% slower). Men with TKA were 37% to 39% weaker and performed 36% to 37% less total work of their knee extensors compared with the control subjects. Similarly, women with TKA had knee extensor strength deficits of 28% to 29% and performed 24% less total work. CONCLUSION AND DISCUSSION: One year after TKA, marked physical impairments and functional limitations persisted.

KEY WORDS: Total Knee Arthroplasty, Physical Impairment, Knee osteoarthritis, Knee Strength

INTRODUCTION

In India and in other industrialized nations,

the high prevalence of osteoarthritis (OA of the

knee 1-3 and OA's severe impact on disability have

been well documented4. When conservative


41

management is ineffective, the surgical treatment

of choice for individuals with severe, end-stage

OA is often total knee arthroplasty (TKA).

Previous research evaluating surgical success

following TKA11-12 focused on either end of the

disability spectrum (impairment-disability).We

believe that a complete description of treatment

outcome requires measures across all levels (i.e,

pathology, impairment, functional limitations, and

disability) of Nagi's model of disablement5.The

pathophysiology of OA of the knee6 and the

effects of alternative surgical interventions have

been investigated7-8. Isolated measurements of

impairment, including measurements of pain and

knee range of motion (ROM), have frequently

been made9. The current trend is to evaluate the

effectiveness of surgical interventions using

patient-reported quality of life measures10-12.

Extensive research regarding disability has led to

an appreciation of the gains expected in patient of

reported quality of life following TKA11.What is

not well described in the literature is the degree of

physical impairment and functional limitation in

individuals following TKA compared with

individuals without knee disease.

Kroll and colleagues13 quantified functional

limitations of male and female patients

preoperatively and at 5 and 13 months following

TKA. They noted a reduced walking speed (22%-

16%) in patients with TKA relative to that of older

men with no diagnosed knee disease. Berman et

all14 compared knee flexor (hamstring) muscle

function between limbs with TKA and limbs

without TKA. Their results suggest that maximal

recovery of hamstring muscle peak torque occurs

by 7 to 12 months postsurgery. It may not be

appropriate, however, to use the side without

surgery for comparison because bilateral OA or

reduced activity consequent to OA and the TKA

may also impair function of the side without

surgery. Jevsevar et al13 compared men and

women who had undergone TKA 1 or more years

previously with a control group of subjects with no

diagnosed knee disease and found that the subjects

with TKA had deficits in angular velocity during

the stance phase while performing activities of

daily living, including walking and stair climbing.

There is a need to document the persistent

physical impairments and functional limitations in

men and women following TKA. The direct goals

of physical therapy are often related to function.

The purpose of our study was to examine the

physical impairments (knee ROM, muscle torque,

and total work) and functional limitations (walking

and stair climbing) of individuals 1 year after

TKA, as compared with of age and Gender

matched individuals with no diagnosed knee

disease. We considered the peak torque (in newton

meters) developed during five maximal

contractions to be an indication of muscle strength.

We considered the total work (in joules)

performed during 15 concentric contractions at

angular velocities of 90˙ and 120˙/s to be an

indicator of Isokinetic knee extensor and flexor

endurance.

Method :

Subjects

The subjects with TKA were 49 consecutive,

consenting individuals (30 women, 19 men) who

had undergone TKA at a single tertiary care

orthopedic hospital. All individuals were assessed

approximately 1 year after surgery (X= 12.6

months, SD= 1.5, range= 11-17). Eight of these

individuals had bilateral knee replacements. Fifty

four similarly aged, control subjects (28 women,


42

26 men) were recruited from the community

through Patients relatives, working individuals etc.

The control subjects were free of any known knee

pathology and reported no functional limitations

during walking or stair climbing. Control subjects

were matched to patients with TKA based on

gender and age (± 2 years). Written informed

consent was obtained from each subject prior to

clinical testing.

Procedure

Standardized methods for measuring weight

(wt) , height (ht), and girths at the waist and the

hip16 were used. Chum lea et al17 reported a

technical error of measurement of waist girth of

0.48 cm in elderly men and of 1.15 cm in elderly

women. Malina et all8 reported a technical error of

measurement of hip girth of 1.23 cm for

intrameasurer errors. M'ilmore and Behnke19

reported a correlation of 0.99 between

measurements obtained 1 day apart in young male

subjects. Body mass index (BMI : Wt /ht2) and

waist-to-hip ratios (WHR : waist girth/hip girth)

were calculated from the measurements.

Percentage of body fat was estimated from

measurements of body reactance and resistance

obtained with a bioelectric impedance device (BIA

101 Body Composition Analyzer). Muscle volume

of the thigh was estimated from anthropometric

measurements using the method of Jones and

Pearson.20

Knee active range of motion (AROM) was

measured bilaterally, to the nearest degree, using a

goniometer. It is generally reported21-23 that the

reliability of goniometric measurements improves

when the assessment is performed by the same

individual, who uses the same measurement tool

with a standard test position and protocol. In our

study, the same physical therapist using the same

goniometer assessed knee ROM. Subjects lay on a

plinth in the supine position with the knee to be

measured maximally flexed and the foot flat on the

plinth. Specifically, as described by Norkin and

White24 the fulcrum of the goniometer was aligned

with the lateral midline of the femur using the

greater trochanter for reference. Finally, the distal

arm of the goniometer was aligned with the lateral

midline of the fibula using the lateral malleolus for

reference. Goniometer alignment for measuring

knee extension was identical. While in the supine

position, the knee was fully extended and a 10.2

cm (4 inch) rolled towel was placed under the

ankle of the lower extremity to be assessed.

Subjects were asked to maximally straighten their

knee, and the measurement was recorded.

There was no difference in height between the

groups. The subjects with TKA, however, were

heavier, with higher BMI scores and greater

percentages of body fat, than the age- and gender-

matched control subjects (Table 1). Despite a

difference in AROM of knee flexion between

groups, all Individuals with TKA had a knee

AROM of ≥ 90 degrees of flexion, which is

adequate for everyday function. Similarly, subjects

with TKA had an extension loss of ≤ 10 degrees,

although the men showed a difference between

groups in extension. Estimated thigh muscle

volume did not differ between groups for the men.

Women with TKA had a higher estimated muscle

volume value than the women in the control group

had (Table 2).

Concentric isokinetic knee torque and total

work were evaluated on both lower extremities

using a LIDO Active Isokinetic dynamometer.

Subjects with one TKA were tested so that the

limb that did not undergo surgery was tested first.


43

This limb was tested first to limit apprehension

that would interfere with testing. For all other

subjects, the choice of limb to be tested first was

determined by convenience. All tests were

performed while the subjects were in a seated

position with the hips flexed to approximately 80

degrees. The dynamometer was preset, using

software controls, to evaluate torque (peak torque

(developed during five voluntary maximal

contractions) through a preset knee range of

motion from 20 ± 2 to 90 ± 2 degrees of flexion in

the sagittal plane. The manufacturer of the LIDO

Active system claims that the device is self-

calibrating, and we did not test this claim. Prior to

each test session, the device is supposed to

compensate for gravity by weighing the patient's

limb through the preset range of motion at an

angular velocity of 5˙/s. We did not check whether

these determinations were correct. The validity

and reliability of measurements obtained with the

LIDO Active isokinetic system have previously

been reported by Patterson and Spivey 25

After the subjects practiced bending and

straightening their knee for two to three

repetitions, they were instructed to "bend and

straighten your knee as hard and as fast as you

can" to elicit five continuous maximal voluntary

contractions of the knee extensors and flexors.

Verbal encouragement was standardized by

repeating the same phrase (ie, "kick up, pull down,

kick up, pull down; work as hard and as fast as you

can") during all isokinetic tests. Torque curves

were accepted only when the coefficient of

variation for the five repetitions was less than

10%. Mean peak torque (in newton-meters) was

calculated as the average of the highest torque

values for the five repetitions. Thus, the mean peak

torque recorded during five concentric

contractions at angular velocities of 90˙ and 120˙/s

was used as an indicator of muscle strength of the

knee extensors and flexors.

Table 1

Physical Characteristics and Activity Level of Study Participants by Group and Gender

Variable TKA Group (n=49) Control Group (n=54)

Female (n = 30) Male (n = 19) Female (n = 28) Male (n = 26)

Physical

characteristics

Age (y) 61.3 ± 1.3 66.4 ± 1.7 61.9 ± 1.1 63.6 ± 1.4

Weight (kg) 76.0 ± 2.9 89.1 ± 3.9 64.2 ± 2.6 76.4 ± 1.8

Height (cm) 160.8 ± 1.9 170.3 ± 1.8 158.3 ± 2.1 171.5 ± 1.3

WHR 0.81 ± 0.2 0.93 ± 0.01 0.77 ± 0.01 0.93 ± 0.008

BMI (kg/m2) 29.5 ± 1.3 30.9 ± 1.4 25.2 ± 0.91 25.9 ± 0.45


44

Percentage of body

fat 37.8 ± 2 25.3 ± 2 31.3 ± 2 21.2 ± 1

Knee active range

of motion

Flexion 114 ± 4.65 110 ± 3.74 143 ± 1.54 142 ± 1.16

Extension - 1 ± 1.43 - 0.4 ± 1.18 - 7 ± 1.37 - 6 ± 0.56

Total score on

physical activity

Questionnaire for

elderly people

23.6 ± 3.71 15.3 ± 2.23 18.2 ± 2.43 19.5 ± 1.56

Table 2

Muscle Thigh Volume and Cross-sectional Area of Study Participants by Group and Gender



Thigh muscle

volume (cm3)

Limb with TKA 3413.7 ± 119.8 3921.3 ± 159.9 ……….. ………..

Limb without

TKA 3453.7 ± 217.2 3979.2 ± 200.2 2852.7 ± 155.0 4020.0 ± 199.3

Thigh Muscle

Cross-sectional

area (cm2)

Limb with TKA 13.1 ± 0.4 13.9 ± 0.4 ……….. ………..

Limb without

TKA 12.7 ± 0.2 13.3 ± 0.4 11.7 ± 0.3 13.5 ± 0.2

Table 3

Knee Muscle Peak Torque (in Newton-meters) for Concentric lsokinetic Knee Extension and Flexion at an

Angular Velocity of 90˙/s


45

Muscle group TKA Group (n=49) Control Group (n=54)


Knee extensors

Limb with TKA 44.8 ± 7.5 69.5 ± 8.7 ….. …..

Limb without TKA 46.3 ± 8.1 82.6 ± 13.0 63.0 ± 3.5 113.6 ± 6.4

Knee flexors

Limb with TKA 26.3 ± 6.9 40.0 ± 6.3 ….. …..

Limb without TKA 31.7 ± 5.0 51.9 ± 6.8 36.0 ± 1.7 61.4 ± 2.3

RESULT

Angular velocity of 120˙/s. Compared with

the angular velocity of 90˙/s, mean peak torque

values were lower at the faster speed in all subjects

except the women with TKA. For these

individuals, the mean peak torques were slightly

higher for both muscle groups (extensors and

flexors) on the side without the TKA and for the

knee flexors on the side with the TKA at 120˙/s

compared with their values at 90˙/s.

When assessed at the angular velocity of

120˙/s, knee peak torque of the women with TKA

improved relative to that of the female control

subjects. For example, their limb with the TKA

had achieved extensor and flexor mean peak

torques of 72% to 85%, respectively, of the values

of the female control subjects. In the male subjects

with TKA, the decrement in mean peak torque

relative to that of the control subjects was

markedly greater at 120˙/s than at 90˙/s. At the

faster angular velocity, extensor and flexor mean

peak torques were just 63% to 65% of those of the

male control subjects. At the angular velocity of

120˙/s, knee peak torque torque of the limb with

the TKA of all individuals who had undergone

surgery was diminished when compared with that

of the control subjects (Table 4).

Knee Total Work

Angular velocity of at 90˙/s. Deficits in knee

extensor and flexor concentric peak torque and

total work were still present 1 year

postoperatively, not only in the limb with the TKA

but in the limb without the TKA of individuals

who had undergone surgery.

On average, total work of the extensors and

flexors of the subjects with TKA was 76% to 73%,

respectively, of the values for the control subjects.

Extensor endurance performance, measured as the

total work of the limb without the TKA in women

who had undergone surgery, was assessed to be

18% less than in the control subjects. Compared

with the control subjects, the performance of the

male subjects with TKA on muscular endurance

testing was generally poorer than on peak torque


46

testing.

The total work of the extensors and flexors at

90˙/s accomplished by the male subjects with TKA

was only 64% and 55%, respectively, of that of the

control subjects (Table 5).

Angular velocity of 120˙/s. As expected, less

work was produced at the faster angular velocity

of 120°/s compared with the angular velocity of

90˙/s. This pattern was evident across both genders

and groups. Similar to patterns at the slower

angular velocity of 90˙/s, deficits in total work at

120˙/s during 15 maximum repetitions were

evident in the female subjects with TKA.

Specifically, they achieved 76% and 74% of the

extensor and flexor work, respectively, of that

achieved by the female control subjects. Extensor

and flexor total work decrements were less in the

limb without the TKA (87% and 90%,

respectively) of the subjects who had undergone

surgery compared with the control subjects. Male

subjects who had undergone surgery produced

similarly low extensor and flexor total work values

(63% and 57%, respectively) in the limb with the

TKA compared to the male control subjects (Table

6).

Self- Paced Walking

Individuals with TKA achieved over 80% of

the normal and fast walking speeds of their age

and gender matched counterparts 1 year after

surgery (Table 7). Ratings of perceived exertion

and heart rates were similar between the groups,

despite the slower walking speeds at both normal

and fast selected paces in the subjects with TKA.

A perceived exertion rating of 2, anchored by the

expression "slight" on the Borg Scale, was

frequently reported by the subjects with TKA.

Persistent knee pain was reported by the subjects

with TKA following fast walking. Mean ( ± SD)

pain scores were 0.8 ± 0.98 for the men with TKA

and 1.8 ± 2.69 for the women with TKA, where 0

represents "no pain" and 10 represents "maximal

pain." These scores were both statistically

significant (P ≤ .02) and clinically significant

compared with those of the control group.

Stair-Climbing Performance

Both women and men with TKA took more

than twice as long to ascend and descend a flight

of 10 stairs than it took the control subjects (Table

8). Although both men and women performed at a

slower pace, the women with TKA reported a

greater perceived effort and pain in completing the

stair-climbing task. Although all subjects were

instructed to try to ascend and descend the stairs

without using a handrail, six subjects with TKA

(including one subject with bilateral TKA)

required this assistance. All except eight subjects

with TKA (including two subjects with bilateral

TKA) used a reciprocal stepping pattern. One

individual declined performing this task due to

fatigue.

Physical Activity

The subjects with TKA did not differ from the

control subjects in their reported total level of

physical activity, as measured ( X ± SEM) using

the physical activity questionnaire for elderly

people30 (19 ± 2.2 versus 19 ± 1.4, respectively).

Large standard deviations for all groups indicate

the diverse physical activity habits of our study

participants (Table. 1).


47

Table 4

Knee Muscle Peak Torque (in Newton-meters) for Concentric lsokinetic Knee Extension and Flexion at an

Angular Velocity of 120˙/s



Knee extensors

Limb with TKA 42.6 ± 6.0 66.4 ±6.9 ….. …..

Limb without TKA 48.8 ± 8.2 77.8 ± 10.4 59.0 ± 2.3 105.2 ±5.7

Knee flexors

Limb with TKA 30.2 ± 6.0 40.3 ± 4.7 ….. …..

Limb without TKA 32.3 ± 4.9 48.9 ± 4.8 35.7 ± 1.5 62.0 ±2.8

Table 5

Total Work (in Joules) for Concentric lsokinetic Knee Extensors and Flexors at an Angular Velocity of 90˙/s



Knee extensors

Limb with TKA 621.8 ± 87.3 892.8 ± 90.7 ….. …..

Limb without TKA 666.8 ± 112.2 1043.6 ± 133.5 816.8 ± 28.6 1397.4 ± 73.0

Knee flexors

Limb with TKA 350.8 ± 84.7 470.9 ± 57.8 ….. …..

Limb without TKA 430.0 ± 67.5 678.6 ± 60.0 482.5 ± 19.8 849.4 ± 31.4

Table 6

Total Work (in Joules) for Concentric lsokinetic Knee Extensors and Flexors at an Angular Velocity of 120˙/s


48



Knee extensors

Limb with TKA 523.3 ± 75.8 810.1 ± 66.7 ….. …..

Limb without

TKA 600.2 ± 112.1 934.4 ± 124.9

Knee flexors

Limb with TKA 331.2 ± 64.8 440.0 ± 42.9 ….. …..

Limb without

TKA 401.8 ± 70.5 563.4 ± 47.6 447.9 ± 23.5 766.1 ± 32.4

Table 7

Performance for the 160-m Walk Test at Normal and Fast Self-paced Walking Speeds



Normal self paced walking speed

Speed (m/s) 1.17 ±0.05 1.31 ± 0.05 1.38 ± 0.03 1.51 ± 0.03

Pain ( 0 – 10 ) 1.0 ± 0.7 0.5 ± 0.3 0.0 ± 0.0 0.0 ± 0.0

RPE ( 0 – 10 ) 1.2 ± 0.4 2.2 ± 0.4 0.5 ± 0.2 0.7 ± 0.2

Fast self paced walking speed

Speed (m/s) 1.36 ± 0.1 1.53 ± 0.06 1.65 ± 0.03 1.84 ± 0.03

Pain ( 0 – 10 ) 1.6 ± 0.7 0.8 ± 0.4 0.0 ± 0.0 0.0 ± 0.0

RPE ( 0 – 10 ) 1.6 ± 0.4 2.6 ± 0.5 1.6 ± 0.2 1.8 ± 0.2


49

Table 8

Group x Gender Performance While Ascending and Descending One Flight of 10 Steps



Stair time (s) 31.10 ± 0.49 23.33 ± 2.3 12.45 ± 0.47 11.81 ± 0.31

Pain ( 0 – 10 ) 1.9 ± 1.0 0.9 ± 0.6 0.0 ± 0.0 0.0 ± 0.0

RPE ( 0 – 10 ) 2.4 ± 0.6 2.2 ± 0.4 0.4 ± 0.2 1.2 ± 0.5

DISCUSSION AND CONCLUSIONS

Our findings indicate that marked

impairments and some functional limitations

persist in individuals even 1 year following TKA.

The relative absence of pain but elevated rating of

perceived exertion and heart rate responses to

physical activity and decreased concentric muscle

strength suggest that physical deconditioning may

strongly contribute to the decreased function in

these individuals. Alternative explanations for the

observations include differences in body

composition or biomechanical efficiency of

walking between the subjects with TKA and the

control subjects. The subjects with TKA were

heavier (12-13 kg) and had a higher percentage of

body fat (4%-6%) compared with their age- and

gender-matched control subjects. Osteoarthritis is

typically associated with increased body fat even

in earlier stages of the disease33 but our study

provides evidence that differences persist even 1

year after TKA. The values for BMI obtained for

the subjects with TKA are associated with

increased risk of morbidity and mortality16. One of

the limitations of our study is that the subjects with

TKA had increased body fat compared with the

control subjects. We are unable, therefore, to

delineate the effects of obesity from those of TKA

on function.

Volunteers are known to have better health

and higher functional abilities than the general

population.34 The results of both the subjects with

TKA and the control subjects may have been

influenced by this volunteer effect. The body

composition measurements (weight, BMI),

although different between the subjects with TKA

and the control subjects, were similar to age and

gender matched normative values from a Canadian

survey.16 Walking speed was within approximately

1 standard deviation of age-predicted values for

men and wornen at both self-selected paces35

These comparisons suggest that our control sample

was representative of healthy older people.

Although no survey data on individuals with

TKA are currently available, data from other

studies suggest that our subjects with TKA may

have had higher than average functional levels.

Berman et all4 reported a normal walking speed for

men and women who were tested 2 to 3 years after

TKA (0.90 m/s) that was slower than our mean


50

value (1.25 m/s) at the normal walking speed.

Mattsson and colleagues36 reported a maximal

walking speed over 4 minutes of 1.25 m/s for 12

men and 16 women who were tested 1 year after

TKA. Free walking speed 1 year after TKA for1 7

men and 11 women was 1.07 m/s in the study by

Kroll et al13 The higher walking speed observed

for our subjects suggests that our estimates of the

degree of impairment 1 year after TKA may be

conservative relative to other individuals who have

TKA surgery.

Osteoarthritis is associated with altered gait

mechanics37 Previous studies38,39 however, suggest

that biomechanical differences in gait between

subjects with TKA and subjects with no diagnosed

knee pathology are minor. Our observation of only

minor deficits in ROM supports those

observations.

Reduced physical activity may be both a

cause and a consequence of physical impairment

and functional limitation. Pain associated with OA

limits physical activity, and surgical intervention

that decreases pain should allow resumption of

normal activities. If reduced physical activity has

become habitual, however, this might contribute to

continuing obesity and deficits in physical

capacity. Our findings indicate no differences in

total physical activity scores between subjects with

TKA and control subjects. The physical activity

questionnaire for elderly people30 used in our study

divides activities into low, medium, and high

categories. It was evident that few of either the

control subjects or the subjects with TKA were

active in more physically demanding activities (ie,

sporting activities). Only 38% of the subjects with

TKA and only 47% of the control subjects

reported involvement in any sporting activity

during the previous year. Spontaneous resumption

of low intensity activities did not appear to be an

adequate stimulus to rebuild muscle torque, total

work, or aerobic condition, nor was the resumption

of active living adequate to reduce obesity.

Impairment in muscle function was evident from

the reductions in mean peak torque and total work

for knee flexion and extension. Force generation is

expected to decrease as the speed of movement

increase40 but this decrease was not observed in

our female subjects with TKA. We also expected

that functional deficits would relate to the degree

of muscle atrophy assessed by anthropometry. We

found no such relationship. No reduction in muscle

volume was evident in the male subjects with TKA

when compared with the control subjects, and the

female subjects with TKA had a greater muscle

volume and estimated cross-sectional area

compared with the control subjects (Table 2).

Clinical examination of the study participants

ruled out thigh edema as a contributing factor.

Given Overend and colleagues' poor success in

validating estimates of thigh cross sectional area

and volume using computed tomography (CT) in

groups of young and old men41 and Sipila and

Suominen's finding of no relationship between

either cross-sectional area or lean tissue to

isometric quadriceps femoris muscle strength

when measured by CT scan and ultrasonography

in 66- to 85 year old female athletes and age-

matched controls42 perhaps our finding is not

surprising. The explanation for this discrepancy

may be two fold. First, changes in intramuscular

fat would not be detectable with the

anthropometric measures used in our study.

Second, changes in neuromuscular recruitment that

may alter mean torque output were not evaluated.

Using the limb without the TKA as a control,

as other Researchers43,44 have done, may


51

underestimate the magnitude of the deficit in the

limb with the TKA. Jevsevar et all5 suggested that

it may not be appropriate to use the side without

the TKA as a comparison because bilateral OA or

reduced activity consequent to OA may impair

function of the limb without the TKA. The

subjects with TKA had lower peak torque and total

work values for the limb without the TKA

compared with the control subjects. The reduced

muscle performance may be due to continuing

effects of inactivity both before and following

surgery or to nonsymptomatic OA of the knee

without the TKA. Questionnaire responses did not

reveal differences in physical activity between the

control subjects and the subjects who had

undergone TKA. The absence of a difference in

thigh cross-sectional area and estimated muscle

volume suggests that decreased muscle size does

riot explain all of the group differences (Table 2).

Walking and stair climbing have been

identified by clinicians and patients15,45,46 as

critical functional activities. Our findings suggest

that although TKA is very successful in reducing

knee pain (a prime motivation for surgery),

patients are still limited in their functional

activities compared with their age-matched

counterparts. When the normal SPW speed of our

subjects with TKA was compared with the locally

required speed to cross a traffic intersection (1.2

m/ s )47 it became clear that a large proportion of

these individuals (55%, n= 16) must walk at a

faster pace than they normally use in order to

successfully clear the intersection before the light

changes. Indeed even at the fast walking pace,

17% (n=5) of these individuals would not be able

to cross safely at a typical city intersection.

Our analyses suggest that men and women are

affected to differing degrees by TKA. Female

subjects with TKA demonstrated greater

functional limitations on the stair climbing test,

with slower times and increased pain and exertion.

Male subjects with TKA demonstrated smaller

deficits during the stair-climbing test but larger

decreases in muscle strength and local muscular

endurance. Performance on the SPW test at both

normal and fast paces was reduced more in the

female subjects, placing many more of them (62%

at a normal pace and 31% at a fast pace, compared

with 25% and 6%, respectively, for the male

subjects) below the threshold required for safe

crossing of street intersections. Our findings

suggest that data for men and women regarding

walking, stair-climbing performance, and

concentric knee strength and local muscular

endurance should not be pooled.

Pain is a critical aspect of disability due to

OA that can be resolved successfully by surgery.45

One year postoperatively, little pain was reported

in activities such as walking, stair climbing, and

concentric muscle strength testing.29 Yet, in the

relative absence of pain, physical capacity remains

diminished. The consequences of a diminished

physical capacity are evident in slower walking

speeds and a higher physiological cost demanding

greater exertion during physical activity.

The most serious consequences of reduced

physical capacity may be evident as aging further

reduces the reserve capacity of these individuals.

Adequate reserve capacity is an important factor in

the ability of older adults to maintain their

independence. A rehabilitation program that

focuses on weight reduction and aerobic

conditioning may enhance the ability of

individuals with TKA to perform important

activities such as walking and stair climbing. This

program may benefit patients with orthopedic


52

problems in the years immediately following the

surgery and, perhaps more importantly, may also

help preserve their reserve capacity and allow

them to maintain functional independence for a

longer period in the future.

REFERENCES

1. Felsor DT, Nainlark A, Anderson J, et al. The prevalence of knee osteoarthritis in the elderly.

Arthritts Rheum. 1987; 30:914-918.

2. Kovar PA, Allegrante JP, Mdckenzie CR, et al. Supervised fitness walking in patients with

osteoarthritis of the knee: a randomized controlled trial. Ann Intern M P ~1.9 92;116:529-534.

3. Quam JP, Michet CJ, Wilson MG, et al. Total knee arthroplasty: a population-based study. Mayo Clin

Proc. 1991; 66:589-595.

4. Verbrugge LM. Women, men, and osteoarthritis. Arthritir Cart C Research. 1995;8:2 12-220.

5. Nagi S. Disability concepts revisited: implications for prevention. In: Pope AM, Tarlov AR, eds.

Disability in America: Toward a National Agenda fm Prmmtion. bvashington, DC National Academy

Press: 1991:309-327.

6. Bland JH, Cooper SM. Osteoarthritis: a review of the cell biology involved and evidence for

reversibility-management rationally related to known genesis and pathophysiology. Sermin Arthritis

Rheum. 1984;14: 106-133.

7. Laughman RK, Stauffer RN, Ilstrup DM, Chao EYS. Functional evaluation of total knee replacement.

J Orthop Res. 1984;2:307-313.

8. Andriacchi TP. Biomechanics and gait analysis in total knee replacement. Orthop Ra,. 1988;17:470-

473.

9. FlettJL, Burnham RS, Saboe L.et al. Effect of measurement time and mode on amount of flexion

following total knee arthroplasty. Canadian Journal of Rehabililation. 1992;5:145-149.

10. Kantz M, Harris W, Levitsky K, et al. Methods for assessing condition-specific and generic functional

status outcomes after total knee replacement. Med Care. 1992;30:MS240-MS2.52.

11. Ritter MA. Albohm MJ, Keating EM, et al. Comparative outcomes of total joint arthroplasty.

JArthrqfdnsty. 1995;10:737-741.

12. McGuigan EX, Hozack U'J, Moriarty L, et al. Predicting quality of life outcomes following total joint

arthroplasty. J Arthropla~ty. 1995;l0: 742-747.

13. Kroll MA, Otis JC, Sculco TP, et al. The relationship of stride characteristics to pain before and after

total knee arthroplasty. Clin Orthop. 1989;239:191-195.

14. Berman AT, Bosacco SJ, Israelite C. Evaluation of total knee arthroplasty using isokinetic testing.

Clin Orthq. 1991;271:106-113.

15. ,Jevsevar DS, Riley PO, Hodge MTA. Krebs DE.Knee kinematics and kinetics during locomotor

activities of daily living in subjects with knee arthroplasty and in healthy control subjects. Phys Ther.

1993;73:229-242.


53

16. Canadian Standarised Test of Fitness (CSTF) Operations .Manual. 3rd ed. Ottawa, Ontario, Canada:

Fitness and Amateur Sport Canada; 1987.

17. Chumlea WC, Roche AF, Rogers E. Replicability for anthropometry in the elderly, Biol,

1984;56:329-337,

18. Malina RM, Roche AF. Manual Physical Status and Performance in Childhood, Volume 2: Physical

Performance New York, NY: Plenum Publishing Corp; 1983

19. Wilmore JH, Behnke AR. An anthropometric estimation of body density and lean body weight in

young women. Am J clin Nutr. 1970;23:267-274

20. Jones P, Pearson P. Anthropometric determination of leg fat and muscle plus bone volumes in young

male and female adults. J Physiol Paris. 1969;294:63-66.

21. Clarkson HM, Gilewich GB. Musculoskeletal Assessment: Joint Range of Motion and Manual

Muscle Strength. Baltimore, Md: U'illianis & Wilkins; 1989: 14.

22. Watkins MA. Riddle DL, Lamb RL, Personius WJ. Reliability of goniometric measurements and

visual estimates of' knee range of motion obtained in a clinical setting. Phys Thrr: 1991;71:C30-97.

23. Rothstein 151. Miller PI, Roettger RF. Goniometric reliability in a clinical setting: elbow and knee

measurements. Phys Thr. 1983;63:1611-1615.

24. Norkin CC, White DJ. Measurement of joint motion; A guide to Goniometry, Philadelphia PA.FA

Davis Co: 1987:88.

25. Patterson LA, Spiwey WE. Validity and reliability of the LIDO Active Isokinetic svstem. J Orthop

Sports Phys ther. 1992;15:32-36.

26. Bassey EJ, Fentem PH, MacDonald IC, Scriven PM. Self-paced walking as a method for exercise

testing in elderly and young men. Clin Sri. 1976;31:609-612.

27. Borg GAV. Psychophysical bases of perceived exertion. Med Sci Sports Exerc 1982;14:377-38.

28. Cunningham DA, Rechnirzer PA, Donner AP. Exercise training and the speed of self-selected

walking pace in men at retirement. Canadian journal of Aging 1986;5(1):12-26.

29. M. Functional Outcome measures: individuals One year post Total Knee arthroplasty Versus Healthy

Controls. Toronto, Ontario, Canada: University of Toronto; 1995. Master's thesis.

30. Voorrips LE, Ravelli AC, Dongelmans PC, et al. A physical activity questionnaire for the elderly.

Med Sci .Sports Exerr. 1991:23:974-979.

31. Baecke JA, Burcma J, Frijters JE. A short questionnaire for the measurement of habitual physical

activity in epidemiological studies. Am J Clin Nutr 1982;36:936-942.

32. Bink B, Van der Sluys BH. Assessment of the Energy Expenditure by Indirect Time and Motion

Study. In Edang EK, Anderson KL, eds. Physical Activity in Health an disease: Proceedings of the

Bertostolen Symposium, Oslo Norway Oslo University; 1996:207-214.

33. Hochberg MC, Lethbridge-Cejku M, Scott WWJ, et al. The association of body weight, body fatness,

and body fat distribution with osteoarthritis of the knee: data from the Baltimore Longitudinal Study

of Aging. J Rheumatol. 1995;22:488-493.

34. Sackett DL. Bias in analytic research. J Chronic Dis. 1979;32:51-63.


54

35. Himann JE, Cunningham DA, Rechnitzer PA, Paterson DH. Age related changes in speed of walking.

Med Sci. Sports Exerc. 1988;20:161-166.

36. Mattsson E, Brostom LA, Linnarsson D. Changes in walking ability after knee replacement. Int

Orthop. 1990:14:277-280

37. Messier SP, Loeser RF, Hoover JL.et al. Osteoarthritis of the knee: effects on gait, strength, and

flexibility. Arch Phys Med Rehabili 1992 73:29-36.

38. Weidenhielm L, Olsson E, Brostrom LA, et al. Improvement of gait one year after surgery for knee

osteoarthritis: a comparision between high tibial osteotomv and prosthetic replacement in a

prospective randomized study. Scand J Rehabil Med. 1993:23:25-31.

39. Andriacchi TP. Functional analysis of pre- and post-knee surgery total knee arthroplasty and ACL

reconstruction J Biomech. 1993; 115:575-581.

40. Lieber RL. Skeletal Muscle Physiology: Skeletal Muscle Structure and function- Implications for

Rehabilitation and Sports Medicine. Baltimore, Md: Williams & Wilkins; 1992:60-61.

41. Overend TJ. Cunningham DA, Paterson DH. Lefcoe HS. Anthropometric and computed tomographic

assessment of the thigh in young and old men. Can J Appl Physiol. 1993;18:26.3-273.

42. Sipila S, Suominen H. Knee extension strength and walking speed in relation to quadriceps muscle

composition and training in elderly women. Cli11 Physiol. 1994;14:433-442.

43. Gross MT, Credle JK, Hopkins LA, Kollins M. Validity of knee flexion and extension peak torque

prediction models. Phys Ther. 1990;70:3-10.

44. Krebs DE. Isokinetic, Electrophysiologic and clinical function relationships following tourniquet

aided arthrotomy. Phys Thpr. 1989;69: 804-815.

45. Bellamy N, Buchanan MW. A preliminary evaluation of the dimensionality and clinical importance of

pain and disability in osteoarthritis of the hip and knee. Clin Rheumatol. 1986; 5.231-241.

46. Ettinger WH, Afable RF. Physical disability from Knee Osteoarthritis; the role of exercise as an

intervention. Med Sci. Sports Exerc. 1994;26; 1435-1444.


*BPT, MPT-Orthopaedics, Senior Physical therapist, Ahmedabad, Gujarat.


55

RESPIRATORY PHYSIOTHERAPY IN TRIPLE VESSEL DISEASE WITH

POST CORONARY ARTERY BYPASS GRAFTING SURGERY (CABG)

Shanmuga Raju P (MPT)*, Renkha Rao (MCh), Rajendhra Kumar J (MD), SuryaNaryana

Reddy V (MS)

ABSTRACT

We are presenting a case of 47 years of old female with triple vessel disease and coronary artery bypass

graft surgery. Her complaint was chest pain and shortness of breath since last 5 months. Coronary

angiogram revealed triple vessel disease and she underwent three coronary artery graft surgery on 24th

February, 2013. Second day aftter CABG, she developed dyspnoea, reduced chest expansion and decreased

arterial O2 saturation. She was treated with daily session involving positioning, chest percussion, deep

breathing exercise, manual mobilization exercise and passive and active limb movements. We observed that

receiving chest physiotherapy has significant effect in recovery of post CABG patient after 3 weeks of follow

up. Our aim of case study is to describe effects of respiratory physiotherapy in post operative CABG in

triple vessel disease.

Keywords: Triple vessel disease, Coronary artery bypass grafting, respiratory physiotherapy

INTRODUCTION

India have 29.8 million symptomatic patients

with coronary artery disease (CAD).

Approximately, one sixth of the world population

lives in India (1). Coronary artery bypass graft

(CABG) surgery is challenging for coronary artery


56

disease. CABG is associated with an occurrence of

pulmonary complications, defined as any

pulmonary abnormality that occurs during the post

operative period (2). A decrease in pulmonary

function is well known after open heart surgery.

Chest physiotherapy is routinely used in order to

prevent or reduce pulmonary complications after

surgery. Post operative treatment includes early

mobilization, change in position, breathing

exercises and coughing techniques (3).

CASE REPORT

A 47 year old female patient was diagnosed to

have triple vessel disease; coronary angiogram

revealed triple vessel coronary artery disease and

was referred to department of cardiothoracic

surgery at Chalmeda AnandRao Institute of

Medical Sciences, Karimanagar on 24th February

2013. Medical history was chest pain and

shortness of breathlessness since last 5 months.

She was known case of type to II Diabetes

mellitus, but no history of hypertension. Coronary

angiogram showed triple vessel disease with left

ventricular dysfunction. She underwent coronary

artery bypass grafts surgery and three grafts were

placed, one graft was placed to obtuse marginal 1

(OM 1), second graft was placed to left anterior

descending artery and third graft was placed to

right coronary artery. She was hemodynamically

stable on first post operative day but on second

postoperative day, she had aspirated gastric

contents and developed hypoxia due to asphyxia.

Her blood pressure was 149/81 mm/Hg, pulse

106 per/minute, heart rate 123 per/minute,

respiration rate 16 breaths per/minute, and

temperature was 1000 F. Complete blood picture

show hemoglobin 6.5 gm/cumm, WBC 5,800

cells/cumm, neutrophils 78%, lymphocytes 17%,

eosinophils 03%, monocytes 05%, basophilis 00%

and ESR is 30mm/1hours.

Biochemistry: Sodium 136 mmol/L, potassium

4.1 mmol/L, chlorides 106 mmol/L, fasting serum

glucose 103 mg/dL. Urine level is 100ml. Blood

group is ‘O’ negative. Chest expansion

measurements were 58 cm at axilla level, 83 cm at

nipple level and, 79 cm at xiphoid level.

Figure: 1 Before CABG and respiratory

physiotherapy transthoracic 2D echo cardiogram

show decrease Left ventricular systolic function

(LV ejection fraction (EF) 20.3 %).

Figure: 2 After CABG and respiratory

physiotherapy transthoracic 2D echocardiogram

show improve LV systolic function (LV ejection

fraction 55.3 %).

DISCUSSION

Patient undergoing cardiac surgery (CS), in

most number of cases post operative pulmonary


57

dysfunction developed with a significant reduction

in lung volume, respiratory function, and lung

compliance and increased work of breathing (4-5).

Atelectasis and hypoxemia are among the main

pulmonary complications post operatively of

CABG (6). Respiratory therapy is often used in the

prevention and treatment of post operative

complications as retention of secretions, atelectasis

and pneumonia (7).

In our case, before CABG, an

electrocardiogram shows Q wave in V1 V2 V3 &

V4 chest lead are poor progression of R wave in

chest lead V5 and V6. After CABG ‘Q’ wave are

present in V1 and V4 chest lead, no new ST- T

changes. Before surgical procedures transthoracic

2D echocardiogram shown normal valves and

normal size chambers. Anterior wall, lateral wall,

anteroseptal wall and apical part of LV were

hypokinetic and reduced LV systolic function.

Second day after surgical procedure (CABG) she

had aspirated gastric contents and developed

hypoxia due to asphyxia. Three week after

respiratory physiotherapy treatment, her chest

expansion, arterial O2 saturation and cardiac

function were improved (EF 55%). She was

discharge and advised follow-up.

CONCLUSION

Our case report showing that post operative

respiratory physiotherapy is an effective

management for a patient with coronary bypass

graft surgery for reducing in pulmonary

complications.

REFERENCES

1. Aggarwal A, Sourabh A, Goel A, Sharma V, Dwivedi S. A retrospective case control study of

modifiable risk factors and cutaneous markers in India patients with young coronary artery disease.

J R Soc Med Cardio 2012, vol:1(38); p: 1-8.

2. O’ Donohue WJ Jr. Postoperative pulmonary complications. When are preventive and therapeutic

measures necessary? Post grad Med 1992, 91(3): 167-170.

3. Westerdahl E, Lindmark B, Almgren SO, Tenling A. Chest physiotherapy after coronary artery

bypass graft surgery- A comparison of three different deep breathing techniques. J Rehab Med

2001; 33: 79-84.

4. Westerdahl E, Lindmark B, Eriksson T, Friberg O, Hedenstierna G, Tenling A. Deep breathing

exercises reduce atelectasis and improve pulmonary function after coronary artery bypass surgery.

Chest. 2005; 128(5): 3482-8.

5. Feltrim MIZ, Jatene FB, Bernardo WM. Em pacientes de alto risco, submetidosa’ revascularizacao

do miocardio, a fisiotherapia respiratioria pre-operatoria previne as complica coes pulmonares? Rev

Assoc Med Brac.2007; 53(1): 1-12.

6. Renault JA, Costa- Val R, Rossetti MB. Respiratory physiotherapy in pulmonary dysfunction after

cardiac surgery. Rev Bras Cir Cardiovasc.2008; 23(4): 562-9.


58

7. Lopes C, Brandao CM de A, Nozawa E, Auler Junior JOC. Benefits of non-invasive ventilation

after extubation in the post operative period of heart surgery. Rev Bras Cir Cardio Vasc 2008; 23

(3): 344-350.


*Dr. P. Shanmuga Raju, MPT, Asst. Professor & I/C Head, Department of Physical Medicine &

Rehabilitation, Chalmeda Anand Rao Institute of Medical Sciences, Karimngar- 505001, Andhra Pradesh,

INDIA. E-mail: [email protected]


59

OCCUPATIONAL THERAPY MARKETING INDIAN PROSPECTIVE

Koushik Sau*

ABSTRACT

OBJECTIVES: The purpose of this study is to find out the present scenario of occupational

therapy marketing in India. METHODOLOGY: An author designed survey questionnaire is used

for this study. Other Allied health staff, other rehabilitation staff and local occupational therapist

revised the questionnaire in three stages. After the three-staged revision final survey questioners

was made and send to different occupational therapist working in various parts of India.

RESULT: All participants (100%) are agreeing with that there is a need of marketing. But they

are not satisfied with the present marketing scenario of occupational therapy in India.

CONCLUSION: This study can use by practitioner for marketing guidance

KEYWORDS: Occupational Therapy, Marketing, Health Care Marketing, Occupational Therapy

Marketing.

1. INTRODUCTION

According to the American marketing

association “Marketing is the process of

planning and executing the conception,

pricing, promotion and distribution of ideas

services and goods, to create exchanges that

satisfy individual and organizational


60

objectives”[1] Simply “marketing consists of

meeting people’s needs in the most efficient

and therefore profitable manner”(marketing

OT Services, 1984, p.4) [2] . Marketing can

use as medium of orientation which makes

satisfying the customer’s requirements [2].

Marketing beings by asking what are the

requirements and desires of consumers [3].

Marketing also includes the analysis of the

competition and then decide on a positioning

plan for the product or service, in other words

finding the market position, the pricing of the

products and services, and then promote the

products or services through continue

advertising, promotions, public relations and

sales.

1.1 Health care marketing

Marketing programs sale everything in

today’s life including health care. Though it

was once thought to be inappropriate or

unethical to use in health care professional [2].

According to Willard and Spacksman (1993)

health care marketing evolved in the middle of

1970 when concerns arose about increased

regulation of health care, decrease resources,

increased struggle for those inadequate

resources and change in reimbursement

practice for health care [3].

The health care market is one of the most

complicated one because health care

professional always face a challenge with

different necessities for same kind of

diagnosis. After each diagnosis there are

requirement of various treatments planning

according to demographic charter, political

and regulatory system, socio cultural status,

economical and geographical background [2].

With each variation basic aim is to improve

client’s health through preventive action or

restoration of good health from a state of ill

health.

Management of health care is becoming

more and more common as the demands of

cost containment are placed on providers of

care [4]. In this regards marketing can help

health care profession. Because it is an

important aspect of service delivery that all

health cares practitioners should understand it

[5]. Of course, there is no denying that using

health information in order for healthcare

marketing does run the risk of invades

privacy. Some time people thought that health

care marketing carelessly handled their

sensitive information. In fact, sometimes

health care marketing might cause shameful

offenses to a person's sense of independence

and self-respect. During marketing health care

professional should consider this aspect.

1.2 Present occupational therapy marketing

scenario in India

As occupational therapy professional we

should focused on the marketing for profit of

our profession. Because all of our best efforts

over more than fifty years the profession still

largely unknown to the general public and our

referral sources. Only providing good service

is not enough to grow as a profession. It needs


61

marketing strategies to develop knowledge

and faith on our profession.

In India the health care services generally

regulated by state government and have rights

to select service area for normal population. In

nineteenth century scenario changed and

private sector started to deliver health service

and person starts to pay for treatment.

Changing scenario society has placed increase

responsibility to consumers in concerning to

their own health care choice. Challenges are

increasing for the occupational therapy

professional and necessary to undertake some

marketing strategies that help them to develop

awareness about occupational therapy services

and there benefits.

Consumer goes through relative reference

about the outcome of different treatment

options. They rely on different information

which are getting from different source like

mouth of patient, service provider, and referral

sources etc. Marketing help occupational

therapy profession to aware those resources

through valuable information. In India many

individuals and organization have been putting

significant effort into creating ways to

increase the visibility and awareness of our

profession but there is a lack of collective

work. Efforts in individuals label are not

enough to overcome barriers of marketing.

Present scenario is not good for occupational

therapy professions in India they understand

the need but don’t know how to market the

profession or don’t bother to spent time for

marketing. This study is a primary effort to

find out the present scenario of occupational

therapy marketing in India and find out the

possible procedure of occupational therapy

marketing in India through open ended survey

questioner.

1.3 Research question

What is the present scenario of

occupational therapy marketing in India?

What are the possible procedures of marketing

occupational therapy in India?

1.4 Objectives of the study

Find out the present scenario of

occupational therapy marketing in India.

Find out the possible occupational therapy

marketing procedure.

2. MATERIAL & METHOD

2.1 Subject:

Occupational therapist graduate were

included for these study. Interns and

student were excluded from this study.

2.2 Survey questioner:

2.2.1 Questioner development:

An author’s design survey questioner was

used for this study [6], [7]. Questions were

definite, concrete and pre-determined,

structured and open ended subjective

question [7]. Same wording and ordering

are maintained for all target people[7].

Three steps were taken to modify the


62

question for final study. First these

questions were provided to five allied

health professional . In second stage these

questioner were provided to different

rehabilitation staff, After getting their input

about the clarity of the questioner such as

the wording of the questioner, grammar

usage, simplicity of questions and case of

understand [6],[8] was incorporated to

revise the initial draft of the questioner and

a revised survey was generated. In third

stage revised questioner were send to five

local occupational therapists. Those

occupational therapists were asked to

complete the questioner and provide

comments and suggestion. Comments and

suggestion from the participant’s

occupational therapist were examined by

the investigator and incorporate those into

the revision of the questioner.

2.2.2. The final version of questioner

Final version of questioner consisted two

parts (see appendix). First part concerned

about personal details about participant.

Second part of questioner was consisted of

twelve questions. It concerned about the

different aspect of occupational therapy

marketing procedure to frame the possible

guideline.

2.2.3. Implementation procedure

Survey type research study generally use

large number of sample, because the

percentage of respond generally less 20 to

30 percentages [6],[7] . The survey was

mailed to six hundred occupational

therapist throughout India After getting all

the responses from respondents thank

giving mailed was send to each participant

separately.

3. RESULT:

3.1 Natures of respondents:

Total 137 (22.83 %) response were

received. Not included 16 responses for

not matching the inclusion criteria. Total

121 (20.16%) responds were included for

this study. Charterstic of respondents was

provided in table 1.

Table 1 : Charterstic of respondent (N= 121)

3.2 Nature of respond:


63

All participants (100%) are belief that

they are not satisfy with the present scenario

of occupational therapy profession in India.

All were belief that after fifty years

occupational therapy not captured enough

market in Indian Allied health field.

Almost all participants (114) are not

presently flowing nitch marketing strategies.

Only few (7) participants are following nitch

marketing style.

All participants are agreed in the

point that we are able to fulfill the need sets of

consumer to capture rehabilitation market

place. In case of fifth question respondents

responds was different. According some

respondents (67) All India Occupational

Therapist (AIOTA) is responsible for

marketing our profession. Some respondents

(30) belief it is a responsibility of AIOTA and

ACOT. Few respondents (7) belief AIOTA

brunches, occupational therapy institution

should take the responsibility. In the other

hand some respondents (15) belief it is a duty

of an individual’s occupational therapist. Two

( 2) respondents belief government or

government health policy are the responsible.

Every respondents are belief that our

profession should be promoted and they

suggested different method for that like

formation of own council, awareness through

media, pass the information through simple

and lay man’s word. Most of the

respondent’s(111) belief is that, surveys is

necessary for occupational therapy marketing.

A few numbers of respondent’s (10) belief that

it may not be useful.

There are mix responses about marketing

style. According to response individuals

marketing and group marketing both is useful

for occupational therapy profession. Most of

the respondents (112) are thought that there

should be change in present marketing style in

context of present health care environment.

Some respondents (9) are not sure the change

is require or not in present marketing style.

According to most respondents belief

electronic media is the best option for

promoting occupational therapy profession in

India. But other beliefs that print media can be

also is another option. Respondent’s belief

that, well documentation of profession is

needful for marketing.

There are so many variation is found in

the response of last question. Respondents

suggested that advertisement should be

publishes in regular basis. Awareness came,

spatial clinic, speech by occupational therapist

in local language is also help in occupational

therapy marketing. Videotapes, documentary

film can be use to promote our services, our

occupational therapy achievement. Physician

awareness also can be use as a technique

because still date they are the main referral for

our services. Some suggested there should be

one liner to promote our profession.

4. DISCUSSIONS

Key finding of this study is that every

participant is not satisfied about present


64

marketing scenario of occupational therapy

after fifty years as a profession. Though there

are differences in there beliefs, marketing is

necessary for occupational therapy in present

health care scenario. Without this a profession

can grow.

We know there are no ideal strategies for

marketing occupational therapy in India.

Because India is country of diversity in terms

of culture, language, religious. But there

should be some guidance about marketing,

which can help a professional to capture large

market.

Through this study tried to cover most of

the component of marketing in India through

12 questions. Respondent’s provided there

view point regarding that. In twenty first

century marketing is an important aspect of

any profession. Gradually marketing becomes

common practice in health care profession

also. This study gathered information about

marketing can use to market our profession in

India.

First strength of this study we use

structure question to gather information from

sample so there is no chance of interview bias.

Second, this study collected data from various

parts of country through email so it is low cost

procedure and easily approach to occupational

therapist over India.

Mail were send six hundred occupational

therapist in India. So this result cannot be

generalized. Last limitation is respondents

rate was (22.83 %).

5. CONCLUSION:

In India occupational therapists are either

private practitioner or working in private

sector. There a few numbers of people are

working in government sector. So most of the

time we have to prove as a better treatment

option compare to other profession. In this

regard we can use marketing for survival. This

study can help professional in marketing

occupational therapy profession in better way.

6. ACKNOWLEDGEMENT

I want to thanks to our entire respondent

for their valuable support. I also thanks to

everyone, who helped me to reevaluate

questioner for developed final version of

questioner.

REFERENCES

1. Nosse. L.J., Friberg D.G., Kovacek P.R.: Markrting it’s more than selling. In : Managerial and

supervisory principles for physical therapist:2nd edition: Lippincott William and wilkins.2005:

277-290

2. Jacobs K: Marketing Occupational therapy. American journal of Occupational Therapy, 1987:41:5,

315-320


65

3. Perinchief J.M: marketing: in service management: in Willard and Spackman’s Occupational

Therapy: 2nd edition:Philadelphia, J.B. lippincote company,1993:396-398

4. Cohn R. Strategies for positioning in the managed health care marketplace. Journal of hand therapy,

1994:7(1), 5-9

5. Jacobs k. innovational to action: Marketing occupational Therapy American journal of Occupational

Therapy, 1998:52:8,618-620.

6. Lannin N. and Cusck A: factors effecting patient requirements in an acute rehabilitation:

randomized control trail. American journal of occupational therapy. 2006:60, 117-181.

7. Kothari. C. R., Research methodology:methods and techniques. 2nd ed. New delhi, New age

international publisher ltd. 2004: 95-117.

8. Mu. K. Lohman H. and Scheirton. L.: occupational therapy practice errors in physical rehabilitation

and geriatrics setting: A national survey study.. American journal of occupational therapy: 60,288-

297.

APPENDIX

Personal details:

Participant Name & Designation:

Age & Sex:

Qualification:

Organization name & Experience (in terms of year):

Clinical experience/ teaching experience:

Marketing questionnaires.

1) Are you satisfied with the present marketing scenario of occupational therapy profession in

India?

2) After fifty years as a profession, has occupational therapy captured enough market in Indian

rehabilitation field?

3) According to you our profession is presently following nitch marketing or any other

marketing strategies in India?

4) According to you our profession is able to fulfill need sets of consumer to capture

rehabilitation market place?

5) According to you who are responsible for marketing occupational therapy profession in

India?

6) For marketing of occupational therapy, does it need to be promoted and if yes point out the

methods of that?


66

7) Is there any need of consumer surveys prior to marketing of the profession?

8) In the present scenario individual marketing or group marketing is essential for

occupational therapy profession in India?

9) According to you with changing health care environment what modification is needed in

the present marketing style?

10) According to you presently which media is effective for promoting occupational therapy

marketing in India?

11) Is there any role of documentation in occupational therapy marketing?

12) According to you how occupational therapy marketing should be done in present situation

in India?


* Department of Occupational Therapy, School of Allied Health Science, Manipal University, Karnataka,

India. Email: [email protected]


67

ANNOTATED BIBLIOGRAPHY OF STUDIES W.R.T STATISTICAL

METHODS

Neha Dewan*

“An annotated bibliography is a list of citations to books, articles, and documents. Each citation is

followed by a succinct descriptive summary and evaluative paragraph, the annotation”.

In the present article, we have provided annotated bibliography of studies from rehabilitation science

that are well written with respect to (w.r.t) the statistical methods aspect of the paper. The identified studies

represents a number of statistical topics addressed in the research.

The purpose of present annotated bibliography is to provide the readers about the effective writing

skills for representing results of statistical analysis in their research papers.

The annotated bibliography mentioned below contains a brief statement of the statistical concepts

effectively conveyed in the paper and a quote or two from the paper illustrating the statements which were

found useful.

1. Bastos FN, Vanderlei LCM, Nakamura FY,

Bertollo M, Godoy MF, Hoshi RA, et al. Effects

of Cold Water Immersion and Active Recovery

on Post-Exercise Heart Rate Variability. Int J

Sports Med. 2012; 33: 873–879.

Participants : “20 young male subjects (age:

21±2 years; height: 175±8 cm; body mass: 72±11

kg; body mass index: 23.5±2.1 kg·m − 2; VO2max:

47.1±3.1 mL·kg − 1·min − 1) were recruited for the

study.”


68

Results: “Also, significant differences in the

time required to reach [Lac]peak were found

between CWI and PR (6.3±2.4 vs. 9.8±3.1 min,

respectively) as well as between AR and PR

(7.13±2.71 vs. 9.84±3.07 min, respectively)

(p<0.05, for all)”

� This can be a good example of the use of

descriptive statistics in describing study

participants as well as summarising the results.

2. Lewis JS, Wright C, Green A. Subacromial

impingement syndrome: the effect of changing

posture on shoulder range of movement. J Orthop

Sports Phys Ther. 2005;35:72-87.

Introduction: “The null hypotheses for this

investigation was that changing posture would

have no effect on shoulder range of movement in

asymptomatic subjects and on shoulder range of

movement and pain in subjects with SIS.”

� This can be a good example of clearly

stating Null Hypothesis.

3. Rhon DI, Boyles RE, Cleland J, Brown DL.

A manual physical therapy approach versus

subacromial corticosteroid injection for treatment

of shoulder impingement syndrome: a protocol

for a randomised clinical trial. BMJ. 2011; Jan

1:1(2).

Methods: “The calculations were based on

detecting a 12-point difference in the SPADI with

a standard deviation of 10 points, a two-tailed test

and an α level = 0.05. This generates a sample

size of 43 subjects per group. Allowing for a

conservative dropout of approximately 20%, we

will recruit 104 subjects into the study. This

sample size will yield greater than 80% power to

detect both statistically significant and clinically

meaningful changes in the other outcome

variables. Sample-size estimation was performed

with G*Power software, V 3.1.2.”

� This can be a good example of Sample size

calculation as authors have provided the

information required for sample size calculation

in terms of Zα, Zβ, minimal clinical important

difference(δ), standard deviation(σ) and level of

significance(α). Further efforts are made in

calculating sample size by taking ‘anticipated

drop out’ into consideration.

4. Barreca SR, Stratford PW, Lambert CL, et

al. Test-retest reliability, validity, and sensitivity

of the Chedoke Arm and Hand Activity

Inventory: a new measure of upper-limb function

for survivors of stroke. Arch Phys Med

Rehabil. 2005;86:1616–1622.

Results: “The ICC(2,1) was .98 (95% confidence

interval [CI], .96 –.99). The SE of measurement

was 2.8 CAHAI points (95% CI, 2.3–3.7)”

� This can be a good example of

representation of Test retest reliability as

authors have reported ICC with 95% CI and

standard error.

5. Maly MR, Robbins SM, Stratford

PW, Birmingham TB, Callaghan JP. Cumulative

knee adductor load distinguishes between healthy

and osteoarthritic knees–A proof of principle


69

study. Gait Posture. 2012 Sep 17.pii: S0966-

6362(12)00318-9.

Results: “The variances of CKAL were unequal

for the two groups. The independent samples t-

test [t = 3.97, df = 51, p = 0.001] revealed that

CKAL was nearly two times larger in the OA

group (80.80± 44.54 kNm s) compared to the

healthy control group (42.79± 28.10 kNm s).”

� This can be a good example of Independent

sample-t test showing comparison of 2

independent samples using t value with degrees

of freedom and level of significance.

6. Wong OM, Cheung RT, Li RC. Isokinetic

knee function in healthy subjects with and

without Kinesio taping. Phys Ther Sport. 2012

Nov;13(4):255-8.

Results: “There was no significant difference in

extension peak torque with and without KT and at

different angular velocities (F(2,28) = 0.24, p =

0.79). Similarly, there was no significant

difference in flexion peak torque in different

conditions (F(2,28) = 0.16, p = 0.86).”

� This can be a good example of Repeated

measures of ANOVA as authors have reported F

value with degrees of freedom and level of

significance.

7. Fernández-de-las-Peñas C, Pérez-de-Heredia

M, Brea-Rivero M, Miangolarra-Page JC.

Immediate effects on pressure pain threshold

following a single cervical spine manipulation in

healthy subjects. J Orthop Sports Phys Ther.

2007;37:325-9.

Results: “Post hoc analysis revealed that the

manipulative procedure produced a greater

increase of PPT in both elbows as compared to

placebo or control interventions (P<.001), and no

significant changes were found after the placebo

or control conditions (P>.6).”

� This can be a good example of presenting

the conclusions of Post hoc analysis and use of

box plots.

8. Rana Jaber, David J. Hewson, Jacques

Duchêne. Design and validation of the Grip-ball

for measurement of hand grip strength. Medical

Engineering & Physics. 2012;34(9):1356–61.

Results: “A linear relationship between the two

readings can be observed (r = 0.997; 95%

confidence interval 0.995–0.998, p < 0.05). The

linear relationship between the pressure recorded

by the Grip-ball sensor and the Vigorimeter

manometer was calculated as:

Grip-Ball Sensor = 0.999 x Vigorimeter

Manometer + 0.533 (1). The coefficient of


70

determination was calculated as R2 = 0.994 (p <

0.05).”

� This can be a good example of Correlation

and Regression analysis where relationship has

been reported clearly by r value within 95% CI

and .05 as the level of significance. In addition,

relationship has been presented mathematically

using regression model and percentage of

relationship has been expressed by R2.

9. Djordjevic OC, Vukicevic D, Katunac L,

Jovic S. Mobilization with movement and

kinesiotaping compared with a supervised

exercise program for painful shoulder: results of a

clinical trial. Journal of manipulative and

physiological therapeutics. 2012 Jul;35(6):454–

63.

Results: “Because there were frequencies less

than 5, we regrouped ultrasound findings into 2

categories and applied Fisher exact P. There was

no statistically significant difference in ultrasound

findings between the 2 groups (Fisher exact, P =

.4209)”

� This can be a good example of Categorical

analysis where expected frequencies are less than

5 in which case Fisher exact P gives the exact

probability of obtaining the results.

10. Cromie JE, Robertson VJ, Best MO. Work-

Related Musculoskeletal Disorders in Physical

Therapists: Prevalence, Severity, Risks, and

Responses. Phys Ther. 2000;80(4):336-51.

Results: “Male therapists had increased odds of

reporting neck symptoms (OR=1.9, 95% CI=1.3–

2.9), wrist symptoms (OR=2.0, 95% CI=1.3–3.2),

and thumb symptoms (OR=2.2, 95% CI=1.5–3.4)

in the last year compared with their female

colleagues.”

� This can be a good example of Odd’s ratio

showing the association between gender and

prevalence of work related musculoskeletal

disorders.


* MPT, PhD Student, School of Rehabilitation sciences, McMaster University, Hamilton, ON. Email:

[email protected]

71

CALL FOR PAPERS

Scientific Research Journal of India (SRJI) globally welcomes research scholars & scientists from

different fields of science like Botany, Zoology, Medical Sciences, Agricultural Sciences, Environmental

Sciences, Natural Sciences, Anthropology etc to contribute their researches in this Open Access

Publication.

::Mail your article/s to::

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scientific research journal of india _srji_ vol- 2, issue- 3, year- 2013

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